In most medical schools, students recite the Hippocratic Oath together to mark the start of their professional careers. The soon-to-be physicians swear to uphold the ethical standards of the medical profession and promise to stand for their patients without compromise.
Though the oath has been rewritten over the centuries, the essence of it has remained the same: 鈥淚n each house I go, I go only for the good of my patients.鈥
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But the principles of the oath, says Dr. Gregg Bloche, are under an 鈥渦nprecedented threat.鈥 In The Hippocratic Myth, Bloche details how doctors are under constant pressure to compromise or ration their care in order to please lawmakers, lawyers and insurance companies.
Bloche says that doctors are increasingly expected to decide which expensive tests and treatments they can and cannot provide for their patients. Their dual role as examiner and cost-cutter can then potentially compromise patients鈥 care, he says, particularly when insurers and hospital administrators urge physicians to only perform 鈥渕edically necessary鈥 treatment.
The Hippocratic Myth: Why Doctors Have to Ration Care, Practice Politics, and Compromise their Promise to Heal
By M. Gregg Bloche M.D., Hardcover, 272 pages, Palgrave Macmillan
List Price: $27
鈥淭he average person thinks that 鈥榤edically necessary鈥 care means all care that might potentially be beneficial,鈥 he says. 鈥淏ut the reality is that it鈥檚 a wide-open term.鈥
Care may be denied, says Bloche, for a variety of reasons, including whether patients have consented to cheaper treatment options through their health insurance plans. What that means, he says, is that doctors who ration care on behalf of insurance providers may simply be following their patients鈥 wishes 鈥 even if patients are not aware that they鈥檙e receiving subpar treatment.
鈥淚n the real world, the choices aren鈥檛 made clear in the employee benefits office,鈥 he says. 鈥淚n the real world, the cheap health plan and the expensive health plan both promise you 鈥榤edically necessary鈥 care and you don鈥檛 really know what that means. So you sign up for this care and you think, 鈥楢ha! This one鈥檚 cheaper than the other. And it鈥檚 promising medically necessary care. You don鈥檛 really know that one car is a Lexus and one car is a Chevy. These two plans are being presented to you as Lexuses. And so you say, 鈥業鈥檒l buy it.鈥 But in fact, in terms of the care it makes available, it鈥檚 cheap because it鈥檚 a Chevy, not a Lexus.鈥
Talking about potential tradeoffs in care is a conversation that doctors and policymakers need to have, says Bloche, because it鈥檚 inevitable that our health care system will need to find ways to set limits on care.
鈥淲e cannot afford anything like what we鈥檙e spending on health care today, and we鈥檙e certainly not going to be able to afford what we鈥檙e projected to spend in the future,鈥 he says. 鈥淲e spend almost a fifth of our national income today on medical care. And within 25 years, unless we change dramatically, we鈥檙e going to be spending a third of our national income on medical care. And we鈥檙e doing that by borrowing from our kids.鈥
Interview Highlights
On the rationale of withholding care:
鈥淭he rationale there is that the doctor who stints on care three years later when you get really sick is acting in accordance with your preferences as you expressed them in the employee benefits office three years before,鈥 says Bloche. 鈥淎nd therefore, the doctor is not violating the Hippocratic Oath. The doctor is merely complying with your preferences when you rolled the dice in the employee benefits office.鈥
On insurers not being required to reveal their criteria to providers for what claims they鈥檒l pay:
鈥淭his is a walk on the wild side. I鈥檝e taken on some of these cases for people that I know, and one thing about it, if you know the system鈥檚 hypocrisies, then you can beat the system. One of the hypocrisies is that the companies take the position that their guidelines for what they will and will not pay for are trade secrets 鈥 that they鈥檙e proprietary. Now imagine a legal system in which the laws were considered trade secrets and their lawyers weren鈥檛 allowed to know the laws in advance because that would mean they could game the system. That doesn鈥檛 fit with our legal values, our due-process values 鈥 but that is what happens for many, not all, health plans. They take the position that they鈥檙e not going to reveal in advance the rules for what they鈥檒l pay for and won鈥檛 pay for because that would enable doctors and patients to game the system.鈥
On randomized clinical trials:
鈥淲hat鈥檚 amazing is that probably only 10 to 20 percent of the treatments that doctors use today have been tested [in] randomized clinical trials. Even when a treatment is shown to work really well for the sample that鈥檚 studied in the clinical trial, in the real world patients are all different. [They] vary hugely. So we鈥檙e never going to be able to have solid science that can tell us for sure whether the treatment is going to work or not. So let鈥檚 do the research but let鈥檚 be realistic and pragmatic about the limits of that research.鈥