Progressive commercialization of American medicine

by Lucas Restrepo, MD

There is only one fundamental problem with American medicine: its progressive commercialization.

Every other problem derives from it centrifugally. Medicine, wrote William Osler, is “a calling, not a business.” Patients are not clients, nor physicians businessmen. People do not spend over a decade studying medicine ―living years in poverty or overburdened with debt― merely hoping to get rich. While it is perfectly legitimate to expect a salary that enables a dignified living and financial stability, any medical student who dreams a life of luxury is misguided. Even doctors or nurses in private practice rarely consider their call a conduit to personal wealth. People become health care providers for many reasons that can’t be encompassed with a neat word; however, altruism can’t be absent from anybody’s list.

Yet we have a medical system that admits into the doctor’s office only those who have money.

This must change. America has a long and uncontested relationship with market forces that have made her prosperous. However, not all human endeavors should become the object of greed. When did our society become persuaded that helping someone in need must generate financial profit? Or that good things in life only come with a price? Can a society call itself fair when falling ill, something that is inextricably linked to our human condition, frequently means helplessness, discrimination or bankruptcy?

Meanwhile, a few individuals become rich beyond our imagination. According to a survey of the American Medical Group Association, family practice physicians received on average a salary of $190.182 in 2008, while CEOs of the main health insurance companies received $24.300.112 to $3.241.042. William McGuire, a physician and legendary ex-CEO of United Health, earned more than 1.13 billion dollars from 1994 to 2006 (1 out of every 700 dollars spent in health care). In other words, executives whose principal preoccupation is to ensure that a company is profitable to themselves and a body of anonymous share holders, receive a salary that would pay for an army of doctors and nurses, whose main concern is to provide health care to their patients. Admittedly, the Patient Protection and Affordable Care PPACA will furnish more clients to these companies, but at least now they will be treated as patients.

Doctors are entrusted with the health of society. The “Charter on Medical Professionalism,” drafted in 2002 by the American College of Physicians and other organizations, declares that “professionalism is the basis of medicine’s contract with society.” This “contract” is the articulation of something essential to medicine: physicians become what they are not only because of their individual capacity and sacrifice, but because society permits their education and practice in the first place. Any physician can express satisfaction or vainglory about his or her skill, but in the end, every doctor learns to suture a wound only because of the selflessness of a patient that understands that medical proficiency must start somewhere. The contract is sealed with the studious efforts of one and the pain and patience of the other. Consequently, all physicians have a social obligation, requiring that the interests of patients are upheld above those of other individuals, including physicians themselves, setting professional standards of integrity, and “providing expert advice to society on matters of health.”

The fundamental principles of the Charter advocate the primacy of patient welfare, that altruism is the catalyst of the physician–patient relationship, and that “market forces, societal pressures, and administrative exigencies must not compromise this principle.” Physicians also must empower patients to make informed health decisions, acknowledging their autonomy. Finally, the charter advocates social justice: Physicians must “promote justice in the health care system, including the fair distribution of health care resources,” working “to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.”

Needless to say, some disagree with these elegant principles, alleging they are “too nebulous.” No. There is nothing airy, ambiguous or utopian about them. Tendencies vulgarizing medicine to the level of the market place motto, greed is good, should be discouraged with vigorous investment in non-profit health care providers, public or private. If health care is deemed a right of every citizen (or more aptly, of every human being), it naturally follows that a legitimate government should protect fully the rights of its citizens and guests (invited and uninvited). “Medicare for all” is the logical and just solution to the argument, but this has not become law. Instead, we have the PPACA, which is a reasonable step forward.

Physicians need to defend such progress. To my silent colleagues, I propose studying, writing to elected representatives, fomenting debate, and healing the wounds inflicted by ignorance and cynicism. To those demagogues still slandering PPACA with Orwellian fantasies, I suggest that our anatomy endows us with two ears and one mouth; hence, we must listen twice as much as we speak.

Lucas Restrepo is a neurologist who blogs at Progress Notes.

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