The following is the text of a petition circulated to health care professionals by email and other means. It was signed by over 2000 doctors and other health professionals and then published in the Journal of the American Medical Association (JAMA) in December 1997.
We are physicians and nurses from across the spectrum of our professions, serving patients rich and poor, in hospitals and clinics, private offices and HMOs, public agencies and academia. Mounting shadows darken our calling and threaten to transform healing from a covenant into a business contract. Canons of commerce are displaing dictates of healing, trampling our professions' most sacred values. Market medicine treats patients as profit centers. The time we are allowed to spend with the sick shrinks under the pressure to increase through put, as though we were dealing with an industrial commodity rather than an afflicted human being in need of compassion and caring. The right to choose and change one's physician, the foundation of patient autonomy and a central tenet of American medicine is rapidly eroding.
Doctors and nurses are being prodded by threats and bribes to abdicate allegiance to patients, and to shun the sickest, who may be unprofitable. Some of us risk being fired or "delisted" for giving, or even discussing expensive services, and many are offered bonuses for minimizing care. Listening, learning, and caring give way to deal-making, managing, and marketing. The primacy of the patient yields to a perverse accountability - to investors, to bureaucrats, to insurers and to employers. And patients worry that their doctor's judgement and advice is guided by the corporate botton line.
Public resources of enormous worth - non-profit hospitals, visiting nurse agencies, even hospices - built over decades by taxes, charity and devoted volunteers, are being taken over by companies responsive to Wall Street and indifferent to Main Street. Communities find vital services closed by remote executives; savings are committed not to more pressing health needs, but to shareholders' profits. Not-for-profit institutions, forced to compete, must also curtail unprofitable activities like research, teaching and charity, or face bankruptcy. Hospital chains' profits reach $100 per patient per day; a single HMO president nets $990 million in a take-over deal; and insurers' overhead consumes $46 billion annually.
At the same time, the ranks of the uninsured continue to grow, while safety-net public hospitals and clinics shrink. Even many with insurance find coverage deficient when they need it most; care or payment are too often denied for emergencies or expensive illnesses. The sick are rushed out of hospital beds and hurried through office visits. Increasingly, patient comfort, the special needs of the elderly, infirm, or disabled are ignored if they conflict with the calculus of profit.
The shift to profit-driven care is at a gallop. For doctors and nurses, the space for good work in a bad system rapidly narrows. For the public, who are mostly health and use little care, awareness of the degradation of medicine builds slowly; it is mainly those who are expensively ill who encounter the dark side of market-driven health care.
We criticize market medicine not to obscure or excuse the failings of the past, but to warn that the changes afoot push medicine further from caring, fairness and efficiency. We differ on many aspects of reform, but on the following we find common ground:
1. Medicine and nursing must not be diverted from the primary tasks; the relief of suffering, the prevention and treatment of illness, and the promotion of health. The efficient deployment of resources is a critical, but secondary objective.
2. Pursuit of corporate profit and personal fortune have no place in caregiving.
3. Potent financial incentives that reward overcare or undercare weaken doctor-patient and nurse-patient bonds, and should be prohibited. Similarly, business arrangements that allow corporations and employers to control the care of patients should be proscribed.
4. Patients' right to a physician of choice must not be curtailed.
5. Health care must be the right of all.
Before the values we cherish are irretrievably lost, we invite all to join in a dialogue on medicine's future. The following urgent measures are needed:
1. An immediate state-wide moratorium on for-profit takeovers of hospitals, insurance plans, HMOs, physicians' practices and other health care institutions - pending the development of comprehensive state and national policies addressing these issues.
2. Meetings in hospitals, clinics, HMOs, offices, medical and nursing schools to discuss the health care crisis. We must educate ourselves, and the public, on the values that are at risk; establish coalitions to resist the onrush of for-profit systems; and discuss the elements of reform necessary to meet the needs of patients and communities. Such discussions must acknowledge the realities of funding as well as caring.
3. A widely representative national convocation to formulate a caring vision true to the community roots and samaritan traditions of American medicine and nursing.
Last modified October 1998 J.M. Wynne