Diagnosis: Inflammation of the Blue Cross

I had first-time appointments with both a dentist and an optometrist this past week: eye-opening and jaw dropping experiences, respectively. I didn't realize that when the dentist asked, "Do you mind if we shine a light in your mouth to check for cancer?" it really meant, "Do you agree to an extra $60 out-of-pocket expense?” Evidently, I didn’t learn from that experience because a couple days later when my optometrist took the very same approach, saying, "I'd like to take some pictures of your retina," I said, "Sure, go right ahead.” In fact, these were both very roundabout ways to gain my informed consent, but I only became "fully informed” by the billing clerk on my way out of the office. Times are a changing, however, and I wonder if it is ethical to ignore discussing fees right up front, along with all the other benefits, risks, and potential complications.

Medical bills prompted over 60 percent of the 1.5 million bankruptcies declared last year -- and even those people with insurance weren’t immune.1 Leading economic experts warn that each of us may be just one major illness away from financial ruin. Dr. Gawande addressed this "cost conundrum” in a recent exposé on the McAllen, TX, health care market.2 In McAllen, "the most expensive town in the most expensive country for health care in the world,” Medicare spends about $15,000 per enrollee, which is $3,000 more than the average per capita income.

Dr. Gawande points out that, "No one teaches you how to think about money. Yet, from the moment you start practicing, you must think about it. You must consider what is covered for a patient and what is not.”

This means that some practitioners cannot help but see patients as revenue; the staff is instructed to schedule appointments for patients who have questions, because insurers don’t pay for phone calls; private offices buy medical equipment to perform expensive diagnostics rather than refer patients to a hospital or university medical center; and, as Gawande says, health providers find ways to increase their high-margin work and decrease their low margin work. After all, it is a business… Isn’t it?

I wonder what kind of damage is being done to the "social contract” by a health provider’s overzealous entrepreneurial spirit. The social contract is "a covenant between medicine and society.”3 Ethical principles underlying this contract include being fair and truthful, keeping one’s word, meeting commitments, and being straightforward.4 At a time when health providers are increasingly invested in the corporatization of health care, it is very difficult to practice professionalism as modeled by medical humanitarians such as Paul Farmer and Patch Adams. In fact, some of my own students have criticized these doctors as being too idealistic. They find it difficult to envision what health care might be like in an ideal world; and, instead of seeing economics as one of many contextual features, they are focused on it as the sole foundation of a health system. Strange perspective, considering that for the brief duration of an ethics course we have a shining moment to focus on humanistic values such as beneficence and nonmaleficence, loyalty, and fairness. According to Dr. Ralph Horowitz, Dean of Case Western Reserve University School of Medicine, medical educators are only now coming to address the growing alienation between providers and their patients.5 Why is it so important to maintain the implicit contract all health providers have with society?

Past president of the American Association of Medical Colleges Jordan Cohen says, "What’s at stake is a set of very special privileges that we too often take for granted.”6 He goes on to list those privileges as:

  1. The ability to self-regulate, to set our own standards.
  2. A degree of autonomy in our interactions with patients that is virtually unheard of in any other sector society.
  3. A level of public esteem that surpasses virtually all other lines of work.
  4. An enviable measure of security as evidenced by unparalleled opportunities for well-compensated employment.

So, why would a physician, an optometrist, a dentist, or any other esteemed health provider want to undermine the social contract by being anything less than straightforward? Greed.

Some states have laws that protect consumers against greed. For example, it is illegal in most states to increase the price of gas, ice, and other commodities after hurricanes, wildfires, ice storms and other natural disasters that result in power outages, or fuel and food shortages. That’s because it is basically unethical to take advantage of a customer’s vulnerable condition. As health providers, we should know something about the vulnerability of our patients – and to prey on someone who is in a vulnerable state, to misuse the trust they have put in us, will surely erode all vestiges of any social contract.

I’m not going to be a favorite among Ayn Rand devotees when I suggest that similar "gouging” laws could apply to health providers during the current economic crisis. During these times it is especially important to make sure patients are not treated as income potential. Medical professionalism aside, business ethics dictates the need to be honest and forthright with the client. If patients are going to have to accept being treated like customers, certainly they shouldn’t have to wonder whether a test is being done because it needs to be done; and if it needs to be done, they shouldn’t have to wonder how much it’ll cost.


  1. Tamkin, T. Medical bills prompt more than 60 percent of U.S. bankruptcies. CNN. Available at: http://www.cnn.com/2009/HEALTH/06/05/bankruptcy.medical.bills/. Accessed June 18, 2009.
  2. Gawande, A. The cost conundrum. The New Yorker. Available at: http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?yrail. Accessed June 10, 2009.
  3. Wear, D. & Aultman, J.M. Professionalism in medicine: Clinical perspectives. New York: Springer; 2006; p10.
  4. Project professionalism. Philadelphia, PA: American Board of Internal Medicine; 1994.
  5. Wear, D. & Aultman, J.M. Professionalism in medicine: Clinical perspectives. New York: Springer; 2006; p. 71.
  6. Cohen, J. (2006). Forward. In D.T. Stern (Ed.), Measuring medical professionalism. New York: Oxford University Press.


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