Professionalism requires that physicians uphold the best interests of patients while simultaneously insuring just use of health care resources. Current articulations of these obligations like the American Board of Internal Medicine Foundation's Physician Charter do not reconcile how these obligations fit together when they conflict. This is the problem of dual agency. The most common ways of dealing with dual agency: “bunkering”—physicians act as though societal cost issues are not their problem; “bailing”—physicians assume that they are merely agents of society (...) and deliver care typically based on a strongly consequentialist public health ethic; or “balancing”—a vaguely specified attempt to uphold both patient welfare and societal need for judicious resource use simultaneously—all fail. Here I propose how the problem of dual agency might begin to be addressed with rigor and consistency. Without dealing with the dual agency problem and getting more specific about how to reconcile its norms when they conflict, the expectations of professionalism risk being written off as cute, nonbinding aphorisms from the medical profession. (shrink)

Physicians have an ethical responsibility to their patients to offer the best available medical care. This responsibility conflicts with their role as gatekeepers of the limited health care resources available for all patients collectively. It is ethically untenable to expect doctors to face this trade-off during each patient encounter; the physician cannot be expected to compromise the wellbeing of the patient in the office in favour of anonymous patients elsewhere. Hence, as in other domains of public policy where individual and (...) collective interests conflict, some form of collective solution is required. Collective solutions may take the form of placing explicit resource constraints on resources available to physicians, or clinical practice guidelines that recognise cost-effective care as acceptable. Such solutions will be politically and ethically sustainable only if patients as citizens of the larger population accept the need for rationing of limited resources in health care. (shrink)

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

Everyone wants to be healthy, but many of us decline to act in healthy ways. Should these choices have any bearing on the ethics of clinical practice and health policy? How may personal responsibility for health be manipulated in health policy debates.

There is more to modern health than new scientific discoveries, the development of new technologies, or emerging or re‐emerging diseases. World events and experiences, such as the AIDS epidemic and the humanitarian emergencies in Bosnia and Rwanda, have made this evident by creating new relationships among medicine, public health, ethics, and human rights. Each domain has seeped into the other, making allies of public health and human rights, pressing the need for an ethics of public health, and revealing the rights‐related (...) responsibilities of physicians and other health care workers. (shrink)

While protection of autonomy is crucial to the practice of medicine, there is the persistent risk of a disconnect between the notion of self-determination and the need for a socially responsible medical system. An example of unbridled autonomy is the preferential use of costly medications without an appreciation of the impact of using these more expensive drugs on the resource pool of others. In the USA, costly medications of questionable incremental benefit are frequently prescribed with the complicity of both doctors (...) and patients. Limiting self-determination in medication choices via an appreciation of the principle of justice reaches a better moral balance, while at the same time acknowledging the goals of doing good and avoiding harm in patient care. (shrink)