Have Doctors Forsaken Their Ethics; J. Singer

While medical ethicists disagree on a number of issues, there are certain princi ples nearly all share. Whether or not we intend to adhere to these principles is the question we must answer. The Hippocratic Ethic One conflict that must be resolved is the choice between remaining committed to the "Hippocratic Ethic" or embracing what is called the "Veterinary Ethic." The Hippo cratic Ethic holds that a physician's ultimate responsibility is to the patient. Conse quently, all advice given regarding therapy is based upon what the physician perceives to be in the patient's best interest. The Veterinary Ethic holds that the physician's ultimate responsibility is to the payer, and that advice is therefore based upon what the physician perceives to be in the payer's best interest. An example of this is when the veterinarian recommends to an owner Dr. Singer practices medicine in Phoenix, Ari zona.

that an animal be "put to sleep" rather than undergo costly treatment. As our healthcare system is reformed, we risk abandoning the Hippocratic Ethic in favor of the Veterinary Ethic. If the system pushes more and more of us into a "man aged-care" setting, where the physician is under the management of insurance com pany administrators who ultimately answer to government regulators, the physician will be put in the position of conforming to a method of practice where the interests of the payer are paramount. Similarly, if our system is changed to a "single-payer" type of healthcare system, the physician will be under the management of government bureaucrats, who in tum are influenced by budgetary constraints and pressure from special interest groups. The doctor will be forced to comply with prac tice guidelines set up by the government. Again, the interests of the payer prevail. Patient Autonomy The issue of patient autonomy is also important. A fundamental precept of pre vailing medical ethics is that patients who are conscious and mentally competent should have control over their bodies in medicaldecisions. Put another way, nothing should be done to the patient without the patient's "informed consent."

To this end, medical schools and teaching hospitals have institutional review boards to 231 232 THE FREEMAN • APRIL 1995 oversee research on patients. These boards insist that researchers develop informed consent documents which explain, in lay man's terms, the reason for the research, what the researcher predicts the patient to experience and gain, and what the re searcher hopes to learn or accomplish by the experiment. Implicit in this policy is the belief that it is possible to make this infor mation clear and understandable to non physicians, and that most patients can make a reasonably informed decision about whether to consent, even in the case of a complex and esoteric procedure. When patients are moved into a situation where their doctor must answer to an over seer, they lose the ability to give "informed consent. " The doctor must follow regula tory guidelines when ordering tests or rec ommending procedures, and can only pre scribe medications that are listed in a formulary. Is the patient ever aware of other options that could have been considered, even if they were more expensive?

When a doctor prescribes a drug in the formulary, is the patient aware of other drugs that could have been prescribed, and their relative risks and benefits as well as their relative prices? Is the generic drug always as good as the brand-name drug? Is there a more expensive alternative form of treatment that does not involve the use of drugs and yields quicker results that is not being brought to the patient's attention? These questions apply whether we place the patient in a "managed-care" system or a Canadian-style "single-payer" system. When people are placed on prioritized waiting lists for surgical or diagnostic pro cedures, they are not fully informed about the risks being taken with their lives by being forced to wait. The ultimate power for decisionmaking is in the hands of a health care bureaucracy that determines how much money will be allocated for each problem, and in some cases, to each healthcare facility. People may be given a degree of choice regarding who their doctor will be, but they are allowed to make very few choices about what type of health care they receive. In most cases they are kept completely in the dark regarding the various options that exist. This is because a third party-government or "managed-care pro vider"-controls the money.

While it is reasonable and appropriate to consider these ethical issues when deter mining how we intend to transform the existing healthcare system, it is important to realize that the time-honored ethical pre cepts discussed above are already ignored. Over the past several years, policymakers and healthcare providers have begun to change the way in which health care is delivered with complete disregard for med ical ethics. In many cases the individual doctor unconsciously violates his ethical credo on a daily basis.. As a clinician in private practice, I make this statement based on firsthand observations. Medicare and Medicaid Consider first the 40 percent of Americans who are on either Medicare or Medicaid, single-payer types of healthcare delivery arrangements. The patient pays little or nothing out of pocket for healthcare expen ditures. The government is the payer. Over the years, in order to control Medi care and Medicaid expenditures, the gov ernment has begun to manage the way health care is delivered. One way in which it has done this is by changing the way in which it reimburses hospitals for services.

Rather than reimbursing on a fee-for-service basis, it does so on the basis of Diagnosis Related Groups (DRG's). The hospital is reimbursed on a flat rate pegged to the patient's diagnosis, regardless of the sever ity of the illness or the amount of hospital based services a particular patient requires. In order to reduce losses, hospital staff utilization review committees have resorted to intimidating and pressuring physicians to treat certain problems ordinarily handled in the hospital on an outpatient basis. They are also pressured to discharge patients sooner than they would ordinarily recom mend. If doctors are found to be "poor utilizers" of hospital resources from a cost effectiveness perspective, they often must HAVE DOCTORS FORSAKEN THEIR ETHICS? 233 go to great lengths to defend their actions before peer review committees or else face sanctions. Most doctors don't have the time or inclination to face such hassles. For this reason, most physicians find themselves tak ingcertain riskswiththeirpatient's healththat go against their better judgment, rationalizing that they are followingthe prevailing "stan dard of care" in making their decisions.

Also in the interest of controlling costs, hospitals have gone to a formulary system for dispensing medicines. A Pharmacy and Therapeutics Committee determines what drugs will be available in that institution. If a doctor wishes to place his patient on a medication, he can select only from the medications in the formulary, a catalog of drugs that the Committee decided should be available to doctors practicing in that hos pital. If the doctor wants to prescribe An tibiotic "A" for his patient, but this drug is not in the formulary, he has to select his second-best (or third-best) choice. Other wise, the doctor has to go through a maze of procedures in order to get special authori zation to order Antibiotic "A." (The Phar macy and Therapeutics Committee deter mines by consensus vote of its members which drugs to place on the formulary, cost being the overriding concern. This formu lary affects all hospitalized patients, not just those on Medicare, since the hospital is trying to recoup its losses from operating under the DRG system.) In most cases, the doctor just decides to "go with the flow"

rather than take the time to fightfor what he sees as the patient's best interest. Again, he finds solace in the rationalization that a hospital committee has made this practice the "standard of care. " Leaving the hospital setting, doctors are under constant pressure to see patients in their offices for a particular illness at a frequency prescribed by Medicare or Med icaid. If they see these patients more often than Medicare or Medicaid "allows" they are not reimbursed for their service. They must choose between practicing medicine that's not in their patient's best interest, or facing financial loss. Oftentimes they opt to follow the Medicare-or Medicaid-prescribed guideline, rationalizing that the fact this is prescribed by a government agency makes it the "standard of care." The same can be said for the ordering of certain diagnostic screening tests. From chest x-rays, to mammograms, from cardio grams to prostate-specific antigen (PSA) tests, the proper frequency and indications for ordering these tests are determined by a government bureaucracy. If doctors don't follow these guidelines, they don't get paid.

What's worse is that they run the risk of being excluded from Medicare or Medicaid if they become identified as "problems." In most cases, doctors simply acquiesce. "Managed Care" Of the remainder of the population not on Medicare or Medicaid, roughly 90 percent receive employer-provided low-deductible health insurance. Few healthcare costs are paid out of pocket by the patient. The insurance company pays most of the bills, and passes the cost on to the employer in the form of premiums. In an effort to hold down rising premiums employers have resorted to placing their employees in "managed-care" plans. Today, if we include Health Mainte nance Organizations (HMO's), Preferred Provider Organizations (PPO's), or regular fee-for-service plans that have "utilization review" and' 'pre-certification," more than 90 percent of the non-Medicare/Medicaid population is in "managed care." In the managed-care setting the same pressures on the physician exist as in the Medicare/Medicaid single-payer system.

The doctor must get authorization from an overseeing entity in order to order tests and diagnostic procedures, perform surgeries, or prescribe medications not in the man aged-care company's formulary. The doctor must get permission to place a patient in the hospital. In many cases, the doctor must get permission to refer a patient to a specialist. The criteria used by the oversight entity granting permission are closely linked to the issue of cost. Whenever there exists a di versity of opinion in the medical literature regarding the proper management of a par234 THE FREEMAN • APRIL 1995 ticular medical problem, it enables the man aged-care company to seek refuge behind a credible source in defending its policy med ico-Iegally. The overseeing entity will then tend to only allow the least expensive ap proach to be authorized. These criteria can be overruled if the doctor is willingto jump through enough bureaucratic hoops to get special permission. Of course, if he does this too often he becomes·too expensive for the insurance company to maintain on con tract. It might terminate the doctor. Conse quently, most doctors tend to comply.

It should come as no surprise that, ac cording to the National Ambulatory Medical Care Survey, managed-care programs are less likely to authorize expensive diagnostic tests. For MRI and CT Scans the difference is a factor of two to one. As a consequence, patients with diseases such as cancer are likely to have their conditions detected at a later stage, making treatment more difficult. Studies by Mark Schlesinger and David Mechanic (Health Affairs Supplement, 1993) conclude that although managed-care and traditional fee-for-service plans tend to adopt the same method of treatment where normal practice guidelines are well-defined, where norms are vague the prepaid plans provide significantly diminished levels of treatment. As an adjunct to their own oversight entities, many HMO's use the primary care physician in the capacity of "gatekeeper. " Many of the decisions regarding appropri ateness of referrals to specialists, or regard ing authorization of procedures or tests recommended by these specialists, are placed in their hands. The primary care physician is financiallypenalized for expen diture outlays by the managed-care program and rewarded for expenditure savings. This again places him in the bind of having to choose between the interests of the patient and possible financial ruin.

New Medical Ethics In all of the above examples, the physi cian is implicitly forsaking the Hippocratic Ethic. He is making decisions based upon what is in the payer's best interests. All of these decisions are being made without the patient having informed consent. The pa tient is never aware of what other options existed with respect to tests being done, medicines being prescribed, procedures be ing performed or not performed, or special ists being consulted. As Merrill Matthews has said, "In effect, medical ethics has succumbed to medical economics, as paternalism is given prece dence over autonomy. " A recent well-known victim of the new medical ethics is former Secretary of De fense Les Aspin. He needed additional vac cinations because of the travel requirements of his job. His doctors gave him a vaccine slightly more risky than one which would have cost $1.55 more. Secretary Aspin was hospitalized in an Intensive Care Unit as a result. Did anyone ask him if he was willing to pay an additional $1.55 out of pocket to avoid the risk? Was he even aware such an option existed?

When Senator Bob Dole opted for a prostate-specific antigen test (PSA) in 1991, it led to a biopsy that detected early prostate cancer, and then an operation which the Senator believes saved his life. Most man aged-care plans don't see much benefit in this blood test and therefore don't routinely provide it. Fortunately, Senator Dole had the opportunity to make his own decision. This ethical dilemma need not exist. Doc tors need not confront the choice between the Hippocratic Ethic and the Veterinary Ethic. If the patient were again the primary payer, there would be no conflict of interest between the patient and the payer. If the patient had control of the money, the burden would be on the doctor to get "informed consent," and to give advice in accordance with the Hippocratic Ethic. The patient would settle for nothing less. But as long as politicians in Washington continue to show a bla:tantdisregard for the ethical consequences of their policies, they willnot avoid creating a healthcare monster with a tragic destiny. D THEFREEMAN IDEASON UBERTY Rising HealthCare Costs: Who's the Villain?