Health Care Reform and the Future of Physician Ethics

Health care reform proposals threaten to exacerbate tensions physicians already face in trying to balance traditional duties to individual patients against increasing pressure to serve broader societal and institutional goals. To cope with reform, medical ethics must clarify physicians' moral obligations, change existing ethical codes, and develop an ethics of institutions. Current proposals for health care reform pose fundamental challenges to the role and ethics of the treating physician. Indeed, they heighten ethical concerns already with us thanks to large disparities in health care coverage, the rise of managed care, and the proliferation of organizations powerfully affecting patient treatment. Physicians are already troubled by the conflict between traditional obligations to serve the patient and claimed duties to serve the broader society by conserving the health care dollar and the health care organization by implementing benefits limits. Reform proposals exacerbate these unresolved tensions by imposing further obligations on physicians without clarifying their proper role. Yet the reform proposals largely ignore this issue. The Clinton administration's proposal is the most detailed of the group but is no exception. Nowhere does the administration's "Blueprint"[1] or subsequent bill (Health Security Act)[2] clarify the role of physicians envisioned in the plan, even though voters may care a great deal about the question. Nor does the administration acknowledge the challenge to physician ethics and suggest how that should be addressed. The "Blueprint" is strong in presenting values and principles, such as universal access and comprehensive benefits, to undergird the plan's system-wide reform. Yet none of these speaks to the role and ethics of the physician at the bedside. It is as if the physician treating the actual patient were somehow outside the system.[3] Despite then candidate Clinton's acknowledgment of the importance of the patient-physician relationship[4] and various authors' urging that reform must attend to that relationship and the governing ethics,[5] we hear nothing. This silence on the physician's role and ethics threatens to deprive the country of a necessary debate on the future place of physicians in a reformed health care system. It also creates great uncertainty about how competing proposals, including die Clinton plan, will work. Resolving the future of physicians' role will be as important as anything in the Clinton proposal or the congressional alternatives. This article is not a brief in favor of or against a particular proposal. It is an argument that each proposal should be explicit about the role envisioned for physicians, and that the U.S. Congress should consider how those roles are defined in comparing alternatives. Equally, the reform of the U.S. health care system requires a mechanism for articulating an adequate and acceptable physician ethics. What we currently have is ethical debate and conflicting suggestions. To cope with reform, some currently accepted tenets of medical ethics will have to be clarified, others changed, and the whole supplemented. There are several major alternatives to the Clinton plan in Congress.[6] Although they differ in significant respects - including universality of coverage, the place of single-payer plans, and the role of employers - each raises in some form the questions about physicians' role and ethics posed by the administration's proposal.[7] These proposals for reform create an urgent need to come to grips with the issues under debate in the ethics literature, while allowing analysis of how abstract recommendations in that literature might work under different plans. Focusing here on the Clinton proposal demonstrates both the urgency and the analytic opportunity. Briefly, the Clinton proposal provides that each state will submit a plan for approval to the National Health Board. That seven-person board can approve a range of plans, including a plan for single-payer health care within a given state. …