A convincing case for resolving financial conflicts of interest
that compromise the judgment of doctors and that bias the clinical
choices they make. Whereas lawyers, certain financial
professionals, and government officials are considered by law to be
fiduciaries - i.e., obligated to work for the benefit of those they
represent - there's as yet no effective policy to hold doctors
accountable in this way. The medical profession has never developed
a framework to address this problem, and, according to Rodwin (Law
and Public Policy/Indiana University-Bloomington), it's unlikely to
cio so. Here, Rodwin examines seven activities that lead to
significant conflicts of interest among physicians: kickbacks;
referral to facilities in which physicians have a financial
interest; the selling of medical products that they themselves
prescribe; hospital purchases of private practices; payments by
hospitals for patient referrals; gifts by pharmaceutical firms; and
risk-sharing in health-maintenance organizations (HMOs). Disturbing
examples of each of these activities dot the text and dramatize how
patients can be adversely affected by them. Rodwin draws on the
regulatory approaches of other professions to offer recommendations
for solving the medical establishment's conflict-of-interest
problems. He argues for setting up new institutions and rules to
hold physicians to fiduciary standards, with legislatures taking
the lead in laying down the ground rules, and with courts,
regulatory agencies, third-party payers, and state attorneys
general enforcing them. One interesting concept the author examines
is the regulation of the medical industry by a federal commission,
similar to the regulation of the securities business by the SEC. A
constructive contribution - featuring a well-presented analysis as
well as concrete proposals for reform - to the ongoing discussion
of our national health-care crisis. (Kirkus Reviews)
Marc A. Rodwin draws on his own experience as a health lawyer--and
his research in health ethics, law, and policy--to reveal how
financial conflicts of interest can and do negatively affect the
quality of patient care. He shows that the problem has become worse
over the last century and provides many actual examples of how
doctors' decisions are influenced by financial considerations. We
learn how two California physicians, for example, resumed referrals
to Pasadena General Hospital only after the hospital started paying
$70 per patient (their referrals grew from 14 in one month to 82 in
the next). As Rodwin writes, incentives such as this can inhibit a
doctor from taking action when a hospital fails to provide proper
service, and may also lead to the unnecessary hospitalization of
patients. We also learn of a Wyeth-Ayerst Labs promotion in which
physicians who started patients on INDERAL (a drug for high blood
pressure, angina, and migraines) received 1000 mileage points on
American Airlines for each patient (studies show that promotions
such as this have a direct effect on a doctor's choice of drug).
Rodwin reveals why the medical community has failed to regulate
conflicts of interest: peer review has little authority, state
licensing boards are usually ignorant of abuses, and the AMA code
of ethics has historically been recommended rather than required.
He examines what can be learned from the way society has coped with
the conflicts of interest of other professionals --lawyers,
government officials, and businessmen--all of which are held to
higher standards of accountability than doctors. And he recommends
that efforts be made to prohibit and regulate certain kinds of
activity (such as kickbacks and self-referrals), to monitor and
regulate conduct, and to provide penalties for improper
conduct.
Our failure to face physicians' conflicts of interest has
distorted the way medicine is practiced, compromised the loyalty of
doctors to patients, and harmed society, the integrity of the
medical profession, and patients. For those concerned with the
quality of health care or medical ethics, Medicine, Money and
Morals is a provocative look into the current health care crisis
and a powerful prescription for change.
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