Government-Run Health Care vs. the Hippocratic Oath

When medical students graduate from medical school, they take an oath—the Hippocratic oath—in which they solemnly swear, above all, to use their best judgment in treating their patients. Doctors hold this oath as sacrosanct; they regard upholding it as morally mandatory, and violating it as out of the question. But in order to uphold this oath, in order to practice medicine in accordance with their best judgment, doctors must be free to practice in accordance with their best judgment. Unfortunately, U.S. politicians are working feverishly to prevent doctors from upholding the Hippocratic oath. How so? By implementing government-run health care.

Politicians’ efforts to impose government-run health care include their goal of “guaranteeing” health care to everyone. But whenever the government attempts to “guarantee” health care, it must also control the costs of that service—which means, it must dictate how doctors may and may not practice. Toward this end, as Harvard professor Martin Feldstein notes, advocates of government-run health care call for “comparative effectiveness” practice guidelines. Quoting the White House Council of Economic Advisers, Feldstein points out that these guidelines are designed to ration health care and reduce spending by “implementing a set of performance measures that all providers would adopt” and by “directly targeting individual providers . . . (and other) high-end outliers.”1 (“High-end outliers” is government-speak for “physicians who order more tests or perform more procedures than the government deems appropriate.”)

An example of such “effectiveness” guidelines is the new federal recommendations for screening mammography. The U.S. Preventive Services Task Force (USPSTF) recently recommended restricting mammogram screening to women over age fifty, despite the fact that medical organizations such as the American Cancer Society and the American College of Radiology—whose conclusions are based on years of peer-reviewed scientific research—have long recommended that women begin routine mammography at age forty.2

The USPSTF argues that eliminating mammograms for women between ages forty and forty-nine would result in only one additional cancer death per nineteen hundred women screened—an increase in death that they evidently consider acceptable.3 The announcement of these new guidelines caused so much public controversy that Secretary of Health and Human Services Kathleen Sibelius quickly backpedaled and stated that these particular USPSTF recommendations would be “nonbinding.”4 But what does “nonbinding” mean when it refers to the guidelines of a government agency? The government is an agent of force. Any government “recommendations” come with at least the implicit threat that recalcitrant doctors may face negative consequences.

Not surprisingly, government medical agencies have already adopted the new guidelines. The California state government has begun using the USPSTF guidelines to determine which services patients in the Medi-Cal program may and may not receive.5 (Medi-Cal is the California equivalent of Medicaid in other states.) Government-funded health programs in New York and Ohio have already begun turning away women under fifty seeking mammograms.6 And, Sibelius’s reassurances notwithstanding, Congress is considering giving the USPSTF legal authority to determine which screening tests will or will not be covered for patients with private health insurance.7

How are American physicians responding to these developments? Fortunately, many have chosen to ignore the guidelines, to continue practicing according to their best medical judgment, and to order mammograms on their female patients between ages forty and fifty as they see fit.8 But bear in mind that the White House Council of Economic Advisers has already pejoratively labeled such physicians “high-end outliers.” If the government decided to enforce its “comparative effectiveness” guidelines, such doctors could be punished at any moment. And bear in mind what the punishment would be for: upholding their Hippocratic oath, their promise to practice according to their best judgment for the best interests of their patients.

In addition to the fundamental fact that a doctor has a moral right to practice in accordance with his own judgment (via the right to liberty), his judgment of the specific facts of each individual patient is the basic ingredient of good medicine. Whereas a doctor’s treatment decisions are based on such facts and rooted in his medical knowledge, “comparative effectiveness” guidelines are necessarily based on statistical averages. Thus, a doctor upholding his Hippocratic oath might reason as follows: “Based on the location of Mrs. Jones’s abdominal pain, she probably has either gallstones or appendicitis. Should I order an ultrasound or a CT scan as my next test? Would her heart murmur make surgery too risky? Does that yellow tint in her eyes indicate a liver problem that warrants a different antibiotic?” In contrast, a bureaucrat upholding the government’s “comparative effectiveness” guidelines would proceed another way: “Someone by the name of Jones who claims to have abdominal pain wants medical treatment. Where are those statistics on abdominal pain?”

If you develop severe abdominal pain due to gallstones, who do you think should decide whether medication or surgery would be most “effective” for you? You—in conjunction with your doctor who placed his hands on your abdomen, viewed your ultrasound, knows your drug allergies, and took an oath to treat you in accordance with his best judgment for your best health? Or a bureaucrat who never met you, never went to medical school, and is beholden to “cost-effectiveness” guidelines that he must follow in order to keep his job with the government?

Dr. Jane Orient summarizes the situation as follows:

Traditionally, medicine is practiced by physicians, one patient at a time. The outcome is assessed by that patient. The right decision is the one chosen by the patient, in consultation with the physician, based on what is optimum for that patient, considering all aspects of his circumstances. The standard of care is the Oath of Hippocrates: providing treatment for the good of each patient according to the best of the doctor’s ability and judgment.

In the “reformed” delivery system, healthcare is practiced from on high by committees of “experts” pulling the strings of marionette physicians (rankings, payment rates, other incentives and disincentives) who are judged on how well they achieve population-based outcomes. Patients are like sheep in the flock, categorized by race, income level, quality-adjusted remaining years (QARYs), compliance, functional ability, diversity score, or whatever metrics the rulers adopt. Any individual can be sacrificed for the good of the whole.9

A doctor’s primary ethical responsibility is to his patient’s medical well-being. But under government-run health care, he must practice with one eye toward his patient’s medical condition and one eye toward a bureaucrat’s statistical decree. To the extent that the government forces a physician to act against his professional judgment, the physician cannot uphold his oath to serve his patients’ best interests.

Consider how this works in the two alleged utopias of government-run health care, Great Britain and Canada.

In Great Britain, the government attempts to provide “universal health care” (the modern euphemism for government-run health care) through its National Health Service (NHS). How has this been working out for the British? Predictably, the NHS imposed cost-control measures that pitted doctors’ financial interests against their patients’ well-being. For instance, the Telegraph reported in 2008 that the NHS paid bonuses to family physicians who reduced the number of patients they referred to specialists.

Under one scheme, GPs stand to gain £59 [approximately $100] for every patient not referred to hospital, if they cut an average referral rate by between two and eight per cent. NHS managers say referral rates, which rose 16 per cent nationwide during the first quarter of this year, have to be cut to save money. . . .

A leading surgeon said that patients’ cancers had already gone undiagnosed after they were denied specialist care under two such “referral management” schemes.10

A survey of British oncologists revealed that nearly one in four admitted to deliberately withholding information from their patients about certain possible treatment options. Why? Because those options, although available in other countries, were not permitted under the NHS system. Why? Because the government considered them too expensive.11

That British doctors would not administer these outlawed treatments is unsurprising: Breaking the law has consequences. But why did these doctors withhold information from their patients regarding treatments that were “widely available throughout Europe”?12 After all, patients rely on their physicians for information about treatment options—including an honest appraisal of all the risks, benefits, and alternatives—so they can make fully-informed decisions about their lives. Failure to disclose such information is a serious breach of a doctor’s Hippocratic oath.

The reason so many of these physicians withheld this information is that the NHS’s “cost-effectiveness” policies put the physicians in the position of having to guess whether revealing the existence of these options to their patients would do more harm than good. When asked why they withheld these treatment options from their patients, the oncologists replied that “there was ‘no point’ in discussing treatments their patients could not have,” and that such discussions might “distress, upset, or confuse” their patients. NHS policies pitted doctors against their patients by creating an ethically perverse situation in which physicians, prohibited by the government from doing what they actually think is best for their patients, had to decide whether it might be best to conceal medically important information from their patients—and patients, trusting their doctors to provide them with all the relevant information concerning their medical conditions and possible treatments, heard a big lie.13

Doctors and patients in Canada find themselves in similar situations. Although Canadian doctors are nominally independent, they receive all or nearly all of their income from the “single-payer” government system; thus, they are completely (or nearly completely) beholden to the government for their livelihood. The Canadian government also controls access to operating rooms and hospital beds through its infamous system of waiting lists or “queues.”14 According to the Fraser Institute, patients in Canada often wait months longer than their doctors consider “clinically reasonable” before they may see a specialist, undergo surgery, or receive advanced treatments.15 One Canadian doctor told documentary filmmaker Stuart Browning that if a surgeon was too persistent in requesting operating-room time for his patients, he could be disciplined as a “disruptive doctor” and have his already limited operating-room time reduced even further.16 Here again, under government-run health care, we see surgeons being forced to choose between treating their patients in accordance with their best judgment and maintaining their capacity to practice medicine.

Although the vast majority of Canadians must suffer the long waits inherent in government-run medicine, Canadians with political pull frequently use their clout to “jump the queue.” Dr. Lee Kurisko, a physician who has practiced in both Canada and the United States, calls this the “deep, dark secret” of Canadian medicine.17 This, too, thwarts doctors’ ability to uphold their Hippocratic oath. When politically connected patients use their pull to influence a physician’s treatment priorities, the physician is no longer acting in accordance with his best judgment for each of his patients; to the extent that the politically connected demand his time and attention, he cannot apportion his time and attention in accordance with his own best judgment—as he has solemnly sworn to do.

The lesson from these (and countless similar examples) from Great Britain and Canada is: Whenever and to the extent that the government dictates how doctors are paid and how they may and may not practice—as the government to some extent must under any form of government-run health care—doctors are unable to act on their own judgment and thus unable to uphold their Hippocratic oath.

What does this mean for America? It means that Americans had better grasp this principle before it is too late.

Consider the proposed new cost-control measures in the Massachusetts “universal” system and in the federal Medicare program. As I discussed in my article “Mandatory Health Insurance: Wrong for Massachusetts, Wrong for America” (The Objective Standard, Fall 2008), the Massachusetts state government’s attempt to guarantee “universal coverage” through mandatory insurance has led to skyrocketing costs.18 To contain these rising costs, a special Massachusetts state commission has recommended eliminating the standard fee-for-service system of medical reimbursement and instead requiring the government or private insurers to pay doctors and hospitals an annual fixed fee for the medical care of each patient.19 Advocates of this plan claim that it will give providers an incentive to improve efficiency and eliminate unnecessary tests and treatments. In reality, however, it will create an incentive for physicians and hospitals to provide as little care as possible.

Under the proposal, if the cost of a patient’s annual care is less than his annual allotment, the providers keep the unused portion. If the cost is greater than his allotment, the difference comes out of the providers’ pockets. This plan patently pits doctors’ interests against their patients’ interests.

Suppose, for instance, the state has already paid out 90 percent of your annual allotment. You then see your doctor for a severe headache. He examines you, peeks at the balance on your allotment, and says, “No need for an expensive MRI scan of your brain. Just take two Tylenol and call me in the morning.” Can you be sure that he is giving you his best medical advice?

Even if, despite the government’s interference, a doctor attempts conscientiously to practice in his patients’ best interests, his decisions will inevitably be questioned—and at least occasionally “corrected”—by government-beholden hospital administrators: “Does Mrs. Jones really need another ultrasound test? Can’t you use a cheaper antibiotic for her infection? Isn’t she stable enough to go home today, rather than spend another expensive night in the hospital? We’ve already burned through the money allotted to take care of her this year. Anything else we do for her puts us in the red.”

Under such a system, doctors will be forced to balance the requirements of their patients’ health against the demands of an administrative bureaucrat—a bureaucrat who may well write the doctor’s paycheck and decide whether to renew his practice privileges.

In an effort to control skyrocketing Medicare costs, the federal government is experimenting with a similar system of “bundled payments” in which the government pays a single fixed sum to hospitals and physicians to care for their Medicare patients.20 Again, advocates claim this will save money by improving “cost effectiveness.”21 And, again, this scheme will thwart the ability of doctors and hospitals to treat their patients in accordance with their best judgment.

As Dr. Larry Martinelli (past chairman of the Clinical Care Committee of the Infectious Disease Society of America) notes, bundled payments “would pressure hospitals to try to save money by bringing on fewer specialists to consult on patients.”22 Just as with the Massachusetts proposal, this proposed Medicare “reform” would reward doctors and hospitals for denying necessary care to their patients.

Fortunately, few American physicians will meekly roll over and obey such insane government guidelines. Most have chosen to disregard the USPSTF guidelines on screening mammography, and most are likely to continue practicing according to their best medical conscience in general—at least for now. But as the government increasingly punishes American doctors for following their best medical judgment, conscientious physicians will have to waste untold hours avoiding detection, arguing with bureaucrats, and defending their actions while their less-conscientious colleagues will just follow orders, punch a clock, and go home. In other words, government policy will routinely punish doctors for their medical virtues and reward them for their vices.

When the government forces doctors to choose between treating their patients in accordance with their best judgment or sacrificing their patients to keep their jobs, it puts doctors in an impossible position in which they can no longer treat their patients properly—and it puts patients in an intolerable position in which they can no longer trust their physicians.

Americans who want to continue receiving high-quality medical care from physicians they can trust must oppose all forms and degrees of government-run health care. We must advocate a free market in health care,23 a market in which doctors can do what doctors are supposed to do: uphold their Hippocratic oath and take care of their patients to the best of their judgment and ability.

About Paul Hsieh

Paul Hsieh, MD, is a practicing diagnostic radiologist in the south Denver metro area. He received his BS in mathematics from the Massachusetts Institute of Technology and his MD from the University of Michigan, and has served on the faculty at the Washington University School of Medicine in St. Louis, MO. Dr. Hsieh is also a founding member of Freedom and Individual Rights in Medicine (FIRM). For more information on FIRM, please visit www.WeStandFIRM.org.

View all articles by Paul Hsieh →