HEALTH ECONOMICS

Health Econ. 7: 565–568 (1998)

GUEST EDITORIAL

MEDICINE, ECONOMICS, ETHICS AND THENHS: A CLASH OF CULTURES?1

ALAN WILLIAMS*Uni6ersity of York, York, UK

ETHICS AND THE PRACTICE OFMEDICINE

The practice of medicine has always been fraughtwith ethical dilemmas. Historically these havemostly been concerned with finding rules of con-duct designed to prevent the powerful and knowl-edgeable doctor from taking advantage of theweak, vulnerable and ignorant patient. This hasgiven birth to a code of ethics which requires adoctor to tell the truth, to respect the autonomyof the patient, and to deal justly with patients. Ithas focused attention on the doctor–patient rela-tionship as the keystone of medical practice, andon the importance of sustaining it as a trustingrelationship. The doctor is also expected to use hisspecial skills to preserve life, to alleviate suffering,and to do no harm.

It will immediately be evident that these objec-tives frequently pull in different directions. Is lifeto be preserved no matter what its quality, andeven when the patient no longer wishes to go onliving? What if the alleviation of suffering is likelyto shorten someone’s life? And if a treatmentcarries a significant risk of doing harm, does thatrisk rule it out from further consideration, orshould the possible harm be weighed against thepossible benefit, and a judgement made as towhere the balance of advantage lies? Who shouldmake that judgement: the experienced doctor orthe frightened patient? Does respecting the auton-omy of the patient mean that the patient should

be told the whole truth, and given full responsibil-ity for the decision and its consequences? Or, iftelling the truth is likely to add to the patient’sanxiety and distress, is the doctor ethically justi-fied in trying to avoid this by discreetly assumingresponsibility and quietly getting on with things?What about dealing justly with patients? Doesthat mean treating cases which are clinically iden-tical in exactly the same manner without showingany favouritism because of a patient’s personalcircumstances, or should a patient who is beingkept off work and losing money because of acondition be given priority over someone in a jobwhere the same condition has a less severe im-pact? Is it right to take grandma into care, whenshe would rather stay with her daughter-in-law,but the daughter-in-law has had enough, and, forthe sake of her marriage and her children’s wel-fare, wants grandma out. Whose interests areparamount?

I catalogue these common dilemmas to demon-strate that inherent in medical practice is the taskof resolving ethical issues, and that these particu-lar ethical issues have nothing whatever to dowith economics. They arise because medicine hasmany different objectives, none of which can bepursued single-mindedly, so compromises have tobe made. Different doctors, appealing to the samecode of ethics, may come to different conclusionsin comparable circumstances. So we may expectconsiderable variation in practice policies fromone doctor to another, even when they are equally

* Correspondence to: Centre for Health Economics, University of York, York Y010 5DD, UK.1 This paper was presented by Alan Williams as one of a series of lectures held at the University of York to celebrate 50 yearsof the National Health Service. The Centre for Health Economics, University of York has published the lecture series in full inRadicalism and Reality in the National Health Ser6ice: Fifty Years and More edited by Karen Bloor.

CCC 1057–9230/98/070565–04$17.50© 1998 John Wiley & Sons, Ltd.

A. WILLIAMS566

knowledgeable about the science of medicine, andequally conscientious individuals. They need onlydiffer in the weight they attach to the differentprinciples of medical ethics.

ECONOMIC INCENTIVES AND THEPRACTICE OF MEDICINE

Economics introduces some complicating factorsto medical practice. Being a doctor is a way ofmaking a living, and a highly respected one. Somedoctors are effectively small businessmen, rentingpremises, hiring staff, buying equipment and con-sumables, and hoping to make a big enoughsurplus at the end of the year to provide forthemselves and their families a standard of livingthat is an adequate reward for their poorly-paidyears of training and for the onerous responsibili-ties they shoulder. Is this likely to affect theirclinical behaviour in any way? It would be verysurprising if it did not.

To take a simple example, doctors pay to main-tain the capacity of their practice to see and treatpatients, but they do not pay for the time ofpatients. So you would expect them to organizetheir practice so that the resources they pay for arekept busy, but the resources that cost them noth-ing can be used freely. Patients, therefore, sitaround waiting for doctors and nurses. Doctorsand nurses do not sit around waiting for patients.Yet patients’ time is also valuable. My dentist asksme to go and see him every 6 months even ifnothing is wrong with my teeth, and if I refuse thisinvitation three times he threatens to strike me offhis list. Going to see him incurs transport costsand occupies at least an hour of my time for a 10minute ‘check-up’ which typically reveals nothing.Suppose he had to pay me £20 an hour for mytime, and meet my travel costs, if he initiated thevisit. Would his enthusiasm for regular 6-monthlycheck-ups remain unabated?

At a more strategic level, it is well known thatthe way in which doctors are paid has a significanteffect on their practice pattern. If they are paid asalary which does not depend on their pattern ofwork, they behave differently than when they arereimbursed on a fee-for-service basis. This respon-siveness creates a powerful set of incentives thatcan be used to induce doctors to change theirpattern of practice. Is this responsiveness unethi-cal? It would be if doctors deliberately did things

that were harmful to patients simply in order tomake money. But as I have already indicated, thebalancing of risks and benefits is part of everydayclinical practice, and even in the absence of anyfinancial incentives to change in one direction oranother, different doctors will strike the balance indifferent ways. In this grey area we are likely toobserve a clustering of decisions at one end of thespectrum instead of at the other end, but all withina zone that is conventionally regarded as ‘ethical’.

These financial incentives are not peculiar to theNational Health Service (NHS); indeed they canbe observed in operation far more blatantly inprivate or quasi-private systems. The notion thatdoctors are now being forced to think aboutmoney for the first time, instead of thinking solelyabout benefits to patients, is nonsense. Doctorshave always been acutely conscious of the need tobe cost-effective in the use of one key resource—their own time. There are many competing de-mands upon time which, at the margin, have to bebalanced one against another. There is time to bespent with the patient in front of you at themoment. But there are also patients waiting orscheduled to see the doctor next. There is teachingor training to be done, a management meeting toattend, some research data to enter and analyse, anew member of staff to appoint, the children to bepicked up from school, letters to write, telephonecalls to make. There is constant pressure to thinkabout the most effective use of the scarce resourceof time, and whether it would be a good idea tohire somebody to take some of these tasks. Thedoctor as practice manager has to consider thecosts and benefits of each practice activity, andchoose that mix of activities that maximizes thebenefits from the limited resources at their dis-posal. Although this may not be recognized as aneconomic problem to be solved by applying well-established economic principles, that is indeedwhat it is, and doctors have been at it for decades,long before the NHS was introduced.

THE NHS AND THE PRACTICE OFMEDICINE

What difference is made by the existence of anNHS? The fundamental difference between a cen-trally-tax-financed public health care system, andany private or quasi-private system, is that accessno longer depends on the patients’ (or their insur-ers’) willingness and ability to pay, but upon some

© 1998 John Wiley & Sons, Ltd. Health Econ. 7: 565–568 (1998)

MEDICINE, ECONOMICS, ETHICS AND THE NHS 567

notion of ‘need’. To short-circuit what could be arather complex debate about the appropriatemeaning of ‘need’ in this context, it will be simplytaken to mean a person’s capacity to benefit fromhealth care. People cannot need something whichwill confer no benefit upon them, and a personwaiting for large benefits has a greater need thansomeone waiting for small benefits. However, whois to judge a person’s needs, as opposed to theirdesires or demands? Not all needs can be met, andneeds have to be prioritized, so a disinterestedexpert is required to do it. Who are the experts injudging the likely benefits of health care? Why, thedoctors of course! So the prioritization of needscomes to be seen as a clinical matter for doctors tosort out. Since doctors have always had to decidewhich cases are urgent and need immediate treat-ment, and which can wait a while, they are alreadywell practised at this painful task.

This additional responsibility creates a new eth-ical dilemma for them. At one and the same timethey have to think:

What is the best I could do for this patient if Iignored the consequences for all other patients?

In the light of all the competing demands from otherpatients, what is the most I should do for this one?

The first part of this deliberation is concernedwith clinical excellence, no matter what the costs.The second part is concerned with cost-effective-ness. Many doctors complain that the second partis really not part of ethical medical practice, whichthey believe enjoins them to do everything theycan for each and every patient no matter what thecosts. But one of the principles of medical ethicswhich I listed at the outset was to deal justly withpatients. Not counting the costs of your actionsmeans not caring about the sacrifices that areimposed on others. In a resource-constrained sys-tem the ‘costs’ of treating one patient are re-sources that might have been devoted to anotherpatient, whose health will be worse by beingdeprived of them. Hence the need for prioritiza-tion, to ensure that what is sacrificed is lessbeneficial than what is done. This is what beingcost-effective means.

A CLASH OF CULTURES?

This prioritization according to needs, conductedon behalf of society at large, brings with it a

demand for doctors to be more publicly account-able for their actions and policies. Alongside thepatients, and the doctors’ colleagues and families,there is now another party involved—the citizen-taxpayers or their representatives. Thus the bal-ancing act has become still more complex, withthe doctor trying to keep his practice viable whileat the same time doing his best for his patients,but observing policies about prioritization and theuse of resources that are acceptable to the citizen-taxpayers. It is an unenviable task.

Unfortunately, it has not been made any easierby the reluctance of the official representatives ofthe citizen-taxpayers (the professional politicians)to put their heads above the parapet and acceptresponsibility for this unavoidable prioritizationof needs. Indeed they sometimes come close topretending that no prioritization is necessary, andassert that all clinically determined needs will bemet. But that disingenuous statement convenientlyignores the fact that these ‘clinically determinedneeds’ are the outcome of the very prioritizationprocess which they had dropped into the laps ofthe doctors and, in the manner of Pontius Pilate,conveniently washed their hands of. But sinceclinicians have limited budgets, and there are farmore beneficial treatments than can possibly beafforded, this pretence is patently false. The worldis not flat, it is round. And it is just not goodenough for those in a position of responsibility tosay that it looks flat from where I stand.

In a democratic society, which depends uponopenness, accountability and a well-informed citi-zenry for its efficient functioning, what should behappening is a systematic effort to bring home tothe citizen-taxpayers the nature of the dilemmasthat have to be faced, the options available andtheir likely consequences, and some considerationof the principles which should inform policy.There are some important strategic issues thatneed to be posed bluntly and clearly. Would youlike treatments to be equally available no matterwhere you live, or would you like local discre-tion to respond to local circumstances? You can’tha6e both. Would you like to reduce inequalitiesin people’s lifetime experience of health, or wouldyou like to avoid discrimination by age? Youcan’t ha6e both. Would you like absolute priorityfor life threatening conditions, or would you likemore resources devoted to the relief of pain andphysical disability? You can’t ha6e both. And soon.

© 1998 John Wiley & Sons, Ltd. Health Econ. 7: 565–568 (1998)

A. WILLIAMS568

The most effective route into people’s homes,through which these issues could be presentedgraphically and in a balanced way, is television.But although there are a small (but increasing)number of programme makers who are willing toattempt this exercise in civic education, the moreattractive option is the shock/horror/conspiracy/scandal mode of operation, ending with a demandthat heads should roll. But this is not a dramapeopled with ‘goodies’ and ‘baddies’, but a seriesof dilemmas in which virtually all of the actors canlegitimately claim to be acting ethically and consci-entiously. They simply differ in the weight theyattach to different objectives.

Some would argue that in the absence of consen-sus it is less disruptive to keep things as quiet aspossible and leave these matters to be settled byknowledgeable and conscientious people in pri-vate. In the public’s mind the knowledgeable andconscientious people are the doctors, certainly notthe politicians. What makes it very difficult for meto accept this apparently easy way out is that I

observe that doctors’ interests as providers ofhealth care often dominate their role as representa-tives of patients’ interests. In addition they are inno position at all to speak authoritatively for thecitizen-taxpayers, whose interests are distinct from(and more detached and long-term than) those ofcurrent patients. Moreover, it is possible to detectan increasing degree of resentment in the medicalprofession that, as the foot soldiers at the battlefront, they are left to improvise a tactical plan withwhatever resources headquarters provides themwith, but without any clear guidance about strate-gic objectives or rules of engagement. In thatsituation, the infantryman’s role is not a happyone! Would it not be better to take the bull by thehorns and make an attempt to engage the publicin a responsible debate about priority setting inhealth care, about the tensions between the poten-tial of modern medicine, the resource constraints,and the ethical principles that should guide theresolution of those tensions? It seems to me to bethe only responsible and constructive way forward.

© 1998 John Wiley & Sons, Ltd. Health Econ. 7: 565–568 (1998)