Book Review

Enemies of Patients

N Engl J Med 1993; 329:893-894September 16, 1993

Article

Enemies of Patients
By Ruth Macklin. 250 pp. New York, Oxford University Press, 1993. $25. ISBN: 0-19-507200-6

In the rapidly proliferating literature of medical ethics, I found Macklin's new book to be a unique and welcome addition. It is well written, clear, and easy to understand. Her use of a case-based approach seems particularly appropriate to the discussion of problems that interfere with patients' care. She identifies a variety of policies, procedures, and people that are threatening the rights of patients and the relationship between them and their care givers. Although they may act in the name of quality control, fiscal responsibility, risk management, and even patients' rights, these “enemies of patients” have served primarily to interfere with optimal care. Macklin's examples and analyses are drawn from her extensive teaching and consultation in the field of biomedical ethics. Using these cases as her starting point, she keeps us focused on the fact that it is patients' care that is threatened. She identifies many things that hinder optimal care and provides a useful framework for working to remove these sources of interference. I believe that the insight she offers can be useful to students, nurses, physicians, and even the persons and agencies that can be the “enemies.”

In her discussion of “Bureaucrats at the Bedside” she illustrates clearly the difficulties that can occur when “risk managers” or other administrators dictate medical decisions. Although these groups may talk of devotion to patient care, they lack the professional commitment of physicians and other direct care givers, and their divided loyalty is often weighted toward issues of economic or legal concern. In a later discussion she identifies how these managers create problems as they try to establish procedures to monitor the quality of care but frequently end up with cosmetic efforts that hide rather than elucidate real deficiencies. She not only identifies the problems but also shows us how easy it is for any of us to become involved.

The chapters on “Doctors versus Patients . . .” and “Physicians as Fiscal Gatekeepers” are especially well written and complementary. Inevitable and destructive adversarial relationships develop when physicians deviate from their primary role as patients' advocates. I found these discussions very helpful, but it was here too that I found my only major criticisms of the author's commentary. I agree with her that the nation has become obsessed with the inflationary rise in medical costs, but I think she ignores the frequent lack of responsibility, on the part of both health care providers and institutions, that contributes to this obsession. I also take issue with her analysis of managed-care systems. Many of her criticisms are certainly justified, but I think her analysis is incomplete. The structure of these systems does provide the potential for administrators to gain inordinate power over decisions about care, but this is not mandated in most of the programs. She attributes the negative features of some health maintenance organizations to all of them. I think that the best of these organizations have been able to avoid the limitations she describes and may actually promote the advocacy for patients she supports.

Major changes in the practice of medicine and the ways in which care givers and patients relate to each other will occur in the coming months and years. As we anticipate these changes and work with them, it will be vital for all of us to be aware of the problems identified in this book to prevent them from further eroding the relationships so necessary to the healing process.

Robert H. Richardson, M.D.
1920 Rockridge, West Linn, OR 97068