Section 1 - The importance of the doctor-patient relationship, and why we can't have it anymore

A deadly wedge is being driven today between patients and their doctors, destroying the sanctity of their time-honored relationship, leaving each to fend for themselves in an increasingly hostile health care environment, and placing each at the mercy of powerful interests whose only real concerns are costs, profit and power.  As a result, both doctors and patients are being shunted aside, separated from one another, marginalized, and reduced to mere ciphers.

This assertion may very will resonate with many of you. It certainly will if you’re a doctor with a reasonably well-developed sense of professional purpose.  And it probably will if you’re a patient who has had a significant encounter with the health care system within the past few years.  What may not immediately resonate is the reason for it.  Why is the doctor-patient relationship being undermined?

It would be natural to assume that erosion of this relationship is merely one of the unpleasant side effects of the radical changes we are now seeing in our health care system.  But that assumption would be wrong.  Destruction of the doctor-patient relationship is not merely a side effect of these changes – rather, it is their centerpiece.  It is necessary.

“Necessary?” You may be asking, eyebrows raised.

Yes, I reply, and wait ‘till you hear why

Destroying the doctor-patient relationship is necessary because doing so is central to – and indeed, is the fundamental mechanism by which we accomplish – covert rationing.  And in the United States today, doctors, hospitals, health insurers, HMOs, and the government, with the subconscious collusion of us all, are fully committed to and vigorously engaged in the covert rationing of our health care.

Now, be assured that I don’t expect you to simply take my word for any of this.  I intend to demonstrate fully that these assertions – that we’re covertly rationing health care, and that this covert rationing requires destruction of the doctor-patient relationship – are true, and then to suggest what we ought to be doing about it.

In Section 2, I will show how rationing health care has become an absolute economic imperative.  While public officials and health care providers do not (and cannot) admit it, the need to ration is accepted as an axiom by health care economists.  We must ration health care and are doing so, economists agree, simply as a matter of demographics and mathematics.  The only question, then, is not whether to ration, but how to ration.

The most straightforward way to ration health care would be to openly establish a set of rules for determining how health care services should be distributed, and to apply those rules equally and fairly, across the board.  Such a process would be called open rationing.  But we cannot conduct open rationing in our society because, well, that would be rationing.  And the notion of rationing health care is anathema in the United States.

If we cannot ration health care openly, the only other choice (since ration we must) is to ration covertly, that is, to ration while denying that we are rationing at all.  And that is what we are doing today.

To see how covert rationing works, consider the problem faced by the CEO of an HMO, (or by a Medicare administrator, or by one of the other individuals we have deputized to reduce our health care costs).  When such an individual looks out over the landscape of medicine as it is traditionally practiced, he beholds a frightening sight: over two million times each day, individual physicians and individual patients – just the two of them, alone in a room – make millions of individual decisions about which health care resources should be called upon for the sake of that individual patient at that particular time.  And when each of these decisions is finally reached, and the doctor places pen to paper and signs her name, the entire medical-industrial complex immediately bends to her will.  

Our CEO, witnessing all this in a cold sweat, is thinking, “They’re spending my money.”

Actually, they’re spending society’s money.  But whoever has dibs on the money, the fact remains that we can no longer allow such spending decisions to be made in a vacuum, as if the cumulative effect of those decisions on society are irrelevant. Since we cannot affect those individual spending decisions through an open system of rules – again, that would be rationing – we must affect them in some other way.  

To both the HMO executive and the governmental regulator, the answer is quite simple.  Coercive pressure must be applied at 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.  

Covert rationing requires that decisions made at the bedside be made with society’s priorities in mind, and not the patient’s.  Indeed, covert rationing demands that the doctor forego his primary duty to his patient, in favor of “the greater good.” The demand is non-negotiable.  If doctors are reluctant to give up their traditional role as their patients’ advocates, they must be coerced into doing so, and the ones who still refuse need to be weeded out. Thus, an essential truth is revealed. The engine that drives covert rationing must be - can only be - destruction of the traditional doctor-patient relationship.

There is no denying that the needs of society are important.  In fact, if the proportion of the gross national product we spend on health care is not soon limited, we will find our society becoming dangerously unstable.  But by choosing to limit our health care spending surreptitiously, by rationing at the bedside, by making our physicians the agents of rationing instead of the agents of their patients, we choose a particularly deadly approach to this problem.

Doctors, as imperfect as they are, are the only thing standing between patients and the growing lust for cost-cutting displayed by HMOs, insurers, hospitals, the government, and the majority of citizens who are not seriously ill at any given time.  When we permit the erosion of the traditional doctor-patient relationship, not only do we abandon patients to their own devices in this hostile environment, we do so in their very hour of need, and at the very time they are least capable of fending for themselves.  The doctors, too, are grievously wounded by the loss of this relationship.  For when doctors turn away from their obligations to their patients, even if only because they are coerced, they betray the first principle of medicine, and devalue their profession to the point of worthlessness.

But covert rationing does far more than just cause harm to the medical profession and to the lives of patients.  For covert rationing also requires that we compromise the founding principle of our culture – our ideal of the primacy of the individual.  Destruction of the doctor-patient relationship is merely the most direct and visible manifestation of this compromise.  Covert rationing, and all it entails, ultimately threaten to leave us a fundamentally changed people. 

We will soon examine in some detail just how covert rationing works, and how subversion of the doctor-patient relationship harms us as individuals and as a society. But first, we ought to look a little more closely at our first premise - that health care rationing is a given, whether we choose to admit it or not.

Next: Section 2: The truth about health care rationing

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