The traditional approach to medicine was for practitioners to accept the intense focus on the individual patient. The current changes in medicine will alter the focus from the patient to a population: “in the emerging medicine, the presenting patient, more than ever before, will be a representative of a class, and the science that makes possible the care of the patient will refer prominently to the population from which that patient comes” (52). Physicians increasingly are bound by accumulating outcomes data (population statistics) to modify the treatment of an individual in view of the larger population statistics. If, for example, the outcome of radical ovarian cancer debulking is only 20% successful in a patient with a certain set of medical problems, that debulking may be offered instead to someone who has an 85% chance of success. Theoretically, the former individual might have a successful debulking and the procedure might fail in the latter, but population statistics were used to allocate this scarce resource. The benefit was measured by statistics that predict success, not by other forms of justice allocation by need, queuing, merit, or contribution. This approach represents a major change in the traditional dedication of health care solely to the benefits of individual patients. With scarce resources, the overall benefits for all patients are considered in conjunction with the individual benefits for one patient.
There was always an inequity in the distribution of health care access and resources. This inequity is not seen by many health care providers who do not care for those patients who are unable to gain access, such as those who lack transportation or live in rural areas or where limits are imposed by lack of health care providers, time, and financial resources. Social discrimination sometimes leads to inequity of distribution of health care. Minorities are less likely to see private physicians or specialists with clear impacts on outcomes of care, regardless of their income or source of health care funding (53–58). Thus, health care is rationed by default.
Health care providers must shift the paradigm from the absolute “do everything possible for this patient” to the proportionate “do everything reasonable for all patients” (19). To reform the health care system requires judicial, legislative, and business mandates, and attention to the other social components that can pose obstacles to efforts to expand health care beyond a focus on individual patients.
Health Care Reform The tension between understanding health as an inherently individual matter (in which the receipt of health care is critical to individual well-being) and as a communal resource (in which distribution of well-being throughout society is the goal) underpins much of the political and social debate surrounding health care reform (56). The questions of health care reform are twofold: 1) What is the proper balance between individual and collective good? and 2) Who will pay for basic health care? Because much of health care reform requires balancing competing goals, legislation to achieve reform should specifically address how this balance can be achieved. The role of government should be as follows:
Regulating access of individuals to health care.
Regulating potential harms to the public health (e.g., smoking, pollution, drug use).
Promoting health practices of benefit to large populations (e.g., immunization, ﬂuoridation of water).
Even with the present changes in health care structure in the United States, health care payers, not individual providers, often make decisions regarding both the amount and distribution of resources. The health insurance industry determines what are “reasonable and customary” charges and what will be covered. The government decides (often with intense special-interest pressure) what Medicare and Medicaid will cover (57–60). These decisions directly affect patient care. For that reason, health care providers cannot ethically remain silent when the health and well-being of their individual patients and their communities are adversely affected by health care reform decisions.
Research on the outcomes of care provided by gynecologists or affected adversely by the current system for financing health care (financial aspects, safety, quality-of-life measures, survival, morbidity, and mortality) will allow the discipline to have a voice in determining choices for women’s health care. This is an ethically important responsibility for all women’s health care providers.
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Steinman MA, Shlipak MG, McPhee SJ. Of principles and pens: attitudes and practices of medicine housestaff towards pharmaceutical industry promotions. Am J Med 2001;110:551–557.