Medicine, Money, and Morals: Physicians' Conflicts of Interest (review)

This book’s provocative and alliterative title promises more than it delivers. It does not tackle the broad subject of conflict of interest, but focuses on recent approaches to regulating physicians’ financial conflicts. Written by a lawyer/health policy analyst, the first fifty pages are more interesting than the remaining two hundred, whose tone is dry, legalistic, and hortatory.

“Morals,” used interchangeably with “ethics” and “ethos,” is never defined. Treatment of the various codes of ethics is highly selective and fragmentary. In the case of the Hippocratic oath and corpus, Rodwin cites one scholar’s reflections on its underlying ethos rather than quoting it at length or discussing the changing attitudes toward its moral strictures. Nor does the section on the AMA’s code of ethics consider the fact that the original 1847 version was rooted in the norms of ethics and etiquette set forth in Percival’s code of the gentleman, and that major revisions in 1950 and 1980 resulted in less specificity as our moral and cultural pluralism was confronted.

Taking as his touchstone Shaw’s Doctor’s Dilemma (published in the early 1900s), Rodwin asserts that financial “conflict of interest was hardly mentioned in professional or popular writing about medicine in the United States until the late 1960s” (p. 2). Forgotten are the many critics within the profession, such as E. A. Codman and A. J. Cronin. In 1937, the latter’s very popular novel The Citadel explored the issue of fee-splitting and other aspects of physicians as moneymakers; so did The Last Angry Man, also made into a popular motion picture in the 1950s. Nor does Rodwin give sufficient credit to medicine, which as a profession has been very prone to hang its dirty linen publicly, providing almost daily fodder for the media.

The opening chapters give some context, mainly through the eyes of politicians and policy makers, but the tremendous impact of Medicare and Medicaid—well-meaning reforms that poured enormous sums of money into the health care sector—is understated. Along with societal and technological changes, these programs catalyzed the transformation of a highly individualistic cottage industry, principally dedicated to caring for specific patients, into a vast jobs-creating and product-oriented enterprise increasingly run by nonphysicians for profit, with patients representing market share. As Arnold Relman points out in the introduction, physicians and even nonprofit institutions became more entrepreneurial. As the health-care sector prospered, warnings (beginning in the early seventies) about rising costs were largely ignored. Finally, an alliance of business, government, and labor has forced hospitals and physicians to cut costs, replacing incentives to “do everything” with equally problematic incentives to minimize care.

Rodwin also fails to consider the influence of the “me” decade, whose shibboleth was “Look out for number one.” If money has become, in the words of a New Yorker cartoon, “life’s report card,” it should not be a revelation that some physicians—like some classmates who went into business, finance, and the law— put a premium on it. That 20,000 physicians put their self-interest above their patients in a drug company-sponsored program is clearly reprehensible, but why not mention that there are more than 600,000 licensed physicians?

The solutions that Rodwin puts forward to resolve financial conflicts of interest are extremely theoretical and are likely to be ill suited to the set of problems being created by the radical transformation in the health-care landscape. Thus, while this book provides a good starting point, interested readers might wish to consult Edmund Pellegrino’s authoritative but uncited writings on the physician as double and triple agent for the views of a philosopher/practitioner, as they wait for the dust to settle.