ObamaCare vs. the Hippocratic Oath
President Obama's health care "reform" plan has been criticized for being economically unsustainable, politically unpopular, and constitutionally suspect. But for many practicing physicians like myself, his plan contains an even greater but seldom-discussed flaw that overshadows those others. ObamaCare would fatally compromise doctors' ability to uphold their Hippocratic Oath to treat their patients according to their best judgment and ability.
Whenever the government attempts to guarantee "universal health care," it must also control that service, if only to control costs. Hence, it will inevitably seek to control how doctors practice. Accordingly, the White House Council of Economic Advisors has recommended controlling costs through "performance measures that all providers would adopt." Physicians who strayed too far from government "comparative effectiveness" practice guidelines would be punished as "high end outliers."
This will place your doctor's medical conscience directly on a collision course with government bureaucrats.
If you developed severe abdominal pain due to gallstones, who should decide whether medication or surgery would be the best treatment for you? The doctor who felt your abdomen, saw your ultrasound, and knows your drug allergies? Or a bureaucrat who has never met you, never went to medical school, and is quoting "comparative effectiveness" guidelines from a book?
Yet if that bureaucrat decides that your doctor is performing more surgeries than government guidelines allowed, then your doctor could face punishment — even if surgery would be the best choice for you as an individual patient. Your doctor would be forced to choose between following his conscience and treating you to the best of his ability — or following a bureaucrat's decree. In essence, he would be punished for upholding his Hippocratic Oath and rewarded for violating it.
Such ethical dilemmas have already arisen for doctors practicing in other countries with government-run "universal health care," such as Great Britain and Canada.
In 2008, a scandal erupted in Great Britain when the public learned that the government-run National Health Service had paid bonuses to family physicians who reduced the number of patients they referred to specialists. According to the Telegraph, "A leading surgeon said that patients' cancers had already gone undiagnosed after they were denied specialist care under two such 'referral management' schemes."
If you physician feels a suspicious lump in your abdomen during a routine physical exam, do you want him to hesitate -- or even worse, ignore it -- for fear of losing his bonus because he referred too many patients to an oncologist?
Similarly, nearly one in four British oncologists admitted to deliberately withholding information from their patients about treatments widely available in other European countries, but not allowed under the NHS system due to cost. These oncologists argued that "there was 'no point' in discussing treatments their patients could not have" and that such a discussions might "distress, upset or confuse" their patients.
But patients rely on their physicians for information about treatment options -- including an honest appraisal of all the risks, benefits, and alternatives -- so they can make fully-informed decisions about their lives. Failure to disclose such information is a serious breach of a doctor's Hippocratic Oath.
Government-run medicine thus pitted doctors against their patients in an ethically perverse situation. Physicians, prohibited by the government from doing what they actually thought was best for their patients, had to decide whether they should conceal medically important information from their patients. Patients were placed in a position of not knowing if their doctors were being fully truthful with them. The result was rationing not only of medical care, but of medical information.
Canadian doctors have been placed in a similar ethical bind due to government control of scarce hospital beds and operating-room time through its infamous system of "waiting lists."
One Canadian doctor told documentary filmmaker Stuart Browning that if a surgeon was too persistent in requesting operating-room time for his patients, he could be disciplined as a "disruptive doctor" and have his already limited operating-room time reduced even further. In other words, the surgeon would be forced to choose between upholding his Hippocratic Oath to his patient and maintaining his capacity to practice medicine.
Similar problems are threatening to develop in the United States as well.
Ever since Massachusetts adopted its "universal coverage" plan in 2006, state health spending has skyrocketed. In response, a special state commission has proposed controlling costs by eliminating the standard fee-for-service system of medical reimbursement and instead requiring the government or private insurers to pay doctors and hospitals an annual fixed fee for the medical care of each patient. Proponents claim this would give providers an incentive to improve efficiency and eliminate unnecessary tests and treatments.
But in practice, this would create an incentive for physicians and hospitals to provide as little care as possible. Under the Massachusetts proposal, if your care costs less than your annual allotment, then the providers would keep the unused portion. If your care costs more, then the difference would come out of their pockets. Such a system thus pits your doctor’s interests against your own.
Suppose the state had already paid out 90 percent of your annual allotment. You then see your doctor for a severe headache. He examines you, peeks at the balance on your allotment, and says, “No need for an expensive MRI scan of your brain. Just take two Tylenol and call me in the morning.” Can you be sure that he is giving you his best medical advice?
Even if a doctor conscientiously attempts to practice in his patients' best interests, his decisions will inevitably be questioned by hospital administrators:
Does Mrs. Jones really need another ultrasound test? Can't you use a cheaper antibiotic for her infection? Isn't she stable enough to go home today, rather than spend another expensive night in the hospital? We've already burned through the money allotted to take care of her this year. Anything else we do for her puts us in the red.
Your doctor will thus be forced to constantly balance your interests against the demands of a government-beholden bureaucrat who might be deciding whether or not to renew his practice privileges.
Because the ObamaCare plan is closely modeled after the Massachusetts plan, the problems unfolding now in Massachusetts are a preview of what the rest of the country could soon expect under ObamaCare.
The great evil of "universal health care" is not that it allows a few bad doctors to cut a few medical corners. Instead, the evil is that it routinely punishes good doctors for their medical virtues and rewards them for their vices. Under ObamaCare, conscientious physicians will have to waste untold hours avoiding detection, arguing with bureaucrats, and defending their actions while their less conscientious colleagues will just follow orders, punch a clock, and go home.
Do we want a government-run medical system which forces doctors to choose between treating their patients in accordance with their best judgment or sacrificing their patients to keep their jobs?
Or do we want free-market reforms that will allow doctors to do what doctors are supposed to do -- namely, uphold their Hippocratic Oath to take care of their patients to the best of their judgment and ability?
Our elected officials are deciding that question right now. If you value your life, let them know what you think.
[This essay is adapted from a forthcoming article in the Spring 2010 issue of The Objective Standard entitled, "Government-Run Health Care Vs. The Hippocratic Oath."]
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