Medicine and money: the ethical transformation of medical practice.
OBJECTIVE
To explore the generalised application of a discourse of cost reduction in the practice of medicine in the USA.


BACKGROUND
Changes in the health services industry over the last 20 years have left much concern in the hearts and minds of many, providers and patients alike. Even for the millions of Americans who are able to purchase health insurance, the standard of care has changed. In some ways, the current managed-care climate has created an atmosphere of distrust between patients and their providers, and, more significantly, a general sense of dissatisfaction with the state of health care in the USA. In the midst of this discontent, health providers have begun to question their own roles in what is increasingly a for-profit health care system. Not surprisingly, medical educators now question whether the current health system is creating a new generation of doctors who are concerned with reducing costs without adequate review of clinical data.


METHODS
This paper examines the rationale applied in the management of a patient with end-stage liver disease in a teaching hospital. The case is re-socialised by situating it in an ethical discourse linked to the function of the for-profit health system.


RESULTS
The decision about whether to give human albumin to an insured patient serves as a lens through which to examine how uncritical appeals to the discourse of 'cost-effectiveness' can supersede a patient- and data-oriented approach to medical decision making.


CONCLUSIONS
This case illustrates the permeation of economic considerations into the core values of medicine, highlighting a detrimental ethical shift occurring in the field. The training of new doctors represents a site from which to resist this unwelcome transformation.
Department of Social Medicine, Harvard Medical School and Department of Medicine, Brigham and Women's Hospital; both Boston, Massachusetts 02115, USA. salmaan@post.harvard.edu
Salmaan
S
Keshavjee
D003362:Cost-Benefit Analysis; D003657:Decision Making; D003695:Delivery of Health Care / Q000191:economics* / Q000941:ethics; D004992:Ethics, Medical; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008329:Managed Care Programs; D008875:Middle Aged