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If it becomes too difficult to follow ethical precepts, just change them.

The physician's change in focus from the individual to the group is more than just tacit.  Until recently, professional codes of ethics still held the physician's primary responsibility to be a fiduciary one toward his or her individual patients.  But in the late 1990s, after a few years of being exposed to Gekkonian HMOs, many healthcare experts and even ethicists began to propose explicitly that this ideal be changed.  For instance, a 1998 article in the Annals of Internal Medicine had this to say about the physician's traditional fiduciary role:

"It is untenable for the medical profession to continue asserting an idealistic ethic that is contradicted so openly in clinical practice. . . . We propose that devotion to the best medical interests of each individual patient be replaced with an ethic of devotion to the best medical interests of the group for which the physician is personally responsible."   

After kicking this sort of idea around for a few years, three prestigious medical societies finally published a new definition of "medical professionalism."   This new statement of a physician's ethical obligations added to the time-honored principles of a) primacy of the welfare of  the individual patient, and b) patient autonomy (the two precepts that required doctors to always make their patients' needs their primary concern), a third precept: c) social justice.  Under social justice, doctors are now exhorted to work for the "fair distribution of healthcare resources," based on "wise and cost-effective management of limited resources."

There's nothing wrong with working for social justice, of course. Social justice is very important.  Even doctors should care about it.  But when they are seeing a patient who has come to them for help, that patient - and not social justice - should be their primary concern. They should not cheat or lie for that patient, not even to rapacious Gekkonian insurance companies.  But within the rules of engagement (rules to which the patient, in one form or another, has signed up for) they should leave no stone unturned to see that the patient gets whatever medical services that might benefit him or her. Doctors should not be placed in the position of having to "fairly distribute limited healthcare resources;" of having to decide which patients are worthy of being offered available services and which are not; of having to weigh the needs of society against the needs of their individual patient and decide, on a case by case basis, which is to predominate; of having to ration at the bedside. But this is precisely what the new professional ethical standards provide for. For the first time, doctors have been given explicit ethical cover for covertly rationing healthcare.

It is noteworthy that this change in ethical standards would not be necessary if we conducted healthcare rationing under a system of open, society-approved rules, where everybody knew where they stood.  Under such a system doctors could still advocate entirely for the individual patient, doing whatever he/she could for that patient under society's explicit rules for rationing (much like a lawyer, pulling out all the legal stops for his/her client.)

This new "social justice" precept is only needed in order to provide some comfort to doctors who find themselves having to ration covertly, and who might be bothered by this clear violation of their traditional fiduciary duties to individual patients.  "Sure I'm violating precept # 1," they can now tell themselves, "but I've got to do that to accomplish precept #3."  If doctors can avoid too much introspection and self-analysis (which should not be a problem for many of us) this new precept may take away some sense of guilt. But in truth, as long as doctors are silently withholding care from patients who need it, without telling them and perhaps without telling themselves, no new revision of ethical principles can rescue them.

The Gekkonian legacy

When (if) the Gekkonians finally withdraw from the field, they will leave doctors, patients, and our healthcare system very different from the way they found them.  They will leave us more cost-aware, and somewhat more efficient. But they also will leave us much readier to sacrifice the individual for the sake of the group. And, with our principles thus subtly softened (or flagrantly redefined) by the Gekkonians, the inexorable escalation in healthcare costs will inevitably lead us to far more blatant violations of individual rights and individual welfare than any we've seen to date.

Next: The Wonkonians strike back.