Social Justice and Medical Ethics

The AMA is actively working in conjunction with Association of American Medical Colleges to inculcate young physicians with the ethics of "social justice."

Since 2005, the "Initiative to Transform Medical Education" has been working to correct what it views as deficiencies in the current training of physicians. These include an over-emphasis on the ability to acquire knowledge and problem solve-- to the detriment of "caring." Traditionally, physicians have expected to be autonomous decision-makers--but according to the Initiative this clashes with "increasing requirements...to be more accountable to various constituencies, including...the public, payers and government." Although physicians are recognized as "prepared to do what they believe is best for individual patients... [t]hey are not...prepared to participate in ethical and political discussions about the allocation of health care resources, which are not limitless." The solution proposed for allocating finite resources is John Rawls' principle of social or "distributive" justice.

"Social justice" is a euphemism for economic egalitarianism--and since people do not naturally come by equal wealth, "social justice" requires taking from some to give to others. "Social justice" is thus in direct conflict with the principles of equality before the law and the individual right to private property. "Social justice" also requires that a physician NOT advise his patients solely based on what is in the patients own best interest. He must instead somehow "balance" the patient's interests with those of the rest of society.

The concept of "social justice" has now been incorporated into several official statements of medical ethics. The Physician's Charter of the American College of Physicians now states:

[C]onsiderations of justice must inform the physician's role as citizen and clinical decisions about resource allocation. The principle of distributive justice requires that we seek to equitably distribute the life-enhancing opportunities afforded by health care. How to accomplish this distribution is the focus of intense debate. More than ever, concerns about justice challenge the traditional role of physician as patient advocate.

The Council of Medical Specialty Societies ethics statement includes the following:

The ethic of medicine must seek to balance the physicians' responsibility to each patient and the professional, collective obligation to all who need medical care.

Not only is this new ethic altering the curricula of medical schools to emphasize "social justice," but admission requirements will also be changed--deemphasizing a background in the sciences and MCAT scores. It is hoped that the selection of more "altruistic" and less competitively driven applicants will result in a larger number of residents opting for a less prestigious and less remunerative career in primary care.

This shift away from academic excellence and autonomy in the doctor-patient relationship toward serving the needs of society follows directly from centuries of medical ethics disavowing the legitimacy of physician self-interest. This error is compounded by a claim of moral superiority because "medicine is a profession not a business."

The distancing of medicine from business has done both a disservice. In claiming to be primarily an altruistic service, physicians have essentially invited the government to enforce this ideal while simultaneously denigrating the honorable occupations of production and trade. In failing to understand and defend the morality of profits, and the harmony of self-interest which characterize voluntary economic transactions, doctors have aided the enemies of freedom and capitalism-- who are now designing medical school curricula and admission requirements.

Capitalism is nothing more than the individual rights of life, liberty and property as applied to trade. Profits, in medicine as in any economic transaction, are not gained by exploiting patients or customers. Profits are simply the proper reward for successfully offering a value to others which is worth more to them than it costs to produce. In a system of free trade, self-interests are not in conflict--not even between a physician and a patient. In a direct-pay, fee-for-service relationship, it is in the best long term interest of the physician to offer advice and treatment based on the patient's best interest. And, it is in the best long term interest of the patient to only deal with a physician who does!

We can not defend patients' freedom without also defending the freedom of physicians. We can not protect the doctor-patient relationship without protecting the autonomy of both. Freedom of association and freedom to contract are interrelated principles fundamental to a free republic, to capitalism and to the ethical practice of medicine. "Social justice" requires that the individual be sacrificed to the collective. Such an act is as immoral in medicine as it is anywhere else.

"Social justice" claims to be what it isn't-- because true justice will never involve the violation of individual rights. The only way to assure justice and an ethical doctor-patient relationship is through the consistent, proud, principled defense of individual rights. The only way to assure justice and an ethical doctor-patient relationship is through the consistent, proud, principled defense of individual rights. In economics, that means capitalism. In medicine, that means the freedom of choice, not government mandates, for both doctors and patients.

Update 5-21-10 Two other articles on the training of physician to advocate for "health care reform"--by which is meant greater government control.

"Train physicians to participate in health care reform" by Sachiin Jain, Jordan Bolman in Skin & Allergy News, July 2010

"A Plea to Medical Students" by Joseph M Scherzer

ACOs Threaten Quality Medical Care

The PPACA is "nudging" doctors out of independent practice and into working as employees of large practice groups or hospitals. This move is occurring because of the bundled payment structure of Accountable Care Organizations (ACOs) which favors "vertical integration" of doctors, hospitals and health plans.

The only problem is that bundled payments are simply capitation rewritten, and employee physicians face divided loyalties between the needs of their employers and the desires/needs of their patients.

This arrangement is especially insidious when coupled with the ethics of "social justice" which gives a physician the moral OK to sacrifice his patients to the "greater good" of society. What is good medicine for the masses is often at direct odds with what is good for the individual patient--and thus, quality medical care suffers.

Resources:

For more on the PPACA effects on private practices see "Killing Marcus Welby: How ObamaCare stifles private practices" by Scott Gottlieb, MD, NY Post 10/18/100

For more on problems with the underlying assumptions for ACO's see "On Being Politically Incorrect and Realistically Correct about ACOs" by Richard Reece, MD at Medinnovation, 10/7/10

For more on the destructive effects of the concept of "Social Justice" on the availability of quality medical care, see Dr. Rich Fogoros at The Covert Rationing Blog.(multiple posts)

See also:'"Deconstructing ACOs" by John Goodman at John Goodman's Health Policy Blog, 8/18/10

When is rationing not rationing?

When is rationing not rationing, a mandate not a mandate and price-fixing not price fixing?

When the government says so.

Supporters of the PPACA react to opponent’s charges of rationing by claiming that the Independent Payment Advisory Board (IPAB) can't ration because the law says it can't. 

"The proposal shall not include any recommendation to ration health care, raise revenues or Medicare beneficiary premiums under section 1818, 1818A, or 1839, increase Medicare beneficiary costsharing (including deductibles, coinsurance, and copayments), or otherwise restrict benefits or modify eligibility criteria. [Emphasis added] Pub. L. 111-148, § 3403"

But when the government takes your money to fund a program (e.g. Social Security and Medicare) and then in any way limits your access to the benefits of that program, that's rationing. Since the law prohibits restricting benefit restriction and increased cost sharing by patients, the only effective way left for the IPAB to achieve mandated spending decreases is to lower payments to doctors and hospitals. But if you end up with less access to doctors and medical care because the government pays them less, that’s rationing. No matter how much you try to deny it, or what you call it instead of rationing: a rose is a rose...and government controlled health care is rationing.

The same people who say the IPAB cannot and will not ration will tell you that markets ration through prices. This is a complete misrepresentation of the role of prices in a free market. Free market prices are a signal. They provide information. Prices do not ration any more than a bathroom scale makes you fat or thin. Free market prices give you information about the relative scarcity of resources and then allowyouto decide how to allocate your own private resources. Free market prices are a reflection of what individuals voluntarily pay. Government rationing is an act of force. It's a fundamentally different kind of interaction when the government determines for you how your resources are to be allocated--whether the government expropriates them first, as in the case of Medicare, or simply mandates how you must spend them, as in the case of the individual mandate to purchase health insurance.

While we are talking about mandates—in the legal challenges to the PPACA, the government is currently arguing before the courts that the “requirement to maintain minimal essential coverage” is not a mandate to buy coverage. The government’s top lawyer, Solicitor General Neal Katyal, argued in court:

Congress is not regulating the failure to buy something, but the failure to secure financing.

The New York Times reports:

Mr. Katyal…argued that the law’s insurance mandate, which takes effect in 2014, does not so much require individuals to buy coverage as it does regulate the way they pay for health care they will inevitably consume. 

This is a distinction without a difference. Lawyers are good at word games, but if you look at the actual real life effect of the law, it is a mandate which offers you no real choice: you can either obtain a government-defined product or you can break the law and pay a penalty.

In language similar to the restrictions placed on the IPAB, the new heath care control law also forbids the use of quality-adjusted-life-years (QALYs) “as a threshold to establish what type of health care is cost-effective or recommended.” But thousands of cost-utility studies use QALYs to determine cost-effectiveness.  Realistically, QALYs are the yardstick currently used to measure and compare outcomes to various medical treatments. It is hard to imagine how this ban could be any more meaningful than the ban on rationing discussed above.

Just over a year ago, The Christian Science Monitor reported:

[T]he Antitrust Division, [of the Dept. of Justice] joined by Idaho Attorney General Lawrence Wasden, forced a group of Boise orthopedists to accept price controls for worker’s compensation and HMO contracts as part of a settlement accusing the doctors of “price fixing”… [T]he Justice Department has unambiguously stated that refusal to accept government price controls is a form of illegal “price fixing”… The FTC has hinted at this when it’s said physicians must accept Medicare-based reimbursement schedules from insurance companies. But the DOJ has gone the final step and said, “Government prices are market prices.”

Through a simple decree, the government thinks it can turn prices set by voluntary exchange into price-fixing, and government-determined prices into market prices. Who are they trying to convince? Must be themselves because any one with a bit of common sense can see that changing the terminology can not change the reality.

Other equivocations by government officials and their defenders include denying that clinical guidelines accompanied by sanctions and rewards do not amount to promoting “cookbook medicine.” And that as long as you call it “evidence-based care,” you can ignore the fact that much of the “evidence” is controversial and that many of the guidelines are written or funded by those with vested interests in a particular outcome.

Lest you think that this verbal trickery is restricted to health care, you can find much of the same in the politicization of energy policy. Regarding the elimination of the incandescent light bulb, Penelope Green writes in the New York Times:

The [Energy Independence and Security Act of 2007] does not ban the use or manufacture of all incandescent bulbs, nor does it mandate the use of compact fluorescent ones. It simply requires that companies make some of their incandescent bulbs work a bit better, meeting a series of rolling deadlines between 2012 and 2014.

Yet, a short week later, again in the NYT, Andrew Rice informs us:

[O]ne day very soon, traditional incandescent bulbs won’t be available in stores anymore. They’re about to be effectively outlawed…Conservatives like Rush Limbaugh have denounced the “light-bulb ban” — actually, [it’s] a new set of federal efficiency regulations that the traditional incandescent can’t meet.

You see, a ban on light bulbs isn’t really a ban on light bulbs, because the law doesn’t call it a ban.

As Richard Ralston so aptly warns:

“When the clear meaning of words is replaced with government fiat in this way, all limits on arbitrary government power and its use of force are destroyed.”

Rationing, mandates, price-fixing, and bans are al terms with precise meanings in plain English. Shame on us if we are fooled by the deliberate distortion of these simple definitions. Stick and stones can break our bones, and words can actually hurt us --when they are used to obscure instead of clarify our understanding of reality.

(This post was published in Townhall.com in a shorter version here.)