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The ethics of entrepreneurial medicine
Ethics
The Ethics of Entrepreneurial Medicine C Rollins Hanlon, MD, FACS
To present this lecture in place of Dr Francis D Moore is a great privilege. My sense of privilege calls to mind Dr Moore’s splendid autobiography, A Miracle and a Privilege.1 In that book he set out a fascinating account of his life in clinical surgery, research, teaching, and administration. Dr Moore developed at Harvard and its hospitals an uncommonly favorable climate for biologic investigation so that his own work and the work of many other investigators flourished. The results of that research facilitated a new era of surgical biology, noted by a cover story about Dr Moore in a national weekly news magazine. The thrust of the cover story indicated that surgical operations had already been made safe for the patient, and in this new, biologic phase of surgical science we were aiming to make the patient safe for the surgical operation. During the American College of Surgeons meeting in San Francisco 9 years ago, we heard the exciting news of the Nobel Prize award to Joseph E Murray, FACS, a member of Dr Moore’s department and another exemplar of the productive fusion of bench research, clinical investigation, and compassionate patient care, all subsumed under an individual ethic that puts the patient in first place. Now we have come to an era of overarching technology, juxtaposed with a phase of commercialization, consolidation, and merger mania in our daily lives, and mutatis mutandis in the field of medical care.
Underlying these radical changes is the bedrock of our moral foundation, which Dr John J Conley wisely and generously recognized by his support of this ethics and philosophy lectureship and by many other philanthropic endeavors related to ethics during more than half a century as a Fellow of this College. At the time of his recent death, Dr Conley was emeritus professor of otorhinolaryngology at Columbia Presbyterian in New York and a poet of substantial accomplishment. His books of poetry entitled Word Paintings underscore his emphasis on the liberal arts. He inspired a host of admirers by his generosity and his professional achievements. The title of Dr Moore’s projected lecture, “Ethics: From Percival to G.B.S.,” implies that many physicians are aware of Thomas Percival and his assignment by the trustees of the Manchester Infirmary in England to draw up guidelines for the conduct of the Infirmary’s physicians in the late 18th century. Percival admonished staff physicians to behave politely so as not to bring discredit on the medical profession by fighting over hospital privileges. The Infirmary’s services had been seriously strained by an overload of patients incident to an epidemic of what was probably typhoid fever, and hospital authorities increased the staff roster with practitioners whose capacities the established staff considered inferior in quality to their own. Percival was not writing originally about ethics in the present sense but rather about etiquette among physicians. The word ethics did not appear in his initial presentation, and a concern about patients was not a focus of his original stipulations. Early ethical pronouncements of the American Medical Association borrowed heavily and even explicitly from Percival’s early formulation, so that we had for many years a confusing mix of ethics and
Based on an Ethics and Philosophy Lecture delivered at the Clinical Congress of the American College of Surgeons in San Francisco, October 13, 1999. Received December 30, 1999; Accepted January 4, 2000. From the American College of Surgeons, Chicago, IL. Correspondence address: C Rollins Hanlon, MD, FACS, American College of Surgeons, 633 N Saint Clair St, Chicago, IL 60611. © 2000 by the American College of Surgeons Published by Elsevier Science Inc.
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etiquette. This was understandably perceived by sociological critics as the self-serving credo of an arrogant profession. I would hazard a guess that the G.B.S. in Dr Moore’s title, obviously a reference to George Bernard Shaw, recalled Shaw’s oft-quoted statement that all professions are conspiracies against the laity. I make no further attempt to divine the content of what would have been Dr Moore’s lecture. Rather, let me indicate briefly what I plan to say about “The Ethics of Entrepreneurial Medicine.” I intend to comment here about three things: first, entrepreneurial medicine as illustrated by managed care; second, the ethics and sociology of the outcomes movement; and finally, the sharp dilemma that faces our profession in attempting to regain our professional authority. What is entrepreneurial medicine? In today’s perception, the term suggests the takeover of a previously individualized profession by entrepreneurs who “undertake,” in the French sense of the word, to organize and convert the basic one-to-one relationship of doctor and patient into an enterprise covering hundreds or thousands of individuals. This is often known as population-based medicine. In the 19th and early 20th centuries, the solo practitioner might properly have been considered a kind of entrepreneur, setting up a medical practice in an environment only lightly touched by external regulation and establishing a physician-to-patient relationship dependent on mutual respect and trust. Toward the middle of the 20th century this picture of sturdy and somewhat romanticized medical individualism came under critical analysis by the sociologist descendants of August Comte and Max Weber. Prominent among these sociologists was Talcott Parsons,2 whose opinion of the vaunted professionalism of medical practitioners was largely favorable. In contrast to later observers such as Berlant3 and Bledstein,4 who emphasized the selfaggrandizing effects of professionalism, Parsons considered the high social status of medical practitioners beneficial to society. In Parsons’ view, society worked best when each individual unit was fully functional. The work of physicians in assuring or restoring full function to each patient was a socially desirable good for which practitioners should be rewarded. Because of the esoteric nature of the knowledge base in medicine,
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society was content to give the profession a selfregulating status that had high social and financial value for physicians, while it benefitted society as a whole. Other sociologists, such as Berlant,3 thought that medical professionalism connoted an occupation consistent with gentlemanly values; indeed, taking up a profession was one way of rising to the status of a gentleman from a lower level. And before the rise of medical specialization, society placed its trust in the individual practitioner because it did not seem feasible to exert control over such solitary units from outside the medical profession itself. The profession was expected to control deviant behavior as a condition of professional autonomy, using internally directed mechanisms such as registration and certification. By the middle of the 20th century, medicine had achieved the status of “a sovereign profession,” as chronicled in the first portion of Paul Starr’s influential book, The Social Transformation of American Medicine.5 Sociologists such as Eliot Freidson in his 1970 book, Professional Dominance: The Social Structure of Medical Care,6 maintained that the monopolistic status of the medical profession arose more out of self-interest than from a laudable concern for patient welfare. Even the favorable assessment of Talcott Parsons rested on a foundation of social utilitarianism, which recognized the conflict (that would later grow much sharper) between maximizing the number of individuals receiving medical benefits and creating maximal benefit for the individual patient. Parsons thought that socialization of the medical profession rested less on the physician’s compassion for a suffering patient than on concern for a dysfunctional individual unit in the social enterprise, a unit that should be restored if sick and protected from harm when well, in order for society to function efficiently. This is not dissimilar to the mission of the US Navy Medical Corps, which I recall being presented to me in World War II as “to keep as many men at as many guns, as many days as possible.” (Personal communication from Lt Cmdr Mark A Friend, MSC, USN, Bureau of Medicine and Surgery, US Navy, November 3, 1999. First enunciated by Capt James D Gatewood, MC, USN, in 1907.) Such a formulation is consistent with what is known today
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as population-based medicine; it resonates with Paul Ellwood’s brilliantly devised and psychologically attractive concept of the health maintenance organization, or HMO. The term HMO was the forerunner of a host of other acronyms such as MCO (managed care organization), which might with equal justice be taken to signify “managed cost organization.” Paul Starr, in his book, The Social Transformation of American Medicine,5 spoke to “the coming of the corporation” as an influence that slipped up on a medical profession so intently focused on governmental intrusion that corporatization, or the business model of medical care, was inside the gates of the medical citadel before many were aware of its relentless approach. Many medical practitioners view corporatization as a plague on the house of medicine, with an associated distaste for those who receive egregiously large sums for their roles in managing the corporate medical enterprise. Comments on the difference between profit and not-for-profit hospitals are often bitterly phrased. For example, Woolhandler and Himmelstein7 recently commented on this issue as follows: “In nonprofit settings, avarice vies with beneficence for the soul of medicine; investor ownership marks the triumph of greed.” This seems to go a bit far in equating the mere notion of making a profit with the pejorative term “greed,” especially when even a not-for-profit hospital is unable to carry out its mission unless it avoids bankruptcy by at least balancing its books. As for the general acceptability of corporatization in our capitalistic society, the Nobel laureate economist Milton Friedman in 1962 stated flatly, “Few trends could so thoroughly undermine the very foundations of our free society as the acceptance by corporate officials of a social responsibility other than to make as much money for their stockholders as possible.”8 The word stockholder has now been replaced by stakeholder, which used to signify one who held the money of two bettors, but has now been extended to encompass a variety of persons or entities with an interest in an enterprise. In a hospital organization, stakeholders run the gamut from the board of directors and president to the patients and those who care for their medical or material needs.
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In the not-for-profit hospital, the motivating force of the hospital community is assumed to be grounded in beneficence toward patients and toward the larger community. The mission of the forprofit hospital is spelled out in its descriptor: despite the undeniable benefits it may confer by its healing, teaching, research, and public health activities, its basic responsibility is to make money for the stockholders who have invested in it. In the words of Woolhandler and Himmelstein,7 “But our main objection to investor-owned care is not that it wastes taxpayers’ money, nor even that it causes modest decrements in quality. The most serious problem with such care is that it embodies a new value system that severs the communal roots and samaritan traditions of hospitals, makes doctors and nurses the instruments of investors, and views patients as commodities.” JT Li9 concisely stated the nature of this new value system: “In the commercial model of medicine the patient is at best a consumer; at worst, a revenue stream when well and a medical (financial) loss when sick.” An even more stark portrayal of patients in economic terms is provided by the economics professor Uwe E Reinhardt,10 who has spoken to the “securitization” of patients. He has noted that “patients can be viewed as biological structures that yield future net cash flows. Whoever can claim legal title to these net cash flows can securitize and sell them in the open market.” Those of us who continue to think of medical and surgical care in terms of individual encounters may be troubled by a medical care system that bundles groups of patients into insurance aggregates known as “covered lives.” These aggregated patients can be bought and sold in an open market as if they were shares of IBM or Microsoft. But such concerns may be muted in the profession by the rise of the outcomes movement, with its implicit promise that in numbers there is strength, and even perhaps clinical certainty. For those of us in clinical practice, and especially in surgery, where we are sometimes constrained to make rapid life and death choices based on incomplete data, the promise of rule-based behavior derived from probabilistic research could be a shining beacon. Such research, we are assured, provides aggregate data from which we can deduce a comfortably certain course of action. It is said that such rule-based be-
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havior can be a shield against our own trepidation and the looming threat of external regulation or litigation. The outcomes movement is driven by thirdparty payors and government regulators in a frank challenge to medical professionalism. Tannenbaum11 has noted the way in which the outcomes movement downgrades the importance of physician’s “clinical judgment” with her comment, The professions are distinguished in part by the possession of specialized knowledge, which renders them authoritative in their respective domains. According to the outcomes movement, however, a physician’s experience contributes little to, and may actually subvert, medical knowledge. The latter belongs to probabilism, and the profession no longer owns the knowledge it needs.
Although Tannenbaum challenges the validity of such a formulation, it represents a part of the general thesis that probabilistic research provides guidelines superior to the judgment of experienced clinicians. If one is inclined to contest such advocacy of a formulaic practice, it seems fair to say that probabilistic research results merely in probabilities, and many of us would prefer the seasoned judgment of a compassionate physician who can factor into the equation the patient’s personal characteristics that are not readily discernible in the aggregated data of the outcomes movement. Defense of personalized practice faces both the aggregated data of the outcomes movement and the corporatization of medical care. Linda Emanuel12 has addressed this issue in her editorial, “Bringing Market Medicine to Professional Account.” In contrast to denigrating the professionalism of physicians, she has suggested that professionalism and attention to medical ethics must be brought into the managed care enterprise to redirect its actions back to its essential purpose of providing better access to care. There must be some moderation of the profit motive. Emanuel has faulted the “widespread assumption in US society that the essence of professionalism is about self-regulation in exchange for expertise,” as Freidson maintained. “This view,” says Emanuel, “has obscured the truer and more helpful understanding that professionalism is primarily about the expert protection of vulnerable people
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and vulnerable values, in this case patients and the values of health care, respectively, and that selfregulation is nothing more than a necessary vehicle for maintaining experts’ standards.” Some of the medical profession’s loss of public respect stems from the notion that physicians have focused on self-interest rather than on their duty to patients. Pellegrino and Relman13 have noted that the ethical obligations of professional organizations have often been overwhelmed by socioeconomic or political considerations. In a concise analysis they outline how the threat to moral leadership by professional associations must be resisted if we are to avoid a deterioration into self-serving guilds or unions. The public perception that organized medicine no longer has the primacy of the patient as its dominant objective is a major cause of distrust directed at medical organizations and their individual members. Pellegrino and Relman have outlined a halfdozen guidelines that should govern national or state medical societies and specialty associations. These include a clearly stated mission that recognizes today’s hostile workplace but balances the economic concerns of its members against the obligation to retain public trust as a patient advocate. In their view “unions and truly professional associations are simply incompatible.”13 They have cited the conflicts of interest that may reside in organizationally sponsored journals and other information sources as well as in the commercial sponsorship of medical meetings. Their pertinent comments on issues of governance with attention to representative democracy and full disclosure of policies and actions are worthy of thoughtful review by all who carry the serious administrative responsibility of major medical bodies. Early in their essay they set out a rather gloomy historical appraisal. “The history of professional medical associations reflects a constant tension between self-interest and ethical ideals that has never been resolved.”13 There is one association well known to me in which a vigorous attempt to resolve that tension has been ongoing for 86 years. Each Fellow of the American College of Surgeons is formally charged in the Fellowship Pledge to adhere to College objectives, as stated in its Articles of Incorporation, “To maintain an association of surgeons, not for pecuniary profit, but for the benefit of hu-
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manity by advancing the science of surgery and the ethical and competent practice of its art.” Through its Central Judiciary Committee, the College has called numerous Fellows to judgment for ethical lapses, and many have been expelled, even in the face of highly expensive resistance by litigation. Such disciplinary actions by the College have commonly been unrecognized or forgotten by a public conditioned to equate the misdeeds of the few with the reputation of an entire profession. But, setting obvious malefactors aside, the medical profession as a whole has clearly lost its former position of high esteem in our society, and there are serious, continuing threats to its current, unstable status. We approach this deplorable situation with two questions: First, what can we do about it? and second, what should we do about it? The first question is operational, dealing with possibilities; the second is ethical, dealing with proprieties and with professionalism in its ideal sense of concern for the best interests of our patients. It is clear that managed care, the leading management tool of the moment, is encountering serious, justified criticism from patients and physicians. Despite this fall from favor, managed care is vigorously resisting legislative and other attempts to restrict its power. How can physicians and their patients level the playing field in their relations with managed care so as to enhance their power to bring about change? The most obvious answer is unionization, or its somewhat more acceptable cousin, collective bargaining. Resort to unionization by the medical profession has been regularly condemned. We have noted the dismissive comments of Pellegrino and Relman.13 What of collective bargaining without formal unionization? At their June 1999 meeting, the AMA House of Delegates “voted to develop an affiliated national labor organization to represent employed physicians and where allowed, residents.” The chair of the Board of Trustees, Randolph D Smoak Jr, MD, issued a press release on June 23, 1999 that stated, “This is not for all physicians. This will not be a traditional labor union. Your doctors will not strike or endanger patient care. We will follow the principles of medical ethics every step of the way.”14 Dr Smoak stated, “By forming an affiliated labor organization, eligible physicians will be able to fight for quality patient care while re-
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maining faithful to AMA’s historic and unwavering commitment to ethics and professionalism.” The matter was vigorously debated in the House of Delegates and the affirmative decision to form a national labor organization was far from unanimous. In a Chicago Tribune editorial,15 Dr Jordan Cohen, president of the Association of American Medical Colleges, wrote that as an AMA member he was deeply troubled by the action of the House of Delegates. “In authorizing the AMA to form ‘negotiating units’ for doctors, members of the House of Delegates have, wittingly or unwittingly, contributed their considerable weight to the already heavy burden of de-professionalization bearing down on medicine.” Cohen went on to say, Unions are marvelous tools for wielding economic power in the marketplace. They are not designed for consumer protection but for extracting benefits for their members. Whether true or not, I worry that economic advantage, not high-minded altruism, will be what most people will perceive as the motive behind this regrettable action. Why regrettable? Because doctors are sworn to serve their patients’ interest first, not to use their privileged status as a lever in the marketplace.
And as a recommendation for the profession, Cohen stated: “The proper course of action for doctors is to create an outcry, not a union.” Recall that Dr Smoak characterized this incipient body as “an affiliated labor organization” that “will not be a traditional labor union.” Despite such a caveat, many will consider this description a distinction without a difference, and will regard the fledgling AMA-affiliated group as a related union. The practical issue is how such a body will be viewed by a highly opinionated public, now informed electronically and in other ways to an unparalleled degree. This is not a matter to be solved by competing slogans, or by promises, however well intentioned, that will not convince an increasingly disillusioned public. Too many patients have ruefully concluded that organized medicine is more interested in its own good than it is in the welfare of the sick. What we need to restore on a broad scale is patient trust. The dilemma lies in our concern over loss of professionalism on one side, and the demon-
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strated reality of political ineffectiveness on the other. For a critically informative discussion of the issues surrounding the physician union movement, one cannot do better than to consult the splendid 1997 monograph When Doctors Join Unions by Grace Budrys, professor of sociology at DePaul University.16 Budrys traced the union story with special reference to the Union of American Physicians and Dentists (UAPD) launched in the San Francisco Bay area by Sanford Marcus, MD, in 1972. Unlike most other physician unions, the UAPD has persisted until the present time, by virtue of its shrewdly planned organization, the tireless work of its founders, and the no-nonsense analysis and rhetoric of Dr Marcus. Professor Budrys was given complete access to the records of UAPD so that she might fairly appraise its performance. She lists some of its considerable successes, especially in California, which has always been its major scene of action. In its early days the UAPD approached the AMA and organized labor for help, but was rebuffed in both places. The president of the AFL-CIO, George Meany, told Dr Marcus in 1973 to come back in 10 years, when most doctors would have become employees and then they would be able to talk. A number of physician unions are currently operating. In April 1999, the Doctors Council of New York, the Committee of Interns and Residents (CIR), and the United Physicians and Dentists merged to form the Doctors Alliance. In combination, it claims to include about 10,000 enrollees. The Federation of Physicians and Dentists of Tallahassee, which has been around since 1983, has grown significantly in recent years and now claims to have about 10,000 members across 25 states. This means that the UAPD, with approximately 5,000 members, is now the smallest of the three well-established physician unions. As of this year all three unions became affiliated with the AFL-CIO, meaning that they are all receiving organizing support. This gives the doctors an opportunity to make linkages with traditional unions, who are then using their leverage to gain concessions suggested by the doctors when they bargain over their respective contracts with their employers. (Cited from personal communication with Professor Grace Budrys, December 22, 1999.)
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The current debate within the AMA is not a new phenomenon. In 1941 an article by William Richardson in Medical Economics argued that the AMA should become a union to free it from the restraints of the Federal Trade Commission.17 Such suggestions were largely ignored until the concept was formally introduced as a resolution at the 1973 AMA convention. Although the House of Delegates rejected the proposal by Dr Stanley Peterson, president of the new Federation of Physicians and Dentists, the subject was clearly exposed in the professional and public domains. The 1973 president of the AMA was Russell Roth, a urologist from Erie, PA. I can recall his oft-repeated response to the collective bargaining initiative, “Anything the union can do, the AMA can do better.” It is important to note that Dr Marcus supported the AMA in its scientific, professional, and educational endeavors, but believed that a union arm of medicine was needed for specialized action in the socioeconomic area. After discussing the issue in 1973, the House of Delegates condemned physician unions. Since the 1973 condemnation by the House of Delegates, the AMA has undertaken a variety of initiatives to teach physicians how to bargain, including forming a Department of Negotiations. After this was discontinued, the American Medical News periodically provided information on negotiating techniques. The 1990s saw vigorous efforts by the AMA directed at legislative reform of antitrust laws to permit collective bargaining by physicians. For those doctors wishing to achieve the right to organize and bargain collectively, the most promising opportunity lies within the states, which could grant such rights in exchange for physician cooperation in cutting costs. Positive action has occurred in Texas and California, but national spread may be a slow process. A number of physician groups have drawn on the reservoir of negotiating skills possessed by the Union of American Physicians and Dentists to secure valuable advice in matters like hospital staff contracts and staff by-laws. This same advice has been made available by national medical organizations intermittently over the years. The recent entity established by the AMA as “Physicians for Responsible Negotiations” with the happy acronym of PRN is a result of the June 1999 action by the AMA House of Delegates. As of Sep-
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tember 1999, the initial five members of the PRN governing board had been appointed to a body expected to number between 9 and 12. A governing constitution has also been recommended by the AMA Board of Trustees. The future performance of this negotiating body will be watched with intense interest by the profession and the public. Its success will be determined by its capacity to regain the public’s trust in the AMA, which has been sorely shaken by a number of recent public relations disasters. I have recently filled out a questionnaire from my state medical society about collective bargaining. The questionnaire noted the essentiality of legally delinking the effort from the state medical society itself, and restricting participation to employed physicians in narrowly defined groups. One question concerns willingness to strike or withhold services as a collective bargaining strategy, with the issue framed in financial terms. One question asks whether one would join a collective bargaining organization and make use of its services if the bill were $500 a year. The next question asks if one would be willing to join at $350 a year. This raised, for me, an interesting question whether a physician’s ethical convictions can be quantitated between willingness to join at $350 a year and unwillingness at $500 a year. My own reaction was to oppose the formation of a collective bargaining unit by the state medical society irrespective of cost factors. The ethical issue turns on whether one considers such action right or wrong. Securing legislative correction of the problems in our managed care system is maddeningly slow and subject to legislative horse trading by which a patient’s right to sue an overbearing HMO could open the door to potentially abusive litigation that will inevitably raise the cost of care. Senator Bill Frist, FACS, (R TN), was quoted recently as viewing with strong concern an arrangement that has “doctors in bed with trial lawyers.” It is clear that “patient protection legislation” comes in a variety of sizes and shades. There seems to be an increasingly favorable climate for collective bargaining by physicians and a certain degree of growth in union membership, although the proportion of all physicians remains small. It is ironic that the social transformation of American medicine written about by Paul Starr has proceeded to empower managed care so strongly that physicians are
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now seeking relief by national legislation. In this rapidly evolving situation, one needs to look carefully at any quick fix that will bring on unintended consequences. An understandable fury at the arrogance of some HMOs should not lead us into regrettable short-term solutions. In these days when national decision making is too often directed by polls, focus groups, and Arbitron ratings, it is refreshing to look back to our surgical heroes (now called role models) to find inspiration and guidance out of the morass in which we are immersed. A knowledge of history and the other humanities may seem at first glance to be a thin reed on which to lean as we struggle forward. But from history and the other liberal arts we can gain wisdom that will keep us from establishing policy without principle, and will avoid actions rooted in emotion rather than cool discernment. Recently I have wondered whether today’s surgeons will be as entrepreneurially ingenious and as forthright and resolute in principle as our forebears, such as Dr Franklin H Martin and his colleagues. I am convinced that at least some surgeons are coming off the production line with the characteristics and capacity to deal honorably and effectively with the massive problems that confront us. These are the young surgeons on whom our future rests. When William P Longmire Jr was chairman of the Board of Regents of the American College of Surgeons 30 years ago, he established the Committee on Relations with Young Surgeons. J Englebert Dunphy, who succeeded him as chairman of the Board, was asked, “What is the objective of the Young Surgeons?” With characteristic quickness “Bert” replied, “To become old surgeons,” knowing full well that this seemingly flippant response contained a prediction of what the Young Surgeons Committee has now become—a vibrant, active part of the College, with vigorous initiatives that hold great promise for our future. Recently I had occasion to participate in a program commemorating the distinguished Chicago surgeon Arthur Dean Bevan. Bevan was a noted clinical surgeon but he was a great educator as well. Despite the objections of those who had a stake in preserving the deplorable system of medical education a century ago, Bevan founded the Council on Medical Education of the AMA, a forerunner of the
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Flexner Report, which reorganized medical education throughout this nation and the world. Bevan and his colleagues, including the founders of the American College of Surgeons, were staunch advocates of a strong moral basis for surgical practice. These were individuals who practiced what they preached. In his presidential address before the American Surgical Association 66 years ago, Bevan emphasized the essentiality of an ethical underpinning for our surgical practice.18 He stressed the importance of teaching our young surgeons an ethical and moral code to ensure the highest character of performance in all their surgical work. In these remarks I have made some comments on words and their significance as indicators of what we believe and how we behave. This is a lecture on ethics and philosophy, presented in a setting where all around us are reproductions of the American College of Surgeons seal and its inscribed motto— “Omnibus per artem fidemque prodesse”—to serve all with skill and fidelity. Eighty-six years ago, a dozen founders of this College established that seal and the principles behind it. Its motto is brief, expressed in what is incorrectly known as a dead language. It speaks of service—service to all; not to a health care organization, not to a distributive ethic or a communitarian theory, but service to each patient whose life is entrusted to our care. That care must be skilled— per artem—and we have today an abundance of skills. Beyond mere skills we must be faithful, not to our own interests, but above all, to an uncompromising ethic and philosophy that, in the words of
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our College pledge, “puts the welfare and the rights of my patient above all else.” As we stand on the edge of a third millennium, I am confident that the Fellows of the College, old and young, will fulfill that pledge. References 1. Moore FD. A miracle and a privilege. Washington, DC: Joseph Henry Press; 1995. 2. Parsons T. The social system. New York: Free Press; 1951. 3. Berlant L. Profession and monopoly. Berkeley; CA: University of California Press; 1975. 4. Bledstein B. The culture of professionalism. New York: Norton; 1976. 5. Starr P. The social transformation of American medicine. New York: Basic Books; 1982. 6. Freidson E. Professional dominance: the social structure of medical care. Chicago: A de Gruyter; 1970. 7. Woolhandler S, Himmelstein DV. When money is the mission: the high costs of investor-owned care. N Engl J Med 1999;341: 444–446. 8. Friedman M. Capitalism and freedom. Chicago: University of Chicago Press; 1962. 9. Li JT. The patient-physician relationship: covenant or contract? Mayo Clin Proc 1996;71:917–918. 10. Reinhardt UE. Hippocrates and the “securitization” of patients. JAMA 1997;277:1850–1851. 11. Tannenbaum SJ. Evidence and expertise: the challenge of the outcomes movement to medical professionalism. Acad Med 1999;74:757–763. 12. Emanuel L. Bringing market medicine to professional account [editorial]. JAMA 1997;277:1004–1005. 13. Pellegrino ED, Relman AS. Professional medical associations: ethical and practical guidelines. JAMA 1999;282:984–986. 14. Smoak RD Jr. Press release by chair, Board of Trustees, American Medical Association. June 23, 1999. 15. Cohen J. Unions are bad medicine for doctors [editorial]. Chicago Tribune; July 25, 1999. 16. Budrys G. When doctors join unions. New York: Cornell University Press; 1997. 17. Richardson W. Union cards for doctors? Med Econ March 1941: 56–58. 18. Bevan AD. Presidential address: the study and teaching and the practice of surgery. Trans Am Surg Assoc 1933;51:1–14.
The Ethics of Entrepreneurial Medicine C Rollins Hanlon, MD, FACS
To present this lecture in place of Dr Francis D Moore is a great privilege. My sense of privilege calls to mind Dr Moore’s splendid autobiography, A Miracle and a Privilege.1 In that book he set out a fascinating account of his life in clinical surgery, research, teaching, and administration. Dr Moore developed at Harvard and its hospitals an uncommonly favorable climate for biologic investigation so that his own work and the work of many other investigators flourished. The results of that research facilitated a new era of surgical biology, noted by a cover story about Dr Moore in a national weekly news magazine. The thrust of the cover story indicated that surgical operations had already been made safe for the patient, and in this new, biologic phase of surgical science we were aiming to make the patient safe for the surgical operation. During the American College of Surgeons meeting in San Francisco 9 years ago, we heard the exciting news of the Nobel Prize award to Joseph E Murray, FACS, a member of Dr Moore’s department and another exemplar of the productive fusion of bench research, clinical investigation, and compassionate patient care, all subsumed under an individual ethic that puts the patient in first place. Now we have come to an era of overarching technology, juxtaposed with a phase of commercialization, consolidation, and merger mania in our daily lives, and mutatis mutandis in the field of medical care.
Underlying these radical changes is the bedrock of our moral foundation, which Dr John J Conley wisely and generously recognized by his support of this ethics and philosophy lectureship and by many other philanthropic endeavors related to ethics during more than half a century as a Fellow of this College. At the time of his recent death, Dr Conley was emeritus professor of otorhinolaryngology at Columbia Presbyterian in New York and a poet of substantial accomplishment. His books of poetry entitled Word Paintings underscore his emphasis on the liberal arts. He inspired a host of admirers by his generosity and his professional achievements. The title of Dr Moore’s projected lecture, “Ethics: From Percival to G.B.S.,” implies that many physicians are aware of Thomas Percival and his assignment by the trustees of the Manchester Infirmary in England to draw up guidelines for the conduct of the Infirmary’s physicians in the late 18th century. Percival admonished staff physicians to behave politely so as not to bring discredit on the medical profession by fighting over hospital privileges. The Infirmary’s services had been seriously strained by an overload of patients incident to an epidemic of what was probably typhoid fever, and hospital authorities increased the staff roster with practitioners whose capacities the established staff considered inferior in quality to their own. Percival was not writing originally about ethics in the present sense but rather about etiquette among physicians. The word ethics did not appear in his initial presentation, and a concern about patients was not a focus of his original stipulations. Early ethical pronouncements of the American Medical Association borrowed heavily and even explicitly from Percival’s early formulation, so that we had for many years a confusing mix of ethics and
Based on an Ethics and Philosophy Lecture delivered at the Clinical Congress of the American College of Surgeons in San Francisco, October 13, 1999. Received December 30, 1999; Accepted January 4, 2000. From the American College of Surgeons, Chicago, IL. Correspondence address: C Rollins Hanlon, MD, FACS, American College of Surgeons, 633 N Saint Clair St, Chicago, IL 60611. © 2000 by the American College of Surgeons Published by Elsevier Science Inc.
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etiquette. This was understandably perceived by sociological critics as the self-serving credo of an arrogant profession. I would hazard a guess that the G.B.S. in Dr Moore’s title, obviously a reference to George Bernard Shaw, recalled Shaw’s oft-quoted statement that all professions are conspiracies against the laity. I make no further attempt to divine the content of what would have been Dr Moore’s lecture. Rather, let me indicate briefly what I plan to say about “The Ethics of Entrepreneurial Medicine.” I intend to comment here about three things: first, entrepreneurial medicine as illustrated by managed care; second, the ethics and sociology of the outcomes movement; and finally, the sharp dilemma that faces our profession in attempting to regain our professional authority. What is entrepreneurial medicine? In today’s perception, the term suggests the takeover of a previously individualized profession by entrepreneurs who “undertake,” in the French sense of the word, to organize and convert the basic one-to-one relationship of doctor and patient into an enterprise covering hundreds or thousands of individuals. This is often known as population-based medicine. In the 19th and early 20th centuries, the solo practitioner might properly have been considered a kind of entrepreneur, setting up a medical practice in an environment only lightly touched by external regulation and establishing a physician-to-patient relationship dependent on mutual respect and trust. Toward the middle of the 20th century this picture of sturdy and somewhat romanticized medical individualism came under critical analysis by the sociologist descendants of August Comte and Max Weber. Prominent among these sociologists was Talcott Parsons,2 whose opinion of the vaunted professionalism of medical practitioners was largely favorable. In contrast to later observers such as Berlant3 and Bledstein,4 who emphasized the selfaggrandizing effects of professionalism, Parsons considered the high social status of medical practitioners beneficial to society. In Parsons’ view, society worked best when each individual unit was fully functional. The work of physicians in assuring or restoring full function to each patient was a socially desirable good for which practitioners should be rewarded. Because of the esoteric nature of the knowledge base in medicine,
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society was content to give the profession a selfregulating status that had high social and financial value for physicians, while it benefitted society as a whole. Other sociologists, such as Berlant,3 thought that medical professionalism connoted an occupation consistent with gentlemanly values; indeed, taking up a profession was one way of rising to the status of a gentleman from a lower level. And before the rise of medical specialization, society placed its trust in the individual practitioner because it did not seem feasible to exert control over such solitary units from outside the medical profession itself. The profession was expected to control deviant behavior as a condition of professional autonomy, using internally directed mechanisms such as registration and certification. By the middle of the 20th century, medicine had achieved the status of “a sovereign profession,” as chronicled in the first portion of Paul Starr’s influential book, The Social Transformation of American Medicine.5 Sociologists such as Eliot Freidson in his 1970 book, Professional Dominance: The Social Structure of Medical Care,6 maintained that the monopolistic status of the medical profession arose more out of self-interest than from a laudable concern for patient welfare. Even the favorable assessment of Talcott Parsons rested on a foundation of social utilitarianism, which recognized the conflict (that would later grow much sharper) between maximizing the number of individuals receiving medical benefits and creating maximal benefit for the individual patient. Parsons thought that socialization of the medical profession rested less on the physician’s compassion for a suffering patient than on concern for a dysfunctional individual unit in the social enterprise, a unit that should be restored if sick and protected from harm when well, in order for society to function efficiently. This is not dissimilar to the mission of the US Navy Medical Corps, which I recall being presented to me in World War II as “to keep as many men at as many guns, as many days as possible.” (Personal communication from Lt Cmdr Mark A Friend, MSC, USN, Bureau of Medicine and Surgery, US Navy, November 3, 1999. First enunciated by Capt James D Gatewood, MC, USN, in 1907.) Such a formulation is consistent with what is known today
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as population-based medicine; it resonates with Paul Ellwood’s brilliantly devised and psychologically attractive concept of the health maintenance organization, or HMO. The term HMO was the forerunner of a host of other acronyms such as MCO (managed care organization), which might with equal justice be taken to signify “managed cost organization.” Paul Starr, in his book, The Social Transformation of American Medicine,5 spoke to “the coming of the corporation” as an influence that slipped up on a medical profession so intently focused on governmental intrusion that corporatization, or the business model of medical care, was inside the gates of the medical citadel before many were aware of its relentless approach. Many medical practitioners view corporatization as a plague on the house of medicine, with an associated distaste for those who receive egregiously large sums for their roles in managing the corporate medical enterprise. Comments on the difference between profit and not-for-profit hospitals are often bitterly phrased. For example, Woolhandler and Himmelstein7 recently commented on this issue as follows: “In nonprofit settings, avarice vies with beneficence for the soul of medicine; investor ownership marks the triumph of greed.” This seems to go a bit far in equating the mere notion of making a profit with the pejorative term “greed,” especially when even a not-for-profit hospital is unable to carry out its mission unless it avoids bankruptcy by at least balancing its books. As for the general acceptability of corporatization in our capitalistic society, the Nobel laureate economist Milton Friedman in 1962 stated flatly, “Few trends could so thoroughly undermine the very foundations of our free society as the acceptance by corporate officials of a social responsibility other than to make as much money for their stockholders as possible.”8 The word stockholder has now been replaced by stakeholder, which used to signify one who held the money of two bettors, but has now been extended to encompass a variety of persons or entities with an interest in an enterprise. In a hospital organization, stakeholders run the gamut from the board of directors and president to the patients and those who care for their medical or material needs.
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In the not-for-profit hospital, the motivating force of the hospital community is assumed to be grounded in beneficence toward patients and toward the larger community. The mission of the forprofit hospital is spelled out in its descriptor: despite the undeniable benefits it may confer by its healing, teaching, research, and public health activities, its basic responsibility is to make money for the stockholders who have invested in it. In the words of Woolhandler and Himmelstein,7 “But our main objection to investor-owned care is not that it wastes taxpayers’ money, nor even that it causes modest decrements in quality. The most serious problem with such care is that it embodies a new value system that severs the communal roots and samaritan traditions of hospitals, makes doctors and nurses the instruments of investors, and views patients as commodities.” JT Li9 concisely stated the nature of this new value system: “In the commercial model of medicine the patient is at best a consumer; at worst, a revenue stream when well and a medical (financial) loss when sick.” An even more stark portrayal of patients in economic terms is provided by the economics professor Uwe E Reinhardt,10 who has spoken to the “securitization” of patients. He has noted that “patients can be viewed as biological structures that yield future net cash flows. Whoever can claim legal title to these net cash flows can securitize and sell them in the open market.” Those of us who continue to think of medical and surgical care in terms of individual encounters may be troubled by a medical care system that bundles groups of patients into insurance aggregates known as “covered lives.” These aggregated patients can be bought and sold in an open market as if they were shares of IBM or Microsoft. But such concerns may be muted in the profession by the rise of the outcomes movement, with its implicit promise that in numbers there is strength, and even perhaps clinical certainty. For those of us in clinical practice, and especially in surgery, where we are sometimes constrained to make rapid life and death choices based on incomplete data, the promise of rule-based behavior derived from probabilistic research could be a shining beacon. Such research, we are assured, provides aggregate data from which we can deduce a comfortably certain course of action. It is said that such rule-based be-
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havior can be a shield against our own trepidation and the looming threat of external regulation or litigation. The outcomes movement is driven by thirdparty payors and government regulators in a frank challenge to medical professionalism. Tannenbaum11 has noted the way in which the outcomes movement downgrades the importance of physician’s “clinical judgment” with her comment, The professions are distinguished in part by the possession of specialized knowledge, which renders them authoritative in their respective domains. According to the outcomes movement, however, a physician’s experience contributes little to, and may actually subvert, medical knowledge. The latter belongs to probabilism, and the profession no longer owns the knowledge it needs.
Although Tannenbaum challenges the validity of such a formulation, it represents a part of the general thesis that probabilistic research provides guidelines superior to the judgment of experienced clinicians. If one is inclined to contest such advocacy of a formulaic practice, it seems fair to say that probabilistic research results merely in probabilities, and many of us would prefer the seasoned judgment of a compassionate physician who can factor into the equation the patient’s personal characteristics that are not readily discernible in the aggregated data of the outcomes movement. Defense of personalized practice faces both the aggregated data of the outcomes movement and the corporatization of medical care. Linda Emanuel12 has addressed this issue in her editorial, “Bringing Market Medicine to Professional Account.” In contrast to denigrating the professionalism of physicians, she has suggested that professionalism and attention to medical ethics must be brought into the managed care enterprise to redirect its actions back to its essential purpose of providing better access to care. There must be some moderation of the profit motive. Emanuel has faulted the “widespread assumption in US society that the essence of professionalism is about self-regulation in exchange for expertise,” as Freidson maintained. “This view,” says Emanuel, “has obscured the truer and more helpful understanding that professionalism is primarily about the expert protection of vulnerable people
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and vulnerable values, in this case patients and the values of health care, respectively, and that selfregulation is nothing more than a necessary vehicle for maintaining experts’ standards.” Some of the medical profession’s loss of public respect stems from the notion that physicians have focused on self-interest rather than on their duty to patients. Pellegrino and Relman13 have noted that the ethical obligations of professional organizations have often been overwhelmed by socioeconomic or political considerations. In a concise analysis they outline how the threat to moral leadership by professional associations must be resisted if we are to avoid a deterioration into self-serving guilds or unions. The public perception that organized medicine no longer has the primacy of the patient as its dominant objective is a major cause of distrust directed at medical organizations and their individual members. Pellegrino and Relman have outlined a halfdozen guidelines that should govern national or state medical societies and specialty associations. These include a clearly stated mission that recognizes today’s hostile workplace but balances the economic concerns of its members against the obligation to retain public trust as a patient advocate. In their view “unions and truly professional associations are simply incompatible.”13 They have cited the conflicts of interest that may reside in organizationally sponsored journals and other information sources as well as in the commercial sponsorship of medical meetings. Their pertinent comments on issues of governance with attention to representative democracy and full disclosure of policies and actions are worthy of thoughtful review by all who carry the serious administrative responsibility of major medical bodies. Early in their essay they set out a rather gloomy historical appraisal. “The history of professional medical associations reflects a constant tension between self-interest and ethical ideals that has never been resolved.”13 There is one association well known to me in which a vigorous attempt to resolve that tension has been ongoing for 86 years. Each Fellow of the American College of Surgeons is formally charged in the Fellowship Pledge to adhere to College objectives, as stated in its Articles of Incorporation, “To maintain an association of surgeons, not for pecuniary profit, but for the benefit of hu-
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manity by advancing the science of surgery and the ethical and competent practice of its art.” Through its Central Judiciary Committee, the College has called numerous Fellows to judgment for ethical lapses, and many have been expelled, even in the face of highly expensive resistance by litigation. Such disciplinary actions by the College have commonly been unrecognized or forgotten by a public conditioned to equate the misdeeds of the few with the reputation of an entire profession. But, setting obvious malefactors aside, the medical profession as a whole has clearly lost its former position of high esteem in our society, and there are serious, continuing threats to its current, unstable status. We approach this deplorable situation with two questions: First, what can we do about it? and second, what should we do about it? The first question is operational, dealing with possibilities; the second is ethical, dealing with proprieties and with professionalism in its ideal sense of concern for the best interests of our patients. It is clear that managed care, the leading management tool of the moment, is encountering serious, justified criticism from patients and physicians. Despite this fall from favor, managed care is vigorously resisting legislative and other attempts to restrict its power. How can physicians and their patients level the playing field in their relations with managed care so as to enhance their power to bring about change? The most obvious answer is unionization, or its somewhat more acceptable cousin, collective bargaining. Resort to unionization by the medical profession has been regularly condemned. We have noted the dismissive comments of Pellegrino and Relman.13 What of collective bargaining without formal unionization? At their June 1999 meeting, the AMA House of Delegates “voted to develop an affiliated national labor organization to represent employed physicians and where allowed, residents.” The chair of the Board of Trustees, Randolph D Smoak Jr, MD, issued a press release on June 23, 1999 that stated, “This is not for all physicians. This will not be a traditional labor union. Your doctors will not strike or endanger patient care. We will follow the principles of medical ethics every step of the way.”14 Dr Smoak stated, “By forming an affiliated labor organization, eligible physicians will be able to fight for quality patient care while re-
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maining faithful to AMA’s historic and unwavering commitment to ethics and professionalism.” The matter was vigorously debated in the House of Delegates and the affirmative decision to form a national labor organization was far from unanimous. In a Chicago Tribune editorial,15 Dr Jordan Cohen, president of the Association of American Medical Colleges, wrote that as an AMA member he was deeply troubled by the action of the House of Delegates. “In authorizing the AMA to form ‘negotiating units’ for doctors, members of the House of Delegates have, wittingly or unwittingly, contributed their considerable weight to the already heavy burden of de-professionalization bearing down on medicine.” Cohen went on to say, Unions are marvelous tools for wielding economic power in the marketplace. They are not designed for consumer protection but for extracting benefits for their members. Whether true or not, I worry that economic advantage, not high-minded altruism, will be what most people will perceive as the motive behind this regrettable action. Why regrettable? Because doctors are sworn to serve their patients’ interest first, not to use their privileged status as a lever in the marketplace.
And as a recommendation for the profession, Cohen stated: “The proper course of action for doctors is to create an outcry, not a union.” Recall that Dr Smoak characterized this incipient body as “an affiliated labor organization” that “will not be a traditional labor union.” Despite such a caveat, many will consider this description a distinction without a difference, and will regard the fledgling AMA-affiliated group as a related union. The practical issue is how such a body will be viewed by a highly opinionated public, now informed electronically and in other ways to an unparalleled degree. This is not a matter to be solved by competing slogans, or by promises, however well intentioned, that will not convince an increasingly disillusioned public. Too many patients have ruefully concluded that organized medicine is more interested in its own good than it is in the welfare of the sick. What we need to restore on a broad scale is patient trust. The dilemma lies in our concern over loss of professionalism on one side, and the demon-
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strated reality of political ineffectiveness on the other. For a critically informative discussion of the issues surrounding the physician union movement, one cannot do better than to consult the splendid 1997 monograph When Doctors Join Unions by Grace Budrys, professor of sociology at DePaul University.16 Budrys traced the union story with special reference to the Union of American Physicians and Dentists (UAPD) launched in the San Francisco Bay area by Sanford Marcus, MD, in 1972. Unlike most other physician unions, the UAPD has persisted until the present time, by virtue of its shrewdly planned organization, the tireless work of its founders, and the no-nonsense analysis and rhetoric of Dr Marcus. Professor Budrys was given complete access to the records of UAPD so that she might fairly appraise its performance. She lists some of its considerable successes, especially in California, which has always been its major scene of action. In its early days the UAPD approached the AMA and organized labor for help, but was rebuffed in both places. The president of the AFL-CIO, George Meany, told Dr Marcus in 1973 to come back in 10 years, when most doctors would have become employees and then they would be able to talk. A number of physician unions are currently operating. In April 1999, the Doctors Council of New York, the Committee of Interns and Residents (CIR), and the United Physicians and Dentists merged to form the Doctors Alliance. In combination, it claims to include about 10,000 enrollees. The Federation of Physicians and Dentists of Tallahassee, which has been around since 1983, has grown significantly in recent years and now claims to have about 10,000 members across 25 states. This means that the UAPD, with approximately 5,000 members, is now the smallest of the three well-established physician unions. As of this year all three unions became affiliated with the AFL-CIO, meaning that they are all receiving organizing support. This gives the doctors an opportunity to make linkages with traditional unions, who are then using their leverage to gain concessions suggested by the doctors when they bargain over their respective contracts with their employers. (Cited from personal communication with Professor Grace Budrys, December 22, 1999.)
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The current debate within the AMA is not a new phenomenon. In 1941 an article by William Richardson in Medical Economics argued that the AMA should become a union to free it from the restraints of the Federal Trade Commission.17 Such suggestions were largely ignored until the concept was formally introduced as a resolution at the 1973 AMA convention. Although the House of Delegates rejected the proposal by Dr Stanley Peterson, president of the new Federation of Physicians and Dentists, the subject was clearly exposed in the professional and public domains. The 1973 president of the AMA was Russell Roth, a urologist from Erie, PA. I can recall his oft-repeated response to the collective bargaining initiative, “Anything the union can do, the AMA can do better.” It is important to note that Dr Marcus supported the AMA in its scientific, professional, and educational endeavors, but believed that a union arm of medicine was needed for specialized action in the socioeconomic area. After discussing the issue in 1973, the House of Delegates condemned physician unions. Since the 1973 condemnation by the House of Delegates, the AMA has undertaken a variety of initiatives to teach physicians how to bargain, including forming a Department of Negotiations. After this was discontinued, the American Medical News periodically provided information on negotiating techniques. The 1990s saw vigorous efforts by the AMA directed at legislative reform of antitrust laws to permit collective bargaining by physicians. For those doctors wishing to achieve the right to organize and bargain collectively, the most promising opportunity lies within the states, which could grant such rights in exchange for physician cooperation in cutting costs. Positive action has occurred in Texas and California, but national spread may be a slow process. A number of physician groups have drawn on the reservoir of negotiating skills possessed by the Union of American Physicians and Dentists to secure valuable advice in matters like hospital staff contracts and staff by-laws. This same advice has been made available by national medical organizations intermittently over the years. The recent entity established by the AMA as “Physicians for Responsible Negotiations” with the happy acronym of PRN is a result of the June 1999 action by the AMA House of Delegates. As of Sep-
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tember 1999, the initial five members of the PRN governing board had been appointed to a body expected to number between 9 and 12. A governing constitution has also been recommended by the AMA Board of Trustees. The future performance of this negotiating body will be watched with intense interest by the profession and the public. Its success will be determined by its capacity to regain the public’s trust in the AMA, which has been sorely shaken by a number of recent public relations disasters. I have recently filled out a questionnaire from my state medical society about collective bargaining. The questionnaire noted the essentiality of legally delinking the effort from the state medical society itself, and restricting participation to employed physicians in narrowly defined groups. One question concerns willingness to strike or withhold services as a collective bargaining strategy, with the issue framed in financial terms. One question asks whether one would join a collective bargaining organization and make use of its services if the bill were $500 a year. The next question asks if one would be willing to join at $350 a year. This raised, for me, an interesting question whether a physician’s ethical convictions can be quantitated between willingness to join at $350 a year and unwillingness at $500 a year. My own reaction was to oppose the formation of a collective bargaining unit by the state medical society irrespective of cost factors. The ethical issue turns on whether one considers such action right or wrong. Securing legislative correction of the problems in our managed care system is maddeningly slow and subject to legislative horse trading by which a patient’s right to sue an overbearing HMO could open the door to potentially abusive litigation that will inevitably raise the cost of care. Senator Bill Frist, FACS, (R TN), was quoted recently as viewing with strong concern an arrangement that has “doctors in bed with trial lawyers.” It is clear that “patient protection legislation” comes in a variety of sizes and shades. There seems to be an increasingly favorable climate for collective bargaining by physicians and a certain degree of growth in union membership, although the proportion of all physicians remains small. It is ironic that the social transformation of American medicine written about by Paul Starr has proceeded to empower managed care so strongly that physicians are
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now seeking relief by national legislation. In this rapidly evolving situation, one needs to look carefully at any quick fix that will bring on unintended consequences. An understandable fury at the arrogance of some HMOs should not lead us into regrettable short-term solutions. In these days when national decision making is too often directed by polls, focus groups, and Arbitron ratings, it is refreshing to look back to our surgical heroes (now called role models) to find inspiration and guidance out of the morass in which we are immersed. A knowledge of history and the other humanities may seem at first glance to be a thin reed on which to lean as we struggle forward. But from history and the other liberal arts we can gain wisdom that will keep us from establishing policy without principle, and will avoid actions rooted in emotion rather than cool discernment. Recently I have wondered whether today’s surgeons will be as entrepreneurially ingenious and as forthright and resolute in principle as our forebears, such as Dr Franklin H Martin and his colleagues. I am convinced that at least some surgeons are coming off the production line with the characteristics and capacity to deal honorably and effectively with the massive problems that confront us. These are the young surgeons on whom our future rests. When William P Longmire Jr was chairman of the Board of Regents of the American College of Surgeons 30 years ago, he established the Committee on Relations with Young Surgeons. J Englebert Dunphy, who succeeded him as chairman of the Board, was asked, “What is the objective of the Young Surgeons?” With characteristic quickness “Bert” replied, “To become old surgeons,” knowing full well that this seemingly flippant response contained a prediction of what the Young Surgeons Committee has now become—a vibrant, active part of the College, with vigorous initiatives that hold great promise for our future. Recently I had occasion to participate in a program commemorating the distinguished Chicago surgeon Arthur Dean Bevan. Bevan was a noted clinical surgeon but he was a great educator as well. Despite the objections of those who had a stake in preserving the deplorable system of medical education a century ago, Bevan founded the Council on Medical Education of the AMA, a forerunner of the
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Flexner Report, which reorganized medical education throughout this nation and the world. Bevan and his colleagues, including the founders of the American College of Surgeons, were staunch advocates of a strong moral basis for surgical practice. These were individuals who practiced what they preached. In his presidential address before the American Surgical Association 66 years ago, Bevan emphasized the essentiality of an ethical underpinning for our surgical practice.18 He stressed the importance of teaching our young surgeons an ethical and moral code to ensure the highest character of performance in all their surgical work. In these remarks I have made some comments on words and their significance as indicators of what we believe and how we behave. This is a lecture on ethics and philosophy, presented in a setting where all around us are reproductions of the American College of Surgeons seal and its inscribed motto— “Omnibus per artem fidemque prodesse”—to serve all with skill and fidelity. Eighty-six years ago, a dozen founders of this College established that seal and the principles behind it. Its motto is brief, expressed in what is incorrectly known as a dead language. It speaks of service—service to all; not to a health care organization, not to a distributive ethic or a communitarian theory, but service to each patient whose life is entrusted to our care. That care must be skilled— per artem—and we have today an abundance of skills. Beyond mere skills we must be faithful, not to our own interests, but above all, to an uncompromising ethic and philosophy that, in the words of
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our College pledge, “puts the welfare and the rights of my patient above all else.” As we stand on the edge of a third millennium, I am confident that the Fellows of the College, old and young, will fulfill that pledge. References 1. Moore FD. A miracle and a privilege. Washington, DC: Joseph Henry Press; 1995. 2. Parsons T. The social system. New York: Free Press; 1951. 3. Berlant L. Profession and monopoly. Berkeley; CA: University of California Press; 1975. 4. Bledstein B. The culture of professionalism. New York: Norton; 1976. 5. Starr P. The social transformation of American medicine. New York: Basic Books; 1982. 6. Freidson E. Professional dominance: the social structure of medical care. Chicago: A de Gruyter; 1970. 7. Woolhandler S, Himmelstein DV. When money is the mission: the high costs of investor-owned care. N Engl J Med 1999;341: 444–446. 8. Friedman M. Capitalism and freedom. Chicago: University of Chicago Press; 1962. 9. Li JT. The patient-physician relationship: covenant or contract? Mayo Clin Proc 1996;71:917–918. 10. Reinhardt UE. Hippocrates and the “securitization” of patients. JAMA 1997;277:1850–1851. 11. Tannenbaum SJ. Evidence and expertise: the challenge of the outcomes movement to medical professionalism. Acad Med 1999;74:757–763. 12. Emanuel L. Bringing market medicine to professional account [editorial]. JAMA 1997;277:1004–1005. 13. Pellegrino ED, Relman AS. Professional medical associations: ethical and practical guidelines. JAMA 1999;282:984–986. 14. Smoak RD Jr. Press release by chair, Board of Trustees, American Medical Association. June 23, 1999. 15. Cohen J. Unions are bad medicine for doctors [editorial]. Chicago Tribune; July 25, 1999. 16. Budrys G. When doctors join unions. New York: Cornell University Press; 1997. 17. Richardson W. Union cards for doctors? Med Econ March 1941: 56–58. 18. Bevan AD. Presidential address: the study and teaching and the practice of surgery. Trans Am Surg Assoc 1933;51:1–14.