Curing and care in the area of conflict between economics and medicine

Given the continued economising of the healthcare system, rising premiums, increasing cutbacks, redundancies and other similar severe interventions, there is a growing number of critical voices warning that one of the best healthcare systems in the world not be put at risk. Objectivity and a focus on solutions are less and less at the centre of public discourse. As a matter of fact, it is said, good care for people has a price, just like everything else. After all, healthcare services are carried out from person to person, and moreover, human relationships and care in the healthcare sector may not be industrially automated, as unfortunately being more and more attempted. In this context, it is striking that the Swiss government – in proportion to GDP – spends far less on healthcare than almost all of our neighbouring countries, which makes the calls for cost reduction even more controversial.
  A more fact-based debate is indeed needed. With this in mind, we would like to take a closer look at the issue of healthcare costs and, in particular, the role of economy with regard to medicine. How should doctors and those working in the medical and nursing professions position themselves in the area of conflict between economic efficiency and the provision of medical and nursing care? What can be required from politics and economy? We think that economy’s purpose is to create a basis on which medicine can prosper and that economic requirements must not prevent necessary medical decisions. Three fundamental texts are presented below, analysing factually and critically the central health economical aspects of our current healthcare system and reflecting on the ethical and political-economical demands arising. The three texts have been published in the July 2023 issue of the Hippocratic Society Switzerland’s publication series “Von der Aufgabe, auf der Seite des Lebens zu stehen” (On the task of standing on the side of life).¹
  The first text is an interview with the renowned Swiss economist Mascha Madörin, an expert in the field of health economy. Her fundamental work at the Zurich School of Applied Sciences ZHAW entitled “Ökonomisierung des Gesundheitswesens – Erkundungen aus der Sicht der Pflege” (Economisation of the healthcare system – explorations from a nursing care’s perspective) is worth mentioning.²
  The second text is called “Ärzte Kodex – Medizin vor Ökonomie” (Physicians’ Codex: Medicine Ahead Economics) published by the German Society of Internal Medicine in 2017.³ It translates the consequences of Mascha Madörin’s critical analysis into concrete demands for healthcare policy. Fifteen of the major German medical societies were involved in formulating the “Physicians’ Codex”, which has been endorsed by many regional, national and international organisations: the Hamburg Medical Association, the Austrian Society of Internal Medicine (ÖGIM), the European Federation of Internal Medicine (EFIM) and others. The third text is the statement by the Swiss Society of General Internal Medicine (SGAIM), which adopted the “Physicians’ Codex” on 8 July 2021.⁴

What are the requirements 
for politics and medical ethics that 
can be derived from the three texts? 

Mascha Madörin argues basically that the most important and fundamental initial question in healthcare policy should not be: 

“Can we cut costs in the healthcare system? But rather: How much funding (and what kind) is needed to ensure that the healthcare system works well, that people-friendly basic care is guaranteed and that everyone has equal access to the medical achievements of the healthcare system”?

Thus, she focuses on the social question and explains plausible why the actual problem of socially just medicine is not an economic one, but a political one. In her opinion, however, the prevailing economic debates on the healthcare system ignore precisely this question and apply false economic theories that fail to address the problems of the healthcare system:

“The crucial point is that in healthcare I don’t “produce” goods like in a factory or on a screen before selling them anonymously on the market, but that I treat people directly. The people receiving this service are a human counterpart. Care or medical treatment don’t generate products, but outcomes that are difficult to measure in monetary terms. Unlike this situation, free market theory assumes that a good has a price, is put on the anonymous market and can be bought by anyone in the world, provided they have enough dollars and want to buy it”.

Here, Madörin is addressing the for many years prevailing political trend to transfer economic models from industrial production to the completely different conditions in the health and care professions, resulting in worrying undesirable developments. Technological progress might mean, for example, that cars can be produced faster and faster in the same period of time. However, despite technological progress, it is not possible to care for the sick or look after children etc. faster and faster in the same period of time. Activities in the health and care professions will always be time-consuming and labour-intensive. Madörin focuses on the crucial point: the higher labour costs in the healthcare sector reflect the inherent structure of medical and nursing professions and have nothing to do with a lack of efficiency.
  Allegations of inefficiency are based on the neoliberal narrative of the prevailing healthcare policy. In other words, in medical and nursing professions, the same economic models apply as in industrial production, and moreover, state subsidies in the healthcare sector are evil. Therefore, Madörin is right in demanding that, in view of the special, labour-intensive conditions in the healthcare system mentioned above, state funding should be increased again – and fairly. By international standards, Switzerland’s state funding ratio is very low anyway.⁵
  A striking example characterising the neoliberal orientation of the leading health economists criticised by Mascha Madörin is a statement from the “Careum Working Paper 2” of the Fachhochschule St. Gallen HSG and Careum Zurich:

“‘New medicine’ is [...] a cost-intensive mass market with high demand and increasing specialisation and division of labour. In the consumer’s perception, the comparison of services is important and there is competition between providers. [...] Highly standardised care is not about craftsmanship or art, but about comprehensible service descriptions. Accordingly, a therapeutic relationship based on an individualistic concept and clinical purism is obsolete”.⁶

The “Physicians’ Codex: Medicine Ahead Economics” represents a complete contrast to this. It opposes the neoliberal narrative by emphasising that the task of economy is a serving one:

“In the healthcare system, given limited resources it is the task of economy to support the objectives of medicine and thus high-quality care. In this way, economy serves medicine – provided that economic standards of behaviour do not dominate medical decisions.”⁷

What both documents, the Pysicicans’ Codex and Madörin’s statements, have in common is that they refer to fundamental ideas that have already been formulated in ordoliberal economic theory after the Second World War. In a lecture given in 1960, Alexander Rüstow, sociologist and economist as well as leading representative of “Ordoliberalism”⁸, described the purpose of the economy as a “servant of humanity” as follows:

“We are convinced that there are an infinite number of things that are more important than economy. Family, community, state, all forms of social integration right up to humanity, religion, ethics, aesthetics, in short, the human, the cultural in general. All these major areas of humanity are more important than economy. But none of them can exist without economy; economy must prepare the foundation for all of them. [...] If economy fails at providing the material basis for a humane life, none of these things can develop. In other words, all these supra-economic things have demands with regard to economy. The economy has to fulfil these demands, it has to put itself at the service of these demands. The real purpose of economy is to serve these supra-economic values”.⁹

Madörin calls for economy to develop a useful set of analytical tools that are adapted to the fundamentally different working conditions in the healthcare sector (in contrast to industrial production) in order to come closer to answering the question of how money flows can be regulated in the healthcare sector.
  In principle, Madörin develops an idea that – although in fact obvious – seems to have been forgotten: Scientific methods must be adapted to reality, and not reality to the theories we have come to cherish. Blindly transferring the reality of the entrepreneur and industrial production to the completely different reality of the health care professions inevitably causes damage and suffering. Relatives and patients, as well as all of us working in the health care professions, are already experiencing this today – in one of the richest countries in the world.
  As it has a profoundly ethical dimension, this idea should be the core of all further health policy considerations. We would like to conclude with Giovanni Maio, the renowned Professor and head of the “Institute for Medical Ethics and History of Medicine” in Freiburg (Germany). He aptly characterises the difference between the reality of industrial production and the reality of the medical and nursing professions, the reality of patients and their relatives, and therefore all of us, as follows. In contrast to the entrepreneur, the doctor makes a human promise,

“to devote one’s skills and knowledge to the service of helping others and thus to give absolute priority to the well-being of the patient. Being a doctor is defined by this objective. If the doctor did not make such a promise [...] he would not be able to help, because the patient only exposes himself physically and emotionally to the doctor if he can take such a promise for granted. [...] Only this promise enables medicine to practically realize itself. The promise related to the patient’s well-being thus characterises the identity of medicine in a special way”.¹⁰

The call for adapting economic models to this reality is therefore profoundly ethical. This means in other words to reflect and to direct thinking and action in politics, business and medicine towards the reality of the suffering human being: 
Salus aegroti suprema lex – the health of the patient is the top priority.  •

¹ Hippokratische Gesellschaft Schweiz, 2023. Brochure available at www.hippokrates.ch oder Hippokratische Gesellschaft Schweiz, Wingertweg, Fanas
² Madörin, 2015
³Deutsches Ärzteblatt Jg. 114., Heft 49, 8 December 2017, S. 2338–2340. https://www.dgim.de/fileadmin/user_upload/PDF/Publikationen/Aertze_Codex/20211130_AErzte_Codex_Plakat_2021_WEBVARIANTE.pdf
⁴Schweizerische Ärztezeitung. 2021;102(2728):911–912.
⁵Mascha Madörin cites concrete figures: “According to OECD figures, healthcare costs in Switzerland accounted for 11.3% of GDP in 2019 (Germany 11.7%, Sweden 10.9%). Of this, 3.8% is attributable to household costs (incl. private insurance, in Germany 1.8%, SE 1.7%). Only 7.5% of the 11.3% of costs are attributable to the state and compulsory health insurance (in Germany 9.9%, SE 9.3%). This also means that, compared to German or Swedish households, Swiss households have to bear more than 14 billion more healthcare costs themselves each year than would be the case with a Swedish or German insurance model”.
⁶ Panfil & Sottas, 2009, p. 8
⁷ Panfil & Sottas, 2009, p. 2
⁸ Ordoliberalism: “ordo” = (legal) order; “liberal” = free – in other words: (economic) freedom limited by (state legal) order. Neither a Marxist planned economy nor neoliberal capitalism without a free and democratic legal order. The social market economy is rooted in this ordoliberal school.
⁹ Rüstow, 1960, p. 1
¹⁰ Giovanni Maio, 2018, p. 176f.

Bibliography (in German)

Deutsche Gesellschaft für Innere Medizin. «Ärzte Codex – Medizin vor Ökonomie». In: Deutsches Ärzteblatt, Jg. 114, Heft 49, 8 December2017. https://www.dgim.de/fileadmin/user_upload/PDF/Publikationen/Aertze_Codex/20211130_AErzte_Codex_Plakat_2021_WEBVARIANTE.pdf

Madörin, Mascha. «Ökonomisierung des Gesundheitswesens – Erkundungen aus der Sicht der Pflege». Februar 2015. https://www.zhaw.ch/storage/gesundheit/institute-zentren/ipf/%C3%BCber_uns/studie-mad%C3%B6rin-%C3%B6konomisierung-gesundheitswesen-version-215-zhaw-gesundheit.pdf

Maio, Giovanni. Werte für die Medizin. Warum Heilberufe ihre eigene Identität verteidigen müssen. München 2018

Panfil, Eva Maria & Sottas, Beat. «Woher kommen die Besten? Globaler Wettbewerb in der Ausbildung – wer bildet zukunftsfähige Health Professionals aus?» In: Careum Working Paper 2 (2009), Careum Verlag. Zürich 2009, S. 8ff.

Rüstow, Alexander. «Wirtschaft als Dienerin der Menschlichkeit». In: Aktionsgemeinschaft Soziale Marktwirtschaft. Was wichtiger ist als Wirtschaft. Vorträge auf der fünfzehnten Tagung der Aktionsgemeinschaft Soziale Marktwirtschaft am 29. Juni 1960 in Bad Godesberg, Martin Hoch Druckerei und Verlagsgesellschaft. Ludwigsburg 1960

Schweizerische Gesellschaft für Allgemeine Innere Medizin. «Der Ärzte Kodex Medizin vor Ökonomie – Gegen die zunehmende Ökonomisierung der Medizin». In: Schweizerische Ärztezeitung 2021;102(2728):911-912

«Ökonomisierung in der Medizin. Rückhalt für ärztliches Handeln»: https://www.dgim.de/fileadmin/user_upload/PDF/Pressemeldungen/2017_Klinik_Codex_01.pd