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This page created October 2000 by Michael Wynne
This page examines the importance of altruism as a community and
medical cultural value. It looks at the impact of a marketplace
culture on this.
This page was stimulated by Graham Samuel's lecture and his view that altruism was a value which was expendable in the move towards a sustainable medical system. By that he clearly means a corporate health care marketplace. His attitude reflects that of the marketplace. It supplements other comments.
Altruism and charitable donations are separate but related. Charitable donations are so often part of claiming an identity, showing who you are and how successful you have been - claiming immortality. Hospitals, research institutions and teaching institutions in the USA carry the names of generous donors. They do not look to see how the money was earned before accepting. Much of the Duke University Medical school was built by the tobacco industry. Many teaching hospitals have depended on this. Altruism is a deeper cultural value and charity can and often is a representation of true altruism.
Pro bono work:- Samuel identifies free "pro bono" work as the marker of altruism and acknowledges that it will decline under his model.
Australia:- While most doctors give more than they are paid to public hospitals universal medicare coverage makes this a non-issue in Australia. Many doctors including myself charged minimum medicare refund rates to those less able to pay and full medicare rates for those who are more affluent. We are simply responding to the needs of those - who are less fortunate. We have enough to live on and don't feel comfortable squeezing those who have less. Why be greedy. We differ from the CEO of a corporation in that our identity is not linked to wealth, although we enjoy the benefits of money. We resent being taken advantage of, and a remuneration system which undervalues our efforts.In response to the market a number of doctors have already adopted Samuel's attitude and anyone not prepared to pay their fee can go elsewhere. Patients complain bitterly about gaps as a consequence.
USA:- It is a major problem in the USA where large sections of the population are uninsured and are rejected by for profit providers. Responsibility for the underprivileged was accepted as a responsibility by not for profit groups and doctors. Competitive corporate for profit medicine has radically changed that and it is now a major social problem. Wallet biopsies, refusals to treat, patient dumping and a number of other unsavoury practices have caused public outrage. One uninsured patient severely injured outside a for profit hospital was refused resuscitation as bystanders watched him die.
Developing Countries:- This will be a major problem for developing countries who simply do not have the funds. For many care is given at markedly reduced rates by doctors who make their money from those who can pay. Hospitals are severely understaffed and depend on staff working hours which would not be tolerated in Australia.
Altruism and culture:- Samuel considers that a loss of altruism may be a necessary cost of moving to a more sustainable system and that doctors should be paid for their services. I am not arguing that doctors should not be paid for their services. The majority of doctors, nurses and paramedical staff enter health care with altruistic intentions. while they may on occasion betray these they are integral to the way they think - their culture. Samuel is proposing a massive paradigm conflict.
Altruism is not simply about providing pro bono care. With medicare there is none to provide. Altruism is about a state of mind, a way of approaching ones work and a way of dealing with others - giving that little bit extra and doing that little bit more - relating that little bore kindly. It is one face of a subculture of which Samuel is critical but ignorant.
Altruism and context:- Working in an environment where every profit penny is counted and where each medical service is tightly negotiated under contact is not an environment in which altruism flourishes. Doctors who come from the top 2% of school leavers see managers and directors who performed poorly and do nothing about providing care receiving massive bonuses. They too are tempted by the gravy train. They don't see why they should be excluded from incentives when that is how the system works. They are not motivated to make extra effort. This change would be felt by patients who would become distrustful.
In the USA altruistic doctors have rejected managed care. Others have accepted it but fight for their patients within the system. Surprisingly doctors have recently lost much of their bad image in the USA. Like the patients they are seen as victims. Television programs portray doctors as the heroes and HMO gate keepers as the villains to be outwitted. Altruism is something admired in the community and health care professionals are expected to display it. This is why scandals involving doctors generate anger and are so newsworthy.
Altruism and the marketplace:- The culture of the health care marketplace is reflected in Tenet/NME's internal documents. Advice for staff interviewing for appointments was sub-headed "Look for a shark". Instructions for writing notes were headed "WEECHEETUM". Administrators were instructed to watch for staff who showed altruistic feelings and weed them out. Columbia/HCA and a number of others had a similar culture.
Tenet/NME boasted of its corporate culture as an "intake culture". They saw nothing wrong with it. From inside it was logical. Doctors were part of this system and adopted its values when their own culture was discredited. We are all human and many will behave like this in the marketplace. A review by the West Australian health department in 1993 clearly identified this problem and the threat it posed to the Australian health system. Samuel's model is a direct attack
At the same time Richard Eamer, Tenet/NME's founder was basking in reflected light as the University of Southern California built the Richard Eamer Pavilion in gratitude for his numerous altruistic donations to the university, including this eye catching pavilion.
Professional and marketplace culture:- Altruism is simply a word reflecting part of professional culture. This culture has dominated the provision of health and aged care for 2000 years. Tenet/NME's written words are a reflection of the marketplace culture which has replaced professional culture as profit priorities and competition have come to dominate care. Over the last 20 years it apparently replaced the now discredited professional culture in the USA.
During the last few years professional culture and altruism have rebelled at managed care and re-asserted themselves. There is a strong lobby away from the commercial for profit model and towards a single payer system.