Physicians torn between two loyalties

A growing unease among young physicians highlights conflict between allegiance to individual patients and the stewardship of medical resources.

By Vida Foubister, amednews staff. May 15, 2000.

It's time for the medical profession to confront a defining moral question, according to a recent article in the Archives of Internal Medicine.

That is, should physicians recommit to the Hippocratic ideal of undivided loyalty to individual patients or should they adopt a new ethic to manage resources for the collective good?

Whom do you serve?

"The data throw this moral question in our face; what are we going to do about this?" explained lead investigator, Daniel P. Sulmasy, MD, PhD.

Dr. Sulmasy and his colleagues came to this conclusion after finding significant ethical disquiet among the 1,549 young physicians who were asked about the methods currently used by many health care payers to contain costs.

Of these doctors, only 17% said they believe it is ethically acceptable to use financial incentives to encourage limits on medical treatments. A majority, 81%, also said the profession's ethic of undivided loyalty to patients had decreased during the past 10 years. Further, 51% said their own patients' trust in them had diminished during the past five years.

"For those of us who think that trust is the essence of what healing means, that is a very disturbing finding," said Dr. Sulmasy, Sisters of Charity chair in ethics at St. Vincents Hospital, New York City, and director of the Bioethics Institute at New York Medical College, Valhalla.

Conflict of interest unsolvable

Physicians interviewed by AMNews had different answers to the investigators' question, which drives at the heart of the medical profession. But many, including the lead author, agreed that it is unsolvable.

"You cannot practice on the individual and serve the collectivity and be the equivalent servant of both at the same time," Dr. Sulmasy said.

To avoid the conflict between individual patients and the collective good, some suggested that decision-making should occur at two levels.

At the bedside, physicians should care first and foremost for the patient in front of them.

But in developing standards of care and clinical guidelines, the stewardship of collective resources should come into play.

In 1993, the Colorado Permanente Medical Group adopted a set of medical practice principles taking that approach. The goal was not to replace the Hippocratic Oath, said Paul Barrett, MD, the group's director of research, but to augment it by giving doctors guidelines to facilitate their decision-making at the bedside.

"You don't have each individual physician trying to make [his or her] own cost-benefit trade-offs on the fly in the course of an office visit or rounding on a patient in the hospital," he said.

It is interesting to note that the Archives article found that doctors who work in staff model HMOs are less likely to say that the ethic of undivided loyalty to individual patients was diminished.

"The reason they don't have a problem with this is because their organizational model has insulated them from feeling the impact," said Thomas Mayer, MD, MBA, executive director of managed care education at the Institute for Healthcare Advancement in Whittier, Calif.

"Most physicians are in organizational models that no longer fit the future of where health care is going."

However, Peter Ubel, MD, a staff physician at the Philadelphia Veterans Affairs Medical Center and a bioethicist at the University of Pennsylvania, believes that physicians at the bedside also have a responsibility to think about controlling costs.

"This is the trade-off that's so important: the cost of health care determines how many people can get insurance," he said.

System level change

Not all physicians feel ethically compromised by the means some managed care organizations use to control costs.

But many of those who question these arrangements say they won't be satisfied by changes at the insurer level that eliminate this conflict. Instead, they say society must set the parameters for doctors to work within.

"There needs to be an open, participatory process in which cost containment measures are decided upon in such a way that everyone's affected equally by them," Dr. Sulmasy said.

Some go further, advocating that universal health care is the answer.

"I'm intolerant of partial solutions," said Quentin Young, MD, a Chicago internist who serves as the national coordinator of Physicians for a National Health Program.

However, others caution that managed care alone is not responsible for this ethical quandary.

"If you're going to try to cut costs, whether you use managed care or another system, there's going to be disquiet and unhappiness and concern," said David Orentlicher, MD, co-director of the Center for Law and Health at Indiana University in Indianapolis.

Because of all the advances in technology, hard choices will inevitably have to be made about what medical treatments should be covered. And despite the drawbacks of financial incentives, which also bring doctors' self-interest into play, they have some advantages.

"They give physicians broad discretion," Dr. Orentlicher said. " If you want to use a drug, use a drug. If you want to hospitalize a patient, hospitalize a patient. ... It's your call. All [insurers] care about is how much you spend overall."

No matter which way physicians would like to see these conflicts resolved, there are always going to be trade-offs.

"The danger of saying, 'I'm only going to worry about my patients,' is that doctors will lose all moral authority and power to deal with other issues that affect medicine," said Marc Rodwin, PhD, associate professor of law and public policy at Indiana University in Bloomington and author of Medicines, Money and Morals: Physicians' Conflicts of Interest (Oxford University Press, 1995).