In past decades, physicians practiced medicine. The majority were dedicated to patient well-being. They were paternalistic and decided what was in their patients’ best interests, and patients generally trusted their judgments. In the 1970s, ethicists concluded that patients and clinicians should make treatment decisions jointly. This position has been championed since then, despite multiple surveys demonstrating that more than 50 percent of patients prefer their physicians to be the decision-makers. Additionally, over 80 percent of individuals have difficulty making rational judgments about their care.
Given the realities of present-day practice, clinicians neither have the time to motivate nor educate patients to enable them to be partners, nor, in my opinion, should this be their responsibility. Health educators could assist in these activities, but patients must be motivated to learn, to set aside established beliefs, and to accept contradictory information. This process can be arduous for many people, as the expectation of a desired outcome can blind them to other possibilities.
More significantly, clinicians’ ability to practice largely unfettered has been co-opted by for-profit executives and politicians, neither of whom is patient-oriented. It was not anticipated that medical care would be discovered as immensely profitable and that mercantile entities would purchase an ever-increasing market share. Executives are driven by expanding earnings and manipulate the health care system, legally and illegally, to achieve this goal, increasingly compromising patient safety and life.
Multiple recent studies, for example, have noted that when a hospital becomes profit-oriented, both staff and salaries are reduced, and when physician practices become for-profit, prices are increased, and patient visit times are decreased. One Medicare Advantage insurance company enthusiastically reported a 52 percent increase in profit for 2024 yet is requesting greater Medicare reimbursement, claiming that their profit margin was less than expected. Another company offered physicians $10,000 bonuses to increase the number of patient diagnoses not requiring treatment because the government paid more for “complex” patients.
Prior authorizations (PAs) have received much bad publicity lately, but their present use is not why they were created. Medicare developed PAs with two goals: to ensure patients received care that followed “best practices” and to slow rising costs. Health insurers quickly adopted them to control payment and increase revenue.
Sometimes, profit-oriented hospital administrators have required patients to prepay surgical bills, even when they are insured, to save themselves any future cost of haggling with an insurer. Will credit reports soon be accessed before emergency treatment and care based on one’s score? One hospital denies patient discharge until it receives a written guarantee of payment by insurance or, if the patient is uninsured, a full cash payment.
Also unexpected was that medical care would become politicized and used by federal and state legislators to favor individual beliefs and benefactors rather than patient health. Many proposed bills lack a scientific basis, defy common sense, and are contrary to the desires of the majority of their constituents. They are poorly written, broadly constructed, and obtuse.
The six-week fetal heartbeat laws are exemplary, as embryologically, the heart is not developed at this age, the “heartbeat” arises from a different structure, and the fetus’s circulation comes from the mother’s circulatory system via the umbilical cord until birth, not from its heart. In their eagerness to curtail surgeries for trans-individuals, Florida legislators passed a law so vague that a surgeon could be imprisoned for removing cancerous reproductive organs. Not to be outdone, Ohio legislators decided that hospitalized COVID-19 patients can request Ivermectin, though ineffective, and its non-provision would result in incarceration! Of whom was not indicated.
Legislators who composed the six-week abortion laws contend they are lucidly written and easy to understand. If so, why do physicians and attorneys have great difficulty interpreting them when confronted with pregnant females* with a life-threatening crisis? Or, when it was pointed out to the lawmaker who originated the Florida law that he had banned mastectomies and prostatectomies for cancer, he did nothing to exempt these and similar procedures from his bill. These legislators did not expect or seem to care that their actions would result in a long-term diminution of physicians practicing in their states, reducing quality care for all citizens.
RFK Jr. doggedly believes that vaccinations cause more harm than good and insists that poor studies in low-quality journals outweigh decades of reputable research. In some states, physicians have been coerced into drug testing pregnant females and reporting those with positive results to law enforcement. Texas Governor Abbott has threatened the loss of state funding to hospitals that do not demand proof of citizenship at admission. In other states, an attorney general wants to deny medical care to “birthright” individuals he considers to have invalid citizenship in violation of the Constitution, while another wants a directory of pregnant women he believes might seek abortions, without defining whom these women may be. Will these unreasoning regulations result in people avoiding care for life-threatening or communicable conditions?
At what point does medicine become wholly manipulated for political or monetary gain? I support reasonable regulation and profit, but the primary purpose of health care must be patient benefit and safety, not ideology, political advantage, or lucre.
* “Pregnant person” is a social construct but biologically inaccurate as pregnancy and childbirth require functional female reproductive organs, regardless of the sex or gender one chooses to be.
M. Bennet Broner is a medical ethicist.