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In the book Taking Sides authors Lisa Newton and Maureen Ford present in issue five the question Are business and medicine ethically incompatible. Professor of medicine, Arnold S. Relmans essay Analysis of What Market Values are Doing in Medicine is used to present a case for yes they are incompatible. Assistant Professor of business, Andrew C. Wicks essay Analysis of Albert Schweitzer or Ivan Boesky? Why We Should Reject the Dichotomy Between Medicine and Business is used to present a case for no they are not incompatible. I will analyze these two works, noting credibility, thesis statement, facts and opinions, problems and propaganda, and logical errors in each individually. The argument against incompatibility is very compelling; nonetheless, it fails to address the possibilities for misconduct that a medicine and business model posses. Without resolving these specific concerns, we must be cautious about buying into Mr. Wicks theory that they are not only compatible, but also similar.
Andrew C. Wicks, the author, is an assistant professor at the University of Washington School of Business. This work of his was originally published in the Journal of Business Ethics, volume 14 (1995). His profession and the respect afforded his work by the Journal of Business Ethics make him credible on the topic of ethics and business. He states early in the essay, that his approach to this subject is that of an ethicist trained to reflect on normative issues.
Andrew Wicks outlines the premise his essay is built on with this thesis statement, My underlying goal is to help reconceptualize how we think about both medicine and business, and in doing so, reshape how we approach the American healthcare crisis.
It is a well known fact that our healthcare needs reform through cutting costs, reducing waste, spurring innovation, recognizing scarcity, avoiding replication of services and expensive technologies, educating physicians to be more active gate-keepers of health services, increasing access and minimizing costs. After acknowledging the need for renovation and reform the author moves on to refute the oppositions rejection of the business model by correcting misinterpreted terms. We are accurately reminded, self interest is a concept different from selfishness and greed, and that the former is perfectly compatible with serving other moral ends while the latter is not.
Mr. Wicks does an effective job in convincing us to share his opinion that the way people view medical ethics should be tempered somewhat, along with peoples view of business ethos. He does this by pointing out that very few physicians are capable of the altruistic ethic imposed on them and very few businesspersons are selfish and greedy as some have implied. The truth about motives, regardless of profession, lies somewhere between the two extreme views, and it would be beneficial to the healthcare system and patients to recognize this reality. With this recognition we can begin to agree that combining ethics and self-interest is about rehabilitating our extreme views and adopt a new view or moral code that makes trust, respect for others, decency and fair play central concepts that can and should be applied to both medicine and business individually and cooperatively.
I want to say it is oversimplified which is true if you try to apply this moral code as the solution to the specific issues of conflict of interest. However, the real problem is that it only addresses an individual piece of the issue. The author is working from the side of business to develop a kinder view of business; he does not address any potential conflict of interest issues.
A double standard exists as Mr. Wicks points out that the oppositions concerns regarding the cost of the commercialization of medicine create an over simplistic picture, while his own essay is based on a single point that innately oversimplifies the medicine and business model issues. In addition, he has thrown a couple of meaningless statements into this work. Included in the meaningless statements is this one where he says the only difference between the medical model and the business model is that the medical model encourages over treatment whereas the business model encourages under treatment. This theory-based generalization is not supported by common knowledge or a single example. Later he makes the same error when he says that when treatments are being offered, they are also being denied, thus implying that there only a fixed number of any specific treatments available to the public. My guess is that he was intending to state that healthcare money is tight, too tight to give everyone every test and service.
Merks story was good to hear, though it offered nothing to disprove the oppositions argument. It was an empty category. The debate is not about whether or not businesses can make humane decisions, it is about who should make healthcare decisions or healthcare facility decisions, doctors or business persons; and can physicians be objective clinicians when they have personally vested interests in healthcare facilities and research programs.
A Selective sample is considered when saying the physician benefits when patients are provided aggressive and excessive care. Though this may hold true for some specialties, it does not hold true for most primary care providers. Third party payers frequently give these physicians a flat fee based on the number patients they serve. This fee is the same regardless of the level of care or number of visits a patient receives. In addition, Mr. Wicks makes the procedural error of arguing in a circle; he does this by reaffirming the same argument throughout the essay.
Though Mr. Wicks notes that this new view of medicine and business is not a healthcare reform fix-all, he does imply that this modified mindset will fix a lot. However, the only points he makes an effort prove are the ones pertaining our views of medical ethics and business ethos. He shifts the burden of proof on all other claims made in this work.
The author, Arnold S. Relman is considered credible as he is both a physician and a professor of medicine. As a professor of medicine he is expected to maintain a keen knowledge of clinical healthcare and the business of practicing medicine. This essay was written in 1992. Recognizing that to some extent, this critical analysis of nine-year-old essay presents an unfair means of judgment and its own type of logical error, I will nonetheless move forward with the analysis.
Dr. Relmans thesis statement is as follows Physicians have enjoyed a privileged position in our society, virtually assuring them of a high social status and a good living. They have been accorded these privileges in the expectation that they will remain competent and trustworthy and will faithfully discharge the fiduciary responsibility to patients proclaimed in their ethical codes.
One fact noted in support of this incompatibility case is the declaration made by the American Medical Association in their Principles of Medical Ethics In the practice of medicine a physician should limit the source of his professional income to medical services actually rendered by him, or under his supervision, to his patients. Though not a law, this declaration, written in 1957, clearly exhibits the ethically belief among peers that physicians should not receive financial gain in the field of medicine beyond that received through their own patient care services. Dr. Relman also wanted the fact known that there is an absence of regulations and laws prohibiting physicians from becoming owners, investors and/or contract staff of healthcare facilities, services or allied healthcare businesses. This was of little concern many years ago, but has becomes a concern with technological advances, an increase in investor owned healthcare facilities, and pharmaceutical company inducements and contracts.
Dr. Relman begins his case for concern by prefacing it with the opinion that professionalism among self employed private practitioners thrives when there is more than enough to do. When there isnt, competition for patients and worry about income tend to undermine professional values and influence professional judgment. He then goes on to note that there is an excess of healthcare providers and facilities at this time. Having implied an open opportunity for misconduct, Dr. Relman goes on to state there is an abundance of proprietorship, investor, and contract opportunities available to these physicians. He plainly states his opinion that physician owned medical businesses create a conflict of interest that inhibit physicians ability to adhere to fiduciary relationships with their patients.
Mine is better is displayed in combination with resistance to change as the history of the Hippocratic oath, Maimonides prayer, the International Code of the World Medical Organization, American Medical Society guidelines, and the de facto contract with society are all offered up as supporting evidence for the case for incompatibility. In actuality, these sources display only two things, the historical and traditional ethic of medicine, and the adherence of that ethic by many peers and peer organizations. However, I do not believe the error of an illogical argument based on tradition is present since substantial cause for concern regarding the mix of medicine and business is noted throughout the essay. As a matter of fact, enough cause for concern is presented to cast doubt on presence of the mine is better and the resistance to change problems if it were not for the obvious either or thinking fallacy. This either or thinking is evident by the absence of any alternative solutions.
An unwarranted assumption was implied. It goes like this – without the medical ethic, many physicians motives could not be trusted, and many commercial vendors have no concern for anything beyond profitability. Though both implications may hold true for some, they by no means hold true for enough to warrant this implications.
Relevant information is omitted in the accusation that consumers are unaware of conflicts of interests when physicians under contract with pharmaceutical companies present information or perform relevant patient care services. Federal and local medical associations require full disclosure to patients and audiences, thus any physician failing to do this makes himself liable for a lawsuit.
The statement [i]f physicians are entrepreneurs and hospitals and healthcare facilities are businesses, then paying patients will get more care than they need and poor patients will get less displays the logical error of absolutism and is not believable as stated. First, third party payers keep physicians in check through pre-authorization requirements and/or tracking of individual referral practices. Second, the poorest among us get full healthcare coverage through Department of Health and Social Services or Medicaid. The most likely to get less is the uninsured patient.
An overgeneralization is made in combination with stereotyping when it is said [o]ur healthcare system is inadequate, inefficient, and too expensive. I have spent years participating and observing the labor, pains, and victories of hospital staff as they utilize Total Quality Management, Continuous Quality Improvement, Statistical Process Control and Health Tracks to maximize efficiencies and quality of care in our current healthcare market. Therefore, I know some facilities are providing quality care while maximizing material and human resources in addition to charging appropriate fees for services.
The burden of proof shifts in several areas. In particular it shifts in the over generalized statement that not-for-profit community hospitals are reluctant to provide free services to the needy as they increasingly see themselves as beleaguered businesses. While it is true these community hospitals are struggling, no evidence is provided to support this statement. My personal work experience has proven it to be not true in the case of Seattles Northwest Hospital. Im willing to bet Northwest is not unique among its peers in regard to charity care.
Hasty conclusions are made; some are due to concerns about commercial vendors and some are out of fear of deterioration of the fiduciary relationship society expects from their heath care providers. The overriding hasty conclusion is the one mentioned earlier; with the mine is better attitude the author assumes that there is nothing to be found in business that would be beneficial to the practice of medicine or patient care.
Mr. Wicks makes a very good argument for reconsidering how we frame medicine and business and how a combined moral code could be a more realistic and appropriate way to approach both fields individually and in combination. He asks us to put on this new mindset as we look for answers on how to provide effective solutions to issues through healthcare reform. He falls short in achieving his goal of reshaping how we approach healthcare reform.
Dr. Relman shows us physician peer organizations recommend that physicians not become owners in medical businesses beyond their own practices; however there is nothing in place to ensure physicians comply with this recommendation. Physician owned businesses; shares of businesses and contracts create potential conflicts of interests for patients, and compromise physicians abilities to maintain fiduciary relationships with patients. Though he fails to convince me that physicians are altruistic, he did convince me that careful thought should be given to the regulation of physicians business activities.
Neither author was able to refute the others argument because one is discussing apples, the other oranges. I agree with Mr. Wicks reality check on motives. Physicians and businesspersons are more alike than different, however he paints a picture that implies most of us are trustworthy, so all of us should be trusted. This argument is appealing but naive and foolish. Physicians have within their hands the lives of our parents, our spouses, our children, our best friends and our selves. The trust and power they hold calls them to a higher level of responsibility and caution. Opportunities for misconduct are plentiful, and measures should be taken to minimize them. Mr. Wicks concepts seem framed and tailored for the encapsulated health maintenance organization, but seem unsuitable for most of the issues discussed by the opposition, Dr. Relman.
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