On wards and in intensive care units, when doctors, nurses, patients and families find themselves at odds with one another, they inevitably turn to the experts of last resort: the bioethicists.


Regularly called upon to weigh in on issues including life support, human research, patient rights and organ transplantation, bioethicists are known for bringing clarity to situations so overwrought with opinions, values and special interests that consensus appears impossible.

Now, as the search for consensus in health care reform grinds toward the end of its first year, a national leader in bioethics has cast his critical eye on the debate. At issue, however, are not the usual moral suspects: pharmaceutical manufacturers, medical device makers and hospitals. This time it is physicians who have lapsed in their ethical responsibilities.

In an editorial in The New England Journal of Medicine, Dr. Howard Brody, professor of family medicine and director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston, writes that the medical profession, unlike other groups, has made little effort to curtail future medical costs. Physicians, Dr. Brody maintains, are not “innocent bystanders” to spiraling health care costs but have been complicit in their failure to take an active role in curtailing them.
Moreover, Dr. Brody points out, certain doctors’ groups have gone so far as to make their support for reform contingent on promises that their own income would remain unaffected. “If physicians seized the moral high ground,” Dr. Brody writes in his editorial, “we just might astonish enough other people to change the entire reform debate for the better.”

I spoke with Dr. Brody recently about the ethical obligations of doctors in the health care overhaul, the role of organized medicine, his “Top Five” plan to regain medicine’s moral ground, and whether it all comes down to money.


Q. You write that doctors have an ethical responsibility to advocate health care reform. Why?
A. Doctors have two responsibilities. First, they have a moral duty as an individual advocate. A doctor has a responsibility to his or her individual patients to make them healthier and to help them live longer.
But doctors have a second moral duty: they have an obligation to the general public to be prudent stewards of scarce resources. Doctors only get about 10 percent of health care costs in their pockets, but they control about 80 percent. That isn’t our money — it’s someone else’s — and the public has entrusted us to spend it as wisely as possible.

Q. Have doctors failed in that second moral duty?
A. Unlike previous health care reform discussions where doctors were put on a pedestal, people are now turning the searchlight, appropriately I think, on the medical profession and asking if we are the problem. But rather than rising to that challenge and exercising moral leadership in health care reform, we are acting like one more special interest group. Instead of saying we care about patients enough to put our own interests on the back burner, it has been as if we were more concerned about maximizing our income.
We make so much more money than so many people in this society. To say that we are entitled to that income rather than we are privileged and should give back to society does not, and should not, win us a lot of friends.
The reason that the public gave us so much regard, trusted us, was because they saw us as willing to make that moral commitment to put the patient first. If we ever retreat from that commitment, we lose so much. I don’t even want to think what that would be like.

Q. But are you referring to individual doctors or to organized medicine? Some doctors would argue that the opinions of organized medicine are not representative of doctors as a whole. Take the American Medical Association, for example; it counts only about 30 percent of licensed doctors as members.
A. Over the years I’ve met doctors from virtually every specialty who firmly place the good of the patient ahead of their own personal income and who have made personal sacrifices in their own income in order to practice the best medicine. But there are certain things that can only be accomplished by professional medical societies, things that doctors as individuals could never do.
I firmly believe that if a professional medical society came out and said, “This is our prescription for health care reform, even if it costs us money,” that would get attention.


Q. So is it all about the money?
A. No. It’s an unfortunate joining of money with other issues and motives. We have an American public that generally believes more is better. And rather than giving up bad habits, exercising and eating right, they would rather believe that the answer to health is in high technology.
When you combine this love affair with high technology with a reimbursement system that pays so much more for technology — and less for thinking and sitting and talking with patients — you end up with an expensive kind of medicine, which, when practiced by doctors, puts more money into their pockets.
In actual fact, there’s such a low chance that technology will help all these patients.

Q. How does your “Top Five” solution work?
A. The basic idea is that each specialty would decide on the top five procedures or diagnostic studies that are done commonly but only really help a small fraction of patients. These are things like arthroscopy for osteoarthritis of the knee or MRI’s and CAT scans, all of which are massively overused, not because they help but because of our enthusiasm regarding high technology.
Once each specialty has gone through the research evidence and decided on its “Top Five,” the respective professional organizations would take a public stand, issuing guidelines and recommendations against overuse of those “Top Five” procedures or studies.
By taking a public stand and making it harder for individual doctors to say, “Oh, I know better,” we could build real momentum for cost containment. And we would ultimately all benefit because we don’t need all that technology. You can still be as healthy without it.


By PAULINE W. CHEN, M.D. (March 3, 2010-NYT)