Medicine today faces many impor tant ethical questions. Some arise from the power of technologies that, pushing the margins of life, have forced us to think about the nature of life itself. Other questions arise be cause of a technology's cost or scar city. Practitioners and institutions seem forced into de facto rationing, such as waiting lists for liver trans plants. (If there are fewer livers than candidates for transplant, who should get a liver? Should alcoholics be treated like other candidates?)

While these (and other) high-profile questions are challenging enough ethically and socially, their actual impact on the daily practice of most physicians is small. What will, I think, shape health care in the United States over the next twenty years is the almost unnoticed takeover of medicine by "health maintenance organizations" (HMOs), "preferred provider organizations" (PPOs), and other multi-billion dollar "managed- care companies".

Corporate Medicine
Managed care became important to medical practice five or so years ago, but I did not appreciate what it does until, after working mostly in non- profit community mental-health centers for seven years after my psychiatric residency, I started my own solo practice. By then (1994), the traditional authority, privacy, and healing of the physician-patient dyad had already become a physician-patient-corporate triad. The managed-care company had become the invisible third party at every phy sician-patient conversation.

Clinical information the physician receives in confidence flows by telephone or writing into the computerized data-base of the managed-care company where anyone with knowledge of the computer and the password can access it. There a "caseworker" employed by the company, usually a masters-level social worker, sifts through the information sent in and decides the type, duration, and length of treatment.

I am always aware of this invisible eavesdropper. I must be careful what I ask a patient, since I must report what I learn back to the company, knowing that one wrong question may make the difference between "approved" and "disapproved".

Because the public has not paid much attention to managed care, my patients are generally not even aware of the corporate presence—until I inform them that I must get the company's approval for our treatment plan. My patients are rather acquiescent, unless, of course, the company decides not to pay for treatment. If the company decides not to pay, the patient can file an appeal with the company's physician, an em ployee, who in turn consults the unpublished corporate "criteria" which decide "yea" or "nay". Appeals are usually unsuccessful.

The Effects
How does managed care change how I practice? Here's one example: I might prescribe a specific antidepressant, say, Prozac. The corporate "gate-keeper" can replace what I prescribe with an alternative but not exactly equivalent antidepressant, such as Zoloft, because it costs less. Sometimes this replacement takes place without my approval—or even my knowledge or that of my patient!

Here's another example: Generally, the company will deny inpatient detoxification even to a heavily addicted user of crack cocaine. The company prefers less expensive outpatient treatment —unless there is a clear-cut, medically threatening physical sign of withdrawal (such as elevated blood pressure)—even though the probability that such an addict will stop cocaine use during those first, critically important few days without twenty-four hour supervision is practically zero.

Letters of denial always end with the disclaimer that "responsibility for the decision to seek a particular course of treatment is ultimately between the patient and his or her physician." In theory, the company does not deny treatment as such, only reimbursement for the cost of treatment. In practice, of course, the two are often the same. The cost of any treatment for which the company will not pay must fall on the physician, the hospital, the patient, or the taxpayer—or the patient must do without. Denying treatment in this way is easy: one does not take responsibility for the consequences or even have to face the patient.

Diagnosis
What went wrong? Before the advent of managed care, the basic eco nomic-political unit in medicine was the individual practitioner with his or her small population of patients. Though physicians had organizations, most notably the American Medical Associ ation (AMA), these were relatively weak and highly decentralized. They could not control medicine. With managed care has come the massive, centrally organized corporations headed by a handful of CEOs wielding great power over a large population of patients and physicians (and with considerable political power too).

Before managed care, medical decisions were more or less left to the individual practitioner. This way of making medical decisions gave the patient certain protections now lost. Unlike the CEOs running large managed-care companies, physicians were trained to put the physical and emotional well- being of patients first, even before their well-being or that of their families. While an ideal not always achieved, this commitment has deep roots not only in medical practice but in the ten-to-twelve years of medical apprenticeship, years of financial, physical, and emotional deprivation in the service of others. The ethically depraved physician—the physician who doggedly pursues personal gain at the expense of his patients—is, in my experience, the exception. Other physicians will condemn him publicly when he is discovered and avoid professional relations with him.

The CEO of a managed-care company has different ethical commitments. These belong to the distinctive intellectual and emotional life of the MBA, the grueling climb up the corporate ladder, the shareholders' questions about return on investment, and so on. For a CEO to place profit above the well-being of paying customers (patients) is, while bad for business if widely publicized, not contrary to his primary commitment to shareholders or, if legal, likely to damage him professionally.

Cure?
What next? So far physicians have been complacent about managed-care, but complacency seems to me unlikely to continue much longer. Physicians are too intelligent, educated, and skilled, too committed to values diametrically opposed to those of the managed care companies, to do nothing about what is happening to health care. Physicians also still have the power, collectively, to oppose the corporate megaliths: the signature of a physician still accounts for most of the billions of dollars spent on health care in the U.S. each year. So, I think physicians might well organize unions as earlier in this century blue-collar workers did. Physicians will, however, have to do it without the help, and perhaps despite the hindrance, of the AMA.

Since the power of a union ultimately rests on the willingness of its members to strike, corporate medicine may one day force on physicians this hard ethical choice: Do I sit by as corporations exact profits at the expense of my patients, or do I strike for better conditions, but at the price of temporarily denying my patients needed medical care?

A physician strike could be justified only if the long-term gain for patients outweighed the short-term harm. But justifying a strike by such a trade-off is itself troubling. Medical ethics has always placed value on each and every patient, present and future, and not just on the overall good of future patients. So, many physicians will be looking for alternatives to unionization.

One such alternative is public outcry against the unmitigated profiteering of corporate medicine. The public could pressure elected officials to pass laws curbing corporate power over medical decisions. In fact, this has already be- gun to happen. This fall Congress returned to the physician the power to allow a post-partum woman and her infant to remain in the hospital an extra day without being denied reimbursement for it. The managed- care company is required by law to pay for care that the treating physician deems appropriate.

While I am not an advocate of a national health program to replace corporate medicine, I do think a governmental solution to delivering health care would probably be better than the current corporate solution. The basic ethical commitment of the typical public servant, whether elected or appointed, is public service. Government medicine, though inevitably less efficient than corporate medicine, would at least have as its chief object the patient's well-being. Corporate medicine is, in contrast, though more efficient, ruthlessly self-serving. Savings accrue chiefly to its shareholders (and CEOs).

Best of all, I believe, would be a return to solo or small group practice. Unfortunately, that alternative does not seem to be open. Big medicine seems here to stay. So, for the next decade or two, medical care will increasingly be dispensed by corporations according to algorithmic protocols derived from a careful analysis of what is necessary to yield the correct profit margin. Medical graduates may even give up the Oath of Hippocrates in favor of one inspired by Lee Iacoca. A brave new world of corporate medicine, indeed!