Op-Med is a collection of original articles contributed by Doximity members.
What are the traits that define your ideal physician? Likely, you want your doctor to be intelligent, curious, and dedicated to the craft. Chances are good that you also want your provider to have a strong moral compass, an ability to put the patient’s issues first, and probably a high level of altruism. You’re surely not alone; society clings tightly to the belief that moral, selfless traits in physicians are a cornerstone of good medical care.
To be sure, all of these descriptors fit the archetypal mold of the perfect doctor. It may actually be the case that physicians embody these traits more than the average person, and certainly they may lead to better patient care…
The problem is that within the bigger picture of medical care, we overestimate the significance of these moral and self-sacrificing tendencies in doctors. Yes, moral, patient-first care is a critical part of decision-making, but doctors are making less and less of the actual decisions. Thus, an understanding of the overall ethics (or absence of them) in medical care requires us to take a step back.
If doctors no longer direct as much medical care, who has taken their autonomy away? The answer is both important and concerning. Corporate interests now increasingly direct medical decision-making. Unfortunately, the dominant goals of these parties may have minimal overlap with the moral, patient-first paradigm we so badly want our doctors to exemplify. These businesses have created clear restrictions on how physicians can practice, limiting the impact of a doctor’s preferences on how to administer medical care.
We physicians are the first to acknowledge this reality. More than half of us feel we have little ability to significantly influence the health care system. We’re becoming slaves to the restrictions imposed by insurance reimbursement, preferred pharmaceuticals, and documentation requirements. The power to independently make patient care decisions is falling victim to externally imposed constraints that do not necessarily benefit the patient, or qualify as morally sound.
The myth, then, is that doctors and their individual moral principles remain the sole influencers of a patient’s health care. It’s nice to have a physician that is willing to go the extra mile for her patients, but this can be completely negated when outside interests push for the exact opposite. We’d like to believe that a code of ethics infuses the medical system; it’s easier to focus on the romanticized doctor-patient relationship than the truth — that more and more important medical decisions are made by those valuing profit over patient care.
Here’s the problem: society has created a value structure for idealized medical care that prioritizes moral and altruistic behavior. The physician is seen as the arbiter of the medical system: intelligent, capable, and able to dictate exactly how and when medical treatment will be dispensed. There was a time when this was a realistic notion. Now, it’s an inconsistent and dangerous anachronism.
Though it would be comforting to believe that health care is governed only by those who possess a strong moral compass, it’s simply not true. There is no escaping the fact that drug companies are strongly influencing the entire health care system. Their influence extends much deeper than direct-to-consumer television commercials or sponsored dinners for physicians. Pharmaceutical corporations consistently rake in massive profits, basically setting drug prices at whatever they feel will make the most money. And while the occasional pharma executive may be penalized for gross manipulation of drug prices, it’s only when unethical behavior is taken to an extreme that anyone seems to notice.
Similarly, insurance companies (regardless of the regulations imposed by the Affordable Care Act) have no real need to put patients first. These are massive, publicly-traded companies seeking to maintain and increase profits. When an insurance agent relays the cost of a medical service, he doesn’t have to feign altruism. These companies are towering money-making enterprises. Their decisions impact the medical care of hundreds of millions of Americans. They determine which providers a patient can see, what procedures can be performed, and which medications will be covered. And yet, we don’t even pretend that these decisions are driven by deep morality or a patient-first perspective.
All of this boils down to a central point: we must look at ethics in the medical system objectively and holistically. Certainly, we should continue to value a strong sense of morality in doctors and other medical providers. However, we must also focus on the massive engines of commerce that powerfully influence medical care. As much as some might wish it were otherwise, medicine is a business firmly rooted in capitalism. It is a fantasy to believe that insurance and pharma giants (that make billions in profit from patients each year) are only in it for the patient’s benefit. It’s equally impractical to assume that physicians with strong morals are sufficient.
I am not saying we need a complete overhaul of the healthcare system (though I’m definitely not ruling out the potential merits of that option). But I do think we need to be honest about an outdated concept of ethical care in the medical world. If corporations are sharing the responsibility for medical decision-making, shouldn’t we require they share the ethical code? It’s good to have your doctor put your health first, but he’s only one vote among many, and his vote is becoming less and less important.
Austin Perlmutter, MD is an Internal Medicine physician based in Portland, Oregon. His current focuses are exploring methods of creating sustainable joy, health, and meaning in the modern world, as well as how to improve wellness for those in the medical field. Austin reports no conflicts of interest.
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