The tradtional doctor-patient relationship constitutes a special covenant between doctors and their patients. Within this covenant, the patient agrees to take the doctor into his confidence, to reveal even the most secret and intimate information related to his health. The physician, in turn, agrees to honor that trust, to become the patient's advocate in all health-related matters, and to place that patient's interest above all other considerations.

Doctors rely on the integrity of the doctor-patient relationship, since their duty as patient's advocate defines their very purpose. Without this role, they loose all claims to the title "professional."

Patents rely on this relationship for far more than merely professional integrity. The traditional doctor-patient relationship is their only guarantee that, in their dealings with a complex health care system, there is at least one knowledgeable professional who is looking out for their interests above all else. The loss of such an advocate, especially at a time when all the other interests in the health care system have never been less likely to coincide with their own, would be catastrophic.

Why we can't have it anymore

While policymakers cannot admit it openly, the need to ration health care - that is, to withhold at least some useful medical services from at least some individuals who would benefit from those services - is an absolute economic imperative. Since policymakers cannot talk openly about the imperative to ration, the necessary rationing must be conducted covertly.

And covert rationing demands the destruction of the doctor-patient relationship.

To see why this is so, all you have to do is consider the two million encounters each day that take place between doctors and patients.  In our time-honored way of doing things, each encounter finds individual doctors and individual patients - just the two of them, alone in a room - making millions of individual decisions about how much of society's money to spend for that patient's sole benefit. And when the doctor finally places pen to paper, the entire medical-industrial complex immediately bends to her will.

Obviously, we can no longer allow such spending decisions to be made in a vacuum, as if their cumulative effect is irrelevant. And since society cannot affect those individual decisions through an open system of rules - since that would constitute openly rationing health care - those decisions must be affected in some other way.

To HMO executives, federal regulators, and anyone else society has deputized to bring down the cost of health care, the solution is simple. Coercive pressure must be applied to the focal point of all health care spending - the physician-patient encounter - to force spending decisions to be made on the basis of something other than what is best for the patient.

Indeed, covert rationing demands that the doctor forego his primary duty to his patient in favor of some "greater good." That demand is non-negotiable. If doctors are reluctant to give up their traditional role as their patient's advocate, they must be coerced into doing so, and the ones who still refuse need to be weeded out. For the engine that drives covert rationing must be - can only be - destruction of the doctor-patient relationship.

The fundamental mechanism for undermining this relationship is simply to make its cost too high for doctors to bear. Both HMOs and governmental regulators have become adept at finding extremely persuasive means of doing so. Indeed, while professional societies still give lip service to the physician's overriding obligation to the individual patient, both health care professionals and ethicists have begun to acknowledge publicly that the traditional doctor-patient relationship cannot stand. The traditional ethical precepts, it is held, are simply impractical today, and cannot be maintained. Because of harsh economic realities, the needs of society (it is said with a reluctant shrug) must be recognized to have at least as much claim on physicians as the needs of their individual patients. 

This fundamental change drives a deadly wedge between doctors and their patients, separating them, marginalizing them, and leaving each to fend for themselves in an increasingly hostile health care system.

Back to news and commentary

YourDoctorintheFamily.com Home Page