A System Surviving on Self-Interest

Pellegrino makes a strong argument for our need for a moral community for doctors. In doing so he highlights the fine line faced in this profession between the ethical obligations to the sick vs. self-interest and the marketplace. As he continues his argument, he makes a clear argument for the former stating the moral and ethical obligations of a doctor to care for the sick over all else. While I morally agree with this statement, in the context of the United States I do not know that I buy this premise.

Pellegrino makes states a variety of examples of situations in which doctors would refuse patients saying, “we must feel demeaned by them and act to repudiate them” pushing for the Hippocratic oath as the ethical guide for doctors. While I completely agree that refusing to see a Medicare patient or patient with HIV is morally and ethically wrong – I want to also understand the other side of the story before agreeing to such absolute statements.

It is no shock that doctors are now making less money than they were before. Medical school costs having increased while pay has decreased leading to a significant number of doctors struggling to pay off student loans. In Escape Fire, the struggles of doctors to pay off current bills in order to stay in business are highlighted as a fault of the system. If doctors are paid by patients seen per day, it cannot be completely faulted on the doctor that slightly unethical practices (referring to the Hippocratic Oath regarding empathy) occur. Many practices are forced to fit in an increasing number of patients simply to stay in business – creating a culture of apathetic treatment as we have discussed many times in class. But is that really the fault of the doctor?

Speaking on patient rejecting, prior to Obama care a study in the Health Policy Journal Health Affairs found that 33% of primary care physicians were not accepting new Medicaid patients. Why? Low government reimbursement rates. Certain practices simply could not afford to stay in business while continually taking on new Medicaid patients while reimbursement rates were so low.

***Increasingly more ironic,  an economist with the CDC found that reimbursement rates were highest in states with high rates of physicians accepting Medicare.

Under Obama Care certain physical salaries will take a decrease depending on the federal decision to expand Medicaid. However, the doctor shortage will also be heightened leading to an increasing number of ethical concerns within Pellegrino’s quest for a moral community.

I do not condone much of the behavior that is being discussed. My position is rather that it is (in many cases) the fault of a system over the fault of a doctor. It is completely rational for a doctor to worry about paying his own bills vs. seeing one patient at times. Beyond Pellegrino’s moral community, I think we should be calling for greater government funding to offset the costs of medical school which will also allow for federal agencies to dictate specialties, etc that doctor’s choose to pursue. The change has to be more than just a call for morality, but true structural change.


Kliff, S. (2012, August 6). Study: One-third of doctors wouldn’t take new Medicaid patients last year. Washington Post. Retrieved , from http://www.washingtonpost.com

Matthews, M. (2013, November 25). When Will The Government Start Forcing Doctors To See Obamacare Patients?. Forbes. Retrieved , from http://www.forbes.com

Pellegrino, E. The medical profession as a moral community. PubMed66, 221-230.

Tyson, P. (2001, March 27). The Hippocratic Oath Today. PBS. Retrieved April 23, 2014, from http://www.pbs.org


8 thoughts on “A System Surviving on Self-Interest

  1. I definitely agree that Pellegrino was placing a great deal of fault on the doctors and forgetting about the many other important factors that affect how how health care is now delivered. Many changes that occur in health care now were not brought on by doctors themselves, but a higher order. In fact, I am certain that the doctors to do not like the new changes and the new expectations they must meet while also trying to pay bills, while also trying to perform their duties, while also trying to care for their patients (their primary concern when deciding to go to medical school). If they try to go against the newly placed orders and restrictions, these doctors will suffer and so will their family as they will be forced to work long hours (maybe even longer hours), just to make ends meet while trying to pay back medical loans.
    As doctors are forced to see more patients, and visit with them for less time, and also forced to realize that there are budget constraints in the health facility and also in their own personal pockets, doctors are faced with a great deal of moral dilemnas that may benefit one party and not benefit another. It is not as if they plan to do harm to the Medicaid patients if they turn them away, but it is difficult to go ahead and take in another Medicaid patient when his “bosses” have put a bind on the number and he may be at risk of losing his job and family’s source of income if he tries to override his superior’s decisions. That cannot be blamed on the physician but on the new, complex interaction between hospital, physician, and patient.

  2. My one problem with the basis of Pellegrino’s argument is that he assumes all physicians use the Hippocratic oath as their moral code. I’m positive that physicians don’t think of the Hippocratic Oath during times that require ethical decision-making. They probably just do what will keep them out of trouble. However, in a setting where doctors do have to make difficult ethical decisions, they might think of balancing non-maleficence and beneficence. So, this is to say that they logically use this kind of moral code that almost every citizen understands whether or not they use the Hippocratic Oath as their guide.

  3. I agree with you that the system plays a big part in the actions of the doctors. Today, doctors are not free to do as they wish. They are part of a system, whether it’s the hospital or the government. In order to keep their practice, they must oblige to the rules of the hospital or the government. While medical students may go into medical school with the goal of helping and treating the sick, that might change completely once they begin to practice as a physician when they have debts, bills, and other things to worry about. They could try their best to be ethical but sometimes they can only do so much. It’s a matter of what outweighs the other. Unfortunately, the system that we currently have does not allow doctors to provide the fullest care to patients.

  4. I completely agree with Niyeti that it is the fault of the infrastructure and not simply the fault of the doctor. Like she says, and like we discussed in class, a Doctor’s office has to make enough money to stay open. If that means shaving off a few minutes from each patient’s appointment, then unfortunately, that’s what has to be done. Generally speaking, any care is better than no care at all (and yes, I’m sure there are exceptions to that). But my point is that the doctors do have to pay attention and tend to the business side of treating patients. This is why I think it is the system that needs to be changed so that doctor’s don’t have to detract from patient care for any reason, or at least, for a lot fewer reasons. The system needs to minimalize the “other loyalties” that a doctor has, so that their focus can be optimally treating their patients.

  5. I agree that it is more the system’s fault than the doctor’s fault. It is the doctor’s role and responsibility to treat the patient with as least harm as possible. The doctor is expected to care not only about the themselves, but the well-being of the patient. The system has been made into a business unfortunately, so I is difficult to criticize doctors for caring about the money aspect of health care. After all, the system tells doctors that they get paid based on what the amount of procedures that have been done, and not based off of how personable they are with a particular patient. I feel as though it would be beneficial for the doctors to somehow develop a balance between the two aspects of communication, and not just operate on two different ends of the spectrum.

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