Morreim E H
Department of Human Values and Ethics, College of Medicine, University of Tennessee, Memphis.
Arch Intern Med. 1991 Mar;151(3):443-7.
Although traditional obligations of fidelity require physicians to deliver quality care to their patients, including to utilize costly technologies, physicians are steadily losing their accustomed control over the necessary resources. The "economic agents" who own the medical and monetary resources of care now impose a wide array of rules and restrictions in order to contain their costs of operation. However, physicians can still control resources indirectly through "gaming the system," employing tactics such as "fudging" that exploit resource rules' ambiguity and flexibility to bypass the rules while ostensibly honoring them. Physicians may be especially inclined to game the system where resource rules seriously underserve patients' needs, where economic agents seem to be "gaming the patient," with needless obstacles to care, or where others, such as hospitals or even physicians themselves, may be denied needed reimbursements. Though tempting, gaming is morally and medically hazardous. It can harm patients and society, offend honesty, and violate basic principles of contractual and distributive justice. It is also, in fact, usually unnecessary in securing needed resources for patients. More fundamentally, we must reconsider what physicians owe their patients. They owe what is theirs to give: their competence, care and loyalty. In light of medicine's changing economics, two new duties emerge: economic advising, whereby physicians explicitly discuss the economic as well as medical aspects of each treatment option; and economic advocacy, whereby physicians intercede actively on their patients' behalf with the economic agents who control the resources.
尽管传统的忠诚义务要求医生为患者提供优质护理，包括使用昂贵的技术，但医生正逐渐失去对所需资源的惯常控制权。现在，拥有医疗和资金资源的“经济主体”为了控制运营成本，实施了一系列规则和限制。然而，医生仍可通过“操纵系统”间接控制资源，采用诸如“蒙混过关”等策略，利用资源规则的模糊性和灵活性来绕过规则，同时表面上遵守这些规则。在资源规则严重无法满足患者需求的情况下，在经济主体似乎“算计患者”、设置不必要的就医障碍的情况下，或者在医院甚至医生自身等其他方可能被拒绝所需报销的情况下，医生可能特别倾向于操纵系统。尽管很诱人，但操纵系统在道德和医学上都有危害。它会伤害患者和社会，冒犯诚信，违反契约和分配正义的基本原则。事实上，在为患者获取所需资源方面，操纵系统通常也是不必要的。更根本的是，我们必须重新思考医生对患者的责任。他们应尽自己所能给予：他们的能力、关怀和忠诚。鉴于医学经济状况的变化，出现了两项新职责：经济咨询，即医生明确讨论每种治疗方案的经济和医学方面；以及经济倡导，即医生代表患者积极与控制资源的经济主体进行交涉。
