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

Why it's important 

One-day, down on your luck and in need of some quick cash, you decide to rob a Seven-Eleven.  You rush in brandishing a .38, and order the clerk to hand over all the cash.  He turns out to be a wise guy, so you shoot him. You quickly clean out the register and head for the door - where you run smack into two burly police officers who happen to be entering the store right then for some of that good Seven-Eleven coffee.  You are quickly and none-too-gently disarmed and arrested.

So there you are - caught red-handed, money in one hand, gun in the other, the blood of the clerk on your shirt, and the whole thing recorded, in living color, by a hidden video camera.

Now, here's the question: What rights are you entitled to?

Despite the fact that anybody can see how guilty you are, you have many rights.  You have the right to a fair trial.  You have the right to be considered innocent until a jury of your peers declares you guilty.  And you have the right to appeal the verdict (assuming, of course, that you won't like it).

But most importantly and above all else, you have the right to counsel, an advocate, an individual who is obligated to defend you against all odds, to the best of his or her abilities, and to protect your interests against the world.

Many physicians find themselves envious of the unbending resolve with which lawyers are able to embrace their most basic role of advocacy.  Lawyers retain this luxury because society recognizes the legal system to be a morass of rules and regulations which ordinary citizens cannot hope to navigate on their own.  Any citizen who becomes embroiled in this morass is universally acknowledged to have the right to a lawyer who is expected to hold that citizen's interests above all others (within, of course, the constraints of the law).  Even those accused of the most heinous of crimes are entitled to legal representation, and even if the evidence against them seems overwhelming, their lawyers are expected to jealously guard their rights.  While the rest of us may become frustrated and angry when we observe the rights that accrue to (in our eyes) an obviously guilty party, on an objective level most of us understand the wisdom of such a system.  And we shudder to think of the abuses that would occur if these protections were removed.

When you are sick, shouldn't you be entitled to the same protections as when you rob a 7-eleven?

Most of us think so.

Sick people are no more capable of navigating the complex healthcare system than are accused felons the complex legal system, and are no less in peril if they run afoul of that system.  And a patient's need of an advocate, a professional whose job it is to protect the patient's own best interests against the conflicting aims of the "system," is no less vital than that of the felon. When you are sick, you should be entitled to at least the same protections as when you rob a Seven-Eleven.  And the doctor-patient relationship is supposed to see that you are.

Over the ages the doctor-patient relationship has been defined, through rules of ethics and rules of law, as a fiduciary one, as a relationship founded in trust. When a patient seeks a physician's help and the physician agrees to give that help, a special covenant is made.  The patient agrees to take the physician into her confidence, to reveal to him even the most secret and intimate information related to her health.  The physician, in turn, agrees to honor that trust, and to become the patient's advocate in all matters related to her health, placing her interests above all others - including his own personal or financial concerns.

Now, to be sure, the doctor-patient relationship was never completely pure in actual practice, even in "the good old days."  But a strong fiduciary relationship has been what patients have expected, what most doctors have striven for, and what everyone else (the medical ethicists, professional societies, and those who write and enforce the laws of the land) have traditionally agreed - and even demanded - should be the standard.  It represents the fundamental expectation of how doctors and patients are supposed to behave toward one another.  

The loss of this doctor-patient relationship has obvious consequences for patients.  Patients, when they are sick and thus least able to fend for themselves, are left without a true, dedicated advocate as they try to navigate the hostile halls of the healthcare system.  Most doctors still try their hardest to do what's best for their patients, but they can only do so within the constraint of needing to maintain their ability to practice medicine; and such constraints often are not trivial.  Loss of the traditional doctor-patient compact leaves patients marginalized and floundering at the time they are most vulnerable.

Less obvious, but no less profound, are the consequences of a destroyed doctor-patient relationship to the profession of medicine.  Abandoning that relationship means that physicians have committed the "original sin." They have abdicated their traditional, ethical, and legal roles as patient advocates; they have broken a sacred pact. They have fully compromised themselves as professionals, and as a result, to their utter frustration, find themselves standing naked before their enemies - the very enemies who forced this abdication.

Thus, the traditional doctor-patient relationship is vital to the professional survival of the physician, and to the physical survival of the patient.  If we lose this relationship, we lose everything.

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 healthcare 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 healthcare 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 healthcare 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 healthcare.

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 healthcare, 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.

Shortly, I will show how rationing healthcare has become an absolute economic imperative.  While public officials and healthcare providers do not (and cannot) admit it, the need to ration is accepted as an axiom by healthcare economists.  We must ration healthcare 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 healthcare would be to openly establish a set of rules for determining how healthcare 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 healthcare is anathema in the United States.

If we cannot ration healthcare 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 healthcare 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 healthcare 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 healthcare 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 healthcare is not soon limited, we will find our society becoming dangerously unstable.  But by choosing to limit our healthcare 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 destruction 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 threatens 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 healthcare rationing is a given, whether we choose to admit it or not.