This post is a part of our Bioethics in the News series
By Leonard Fleck, PhD
Dr. Stanley Goldfarb is the former Associate Dean of Curriculum at the University of Pennsylvania Perelman School of Medicine. In a recent Wall Street Journal opinion piece, “Take Two Aspirin and Call Me by My Pronouns,” he complained that curricula in medical schools “are increasingly focused on social justice rather than treating illness.” He goes on to say, “A new wave of educational specialists is increasingly influencing medical education. They emphasize ‘social justice’ that is related to health care only tangentially.” Really? Only tangentially?
Readers will recall Dr. Mona Hanna-Attisha, a pediatrician in Flint, Michigan. She had discovered elevated lead levels in many of her pediatric patients. She could have “stayed in her lane,” provided chelation therapy, hoped for the best, and gone home for dinner. If this is what we would have taught her during her medical education, we would have been complicit in suborning a major injustice.
Dr. Hanna-Attisha did the necessary background research, discovered that public officials had switched the source of Flint’s drinking water to save money, which, in turn, resulted in lead being leached into the drinking water. She brought her case to the media and vigorously advocated (successfully) for correcting this health hazard. She did this for the sake of the children in Flint, many not yet born. This was not tangential to her role as a physician; this was integral and essential. This was a matter of social justice. This was part of her medical education in the College of Human Medicine.
The practice of medicine today is suffused with social justice challenges. As we explain to our first-year medical students, the clinic is not an island of “pure caring,” isolated from the injustices that are pervasive in our health care system and governing policies. Those injustices frequently seep into clinical practice through the hands of physicians who, no doubt, see themselves as just and caring practitioners. This may sound like hyperbole, but I ask you to consider the evidence.
For the past forty years the dominant demand in health policy has been for health care cost containment. I will remind the reader that last year in the United States we spent $3.65 trillion on health care, roughly 18% of our GDP, compared to 11% of GDP in most European nations. If we ask who is responsible for spending more than 70% of those dollars, the short answer is that physicians in the clinic are the responsible agents. Physicians decide whether a patient needs surgery, which drugs to prescribe, what diagnostic tests are necessary, how much home care is needed, and so on. Consequently, if a focal point is needed for controlling health care costs, it will be physicians.
Note that cost control can be a matter of justice or injustice. In either case, physicians will have to be mindful of the justice-relevant consequences of their diagnostic or therapeutic choices. In the 1990s a number of managed care plans used “at risk” reimbursement to elicit more cost-conscious physician clinical behavior. In some cases, as much as 30% of a physician’s income could be “at risk” if they ordered too many tests. They could also earn 30% bonuses if they were especially stingy in their use of tests. Patients knew nothing of these arrangements. Income risks and opportunities such as those could readily shape physician behavior in ways that were less than just. Whether physician judgment in these circumstances would be corrupted would depend upon whether in their medical education they had had the opportunity to reflect upon such future challenges (as opposed to thoughtlessly accepting such practices as “this is the way medicine is practiced today.”)
Putting physician income at risk to control costs related to patient care is crude and obvious. More problematic are the subtle and invisible ways in which physicians control costs justly or unjustly. For example, a patient demands an MRI to rule out brain cancer when a physician is medically certain these are tension headaches. But the physician authorizes the MRI because “insurance will pay.”
If thousands of physicians are indifferent to authorizing such unnecessary care, then the costs of health insurance to employers increase. For employers at the economic margins, that cost increase may mean dropping health insurance as a benefit, thereby adding those employees to the ranks of the uninsured. From the perspective of any individual physician, this is a very remote, invisible consequence of their decisions that creates an injustice. Medical students need to know this to practice medicine justly.
Other employers will change insurance coverage to reduce their costs. They will require their employees to accept insurance with $5000 front-end deductibles. Financially less well-off workers will deny themselves that unnecessary MRI (no injustice there), but they will also deny themselves medically necessary diagnostic procedures (sometimes with deadly consequences) by not even walking into a physician’s office. Why, physicians might ask, should they as physicians be responsible for those bad decisions by patients; there was nothing to diagnose in the examining room. But maybe there was something to diagnose in society? This is sounding a bit more like the situation in Flint. Non-physicians made cost control decisions but counted on physicians to see such decisions as “merely tangential” to the practice of medicine, nothing that should concern them.
Precision medicine has generated more than 90 FDA approved genetically-targeted cancer drugs with annual costs of more than $100,000. These drugs are used with patients with metastatic disease. The vast majority of these patients will gain no more than extra months of life from these drugs, not extra years (though clever media campaigns create a very different impression). For most workers, their health plan will require a 20-30% co-pay for these drugs, which is unaffordable for most workers. Financially well-off managers and executives will be able to afford those co-pays, which means that workers who could not afford the co-pays will have contributed through their premiums to subsidizing that other 70-80% for the well-off. Is that fair? Is that just?
Should physicians caring for these patients silently acquiesce to these insurance arrangements as “too tangential” to medical practice, too far removed from the clinic? Should we, as teachers of future physicians, also silently acquiesce so that more curricular time can be allocated to understanding the mechanisms of action of the next 90 FDA approved targeted cancer therapies? WWHAD: What Would Dr. Hanna-Attisha Do?
Leonard M. Fleck, PhD, is Acting Director and Professor in the Center for Ethics and Humanities in the Life Sciences and Professor in the Department of Philosophy at Michigan State University.
Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, October 24, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.
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More Bioethics in the News from Dr. Fleck: Medicare For All: This Is Going to Hurt; Greed Is God: The Divine Right to Avaricious Drug Pricing; Gene Editing: God’s Will or God’s Won’t
References
- Goldfarb S. Take Two Aspirin and Call Me by My Pronouns. Wall Street Journal (9/27/2019). https://www.wsj.com/articles/take-two-aspirin-and-call-me-by-my-pronouns-11568325291.
- Gross T. Pediatrician Who Exposed Flint Water Crisis Shares Her ‘Story of Resistance.’ National Public Radio (6/25/2018). https://www.npr.org/sections/health-shots/2018/06/25/623126968/pediatrician-who-exposed-flint-water-crisis-shares-her-story-of-resistance.
- Centers for Medicare and Medicaid Services. National Health Expenditure Projections 2018-2027. (Feb. 2019). https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/ForecastSummary.pdf.
- Woolhandler S. and Himmelstein DU. 1995. Extreme Risk — The New Corporate Proposition for Physicians. New England Journal of Medicine 333: 1706-08. https://www.nejm.org/doi/full/10.1056/NEJM199512213332510.
- With High-deductible Employer Health Plans, Who Wins? Knowledge @ Wharton. (June 17, 2019). https://knowledge.wharton.upenn.edu/article/high-deductible-health-plans-pros-and-cons/.
- Emanuel E. We Can’t Afford the Drugs That Could Cure Cancer. Wall Street Journal (Sept. 20, 2018). https://www.wsj.com/articles/we-cant-afford-the-drugs-that-could-cure-cancer-1537457740.
- Feller S. Study: Superlative use by media overhypes medical research. UPI: Health News (Nov. 2, 2015). https://www.upi.com/Health_News/2015/11/02/Study-Superlative-use-by-media-overhypes-medical-research/9381446470460/.
MSU Bioethics 
Hello! I’m curious in what ways a social worker can take part in aiding this issue?
Dr. Fleck,
Thank you for sharing this compelling post. It sounded like you were trying to advocate for more physicians to learn about social issues and do something about them. While I agree that physicians should be educated about social issues and should act as advocates if they see something happening, do you think that, in addition to this, having other people such as social workers be a part of the treatment team could improve the chances of discovering issues such as the ones in Flint and successfully advocating against them?
Kayla H.
Megan and Kayla,
To give a short answer to your question, all members of the health care team have a responsibility to address social justice issues that involve the health needs of a community. I happened to restrict myself to writing about medical education because the piece I was responding to involved an Associate Dean for medical education. I would argue just as strongly that attention to matters of social justice (and related ethics issues) should be an integral part of the education of students in social work, nursing, physical therapy, occupational therapy, physician assistants, and so on. Thank you for your comment.
Hi Dr. Fleck, I am a current MSW student at MSU and I had a question in regard to your original article Take Two Aspirin and Call Me by My Pronouns (2019). You quoted in your article from the Wall Street Journal, “The zeitgeist of sociology and social work have become the driving force in medical education”. With that being said, what can future healthcare social workers do to assist medical physicians in the future?
Tiffany,
I cannot give a simple or complete answer to your question. Social workers, I am sure, have a better sense of the social justice challenges faced by numerous patients these days. Physicians tend to be isolated from recognizing those challenges. Social workers need to educate physicians in that regard, both in the clinic and at professional conferences, then work with physicians in policy contexts to effect necessary policy changes.
Hi Dr. Fleck, I’m an MSW student at MSU. I wonder if you could discuss what I believe to be the root of this issue: for-profit health care. If health insurance companies weren’t pushing to make a profit, and if the cost of drugs, medical equipment, and services in the health care industry were controlled at the front end (research for drugs, manufacturing for equipment, education for health care workers), perhaps the delivered products would not cost so much. You cite the incessant demand for cost reduction in health care environments and the huge amounts Americans spend on health care each year, yet these costs are set by companies making money off the use of these goods and services. I wonder if reducing the cost of health care is exactly the social justice issue at hand. What role do you think health care workers of all kinds–doctors, social workers, nurses, physical and occupational therapists, educators, etc–can play in advocating for a system that does not monetize illness or inequitably distribute costs?
If someone in for profit health care had to “call a friend” I would be the very last person they would wish to call. Arnold Relman, former editor of the New England Journal of medicine got it right when he wrote about the dangers of the medical-industrial complex. That was in the mid-1980s. Note that he did not say the “for-profit” medical industrial complex. Not for profit health care organizations do not have shareholders who demand profits. Apart from that, the behavior of not-for-profit hospitals etc. very much mimic the behavior of their for-profit “evil twins.” Both seek to build health care empires which allow them to increase income (even if not paid to shareholders) by being more competitive so that they can dictate prices to insurers and other payers. Some injustices in the system would disappear if there were no for-profit health care, but many others would remain and costs would continue to rise all around for numerous reasons.