Last Word

February 18, 2005

Forced charity isn't charity at all

In a recent issue of American Medical News, AMA president John Nelson offered his views on the role of medical ethics, describing it as "a living contract" between physicians and society. Under this contract, he held, physicians have an obligation to expand access to care, improve the quality of care, and build public trust in the medical profession.

Actually, Western medicine had an earlier contract with society called the Hippocratic oath, but that's been rendered basically irrelevant. That the AMA's president would piously describe a contract with a society that's increasingly hostile toward the medical profession tells us a lot about his agenda, and about the present state of the AMA.

One would expect that as an ob/gyn, Nelson would be viscerally aware of the malpractice climate in this country, and what that climate says about society's view of its half of the "contract." He states that expanded access to health care is "an ethical issue," a view that I think is representative of the standard medical ethics taught in medical schools, and generally accepted by the medical community.

To underscore that point, Nelson urges more physicians to work in free clinics, "protected from lawsuits as if they were federal employees." Under this system, malpractice judgments would be covered by a national liability pool.

Nelson hails the free clinics currently being run by medical students in Minnesota and New York as "classrooms in charity care." That's exactly the wrong lesson to teach idealistic young medical students. He also notes proudly that the AMA Ethics Institute is "informing physicians of the sensitivities [and] . . . historic sources of mistrust, especially among minority patients."

There's a pattern here that goes beyond the AMA. Mary Frank, the new president of the American Academy of Family Practice, calls on members to "realize-and to embrace-the value of 'the power of one'." She wants "to help create a world where all people are treated with fairness, decency, and respect."

Who could argue with that? But Frank doesn't stop there. She amplifies "all people" to include the "45 million who don't have access to healthcare." She notes that in her own Sonoma County, CA, only one surgeon and one ENT still accept Medicaid. The implication is that our system has actually made healthcare less available and less affordable by inflating healthcare costs and encouraging patient irresponsibility. Yet organized medicine has the audacity to call on more physicians to embrace this burdensome and costly system.

This is foolishness. A real contract involves voluntary joining by all parties involved, and a shared realization of value exchanged for value. Whether or not one wishes to participate in charitable activities, if the contract contains an obligation to participate, that removes all charity from the endeavor, and hence all real value.

Call this cynical if you like, but it is realistic. Everyone does everything for some incentive. One gets out of bed, goes to work, exercises, plays a video game, or pats a dog for some perceived gain, and charity is no exception. This is not a devaluation of charity, but recognition of its true meaning.

Engaging in charitable acts celebrates the value of our fellow man, thereby enlivening our own values and self-worth, which is a glorious and noble incentive. But by attempting to force doctors to provide charity care for the needy, the AMA and AAFP devalue both the voluntary efforts of America's physicians and the virtues of those who need their care.