Balancing Act: The New Medical Ethics of Medicine's New Economics. - book reviews

Business Economics, Oct, 1993 by Merrill Matthews, Jr.

ONE OF THE factors driving up health care costs for business is the problem of uncompensated care. The cost of caring for those who are unable -- or sometimes simply unwilling -- to pay for their health care is frequently shifted to those patients who do pay. And because those paying patients are usually covered by employer-based health insurance, it is frequently the employers who absorb the cost shifting.

Defenders of this system contend that someone who can afford it, i.e., employers and health insurance companies, must pay for the care because it would be unthinkable to let an individual be denied health care simply because they do not have the money.

Well, maybe not. In fact, it may be time for us to reevaluate our medical ethics in light of the changing face of medical economics and embrace an idea of patient autonomy that includes patient responsibility, even if that means that the patient suffers adverse consequences from voluntarily deciding to underinsure.

So argues Prof. E. Haavi Morreim of the Department of Human Values and Ethics at the University of Tennessee in Memphis. Prof. Morreim has thoughtfully addressed some difficult issues in her new book, issues that are being forced on the medical community for a number of reasons.

"The changing economics of medicine have fundamentally, permanently altered the relationship between physician and patient," writes Morreim. "Traditionally, that relationship has been dyadic," but no longer. "In the vastly more complex present and future, the physician's obligations to the patient can no longer be a single-minded, unequivocal commitment, but rather must now reflect a balancing. Patients' interests must be weighted against the legitimate competing claims of other patients, of payers, of society as a whole, and sometimes even of the physician himself."

Although the notion is not new that physicians should exercise a broader, more utilitarian perspective when determining how to allocate scarce medical resources, Morreim's recommendation for achieving that goal will go against the grain of many ethicists, health care providers and politicians. That is in part because Morreim approaches her subject from the viewpoint of economic realism, incorporating how people actually behave economically, rather than how we would like them to behave or how they ought to behave.

In an effort to contain costs, some insurance companies and health care providers have created systems where physicians benefit financially from cost-conscious care. This "impetus to restrain health care is not necessarily bad," writes Morreim. "There are many ways in which the medical profession can reduce quantity of care without reducing quality," while forces such as competition, legal scrutiny and societal and professional values will pressure physicians to continue their high standards.

In light of these pressures, "this newly complicated nexus," the author writes, "it become necessary to reexamine traditional concepts of physicians' fidelity....And we can no longer require such a strong presumption that the physician will promote his patient's interests above the competing claims of other patients, or of payers, institutional providers, and the society as a whole. We must therefore consider more closely just what the physician does owe his patient and, equally important, what he does not owe."

What Morreim believes the physician does not owe his or her patients would be anathema to many people: "They do not owe it to their patients to commandeer others' money and property just because a given patient has need of it. They are not obligated to hoard, poach, cheat, lie or game the system in order to obtain resources to which the patient is neither legally nor ethically entitled. And they are not ethically authorized to undertake those tactics even where they believe a patient is being denied a resource to which he is morally entitled."

What physicians do owe their patients, besides the traditional obligations, "if not actually new, now arise with new dimension and force." First, writes Morreim, the physician "owes his patient economic disclosure." And second, "the physician has an obligation to minimize the conflicts of interest that may minimize his loyalty to the patient," by which she means that associations with, say, institutional payers do not "unduly intrude upon his duties to his patient."

The real crux of Morreim's proposal, however, is to make the patient an economic player in health care decisions, and let the patient bear the impact of those economic decisions. Morreim rightly points out that the trend in medical ethics is away from paternalism and toward autonomy. Yet this has not been the trend in medical economics. If we believe in patient autonomy, we must also believe in patient responsibility, because autonomy without responsibility is not autonomy.

"If someone who has chosen a minimal health plan (e.g., to save money for skiing trips) subsequently needs the costly care that he rejected earlier, we may feel compassion for him. We may even wish charitably to help him, but we have not wronged him if we refuse, because his choice was made knowingly and rationally." And if a patient finds himself uninsured or underinsured based on a previous rational decision, "he either must pay for the care himself or go without."