The web listing of No Free Lunch pledge adherents has yet to appear on line despite having been promised on the site for several years. One wonders if more than a small handful of doctors has taken the pledge. Indeed on close examination very few practicing physicians, at least in the United States, could honestly sign the pledge because of this requirement: “to avoid conflicts of interest in my practice”¦.” That pretty well disqualifies most doctors who practice medicine for a living. Depending on our compensation model most of us practice under either positive or negative financial incentives. These incentives influence the types and numbers of patients we see, the procedures we do, the tests we order and our referral patterns. Compared to the measly drug company pens, note pads and lunches these conflicts are much more powerful. They’re about real money and they impact each and every patient encounter.
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Most? Indeed all practice under either a positive or negative financial incentive. Even the salaried government doctor has a clear financial interest. The less effort she expends for her fixed salary, the more she is being compensated for her effort.
There is not system or set of rules that substitutes for a moral and spiritual commitment to putting the interest of your patients first in choosing what treatment to recommend. It is that very necessity which makes necessary the right, so disturbing to some, of physicians to have autonomy in choosing whom to accept as patients. Only with the exercise of that right, can the physician restrict her services to those patients in those situations in which she knows that she can and will make that commitment. It is an obligation that can’t effectively be legislated except in the most flagrant violations, and only the doctor can see into her own heart and examine the purity of her motives.
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