Correspondence

Physicians' Autonomy

N Engl J Med 1993; 329:1048September 30, 1993

Article

To the Editor:

In his article on public and professional expectations about physicians' autonomy, Dr. Mirvis (May 6 issue)1 makes no distinction between medical services purchased by the government with tax dollars and services purchased by private patients with their own money. If the government pays the doctor, the government will control the doctor and dictate the practice of medicine. The physician will not be independent. Not all physicians wish to work for the government, however. Some prefer to be independent and to work for patients paying for services with their own money. Without providing any specific examples, Dr. Mirvis nevertheless implies that he believes that the government has the right to control the private relationship between physician and patient as the government sees fit, as long as it can somehow claim that it is representing the public. He urges physicians not to “subvert the system” in matters such as “health care budgets.”

Let me describe a hypothetical situation. If the U.S. government passes a law stating that annual health care expenditures should not exceed $1 trillion, what should I do if the budget runs out before the year is over? Suppose a patient comes to my office in desperate need of medical care and is willing and able to pay for my services with his or her own money? I plan to take care of the patient.

Bruce Schlafly, M.D.
Hand Surgery Associates, P.C., St. Louis, MO 63128

1 References

1. 1

   Mirvis DM. Physicians' autonomy -- the relation between public and professional expectations. N Engl J Med 1993;328:1346-1349
   Full Text | Web of Science | Medline

To the Editor:

Dr. Mirvis cites examples of societal intervention in health matters that organized medicine did not address effectively. He does not mention that most American physicians were either eager participants or silent observers during the past 30 years of unrestrained and unplanned growth in the health industry. Our profession was unable to resolve by itself the resulting crisis in health care costs. Consequently, the medical profession has lost some autonomy and has forfeited a major role in health care reform.

H. Phelps Potter, Jr., M.D.
208 Ivy Ln., Haverford, PA 19041

Author/Editor Response

Dr. Mirvis replies:

To the Editor: Dr. Schlafly addresses two important issues. The first is the intervention of government in the patient-physician relationship. The critical point is not that the government should assume all of our autonomy -- which it clearly should not -- but that there are limits to our autonomy. Much should be left to us within broad bounds that can be appropriately set by society. Indeed, the current micromanagement is a result, at least in part, of the absence of a national health care plan. Physicians in other nations with greater central health care planning by the government report less -- not more -- interference in patient care.

The second issue is a critical one for all health care planners. What happens when the money runs out? It is clearly illegitimate to penalize a patient simply because he or she becomes ill late rather than early in the fiscal year. If global budgeting is adopted, the plan must account for this. Several alternatives are possible. For example, if expenditure targets are exceeded, additional funds can be infused, but the health care targets for the following year may be adjusted either to constrain expenditures further or to provide more funds for needed, appropriate services.

It is also important to recognize that this situation already exists on an individual level. Personal funds and insurance coverage commonly run out before all needed care is provided; the result now is denial of needed services. A national plan should be able to mount a more equitable response than can individual citizens.

Dr. Potter suggests that physicians have contributed to the development of the current crisis, by acts either of commission or of omission. I fully agree. We have been viewed, with some but not total justification, as having shirked our responsibility to patients. We largely ignored calls from society to address issues of access, cost, and quality. Although a solution to any of these problems is beyond our ability, acting alone, it may be reasonably claimed that we did not do our part. As an inevitable result, society has responded, as Dr. Potter suggests, by increasing its intervention.

David M. Mirvis, M.D.
University of Tennessee College of Medicine, Memphis, TN 38163