Another Breach in Hippocratic Ethics: Shouldn’t Medicine Be More Than a Business?

Teaching about the “New Healthcare Paradigm” at the 2010 Summer Conference forced me to confront the “corporate transformation of medicine” in more detail than usual. In contrast to the “Hippocratic triangle,” connecting God at the apex to doctor and patient at the lower angles, this specific transformation has become both insidious and under-appreciated. It has taken any semblance of a covenant model away from doctor-patient interactions and negatively transformed them into contracts—wherein supply forces demand, but only for those who can pay. Let us look at some recent trends suggesting medicine has devolved professionally into a business.

Did you know that feeding tube placement in elderly demented persons does not prolong life, decrease infections or aspiration, and probably offers no advantages over hand feeding? Then why are more feeding tubes placed in this population at for-profit rather than not for-profit hospitals?[1] Consumer Reports rated spinal surgery as number one on the list of overused treatments.[2] Did you know that the fastest growing demographic receiving lumbar spinal surgery is elderly persons with lumbar stenosis? There are three types of surgery for this population. The most complex surgery has increased 15-fold from 2000-2007, correlating with a higher rate of complications, deaths, and rehospitalizations.[3] The complex surgery costs $89,888, the simplest $23,724.[4] Yes, physician reimbursement increases similarly as well.[5] The editorialist was taken aback. Here are excerpts of what he said in response to the trends for spinal surgery, “Newer and more complex technologies are being used for patients with little specific indication … as currently configured, financial incentives… (are) a formidable economic and social problem.”[6] Did you know that some physicians prescribe medicines based on marketing stimuli rather than scientific proof of efficacy and safety? Ezetimibe, a cholesterol-lowering drug, may be a case in point.[7] Costs for prescriptions increase, and if anything else, evidence-based treatment is compromised and pharmaceutical suppliers make profits. These are just a few examples, a veritable “tip of the iceberg” (percutaneous coronary dilatation for stable coronary disease is another). What about a more pervasive context for these behaviors?

For-profit hospitals are 3 to 11% more costly than not for-profits.[8] Not for-profits that convert to for-profit curtail the volume of uncompensated or charity care after conversion. During the 2001 recession, pharmaceutical companies increased profits (33%) while Fortune 500 companies experienced a decline (53%).[9] More than 80% of managed mental health firms are for-profit. As a group they limit care based on payment. Eighty-five percent of dialysis centers in the U.S. are for-profit. Their death rates are 30% higher with 26% less referrals for transplant.[10] Why are less people referred for transplant? If they undergo a successful transplant, they no longer require dialysis and that dialysis center loses reimbursement for their treatment. Again there are many more examples attesting to a pervasive corporate transformation (nursing homes fit the paradigm as well).

Is this merely a business discussion or does it have serious ethical ramifications as well? Appropriately, the evangelical healthcare community has stood their ground in the pro-life arenas of abortion, euthanasia, and stem cells. Where is their voice regarding the corporate transformation of their profession? No wonder unbelievers’ criticism of conscience clauses includes “conscience without consequence.”[11] Any mitigation in the corporate transformation will have a consequence for evangelical healthcare providers—it will be financial. But can our witness in the pro-life realm be authentic, if unlike the gospel, we do not penetrate every unjust practice associated with our profession? The individuals who alleged that Christian physicians exercising their pro-life conscience avoid consequences of their choices, also identified less enthusiasm from this group in providing charity care. Is this a just criticism?

Recently, I attended a welcome for incoming Christian medical students. A urologist was recounting his many overseas mission trips. At our charity hospital, there is not one community urologist who will see our uninsured patients. Although both a pro-life conscience and missionary zeal are laudable, there is more to being a healer than those two activities. In a historical survey of early Christian medical practice, Gary Ferngren observes, “With the exception of issues like abortion, exposure and assisted suicide, the medical ethics of Christian physicians are not likely to have been defined very differently than were those of their pagan colleagues, except perhaps for a greater willingness to help the poor.”[12] The progression of discipleship in Scripture went from Judaea (home base) to Samaria (close by) to the “ends of the earth.” Charity for physicians should begin at home (depending upon which source there are approximately 50 million uninsured) and progress outward to the mission field. Local charity for physicians has been a historical constant, just as the missions’ field has. There will be less time to see insured patients and a financial consequence as well.

The corporate transformation of our sacred profession is a serious threat to human dignity. The evangelical healthcare community has to expand the horizons of its witness and respond explicitly. Dietrich Bonhoeffer observed that we are called “to stand with those who suffer” and “speak out for those who cannot speak.”[13] A paradigm shift in medicine as merely business is a golden opportunity to tell unbelievers that Christian conscience welcomes consequences, even the negative ones.

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References

[1] Joan M. Teno, et al., “Hospital Characteristics Associated With Feeding Tube Placement in Nursing Home Residents With Advanced Cognitive Impairment,” The Journal of the American Medical Association 303, no. 6 (February 10, 2010): 544-550.

[2] “Ten Overused Tests and Treatments” Consumer Reports November 2007 http://www.consumerreports.org/health/doctors-hospitals/medical- ripoffs/10-overused-tests-and-treatments/medical-ripoffs-ten-over_1. htm (accessed February 21, 2011).

[3] Richard A. Deyo, et al., “Trends, Major Medical Complications, and Charges Associated With Surgery for Lumbar Spinal Stenosis in Older Adults,” The Journal of the American Medical Association 303, no. 13 (April 7, 2010): 1259; Eugene J. Carragee, “The Increasing Morbidity of Elective Spinal Stenosis Surgery,” The Journal of the American Medical Association 303, no. 13 (April 7, 2010): 1309.

[4] Deyo, et al., 1263.

[5] Carragee, 1310.

[6] Ibid.

[7] Cynthia A. Jackevicius, Jack V. Tu, Joseph S. Ross, Dennis T. Ko, and Harlan M. Krumholz, “Use of Ezetimibe in the United States and Canada,” The New England Journal of Medicine 358, no. 17 (April 24, 2008): 1820.

[8] John P. Geyman, “The Corporate Transformation of Medicine and Its Impact on Costs and Access to Care,” Journal of the American Board of Family Medicine 16, no. 5 (September 1, 2003): 444.

[9] Ibid., 446.

[10] Ibid, 449.

[11] R. Alta Charo, “The Celestial Fire of Conscience – Refusing to Deliver Medical Care,” The New England Journal of Medicine 352, no. 24 (June 16, 2005): 2471.

[12] Gary B. Ferngren, Medicine and Health Care in Early Christianity (Baltimore: The Johns Hopkins University Press, 2009), 107.

[13] Eric Metaxas, Bonhoeffer: Pastor, Martyr, Prophet, Spy (Nashville: Thomas Nelson, 2010), 128, 247.