Rationing and professional autonomy

A loss of faith: the sources of reduced political legitimacy for the American medical profession

The political legitimacy and policymaking influence of the medical profession have greatly declined in American society over the past 30 years. Despite speculation about the causes, there has been little empirical research assessing the different explanations. To address this gap, data collected in 1995 are used to compare attitudes of the American public and policy elites toward medical authority. Statistical analyses reveal that (1) elites are more hostile to professional authority than is the public; (2) the sources of declining legitimacy are different for the public than they are for policy elites; and (3) the perceptions that most threaten the legitimacy of the medical profession pertain to doubts about professional competence, physicians' perceived lack of altruism, and limited confidence in the profession's political influence. This article concludes with some speculations about the future of professional authority in American medicine.

Saint Martin of Tours in a new world of medical ethics

I end with another parable, but it is also a true story. Harvey Cushing, the famous surgeon after whom the Cushing Lectures are named, made an international reputation in his allegiance to quality. He badgered his profession to a higher standard of self-effacement and railed against the debasement of clinical skills and overemphasis on research and pursuit of personal gain. We honor him to this day because those were, and remain, important points. Yet, Harvey Cushing served as a surgeon during World War I and at Ypres. Although the Allied mortality was as much as 50,000 soldiers a day, not counting the wounded, Cushing refused to operate on any more than two patients each day, arguing that to do so would have lowered his standard of care for his patients--a standard that made sense in one time but that became strikingly insensitive, and I suggest even unethical, in another when confronted with a different reality. The ethical claims for professional autonomy based on such standards of professional ethics has had the effect of supporting widespread distributional inequities. These inequities are clearly a form of rationing that have been condoned implicitly by the professional ethics in the name of professional autonomy. Many of the condemnations we hear today of prospective payment systems and how they will "ration" medicine contain a similar sense of unreality. The high standards are laudatory, but they should not be used as an excuse to not meet other pressing needs. High standards should never be used to make a problem worse.(ABSTRACT TRUNCATED AT 250 WORDS)