Physician Conceptions of Responsibility to Individual Patients and Distributive Justice in Health Care

This generally useful and thoughtful study has one unfortunate feature. The results tend to undermine the notion that there is a perceived ethical conflict between commitment to the well-being of the individual patient, and a concern for distributive justice and the health care needs of the entire society. But the authors, in their commentary, express some surprise at this result. It is as if they wish to keep alive a dichotomy that is best dispensed with.

Admittedly the dichotomy has an apparently distinguished pedigree, perhaps having been stated most baldly by Jerome Kassirer (Managing care—should we adopt a new ethic? N Engl J Med 1998; 339:397-98). But the view that there is a direct ethical conflict between fidelity to the interests of the (individual) patient, and trying to conserve scarce resources for the good of society as a whole, can only be perpetuated by adopting the perverse viewpoint that society is not made up of other patients.

The problem with the supply of flu vaccine in the U.S. in the fall of 2004 may serve as an example. Most of us in family medicine, I would assume, realize that receiving a flu shot is a benefit for the individual patient. Once we were told that there was a shortage of the vaccine, most of us took appropriate steps to discourage its use among our healthier patients, and to restrict its use to high-risk patients. Would it have made any sense to conclude from this that our ethical commitment to the well-being of our individual patients had suddenly taken a nose-dive? Rather, it would make more sense to imagine that we all realized that if we used up the vaccine supply on healthy individuals, and then some high- risk elderly went without the vaccine and became seriously ill during a subsequent epidemic, real, individual patients would suffer. Some of these sufferers might be “my own” patients, while others might be “somebody else’s” patients. But that supposed distinction would be ethically irrelevant. The fact would be that they suffered, and that I, as a physician, took action that played a causative role in bringing about their suffering.

It is therefore not all that surprising that the study revealed data showing that the survey respondents did not equate more commitment to the individual with less commitment to society. We would, it is true, like to know more than the mere lack of a statistical association. Ideally we would like to know the respondents’ reasons for making or not making such an ethical association. Our inability to discern this is, unfortunately, a weakness of the survey method of research.

The authors mention a further limitation to the study that I think deserves highlighting. To what extent can we extrapolate results from a 1996 survey to today’s environment? I would count 1997 as a watershed year for managed care in the US. That is the year that movie audiences reportedly cheered the screen when an actress spoke the line, “F****** HMO bastard pieces of s***!” (“As Good As It Gets”) To many commentators, US managed care got the message that its popularity had sunk to the level of pond scum, and in response, mostly has stopped managing care. One thing that has largely disappeared is the role of the primary physician as gatekeeper. It is therefore very probable that factors in the workplace that could have been perceived as pitting the managed care organization against optimal care for the individual (presuming that optimal care cost more, not less) were in evidence in 1996 but are much less so in 2005. This might well change the way a group of MCO physicians today might respond to such a survey.

Competing interests:   None declared