M.D.'s Focus Should Stay on Patients, Not Populations

The individual patient is number one.

That's what APA Speaker-elect Jeremy Lazarus, M.D., affirmed in an address last month at the Council of Medical Specialty Societies' conference titled "Contemporary Health Care and the Ethic of Medicine: What Is a Physician to Do?"

Rejecting the notion of "rationing at the bedside," Lazarus said it is up to the larger society--its political leaders and institutions--to make decisions about the rationing or allocation of scarce resources. Meanwhile, the physician must be the advocate at all times for the individual patient, he said.

"We should not be held principally responsible for allocating health care services," Lazarus said. "Our ethics should serve as an anchor to protect the health care of our patients, and we must constantly question the wisdom of moving to an ethic [of population health] when our current system is propelled by market forces and not by a society that has agreed to universal access and fairness in health care delivery.

"The trust and integrity of the medical profession rely on our willingness to question. . .these forces by entering into a dialogue with our patients, our health care payers, and our government about what an ethical health care system in our country should look like," Lazarus said.

Lazarus, a former chair of APA's Ethics Committee, acknowledged that physicians have been late in providing accountability for their treatment decisions. Yet he emphasized that in his view the new demand for outcomes has been motivated primarily "by market needs and not by [attempting to improve] the health care needs of the country."

He noted, moreover, that the effort to derive meaningful outcome data from a variety of treatment settings is in its infancy. Any attempt to allocate resources on the basis of the minimal data currently available cannot be valid, Lazarus said.

Lazarus echoed medical ethicist Edmund Pellegrino, M.D.,when he noted that it is becoming increasingly difficult for physicians to "maintain the moral high ground while surrounded by health care systems that are propelled primarily by market forces, which do not have the same ethical constraints, and where deals are constantly being made."

The increasingly entrepreneurial atmosphere exerts a "weakening effect on the physician's resolve to maintain professional standards while providing care that is both necessary and beneficial," Lazarus said.

Importantly, most patients simply do not understand that their medical care is being managed in the interests of conserving resources and still expect a physician to do everything possible for him or her, he said.

If a physician acquiesces in the rationing of care, he or she cannot help but be seen as a "double agent," Lazarus said.

No to Public Health Orientation

He refuted the notion put forward by Christine Cassel, M.D., that physicians should be charged with balancing the needs of a community against the needs of an individual patient.

"If the physician is constantly placed in the position of gauging benefits for one patient versus the whole population of patients--in conjunction with financial incentives to be more cost-effective--this is a recipe for the physician to slip into a pattern of behavior that may not be in the individual patient's best interest," he said.

"In my view, without a universal societal directive to allocate health care resources in a fair fashion, a competitive business approach will permeate health care services, eroding centuries of trust in the medical profession and resulting in undisclosed rationing and increased morbidity and mortality."

Suggested Guidelines

To reaffirm trust in the "integrity of medicine," Lazarus outlined the following rules to guide physicians in changing times: