Medicine, Money, and Morals Physicians' Conflicts of Interest

by Rodwin, Marc A.

• ISBN13: 9780195080964
• ISBN10: 0195080963
• Format: Hardcover
• Copyright: 1993-05-13
• Publisher: Oxford University Press

Summary

Conflicts of interest are rampant in the American medical community. Today it is not uncommon for doctors to refer patients to clinics or labs in which they have a financial interest (40% of physicians in Florida invest in medical centers); for hospitals to offer incentives to physicians who refer patients (a practice that can lead to unnecessary hospitalization); or for drug companies to provide lucrative give-aways to entice doctors to use their "brand name" drugs (which are much more expensive than generic drugs). In Medicine, Money and Morals , Marc A. Rodwin draws on his own experience as a health lawyer--and his research in health ethics, law, and policy--to reveal how financial conflicts of interest can and do negatively affect the quality of patient care. He shows that the problem has become worse over the last century and provides many actual examples of how doctors' decisions are influenced by financial considerations. We learn how two California physicians, for example, resumed referrals to Pasadena General Hospital only after the hospital started paying $70 per patient (their referrals grew from 14 in one month to 82 in the next). As Rodwin writes, incentives such as this can inhibit a doctor from taking action when a hospital fails to provide proper service, and may also lead to the unnecessary hospitalization of patients. We also learn of a Wyeth-Ayerst Labs promotion in which physicians who started patients on INDERAL (a drug for high blood pressure, angina, and migraines) received 1000 mileage points on American Airlines for each patient (studies show that promotions such as this have a direct effect on a doctor's choice of drug). Rodwin reveals why the medical community has failed to regulate conflicts of interest: peer review has little authority, state licensing boards are usually ignorant of abuses, and the AMA code of ethics has historically been recommended rather than required. He examines what can be learned from the way society has coped with the conflicts of interest of other professionals --lawyers, government officials, and businessmen--all of which are held to higher standards of accountability than doctors. And he recommends that efforts be made to prohibit and regulate certain kinds of activity (such as kickbacks and self-referrals), to monitor and regulate conduct, and to provide penalties for improper conduct. Our failure to face physicians' conflicts of interest has distorted the way medicine is practiced, compromised the loyalty of doctors to patients, and harmed society, the integrity of the medical profession, and patients. For those concerned with the quality of health care or medical ethics, Medicine, Money and Morals is a provocative look into the current health care crisis and a powerful prescription for change.

Author Biography

About the Author: Marc A. Rodwin, Associate Professor of Law and Public Policy at Indiana University-Bloomington, has an M.A. from Oxford University, a J.D. from the University of Virginia Law School, and a Ph.D. from Brandeis University.

Table of Contents

Foreword	p. ix
Introduction	p. xiii
The Problem and the Profession's Response
Physicians' Conflicts of Interest	p. 1
The Patient-Physician Relationship	p. 1
What Are Conflicts of Interest?	p. 8
The Changing Context of Medicine	p. 11
The Medical Profession's Response: 1890-1992	p. 19
Conflicts of Interest and the AMA and ACS Response: 1890 to 1950	p. 21
The Commercial Transformation: 1950s to 1980	p. 31
The Ethics of Markets: 1980 to 1992	p. 40
Bioethics	p. 46
Conclusion	p. 51
Current Problems and Institutional Responses
Incentives to Increase Services: The Range of Existing Practices	p. 55
Financial Arrangements That Create Conflicts of Interest	p. 55
The Maze of Financial Incentives	p. 57
The Unity of Conflicts of Interest	p. 94
The Dangers of Incentives to Increase Services and the Ineffectiveness of Current Responses	p. 97
The Dangers of Financial Incentives	p. 98
Countering Financial Incentives: Utilization and Peer Review	p. 111
The Limitations of Current Law and Policy	p. 115
Incentives to Decrease Services In HMOs and Hospitals	p. 135
Withholding Services and Conflicts of Interest	p. 135
HMOs and Financial Incentives	p. 138
Hospitals and Financial Incentives	p. 148
The Dangers of Incentives to Decrease Services and the Ineffectiveness of Current Responses	p. 152
The Dangers of Financial Incentives	p. 152
Countering Financial Incentives: Peer Review and Quality Assurance	p. 162
The Limitations of Current Law	p. 165
Inferences for Policy
Fiduciary Law and the Professions: Regulation of Civil Servants, Business Professionals, and Lawyers	p. 179
Fiduciary Principles and the Professions	p. 179
Conflicts of Interest of Public Officials	p. 184
Conflicts of Interest in Business	p. 192
Conflicts of Interest of Lawyers	p. 200
Common Intervention Strategies to Hold Fiduciaries Accountable	p. 207
Lessons for Physicians	p. 210
What Needs to Be Done?	p. 212
The Limits of Disclosure as a Remedy	p. 213
The Limits of Public Intervention	p. 220
Policies for Physicians' Conflicts of Interest	p. 223
The Job Ahead	p. 234
Incentives, Ethics, Law, and Social Policy	p. 244
Table of Acronyms	p. 249
Appendices
The Concept of Conflict of Interest	p. 253
Note on Physicians' Divided Loyalties	p. 256
Bioethics and Medical School Ethics Education	p. 259
The Sources and Data Used	p. 264
Excerpts from Medical Codes of Ethics	p. 268
Notes	p. 271
Acknowledgments	p. 391
About the Author	p. 397
Index	p. 399
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