Is Medicine Greedy and Morally Bereft?
There may be another consideration.
This post was published earlier today in Psychology Today in a slightly different form.
We must consider what many believe: that the U.S. healthcare system, represented by the medical industrial complex (MIC), is rigged for profit at the expense of care. The MIC comprises medicine, hospitals, insurance companies, and pharmaceutical/medical equipment houses.1,2 To evaluate this claim, we need to look at the origins of the MIC.
With the hospital as its centerpiece, modern medicine was imported from Europe in the late 19th century.3 By the early 20th century, dramatic discoveries occurred. This means that people lived when they formerly would have died (due to the impact of antibiotics, general anesthesia, x-rays, and modern surgery). This care was provided almost exclusively in the hospital. With continued advances, our life survival has approximately doubled from age 40 in 1900 to about age 80 at present.
Jesus Solana from Madrid, Spain—author
With success, costs rose dramatically, especially for hospitals.1 This led to insurance companies. Initiated in the 1930s and 1940s, the not-for-profit Blue Cross programs altruistically sought to alleviate ever-increasing hospital costs. But the for-profit insurance companies sensed a lucrative market and took over, forcing the Blues into for-profit status to survive. Insurance company administrative charges rose from 2-5% to 20-35%, the source of the familiar high salaries and bonuses for today’s insurance executives. At the same time, with insurance now paying the way, hospital and physician costs skyrocketed into what today is a greater than $3 trillion yearly expenditure on healthcare, 40-50% of which is for hospital care. Hospital costs of $5 per day in the early 1900s rose to $4300 per day in 2013. Experts estimate that by 2027 19.4% of our gross domestic product will be consumed by health care, now in the range of 17%. Although pharmaceutical houses originally charged modestly with altruistic intent, this evaporated with the AIDS epidemic. The first drug, AZT, cost over $8000 per year, as did later AIDS drugs—an order of magnitude higher than medications for equally serious conditions. The precedent for charging astronomical prices led to increased costs not only for new drugs but also for many old drugs. The medical equipment companies followed suit, also with exorbitant, inexplicable costs, such as a $36,800 cost for a knee or hip implant that cost $350 to produce.1
Liz West: Hand clutching money
Not surprising is that among about one million bankruptcies per year, over half are due to medical costs—the tip of the iceberg for what most Americans now experience from the burden of health care costs, especially patients with pre-existing conditions.
We cannot escape the worrisome conclusion that modern medicine lacks professional guidelines and that there is insufficient moral leadership. This deficiency became painfully apparent when the American Medical Association (AMA) removed the following from its code of ethics in the 1980s: that physicians’ fees “should be commensurate with the services rendered and the patient’s ability to pay.”1 Medicine’s most influential representative laid the groundwork for the ethical and moral shortfalls now characterizing the MIC.
Nevertheless, maybe you find it difficult to believe that people and institutions devoted to health care are motivated more by financial profit than by the care of their patients? In evaluating greed and morals, comparing the MIC to other industries whose greed has wreaked havoc on society opens the door for another consideration. Contrasted to similar derelictions by, for example, the auto industry, the tobacco industry, and the chemical pesticide industry, medicine has not been deceptive or secretive, we do not see a similar conscious, willful neglect, medicine is not hiding incriminating data, and the public has full information. Could medicine’s “guilt deficiency” for high costs suggest a different or additional explanation for greed, perhaps one that is subconscious and renders medicine at least somewhat oblivious, not fully aware of the problem?
Ronnie Robertson – author
Oblivious—Animals of the Shetland Islands
This is tenable if we take the next step and consider the unique authoritative structure of the MIC institutions, for example, the AMA, medical education, federal and non-federal funding agencies, hospital associations, and insurance companies. The MIC sets medical standards and transmits them to new learners without appreciable public input. The MIC monolith sets its own criteria, determines what is done, and then evaluates its success in doing so, a business, some say, that won’t police itself.1 Such insularity at least can suggest why medicine might not respond to the well-known, common problems of excessive costs. How so, what’s the impact of such an authoritative, self-contained structure?
Who has not heard of the bad things seemingly good people can do, soldiers killing enemies without guilt, oncologists administering chemotherapy to dying cancer patients with no hope of improvement, or physicians seeing impecunious patients go without care. One insight into medicine’s obliviousness in this regard might be found in the famous electrical shock experiments in the 1960s. Stanley Milgram demonstrated that ordinary, nonviolent research subjects readily inflicted inordinate suffering on others at the command of the researchers.4 Milgram’s work provides clues that could explain how humane health care people adopt the authoritative directions of the MIC institutions regardless of what happens to those who cannot afford it.2
Milgram’s research showed that it is a psychological characteristic that people will act obediently to conform to what is expected of them or what is commanded of them by an authority.4 Obedience can effect actions alien to one’s usual behaviors. We ask, would a soldier kill if there was no demand, would a physician or hospital overcharge if MIC authority to do so did not exist? Subconscious obedience is a process that shifts the individual’s responsibility from themselves to the authority commanding obedience, such as the impervious, long-established rules of MIC institutions.2
A new viewpoint occurs with obedience so that one’s thinking changes in a way to justify actions outside one’s usual moral code.4 One no longer feels responsible, and may even be eager to cooperate. An individual may also conclude that their obedient actions are necessary, and adverse consequences are unavoidable, perhaps even deserved.4 There is also a protective shift of attention to the detail of the task requiring obedience. This interdicts awareness of what one formerly would have found abhorrent. Now concerned with a competent performance, previous moral concerns vaporize. Indeed, Milgram says morality is not lost, rather, it changes focus from being fair and humane to obediently living up to expectations. Fostering the new attitude and behavior, one often then ascribes impersonal attributes to what beforehand would have been humane concerns, for instance, “they’re just drunks (lazy, drug seeking, neurotic).” The new morality may also be undergirded by a sense of benevolence and value to society.4 With the transformation of U.S. healthcare from a cost-minimizing service to a profit-driven industry, medicine and the rest of the MIC have legitimated their interest in maximizing profit by continuing to believe they’re doing a good job and helping people. Ask them.
Does this likely contentious explanation for what should be a moral dilemma in medicine merit consideration?2 If so, while it certainly does not excuse them, it means that we must expand medicine’s intellectual and attitudinal orientation—consciousness raising. Simply chastising them for greed will not suffice if they are even partly oblivious of the problem.
Copyright Robert C. Smith
May 5, 2019
1. Rosenthal E. An American Sickness — How Healthcare Became Big Business and How You Can Take It Back. New York: Penguin Press; 2017.
2. Pearl R. Mistreated–Why We Think We’re Getting Good Health Care –and Why We’re Usually Wrong. New York: Public Affairs; 2017.
3. Starr P. The Social Transformation of American Medicine. New York: Basic Books, Inc., Publishers; 1982.
4. Milgram S. Obedience to Authority. New York: HarperPerennial; 1974.