While the medical community is still struggling to recover from the knockout blows delivered this past decade by the insurance/banking cabal and its HMOs, it is disappointing to have Frank Chervenak, MD, and Laurence McCullough, PhD, serve up their solutions in such an admonitory way as in “Rising to the challenge: ethics in the era of managed care” [May]. Such a chimeric attitude is just about the last thing we physicians need. As they noted, our profession is one based on trust, so being fiduciary is our first priority. Perhaps, now that sides have been drawn, the lineup of physician and patient versus hospital and HMO is finally right.
It was not clear whether the authors agreed with managed care organizations that there is an oversupply of physicians in the United States. The contrary is true. In fact, the U.S. has a population-to-doctor ratio of 350:1; double the optimum 180:1, which is achieved only in Cuba and Israel. Also, we lag behind national health-care plan countries such as Canada and England, both with ratios of 260:1. The bottom line: Doctors are needed in the U.S.
Drs. Chervenak and McCullough never approached the root of the problem: The U.S. is the only developed nation without a universal health-care plan. Arguably, that is our greatest shame. The answers are not found in pondering our ethics. Instead, we need to declare health care a right, not a privilege.
Lastly, the authors concluded with “anger does not lead to appropriate…solutions.” But they should have urged doctors, in their fiduciary role, to stay angry—and to get even angrier. Only then will there be a chance to put medicine back into the hands of physicians. Until then, our ethical manipulations will only fall into the hands of those who have taken over, leaving the public to obtain health care from MBAs rather than MDs.
Don Sloan, MD
New York, NY
DRS. Chervenak and mccullough respond:
We thank Dr. Sloan for his interesting and provocative comments. He appears to be of the view that managed care organizations—and perhaps, hospitals—are the enemies of the physicians and patients. Indeed, if this were the case, physicians should become very angry and dig in for the long twilight struggle of good versus evil, confident that if they were to regain power, everything would be fine.
However, in our judgment, this advice would misdirect the reader’s moral energies down the fruitless path of anger. To control costs, managed care organizations do not respond to us, but to those who pay for health care, e.g., employers and government agencies such as Medicare. Getting angry at economic rationale may feel good—for a few minutes, at best—but only will serve to provide an ineffective response to the implacable realities.
In addition, Dr. Sloan states that we negligently excluded our thoughts on what the best patient-physician ratio is and whether the U.S. should create a universal right to health care. However, these are large public policy questions to which there are no reliable answers.
The purpose of our article was to equip physicians with professional virtues, enabling them to respond to the business tools of the managed practice of medicine. Physicians should never expect to regain sole control of medical care. Rather, they can and must be able to conduct themselves in an ethically responsible fashion in order to freely and systematically assume fiduciary responsibility for patients and hold managed care organizations and hospitals to their cofiduciary responsibilities. Throughout the history of medicine, ethics has shown itself to be a far more effective tool for responsible leadership and change than anger.