Medicine, Money and Morals: Physicians' Conflicts of Interest By Marc A. Rodwin (review)

temporary, William Stewart Halsted, Murphy did not develop and promote a distinguished school of surgeons. There apparently was little interaction between these two giants. Murphy did describe a sort of radical mastectomy, but it was not guided by Halsted's principle (" . . . the suspected tissues should be removed in one piece"), Halsted was not mentioned in this article (Surg. Gyn. Obst. 2:84—89, 1906), nor was there a follow-up of patients. Murphy's gravest fault was a lack of simple honesty, documented in another interesting biography by Loyal Davis (J. B. Murphy, Stormy Petrel ofSurgery, N.Y., Putnam, 1938, p. 163). (I did not find this note in the present volume, which tends to be more laudatory.) Murphy wrote to a coauthor who was preparing a paper on the "button" for publication: "If Abbe's case terminates fatally, as I have some fear it will ... I would not include it in the numbers." This smoothing of reported facts, not of course acceptable, is perhaps justified in the minds of originators, whose ideas may be undervalued if not thus promoted. Be that as it may, J. B. Murphy contributed solidly to the advancement of surgery and Drs. Schmidt and Oh and their colleagues have usefully described his life's work. Donald Ferguson Department of Surgery University of Chicago Medicine, Money and Morab: Physicians' Conflicts ofInterest. By Marc A. Rodwin. Oxford Univ. Press, 1993, Pp. 411. Concern with the issue of conflicts of interest is on the rise in all professions, and Rodwin's book provides a detailed and compelling account of the pervasive nature of the problem as it exists in modern medicine. He skillfully compares conflicts of interest as they arise in medicine with parallel problems in other areas of human endeavor, such as law, public service, banking, and real estate. He conducts a careful, thorough historical investigation of the erratic regulation of conflicts of interest, and gives a nuanced account of the differences in position taken by the AMA and the ACS over time. And he is especially insistent of the enormity of the problem created when financial matters create a wedge between the interests of a patient and those of the treating physician. His book is carefully researched and documented; it contains excellent references to empirical studies of the problem, and is overall an indispensable font of information on conflicts problems. Another strength of Medicine, Money & Morab is that Rodwin shows a keen sense of the difficulties when he ticks off the imperfect response now provided to the conflict of interest question by legal doctrines of informed consent, consumer protection legislation, and the practice of disclosing conflict to patients or to some IRB. His measured approach to these potential forms of regulation shows that he is sympathetic with many scholars who no longer see various forms of government regulation as a silver bullet that effortlessly kills all forms of private misbehavior. 310 Book Reviews Yet even with that sophistication, Rodwin still underestimates the difficulty of the conflict of interest question and the social response to it. He skillfully uses George Bernard Shaw's The Doctor's Dilemma to show that conflicts of interest are inherent in any contractual arrangement. Yet, he oddly understates the costs of responding to the problem by creating laws prohibiting certain types of transactions . Suppose, for example, that one adopted a rule that physicians were never allowed to obtain, even with full disclosure, a fee for referring patients to another physician. At one level this approach would eliminate the conflict of interest that arises when the collection of the fee takes precedence over the care and welfare of the patient. Yet that prohibition creates a new conflict of interest that cuts in the opposite direction. Now a general practitioner has an incentive to keep patient in his or her care for too long a period of time. After all, the specialist referral will generate no income for the physician, and will represent the loss of future income. At the margin the physician will be better offcollecting fees until it becomes clear that some specialist care is needed: let's watch this case a bit longer to see if surgery is really needed. The use...