CLASSIC HEALTH AFFAIRS: Reinhardt And Relman Debate For-Profit Medicine, Medical Ethics
July 13th, 2007
by
Jane Hiebert-White
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Editor’s Note: As Health Affairs celebrates its 25th anniversary, we look back at some health policy highlights of the past quarter century—many of which are still highly relevant to today’s debates. Watch this space for regular postings on the “classics.”
On June 12, 1986, the Wall Street Journal stated: “If you read nothing else this year about the future of health care, you should read this exchange of salvos on the nature of American medical practice.” More than twenty years later, this exchange of letters (before e-mail) between physician and then New England Journal of Medicine editor Arnold Relman and Princeton economist Uwe Reinhardt still stands as a lively examination of the cost crisis in health care and the emergence of medicine as a for-profit business.
The exchange of letters was originally buried in a 550-page Institute of Medicine committee report, a committee on which both Relman and Reinhardt served. Its publication introduced Health Affairs’ readers to Reinhardt, who has become a highly sought-after speaker and one of the journal’s most prolific contributors over the years, with nearly fifty papers to his credit. Here’s a sampling of the debate:
Arnold Relman: Do you really see no difference between physicians and hospitals on the one hand, and “purveyors of goods and services” on the other? Do you regard the health care system as just another industry, and physicians as just another group of businessmen? Where does the professional commitment to service fit into your view of medical care? Do hospitals have no responsibility to serve the community, or do you reserve that obligation only for the public tax-supported hospitals?
Uwe Reinhardt: What, in the history of the American medical profession, aside from that profession’s own rhetoric, should lead a thoughtful person to expect from physicians a conduct significantly distinct from the conduct of other purveyors of goods and services? I do not deny that there have been grand and noble physicians among the lot, just as there have been grand and noble financiers, lawyers, and even economists. Rather, I am referring here to central tendencies, to the mainstream of American medicine as it has revealed itself through the ages to a paying public. What, then, in the conduct of mainstream American medicine should have led a thoughtful person to expect from physicians a conduct distinct from other ordinary mortals who sell their goods and services for a price? And what in the history of American mainstream medicine would you have serve as a role model for the emerging for-profit institutions delivering health services?
Relman: For someone who declares that he really likes and respects physicians, you certainly have managed to roast the medical profession to a crisp. I shudder to contemplate the fate of debating an adversary you didn’t like! The questions I was trying to raise with you concern broad issues of public policy and social philosophy….Are there differences between health care and other services that would justify different public expectations for the behavior of health care institutions and business firms?
Reinhardt: The shift from labor-intensive to more capital-intensive medicine confronts society with two distinct questions: (1) Who should finance, own, and control the equipment and structures used in modern health care? (2) Should physicians ever be among the owners?….Frankly, I remain a little puzzled by your own views on medical ethics. Sometimes you seem to suggest that physicians are endowed with a strong commitment to ethical conduct. If that is true, why do you worry so? At other times you lament the erosion of medical ethics in the face of capitalist medicine. If medical ethics erode so easily, what then does set physicians apart from “other purveyors?”
For more, read the full debate, which is free access online in the Summer 1986 Health Affairs.
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