“Medicine must not abandon its very essential task as the patient’s attorney to the economy”

A critique of the economic transformation of medicine

by Prof Dr med Giovanni Maio*

We live in a time when medicine is being transformed in a radical way. Medicine is to be transformed from a genuinely social practice into a health market. Concepts that originally were meant just for industry, are more and more forced onto all aspects of society. Especially in hospitals a kind of thinking has already begun which is stronger influenced by management  than by medical thinking. But actually, what is the difference? How do  economically guiding categories change thinking in medicine?

The structural elimination of care

Economy and its aspirations to heighten efficiency inexorably enforce acceleration. The dictates of the market are dictates of time-economy: All processes in hospitals are accelerated in such a way that in the end everything crucial for the treatment  is rationalised – the  time for a chat in between, for the chat that is not compulsory but essential in personal care. More and more personal care is considered as the idealistic icing on the cake which can be spared because there are more essential tasks as for example maintaining quality standards. And personal care may hardly be counted as one of these standards, since it can’t be measured.

Formal standards instead of human relationship

By obeying the politically decreed dictate of time, a culture of healing withers away, because the treatment of sick people is increasingly considered as a measurable action. In a problematic way, the economized system suggests that treatment ends with the application of what is correct. By this auspices, the meaningful service for people is changed into a service close to the person – according to economic-administrative requirements. However, this leads to an underestimation of just what for many people was the real reason to opt for the helping profession doctor. Fulfilment for the doctor and real help for the sick do not only require sound knowledge as a basis for medical treatment but  also a second base that allows an attitude of appreciation for the patient, an attitude of an authentic readiness to help, an attitude of concern related to the patient. Such values become an annoying obstacle if regarded as a bar to an increase of efficiency and profitability.

Economic transformation of the medical goals

Of course, the economic thinking in medicine is very important. Without economic thinking you would waste too many precious resources. But you have to allot space for economy. This space is where it helps medicine to reach its genuine medical goals without waste. Therefore economy is a servant to medicine which should gain free spaces by sensible economizing, so that medicine can take place at all.
However, in our days economy is not the servant of medicine, but medicine is serving economy. Economy makes the rules and dictates exactly what is worth and what treatment is appropriate to make the figures satisfying in the end. So, if economy is becoming the main thing instead of medicine, it means we are saying goodbye to certain values of the society.

Devaluation of the medical work

Basically, it is no longer preferable to have real doctors in a modern health system, but rather one wants managers, who skilfully assemble the prescribed treatment packages. A system is preferred where all activities are organizationally fractionized. This way the characteristic feature of the medical work, the holistic perspective of human being, the very specific medical qualification can hardly come  to its own. Economisation gradually leads to a sort of keyhole medicine, because doctors are rewarded when they limit themselves solely to a DRG diagnosis or to an initial diagnosis and thus to a narrow view, without ever claiming to see the person in his or her entirety.
In the course of excessive commercialization, the appreciation of the medical profession seems to vanish. This is also reflected in the fury of documentation  accompanying commercialization. Everything must be measured, everything must be proven, and above all: everything must be controlled. Nothing is taken for granted, but for everything the doctor must  account; he is facing a permanent general suspicion. One doesn’t give credit to the doctors assuming they act properly in their own responsibility, but they are constantly controlled and must be prompted by financial incentives to do the right thing. This homo oeconomicus is the exact opposite of the doctor  whose help is unconditional and completely natural.

De-professionalisation of the medical faculty

The doctor has hardly any margin of discretion; for ever less  is left to his genuine medical experience, instead the doctor is told in detail, what he has to do. Working by instructions this way, almost according to an operation manual, has nothing to do with professional medicine. Instead a politically deliberate de-professionalisation of the medical faculty is being observed in the course of economization. The greater the economic incentive is for the doctors, the more they lose the freedom to work solely to the welfare of the patient – the very basis for exercising this profession. Every day, the doctor is driven into a role conflict, he is to believe he might cope only if he departs from the lofty ideals of his profession and bases his business on the economic requirements and constraints.
It is overlooked that this is tantamount to a sell-out of the medical craft and thus a sell-out of the trust in medicine.
The loss of confidence in  medicine is exacerbated when in the health system that is oriented towards competition advertising is increasingly becoming a reliable agent. It remains unnoticed that the self-understanding of a free profession is basically irreconcilable with advertising; since otherwise it would be suggested that there’s only competition and no ethics within this profession. Through advertising, the medicine experiences a trivialisation of its goals. So a culture of distrust is incited, which will finally harm the reputation of medicine in an elementary way.

Trivialisation of the medical services

Taking over economic principles as a guiding element leads the longer the more to objectification, legalization and depersonalization of medicine. It is this depersonalization that prevents interactions to occur between doctor and patient, which could be described as a necessary aid, but gradually the “supply” of the physicians is being transformed as well. Where the economic logic rules, it is no longer evident why doctors should offer just help; it is much more lucrative to simply transform aid into a consumer good. In a medicine, which sees itself as a market, the ways of interacting change, and new «products» are created and advertised – products which have nothing to do  with healing and helping, but with multiplying sales. Those products are to even reach healthy people, because then sales opportunities are higher. The economization leads to a marginalization of medical indications and to a promotion of unnecessary goods on the bazaar of medicine.
By the economic transforming of the medical activity a caring and committed practice  is transformed to become a market-shaped service.

From care to a market-like service

The most serious consequence of the economic re-defining of the medical profession is its transformation from a caring practice to a market-like service. In times when economy rules, it doesn’t matter whether a physician has an internal motivation to help or not. Nowadays, something else is requested from the physician. He is expected to provide verifiable and secure solutions, doctors are subject to programs and requirements. There is a legal encroachment in the field of medical assistance, which is transformed into delivering a quality-assured product. This is called “output-oriented quality assurance”.
However, a humane medicine cannot be realized by output alone. Especially, the confrontation with a serious disease means an extreme borderline experience, and when facing such a fundamental existential experience the patient does not  need any service provider but a person with whom he feels to be in good hands. The orientation on the good and measurable outcome is a necessary condition for good medicine, but it is not enough. For the encounter between doctor and patient is inevitably dependent on trust. Such an encounter often involves existential experiences that require more than just expertise.
In an economistic system, there are no longer helpers but service providers, there is the delivery of ordered and contracted health goods. Thus, economy just leads to the replacement of a relationship based on mutual trust to a contractual relationship. This is a business model, and it was introduced stealthily.

Exchange ratio instead of unconditioned help

A medicine, which conceives itself as commercial, introduces a logic of exchange. You supply something and you get something in return. However, the logic of exchange is entirely different from that logic which a genuinely social medical practice should have. There is a fundamental difference whether the patient is considered as an exchange partner to whom something is offered or even sold, or whether he or she is considered to be a person in need. If human assistance is more and more subject to the logic of exchange, it will cease to be considered as an end in itself step by step. Instead, it will be considered on a mere instrumental level – as an aid that is carried out in order to achieve good figures, to perform well with regard to benchmarking or  appeal to the managing director.
The basic problem is that in establishing an economic view medicine  distances itself  more and more from its basic identity. The latter consists of professional caring for a person in need. Helping has inevitably  to do with giving – and  not with exchanging. Reciprocity as it is the case in exchange isn’t a basic element in medical practice. Instead it is a doctor’s unilateral giving to a person in need. At best, the helper is a person who doesn’t calculate nor count up, but who just gives as a matter of course. This matter of course, the determination with which one should be willing to give, this naturalness of helping will be eliminated more and more in an environment conditioned by economic factors.

Impartiality instead of sympathy

The greatest damage of the above-described purely economic thinking is that it will lead  to an emotional  distance to the patients in the end: There may be perfect service without personal sympathy for the fate of the sick person. Economy introduces new values; instead of empathic engagement there is impartial performance. The natural immediacy of giving is turned into calculated help, into help according to calculation.
Many patients feel, that something does not match here. They are wondering whether a therapy recommended by a doctor, might be a recommendation due to calculation by the hospital or the practice. The simultaneity of help and calculation is a constant threat to the foundations of medicine as a discipline of help, as a discipline of care, and thus it is a threat to the indispensable bond of trust.
Medicine must rediscover itself once more as a social practice based on the indispensable fundamental attitude of appreciation for each other beyond calculation. A good physician will be the one where you really feel that he is doing all the good he can assuming an attitude of unselfishness without any calculation or reservation. A good doctor donates, he gives his time, he donates his attention, he donates his interpersonal interest. In the end, a doctor can only be good if he signalizes that in the contact with his patients he disposes of a last resource and this means a rest of free time which he can dispose of willingly without fearing disadvantages.

Submission to the dictate of success

Policy believes that many problems might be solved by establishing economic concepts and that patients could be changed into customers; this new customer status is sold with the slogan “freedom for the patient.” However, behind this notion of freedom there is the tendency to place all liability on  the patient. The patient is given the responsibility to inform himself and to come to a good decision. In case of failure he will be the one who is to blame  because he failed to inform himself sufficiently as a responsible citizen. Dealing with ill people in such a euphemistically veiled way is nothing but a subtle form of negating solidarity.
It is a retreat from a social attitude, the retreat hiding behind this pretty concept of freedom and responsibility;  the new “empowered” patient may make claims on the one hand, on the other hand, however, he is compelled as a patient to always be on guard and protect himself. With regard to a seriously sick  patient who after having received a diagnosis may experience a severe crisis, the paradigm of the well-informed customer can’t work because such patients in need can’t be expected to simultaneously be on guard.
The patient should be a customer, this is favoured by health policy. However, as a  customer he doesn’t receive primarily any  but he is being sold a good – and whether he actually will receive help is by no means certain. This is the ultimate consequence of a completely economic approach to medicine. Consequently, help is no longer awarded to everybody;  help will only be granted if it’s worth it. The real art of a more economic approach to medicine is to have a proper patient selection of patients, to acquire patients that promise a good record, patients that are good for good statistics and who might be offered additional services.
However, patients with problems more difficult to deal with will be classified as too risky and therefore shunned and further marginalized. For, if a significant improvement can’t be achieved quickly and without complications, each measure will be looked on as inefficient and threatening for the company. All measures that cannot be assured to succeed or take too much effort will be more and more excluded, simply because they do  not meet the newly established pattern of profitability. The criterion of profitability replaces the genuine social attitude. It was once essential that you try to help even when there is little chance. However, seen from an economic viewpoint, this imperative is considered as waste and consequently as not necessary.
Medicine must not abandon its very essential task, especially to be an attorney of the patient, to the economy. Because if medicine gives in to a business model completely, there will be no more medicine in the end.     •

*    Born in Italy, Professor Dr Giovanni Maio studied medicine and philosophy and then worked as an internal specialist. In 2002, he was appointed appointed Member of the Central Ethics Commission on Stem Cell Research by  the German Federal Government. Furthermore, he is a member of various advisory boards on ethics, such as the Board for Ethical and Medical-Judicial Questions of Principles of the German Medical Association or Malteser Germany and since 2010 he is adviser on bioethics to the German Bishops’ Conference.       
      Since 2005 Maio has been Director of the Interdisciplinary Ethics Centre in Freiburg and the Institute for Ethics and History of Medicine. He was repeatedly rewarded prices for his teaching activities. In more than 300 publications Maio dealt with ethical issues of medical practice and medical-technical progress. He criticizes the notion of feasibility of technological medicine and is an advocate of a new ethics of prudence.www.igm.uni-freiburg.de/Mitarbeiter/maio

Source: Deutsches Ärzteblatt, Vol 109, Issue 16, 20.4.2012

(Translation Current Concerns)

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