The ethical basis for the physician-patient relationship: covenants or contracts?

Introduction Dr. David C. Thomasma's article is a thoughtful, provocative challenge to the traditional physician-patient relationship values. He describes the multiple and often conflicting roles that physicians find themselves in when trying to achieve the best they can for an individual patient while also stewarding resources to benefit a population of patients or maximizing the profitability of a health plan. The failure of America to implement universal healthcare for all of its citizens, leaving 41 million people uninsured and nearly that many underinsured, has created enormous barriers to the provision of care in a socially just manner. It is hard to imagine that physicians are motivated as much by the social justice issues in the allocation of healthcare resources as they are by reimbursement incentives because they cannot readily perceive how their decisions impact social policy on a macroeconomic level. We should not be naive in calling for new promises and ways to monitor promisekeeping that substitute legalism and contract language for professionalism in our efforts to protect patients from the ill effects of the corporatization and commoditization of medicine and health. A covenant relationship is still a superior foundation for the physician-patient relationship than promises made enforceable by contract or efforts to improve informed consent and better educate patients concerning their condition. The underlying principles of bioethics, as Dr. Thomasma points out, can be in conflict both in the "fee-for-service" model of healthcare reimbursement where physicians make more by doing more, necessary or not, and the new reimbursement strategy of managed care where doing less may actually lead to higher profits. In each of these reimbursement scenarios tension exists between what is absolute and what is relative, what is primary and what is secondary, and what is centered on the patient and what is centered on the provider or the health plan's bottom line. In any scenario, patients must not be a means to an end (typically profit), but the end itself. How that is best achieved would seem to be the question Dr. Thomasma and I are both asking. Hippocratic Oath as a Covenant: Timeless or a Time to Change? Edmund Pellegrino (1996/ highlights the fact that "thirty years ago, at the inception of the era of contemporary bioethics, the Hippocratic Oath and the moral precepts it embodies were the immutable bedrock of medical ethics." This covenant reaches across time and culture as well as national boundaries. There are many who feel that the Hippocratic Oath has become morally irrelevant because it is now inconsistent with contemporary mores. In an era where corporatization of medicine, along with forprofit motives, have become rampant, we may still best be served by the old-fashioned notion undergirding the foundation of the physicianpatient relationship. I agree with Dr. Thomasma that over the last three decades autonomy has become one of the primary values in bioethics, a change that occurred before the corporatization of medicine made significant inroads into the healthcare industry. Instead of behaving as neighbors, we instead moved away from the concept of community and its inherent strengths. Even the practice of insurance evolved during this time from shared risks to avoidance of risk. During this time, patients wanted more control and say in their care as doctors spent less time at the bedside and modem medical miracles were beginning to be seen, perhaps accurately, as half-technologies. As people recognized the limits of physicians, they demanded more information and more participation in decision making. Most of these changes actually improved physician-patient relationships, but not without occasional trials and significant stress between competing values. The foundation of the Hippocratic Oath indeed is one of beneficence first, followed by the admonition at least to do no harm-nonmaleficence. …