In part one of this article, we discussed the intrusion of corporatization into a profession. The question was asked whether Adam Smith’s economic principles could be applied to health care. In this segment, physician responsibility will be examined.
Hippocratic Oath and the Oath of Maimonides
Most physicians take the Hippocratic Oath or the Oath of Maimonides. Both call for the physician (Healer) to hold a high standard of ethics to benefit their patient. It calls for physicians to help the sick, abstain from causing harm, teach the art, keep confidentiality. Maimonides goes farther: appointing the physician and pharmacist “to watch over life and health of Thy creatures.”
“May the love of my art actuate me at all times; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty ai of doing good to Thy children.” Predictive of the future, Maimonides asks the physician “to correct what I have acquired, extend its domain, for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements. Today he can obtain a new light on what he thinks himself sure of today.”
It concludes: “Oh God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.”
Perhaps forgotten or intentionally ignored, these principles have served us well for millennia only to fall increasingly into desuetude as physicians have been drawn unwittingly and sometimes by force of circumstance into a system not of their choosing. In the nineteenth century, Rudolf Virchow wrote that “physicians are the natural attorneys of the poor.” The luster of our star has diminished.
The conflict between the Federal Trade Commission (FTC) and the medical profession has been painfully debated. Edmund Pellegrino, MD from the Kennedy Institute of Ethics and John Carroll, MD, from Georgetown University, debated this issue in 1982. Their monograph was titled What is a Profession? The Ethical Implications of the FTC order and Some Supreme Court Decisions. Their article responded to a1982 Supreme Court opinion overturning a writ of certiorari of the Court of Appeals March 23,1982. The Supreme Court opined that competition among providers is deemed to be paramount to ethical obligations. “This is a rather interesting subjugation of ethical norms to the service of competition,” wrote Pellegrino and Carroll. They cite earlier opinions of the Supreme Court in 1952 (U.S. vs. Oregon): “…there are ethical considerations where the historic direct relationship between patient and physician is involved which are re quite different from the usual considerations prevailing in ordinary commercial matter. This Court has recognized the forms of competition usual in the business world may be demoralizing to the ethical standards of a profession” (emphasis added).
Obviously, the Supreme Court has strayed even further since 1982. Pellegrino and Carroll went on to write that the medical profession has not done a very good job policing itself. “We need to restore the ideal of a physician as a virtuous person who does not need philosophy, law, competition or even an ethical code to instruct (them) on what is (their) moral behavior in his relationship with those who are ill.” If anything, the intrusion of corporations and supportive antitrust laws make it even more difficult to resurrect “Medical Morality.”
Pogo
Walt Kelly’s Pogo was comic strip syndicated from 1948 until 1975 using animal characters to satirize social and political events of the era. Probably the most famous is a cartoon where Pogo (who resembles a cute porcupine) is walking through a pristine bayou with his son. The son says, “Ah Pogo, the beauty of the forest primeval gets me in the heart.” Pogo, who is tiptoeing, responds, “It gets me in the feet, Porkypine.” In the next frame, they are looking at a rubbish-filled forest with tires hanging from trees. Porkypine comments, “It is hard walkin’ on this stuff.” To which Pogo replies, “Yep, son. We have met the enemy, and it is us” (emphasis added).
Organized medicine has stood on the ramparts of opposing the expansion of nurse practitioners (NPs) for much of the last several decades. Articles have been written exposing their deficiencies in an independent setting. An article from the Journal of the Mississippi State Medical Organization published in January 2022 revealed independently practicing NPs at the Hattiesburg Clinic increased costs to patients by $28 million annually. This resulted from increased tests, referrals to specialists and emergency room visits. Trends reveal that nurse practitioners are leaving primary care into specialty areas where they are especially unprepared.
While decrying the overuse of nurse practitioners, doctors themselves open free-standing clinics staffed by unsupervised NPs for their own monetary benefit. Likewise in hospitals, while nominally prohibited, initial consultations are done by nurse practitioners then signed off by neurosurgeons, vascular surgeons, cardiologists, etc. with only a cursory glance at the patient and a nominal conversation. Perhaps this is being done for expediency and to meet the time constraints of their employer.
Similarly, Team Health is a national corporation that hires doctors, primarily hospitalists and emergency department (ED) physicians. Doctors must meet efficiency goals. In some EDs they must also supervise more than four mid-levels in addition to their own more complicated cases. Given the limited amount of time, a conscientious physician will not know what they are missing. An admitted patient must be seen with a note written in 15’ and new patient evaluated in 30’. While permissible for an 18-year-old coming in with appendicitis, it is certainly not for an 80-year-old with multiple admissions for heart failure, COPD, CKD stage V, and ischemic legs. This suggests that we have abandoned our responsibility to the patient. If we accept that a doctor must place the needs of the patient before their own, then what is the doctor’s responsibility when corporatized medicine has forced the physician into a compromising treatment paradigm?
We doctors have not been good stewards of our profession. Having succumbed to external pressures, there is little wonder that healthcare executives regard doctors and patients as a commodity. We have not pushed back on those forces who regard doctors not as professionals but as skilled and highly paid workers. Insurance executives would be thrilled to eliminate us if they could. We are now valued for our economic productivity and no longer for knowledge or commitment. Those who control us serve a different master, their stockholders. They seek to expedite health care services to a dangerous extreme. The time allocated to brain surgery, a pancreatic resection, or a thoracoabdominal aneurysm can be hastened only with peril. Limiting time spent with a patient erodes the physician-patient bond and ignores the integral nature of healing: that the patient enjoys the confidence that we can make them better. We don’t heal patients; we create pathways that allow them to heal themselves.
We can speculate what will happen to practices with the advent of new drugs. GLP-1 agonists and PCSK-9s succeed in reducing the incidence of arteriosclerosis, aneurysms, and with it, the need for intervention. GLP-1s have already diminished the need for bariatric surgery.
Pity the poor physician who has just completed their fellowship with more than $200,000 in debt. Married, with a young family as they struggle to begin a career. Most countries pay for or lavishly subsidize medical education and doctors are considered a public service. In this country, student loans become payable immediately relegating the new attending to that of an indentured servant. Once employed, they have no option but to follow their employers’ mandate or risk dismissal. This loss of authority is accompanied by the moral injury of ignoring the basic tenets of our profession. Regretfully, organized medicine has provided little protection for the employed physician. Which may be why so few of them join.
Where do we go from here?
Health care in our society is at an inflection point; we can no longer afford our health care system. Insurance premiums are unaffordable, as are deductibles and co-pays. In 2024, America spent $13,676 per person, per year, or $4.22 trillion, 17.9% of the GDP. Of that, 32% was spent on hospital care, 20% on physician and clinical services (?) and 10% on prescription drugs. Where did the other 38% go?
In 2025, we spent $5.6 trillion, an increase of 7.1%. Despite spending this egregious amount, roughly twice that of any other developed country, America still has a problem with accessibility. Affordable Care Act (ACA) subsidies were discontinued leaving four million people uninsured because of increased premiums.
Paraphrasing Adam Smith’s Wealth of Nations, “the butcher will not sell his meat out of the goodness of his heart but for his own benefit.” Doctors are different. We became doctors for altruistic reasons. We are entitled to earn a living compatible with years of training and complexity of service. But even Smith’s butcher will get sick and need care.
As we all will need medical care, our commitment renders health care a right and not a privilege. Because they depend on us, patients would become our natural allies, many of whom cannot afford insurance. Currently, their saving grace is EMTALA (Emergency Medical Treatment and Active Labor Act, passed in 1986.) EMTALA obligates hospitals to provide care to patients who come into their emergency departments and require treatment. The question is how to pay for it.
Ewe Rinehart, the late eminent medical economist, wrote that “There are only two repositories for money in health care: private insurance or the government.” Some legislators have advocated creating Health Savings Account. They work fine if you’re not sick and have plenty of money. But if you don’t, they won’t solve the problem since hospital costs are enormous and lack consistency and transparency. A trip to the ED will run over $10,000 after several CT scans are factored in. Let alone exorbitant facility fees. Heaven forbid you need chemotherapy which will render a wealthy person penniless.
Capitalism — when applied to healthcare — clearly is not working. Health care insurance companies, private equity firms, for-profit hospital chains and organizations that place profit over patients have not demonstrated cost savings or improved outcomes. There is too much entropy (bureaucracy) in the system. Perhaps expanding Medicare and allowing patients to buy into it at a younger age is an alternative. At least taxpayers and voters maintain some control. Medicare works well, although CMS has tended to ignore physicians over the last 26 years while generously subsidizing Medicare Advantage Plans. (Medicare is attempting to recover overpayments to Medicare Advantage Plans “soon.”)
At the Interim Meeting of the American Medical Association in November 2025, Mehmet Oz, Director of Medicare/Medicaid Services, requested more physician involvement in the process of solving this crisis. He proposed an alternative to insurance companies: the formation of Accountable Care Organizations, a collaboration between doctors and hospitals. Since we are the only two with direct patient contact and understanding of patients’ needs, we would be natural allies.
To be successful, doctors will have to demonstrate the ability to regulate large institutions and assert leadership. We will have to be stewards of the profession and curb excessive care. Cognizant of medical necessity, doctors can exercise that function without harming patients. Physicians have become docile, often complacent, and reluctant to criticize harmful policies. It will be a painful transition, but doctors retain an attribute which corporatized medicine lacks: integrity. History appears to be providing physicians with an opportunity to reclaim our profession. The nation and the patients are waiting.
