A recent trend in medicine involves individual physicians becoming members of some larger entity – a group practice either single specialty or multi-specialty, some form of managed care practice, or a hospital/clinic. This poses a potential conflict of interest with regard to patient care. Will care be directed and decided upon by the physician/patient relationship or will some larger entity direct care through financial incentives not based on evidence based research? Will pressure be brought to bear on the physician to function at the lowest possible cost based on some arbitrary valuation of the cost of a particular patient's life? Do value judgments have a place in making therapeutic decisions?
The Edwin Smith Papyrus and Ebers Papyrus (1600 to 1500 B.C.) specified the duties of surgeons and general physicians at some length – perhaps the first primitive effort at evidence based medicine and quality control. The code of Hammurabi (2123 B.C.) likewise delineated the appropriate practice of medicine. Hippocrates (some say the father of the profession of medicine) specified a code of ethics for treating physicians that in some modified form is still used today.
Currently the American Medical Association (AMA) states, “A physician has a duty, to do all that he or she can for the benefit of the individual patient.” The AMA feels that policies for allocating limited resources may adversely affect the ability of physicians to care for their patients. Any efforts at limiting or “rationing” healthcare resources must be made in a transparent fashion utilizing ethically appropriate criteria. Great care must be exerted in making quality of life decisions or decisions that result in loss of life or poor outcome. Specifically, non-medical criteria such as ability to pay or insurance coverage, age, social status, difficulties with providing treatment, patient's contributions to illness, or past use of resources are not to be considered in making such decisions.
Where is all this leading? Physicians must accept that they are their patient's advocates and should not make allocation decisions for their patients. This would obviate potential conflicts of interest with regard to physician's reimbursement, especially those in large groups. If the Accountable Care Organization is to be a viable concept it is critical that physicians respect that their primary responsibility is to the individual patient. Hopefully, this can be accomplished without further legislation, and it should not be necessary to legislate physician ethics.