"Feds raid Columbia facilities."
"Medicare billing probes widen."
Recent headlines related to federal investigations of Columbia/HCA Healthcare Corp. and other healthcare organizations reinforce concern about the ethical soundness of parts of this nation's healthcare system.
These events only confirm for some a belief that kickbacks, under-the-table dealings and inappropriate relationships in the healthcare industry are the result of an unhealthy mix of proprietary healthcare, market forces and medicine.
Let's examine this tangle of money, ethics and medicine that often appears, like the mythological Gordian knot, to defy unraveling.
Actually, the pairing of money and medicine is as old as the profession of medicine itself. The practice of medicine almost always has had one foot in the business world and the other in a professional and ethical world of advocacy for patient interests.
Physicians and other healthcare providers traditionally have used the medical profession to make a living, seeking compensation for their services. Under the fee-for-service delivery structure, fees were generated, for example, by office visits, lab tests and chest X-rays. The tests and X-rays often were performed in a physician's office using equipment purchased by the physician or the physician's practice partners.
It was assumed a professional and ethical commitment prevented the physician from using these office visits, tests or X-rays simply to generate extra revenues. Whether this assumption was accurate is not known.
As healthcare services have become more commercialized, new ethical concerns have arisen. Some people believe the recent economic changes in healthcare delivery have created a corrupting environment. In this environment, they believe, the physician's traditional commitment to patient care and advocacy is subordinate to profitability-on behalf of the physician, corporations or investors in publicly traded companies.
Unethical practices cited include kickback arrangements for referrals; arrangements with pharmaceutical or medical suppliers; and physician equity arrangements designed to entice physicians to refer patients to a particular hospital.
Across the nation, the response to this concern has been to create rules governing these market-driven arrangements, to prohibit the arrangements altogether, and to penalize those who violate the sometimes unclear regulations.
Ironically, these regulatory requirements have tended to undermine the ethics of the medical profession by minimizing the traditional commitment found in the doctor-patient relationship. If, for example, a patient gives informed consent to going to a diagnostic center in which the physician has partial ownership, the arrangement is deemed legal. One might argue, however, that it is not ethical.
It should be pointed out that how one views the relationship between money and medical practice depends on whether one believes the practice of medicine has an inherent value. There are those who believe medicine is fundamentally contractual and that contracts best define the various relationships in medicine.
People who do not attribute an internal ethic to medicine when examining relationships dictated by contemporary market realities will ask questions different from those who do. I would argue that an internal ethic does exist and propose the following points for consideration:
The relationship between the physician and patient is one of service, vulnerability and collaboration. The physician acts as a free agent who strives to achieve a particular end related to the patient's needs, and, by implication, the needs of society. The physician-patient relationship deserves protection from financial interests that may jeopardize the vulnerable patient.
The science-and-art nature of medical practice results in variability in the treatment of patients in part because of the variability of the experience of illness. This acknowledgment of variation doesn't preclude the use of sound care pathways or clinical guidelines, but it does require the physician to be flexible in diagnosis and treatment. This flexibility should never be an excuse for inefficiency, nor should it be used to deny the need for good stewardship of limited resources.
Physician judgment involves a recognition of the nature of the medical problem and an identification of effective and available treatments. Variation occurs from one patient to another as a result of the objective data used in assessing treatments and outcomes, the medical condition of the patient and the value decisions patients may make about the acceptance or rejection of proposed medical treatments.
Too little treatment, especially when the motivation is to generate larger financial returns, is unacceptable; too much treatment is a waste of resources or an indication of poor professional judgment.
Commercial interests within the context of medical practice can bias even the most devoted professional. Commitment to the nature of the profession and prudent clinical judgments minimize any conflict of interest that might exist. While conflict cannot be eliminated totally, commitment to patient care ameliorates its impact.
Physician alignment, a buzzword in developing networks, raises ethical concerns regarding the effect of hospitals and physicians sharing a common economic interest. Is an employed physician, for example, aligned with the corporation or with the corporation's mission to improve patient care and community health status? To whom do financial arrangements align a physician-the people being served or the people who pay for the healthcare? Service to patients should predominate in all relationships.
The current emphasis within the healthcare industry on structure, economic incentives, physician alignment and general management does, in some cases, divert attention from the critical decisionmaking role of the physician acting on behalf of his or her patients. It is wise to keep in mind that while market forces may create economic efficiencies, they have never been known to guarantee sound ethical values. Distance between money and medicine is a prudent thing to create and protect.
Brodeur, a healthcare ethicist, is senior vice president-stewardship for St. Louis-based SSM Health Care System.