Medicine and Commerce. 1: Is Managed Care a “Monstrous Hybrid”?

The intrusion of commerce into medicine during the past decade has had a great deal to do with creating the tangled web of administrative and financial systems that we know as managed care. Although these new systems have brought about new efficiencies and have slowed the rate of increase in medical costs [1], they have also brought with them a growing sense, both in the profession and the public at large, that something profoundly wrong is happening to medicine [2]. Various explanations for this “angst” have been advanced, many of them reasonable but none, in my view, sufficient to account for the depth and degree of malaise abroad in the land. This editorial explores the deep “seismic shifts” that I believe are the major sources of our professional and public angst and suggests some ways of coming to grips with these root causes.

For a very long time, two strong, cohesive forces have characterized western medicine. The first is a set of governing moral precepts (a “guardian moral syndrome”) related to those that govern life in the military, the government, and the church; the second is a network of social relationships (“gift relationships”) based on mutual acts of giving and receiving. These precepts and relationships have created the context in which healing takes place and have, in many ways, contributed directly to that healing. They are, however, fundamentally incompatible with the divisive precepts and relationships that govern commerce. It is the thesis of this editorial that as medical care is increasingly bought and sold in the marketplace, we sense that we are forced to compromise more than individual moral precepts and that we are losing more than individual gift relationships. We realize, in effect, that the entire moral, cultural, and social fabric that has always defined medicine-the integrity …