John La Puma, M.D.

John La Puma, M.D.

Autonomy has transformed medical ethics in just half a century. Gone is beneficence-based medical ethics in which the doctor knows and acts for the patient's good, and patients do their best to get better. Earlier in this century, our country had more of a sense of community, togetherness and scarcity. Not everyone could have everything, and we knew it.

In the place of do-good medical ethics has come me-first medical ethics. Many patients know more about their conditions, as they should, but worry more too. Some worry about the little things — a headache could be a brain tumor — but miss the big picture: Their obesity exacerbates their hypertension. As often as not, patients worry just about themselves, without acknowledging their community or its limits.

For the 21st century, the 20th-century principle of patient autonomy will prove inadequate. The single doctor - single patient relationship cannot provide enough care for all who need it.

One quarter of New York City residents under 65 have no insurance; most have full-time jobs. Those fortunate enough to have insurance must be willing to share, because autonomy without justice is just selfish. We cannot afford to care just about ourselves and our families anymore.

The reality is that we have tough choices and finite resources. Discussions of managed care ethics must now include the principles of accountability and fairness to others.

Patients should be accountable for preventing and managing diseases that are largely within their control. Patients who either choose to ignore physician advice about their medication and life styles, or deny the inevitable consequences of diabetes and hypertension, or just don't want to be bothered, are acting autonomously at the expense of others.

Likewise, physicians should be accountable for sound advice and good service to their patients, and should create medical forums inside their offices for helping patients prevent illness in organized, primary prevention-oriented programs.

Both patients and physicians should have incentives to do the right thing.

Patient commitment

Why should patients be more accountable for managing their own diseases? Here are some financial reasons.

If you're a smoker, let's say you'll save $700 cash annually if you stop smoking and test negative for plasma cotinine. If you're a diabetic, let's say you'll save $800 annually if your random glycohemoglobin is less than 8 percent. Now do you plan to change your behavior and take control of information about your care?

Here are some popular reasons. The Marcus Welby doctor-dependent patient paradigm changed decades ago. People are no longer dependent on physicians for medical information. Talk radio and television started this revolution. The Internet and vitamin displays at drugstores will likely finish it. There isn't an American adult who doesn't know that tobacco and lung disease are related.

Take dinner, for example. Supersizing is killing us. When I was growing up, dinner plates were 9 inches, and a glass of water was 8 ounces. Today, they're 13 inches and 32 ounces, sometimes more. Portions more than fill our extra large plates. More is better, it seems. More is not cheaper, however, as the true price of a 55-cent Big Mac depends upon the CPT code for angioplasty.

Obesity? Thirty-three percent and climbing. Hyperlipidemia? Rampant. Diabetes? Epidemic.

Physician commitment

Why should physicians be more accountable for preventing disease?

Here are some financial reasons.

If you're capitated for 100,000 lives, you want the water to be pure and food safety to be high. You want sexually transmitted diseases and resistant organisms reported. You want Joe Camel off billboards and cigarettes out of sports arenas. You want 2-percent milk to be called what it is, which is 38 percent of calories from fat.

You want mandatory seatbelt and helmet laws. You want people to change some life style habits and mean it. You don't want to pay for other people's carelessness out of your patients' money.

You want your patients to schedule regular office visits, attend smoking cessation courses, and investigate yoga and mind-body techniques to manage stress and hypertension. Making it easy for patients to prevent disease and to invest in their own health is good service, good medicine and worth compensating explicitly.

Two principles in partnership

Accountability should partner with autonomy as the most important principle in managed care ethics. Insisting that patients take proactive, positive steps to change what and how they eat, when and where and how often they exercise, whether they smoke and how much they drink can work for physicians who feel their time is wasted unless the patient gets serious about his or her disease.

Is accountability a viable partner for autonomy in this age of get-ahead, me-first, you-second, faster, quicker, better?

I think so. Accountability and managed care ethics are all about control and choice — our favorite American values. Self-reliance and enlightened self-interest for both patients and physicians have "self" written all over them.

Yet invoking "accountability" is not a panacea. It will not get the government out of the examining room, or reossify osteoporotic hips. No physician wants to abandon patients unable or unwilling to help themselves. No patient wants to have diabetes or hypertension or heart disease.

But accountability is not about abandonment or blaming the victim. It is about resource allocation and fairness. Too many people covered by managed care have medical problems that they can address but do not. Too many people outside of managed care want in, but cannot get in. Emphasizing wellness could make more room.

What to do?

  • Tell patients that their health is in their own hands.
  • If you make a deal with patients, make sure the deal isn't personal, so you do not suffer if the patient fails.
  • Notice the advertising in sports arenas and the FDA labels on animal food products — think of their impact on the capitated payments you may be receiving.
  • Ask patients to notice these messages too.
  • Don't complain that no one listens or get angry when patients fail. It doesn't work.
  • Relinquish the responsibility for healthful living to patients. Congratulate them when they accept it.

John La Puma, M.D., practices internal medicine with Alexian Brothers Medical Center in Elk Grove, Ill., and is a Chicago-based speaker and educator. With David Schiedermayer, he is the co-author of The McGraw-Hill Pocket Guide to Managed Care: Business, Practice, Law, Ethics (McGraw-Hill, New York, 1996).

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