Does health reform require doctors to stray from their ethical code?

The difference between a job and a profession is a matter of ownership. Anyone who is applying for employment understands that the job they seek actually belongs to someone else. It is typically offered by an individual or a corporation who defines the job and determines who is qualified to perform it. If the job holder is unable or unwilling to do the work, the owner takes the job back and finds someone else to fill the position.

By contrast, a professional owns their own job, having obtained the requisite knowledge and skills through very specific education, training and subsequent experience. Each professional is also charged with being a steward of the profession they have dedicated their life’s efforts to achieving. This stewardship requires the establishment and maintenance of an accepted set of core principles, and it is those core principles that define the profession to the rest of the world.

As a physician, my profession’s core principles have been in existence for about 2,500 years. They have been modified somewhat over the centuries, but by and large they have remained relatively constant since they were first outlined by Hippocrates. His rules for the profession were relatively simple; first do no harm, always do what is best for the patient, consider the patient before self, create no mischief and keep confidential what you see and hear. There is nothing specific in the Hippocratic Oath about charges or payments for physician’s services, but it concludes with the statement, “if you keep this oath, it will be granted to you to enjoy life and the practice of this art, respected by all men in all times.”

Through the ages patients have relied on the physician’s adherence to this basic Code of Medical Ethics as the fundamental basis for the social contract, commonly refer to as the patient/physician relationship. However, in recent years we have witnessed a steady erosion of that relationship as the practice of medicine has centered more on payments than patients. When America’s physicians allowed the camel’s nose of third party payers under their tent, they invited an assault on their time-honored ethics. For decades the patient/physician relationship has been under siege by a variety of forces associated with our convoluted payment system. Does your doctor do what he or she believes is best for you, or follow some “best practice guidelines” offered by a public or private bureaucrat who is holding the purse strings?

For a century and a half the American Medical Association has been the standard bearer for the Code of Medical Ethics in this country, and at one time nearly every physician was a member of that organization. But, since the mid 1960‘s AMA membership has declined steadily until today more than 80 percent of America’s doctors are not members. The reason for the mass exodus from the AMA is simple. Most physicians believe that it is no longer representative of the core values of their profession. As a delegate to the AMA House of Delegates for the last 4 years, I witnessed for myself how the “business of the house” focuses far more on the finances, politics and social engineering efforts surrounding healthcare than it does in preserving and improving the art, science and ethics of medicine.

At the Interim Meeting of the AMA House of Delegates I was reminded of just how far our professional leadership has drifted away from its core values. The AMA President, Dr. Jeremy Lazarus, gave a speech during the opening session. He called on America’s physicians, “To move from divisiveness to diplomacy, from conflict to collaboration, from the narrow self interest of personal gain to the national interest of mutual goals.” He went on to say, “We need to have a difficult but necessary conversation with the public and our leaders about the tough choices ahead. In June, the AMA passed ethics policy that calls on physicians to be stewards of the resources society entrusts to us. To follow policies on issues such as: cost versus value. End of life care. The responsibility of patients to own their own health. The need for more public health investment. The very unsustainability of the system itself – absent fundamental change.”

Dr. Lazarus was presenting the AMA’s new strategic plan that promises to discard those core principles which are centered on the individual patient, and replaces them with a new ethical code that shifts the profession’s priorities to meeting the collective good. In his remarks he accused physicians of being selfish, suggesting that we should “… listen to our heart and be driven by science – and not the latest fad or the biggest pile of cash. Knowing in our heart that a medical school diploma is not a treasure map.” Perhaps the new AMA strategy was best summed up when Dr. Lazarus said, “It seems to me the stars have aligned in such a way that our loftiest aspirations are exactly what’s needed now to transform our health care system. And to embrace a new set of core values – ones better suited to integrated care … It once made sense for physicians to value autonomy, independence, and self-sufficiency. But the game has changed.”

This new AMA plan and strategy are merely a continuation of the organizations trend over the last 50 years, which clearly runs contrary to the traditional Code of Medical Ethics. So, it comes as no surprise that the next step will be to make the needed alterations to that pesky code. The Speaker of the House, Dr. Andrew Gurman, spoke to this issue shortly after Dr. Lazarus. He told the delegates that over the next few sessions there was much work to be done on a number of important issues. At the top of the list was the need to “revise” the AMA’s Code of Medical Ethics to be more relevant given the changing healthcare environment. The objective seems obvious. The ethics of Hippocrates simply won’t allow physicians to participate in such things as Accountable Care Organizations, pay-for-performance initiatives, gain sharing, resource stewardship, cost versus value, end of life care and other similar euphemisms, each of which translate into rationed care orchestrated by the physician.

The “brave new world of healthcare” has become one in which payers exert more and more pressure on physicians to manage costs, and professional organizations abandon their core principles for political expediency. Not surprisingly, many physicians are overwhelmed by this changing environment and feel compelled to seek the safety of employment by a hospital or large integrated system. But when they do, their commitment to individual patients becomes subordinate to the rules of their employer, and their profession with its defining code of ethics is lost forever in favor of job security.

Robert Sewell is a surgeon who blogs at The Spirit of Healthcare.

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  • Steven Reznick

    Well written and appropriate. Gave up my AMA membership years ago.Will probably give up my ACP membership because it has been kidnapped by those physicians beholden to insurance companies and employers rather than being an advocate for the patients.

  • Dike Drummond MD

    Thanks for the article Dr. Sewell – and for being an AMA delegate for four years.

    Fortunately, the issue of the personal relationship between the doctor and their patient in an era where we are focusing more on the “collective good” is relatively straightforward. The Hippocratic oath is NOT between me and a hospital, health insurance company, the government or any other person writing my check. That oath is between me and the patient.

    Just like in the last wave of managed care in the 1990′s – one of the roles doctors will need to take on now is that of patient advocate when “the system” denies appropriate care. And let’s not throw the baby out with the bath water here with statements like, “The ethics of Hippocrates simply won’t allow physicians to participate in such things as Accountable Care Organizations”. Hold on just a second.

    The fee for service payment model was riddled with conflicts of interest resulting in too much inappropriate care and you know it. AND ACO’s and other structures that force healthcare to look for better ways of providing care are already producing significant advances that would not have occurred without being at risk for cost overruns. Here is an example:

    The recent proliferation of programs to follow up by phone or home visit in the post hospital discharge period. These initiatives are showing huge improvements in care quality, patient satisfaction, lower readmission rates and (hold your breath now) cost savings. When you look at these programs it becomes clear that in the good old days we were discharging patients and just hoping they would survive to their follow up visit.

    I don’t believe doctors – even when they become employees – become sheep and begin to subordinate what is good for the patient with the financial goals of the organization they work for. Do you? And if so … what do you propose as a solution here? ACO’s and at risk contracting are not going away and there are 40 Million “new” patients on the way.

    I don’t believe this is black and white – continue to be a good doctor vs. sell your soul to the bean counting devil – there is plenty of grey here and plenty of room for Hippocrates.

    My two cents,

    Dike Drummond MD

    • Margalit Gur-Arie

      I’m not sure I agree, Dr. D. The “plenty of grey” seems to me to be a huge problem when something ought to be all white. And it becomes very difficult to ascertain when something is too grey for comfort.

      It is difficult for a person to advocate against those who can take away their livelihood with a moment notice. So initially, you compromise on one harmless, or even beneficial, little thing, then another, and another, until compromise becomes a modus operandi, and the grey is now rather dark.

      I think the historical ethics are at odds with the notion of actuarial-centered practice (ACOs and risk assumption) and national agendas and all that rhetoric that obscures the simplicity of who your first and foremost allegiance should be to. And once this distinction becomes greyish, the part about enjoying life and being respected by all men, will also dissipate into grey thin air.

  • Robert Luedecke

    I respect Dr. Sewell’s opinion, but I strongly disagree with it. Is his real
    concern abandoning the patient-physician relationship or that the AMA is
    drawing negative attention to the common practice of charging as much
    we can and the rest is not my problem? Possibly his real objection is
    the AMA recognizing that economic resources are limited and must be
    managed in an efficient fashion so there is money left to take care of
    the next patient.

    Over the last several decades there have
    been various ways we get paid for our services. Getting paid for our
    services is essential, not a grey area or a bad word. We may call the
    way we get paid by new names, but it is still just the way we get paid.
    There is a possible ethical problem with every way we get paid, not
    with just the new ways. The problem with “pure” fee for service is that
    we might perform more services just to get paid more. It is a reality
    in the US that our healthcare system is too expensive. Either we find
    ways to save money or someone will cut our payments. As an
    anesthesiologist, I would rather find ways to save money. The AMA is on
    the right track!


    This piece tells it like it is. In one of the hospitals to which I bring my patients, the employed physician (by the hospital) of my same specialty, advocates that we submit to pathology all specimens regardless of the need so the pathologists can make money. The same hospital system requires that we submit these specimens even though the literature shows it is not necessary. Why? Because they need the revenue to pay the employed pathologists and other physicians such as my “colleague.”

    Relationships in medical care have become exceedingly complex, and so our code of ethics must be made simpler. If a doctor is going to neglect the code of doing no harm and always place the interests of the patient first, that will not change with another, more inclusive, code.

  • Robert Sewell

    With all due respect to Dr. Lazarus, the quotes included in this article came directly from the transcript of his speech, which he sited above. I do not wish to enter into an ongoing cyber debate with him or anyone else over what the AMA’s policies are or their intent, I would simply point out that the vast majority of America’s physicians have left the ranks of the AMA because those policies and subsequent actions over the last several decades have not corresponded with their own philosophies.

    The purpose of this writing was to raise what is clearly a growing concern about the future of the medical profession. Another physician who is an AMA Delegate, and was at the same meeting, commented elsewhere that “…we Doctors should be at the helm of the ship, even though going through turbulent waters, to lead health care as the remaining representative on the patients side.” My response to her and to the AMA Leadership is to simply point out that every ship’s captain must be able to rely on his or her charts and compass. In this case the chart is our education, and the compass is our Code of Medical Ethics. I fear that tinkering with that compass threatens the safety of the voyagers, our patients.

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