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Marcia Angell

Kennedy Institute of Ethics Journal, Volume 3, Number 3, September

1993, pp. 279-286 (Article)

Published by The Johns Hopkins University Press

DOI: 10.1353/ken.0.0253

For additional information about this article

http://muse.jhu.edu/journals/ken/summary/v003/3.3.angell.html

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 Mareta Angell

The Doctor as Double Agent*

abstract. American doctors in the 1990s are being asked to serve as "double
agents," weighing competing allegiances to patients' medical needs against the
monetary costs to society. This situation is a reaction to rapid cost increases for
medical services, themselves the result of the haphazard development since the
1920s of an inherently inflationary, open-ended system for funding and delivering
health care. The answer to an inefficient system, however, is not to stint on care, but
rather to restructure the system to remove the inflationary pressures. As long as we
are spending enormous resources on an inherently inefficient and inflationary
system we cannot justify asking doctors to withhold beneficial care to save money
for third-party payers. Doing so serves a largely political agenda and endangers the
patient-centered ethic that is central to medicine.

IN EARLIER TIMES—that is, before 1980—it was generally agreed that

the doctor's sole obligation was to take care of each patient. The doctor
was the patient's fiduciary or agent, and the doctor was to act only in
the patient's interest. Now all that has changed. Many of us—economists,
governmental officials, corporate executives, even ethicists, and yes, even
many doctors themselves—now believe that doctors have other obligations
that compete with their obligation to the patient. In particular, they believe
that doctors have acquired an obligation to save resources for society. Doing
so requires doctors to practice with one eye on costs, which may mean
sometimes denying beneficial care that they would surely have provided in
earlier times.
According to the new view, doctors are no longer simply agents for their
patients. They are now agents for society's needs as well. They are, in short,
double agents, expected to decide whether the benefits of treatment to their

This article is based on the annual Edmund D. Pellegrino Lecture at the Kennedy Institute of Ethics.

Kennedy Institute of Ethics Journal Vol. 3, No. 3, 279-286 © 1993 by The Johns Hopkins University Press
 KENNEDY INSTITUTE OF ETHICS JOURNAL · SEPTEMBER 1993

patients are worth the costs to society. Many distinguished ethicists have
enthusiastically embraced this new ethic (Callahan 1990; Morreim 1991). To
them, keeping an eye on the price tag means saving scarce resources for
other, more important uses.
How did this extraordinary shift in our view of doctors' obligations come
about? Is it just coincidence that it began with our first realization—roughly
in the mid-1970s—that our seemingly endless resources were in fact finite?
And is it just coincidence that it accorded with the wishes of the third-party
payers—who discovered during the 1980s that they had severe and growing
budgetary problems? In short, can it be that the ethical underpinnings of the
practice of medicine have been scrapped in a single decade for financial
reasons? Is economics driving ethics?
I'll begin with my conclusions. I believe that doctors are now asked to be
double agents and that their dual obligation is a recent construct, which
arose out of the economic difficulties of the large third-party payers. I will
argue that we embrace this new ethic at our peril. Even if we as a society
decide that health care should take a smaller piece of the national economic
pie, there are ways to do this that do not entail rebuilding—and perhaps
destroying—almost overnight, the ethical underpinnings of the profession.
HISTORICAL REVIEW

First, a quick review of how we got here. This requires an economic

analysis, since my thesis is that economics is now driving ethics. The
economic history of health care in the United States can be divided into three
phases. First, there was the phase of the true market, lasting until roughly
World War II. Patients paid doctors out-of-pocket for their medical care. If
the price was too high, the doctor was confronted with an unhappy patient.
Even after private insurance companies began to flourish in the 1930s, the
premiums were still paid out-of-pocket and so patients continued to feel the
costs, although the pain was blunted. Fortunately, medical care was fairly
inexpensive. Unfortunately, it was also relatively ineffective, compared with
the power of modern medicine.
The second phase was marked by the entry of big business into the health
care picture. Big business began to offer health insurance as a fringe benefit
in order to evade the wage and price controls in effect during World War II.
Offering health insurance was tantamount to increasing wages, and further-
more, it was not taxed. The connection between employment and health
insurance was thus an historical accident that haunts us still. But the
important effect of this connection for the discussion here is that it insulates
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patients from the costs of medical care. Neither doctors nor patients had to
worry any longer about the costs of medical care. With the enactment of
Medicare and Medicaid in 1966, this insulation from costs spread to the poor
and, most importantly, to the elderly—a politically powerful group. By the
end of the 1960s, anything resembling a true market in health care had
vanished. Nearly everyone was covered by third-party payers—govern-
ment, business, and private insurance companies. And medical care was
becoming both more expensive and more effective. Despite the increasing
costs, the third parties happily paid the charges, with few questions asked.
The third phase began with the realization that health care costs were
consistently rising far more rapidly than the GNP. Now that patients and
doctors and hospitals were insulated from accountability, there were no
limits on the expansion of the health care industry in this country. It was
open-ended and nearly risk-free, absorbing an ever greater share of our
domestic spending. While national expenditures for other social goods, such
as education, stagnated or declined, expenditures for health care rose
rapidly—from roughly 6 percent of the GNP in 1965 to nearly 10 percent in
1980 to 13 percent in 1991 (Stoline and Weiner 1993).
Not only was there nothing to stop the inflation, but there were features
that virtually guaranteed it. These included the piecework, fee-for-service
reimbursement system that is greatly skewed toward high-technology
procedures and specialists. Doctors, of course, act as both providers and
purchasing agents, so these highly paid specialists could easily generate their
own business. For example, the cardiologist who recommends coronary
angiography to a patient also bills for it.
COST CONTAINMENT

In the 1970s, the Arab oil embargo made Americans realize that our
resources were finite. Health care costs began to occupy the attention of
some experts and policymakers. By the 1980s, it became clear to nearly
everyone that we could not indefinitely sustain rising health care costs, and
for the first time, efforts were made to control them. "Cost containment"
crept into the lexicon, and by the end of the 1980s the New England Journal
of Medicine probably received more manuscripts about cost containment
than about cancer. The efforts to control costs were spearheaded by the
major third parties—government and big business. They were responding
essentially to budgetary problems, not to moral problems. They went about
cost containment in a number of ad hoc, uncoordinated ways, as briefly
mentioned below. None of them was notably successful. In fact health care
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 KENNEDY INSTITUTE OF ETHICS JOURNAL · SEPTEMBER 1993

costs rose even faster—I believe, because of cost containment efforts, not
despite them.
Regulation by third parties, including managed care, simply led to the
growth of an expensive and intrusive new bureaucracy. Efforts to foster
competition led to increased marketing, not to lower prices. And attempts
to limit demand through higher deductibles and copayments simply shifted
costs and limited care, primarily to the most vulnerable. Efforts by insurers
to avoid risks also shifted costs. In general, savings to one part of the system
were costs to another. In fact, the dominant characteristic of the American
health care system is that there is no system. There is just a hodgepodge of
arrangements, existing independently, often working at cross purposes, and
generating enormous administrative costs. Indeed, administrative costs—
billing, marketing, underwriting, claims processing, utilization review—
now consume more than 20 cents of the health care dollar (Woolhandler and
Himmelstein 1991).
Why do I recapitulate this sorry history of the economics of the American
health care system ? I do so because it is important to understand the context
in which doctors are being invited to act as double agents. They are invited
to do so in an open-ended, inherently inflationary system (or, rather, non-
system) that spends roughly 40 percent more per citizen on health care than
the next most expensive health care system in the world and at least twice
as much on administrative costs. Further, this system is embedded in a
society that routinely spends billions and billions on such goods as tobacco,
television ads, and cosmetics. Clearly, we as a society are not facing scarcity;
instead we are facing the inefficient and frivolous use of vast resources.
SAVING FOR THIRD PARTIES

What precisely is the doctor supposed to do as double agent? In a nutshell,

doctors are supposed to tailor their care of patients to save money for third
parties. For example, under the DRG system of hospital reimbursement for
Medicare patients, doctors are supposed to be agents for the hospital,
discharging patients as rapidly as possible and keeping services to a
minimum so that the hospital can game the system. In many HMOs doctors
are expected to keep costs as low as possible, and some HMOs even directly
reward doctors with bonuses when the HMO comes out ahead. They may
also withhold a portion of doctors' salaries if they refer patients to specialists
too often or use too many tests and procedures. Thus, doctors are agents for
the HMO and have a direct incentive to undertreat their patients, just as in
the fee-for-service system they have an incentive to overtreat them. Other
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forms of managed care also deter doctors from delivering care. Those that
require utilization review often make it so complicated and difficult to get
approval for hospitalization or procedures that the doctor is reluctant even
to try. And it should be noted that nearly all medical care these days is
managed in one way or another, by which I mean it is subject to efforts of
insurers to limit care.
In essence, then, doctors are increasingly being asked, in one way or
another, to save money for a third party—and sometimes for themselves—
by scrimping on the medical care they deliver. But the pressure is seldom
described in these terms. Instead, it is described as practicing "cost-
effective" medicine. "Cost-effective" is the new watchword. It used to be a
technical term that referred to the least expensive of two equally effective
alternatives, or to the most effective of two equally costly ones. Now it is
simply a shorthand for any attempt to save money. The word sounds fine,
and who can object to it?
JUSTIFICATION FOR DOUBLE AGENTS

But how can we justify asking doctors to deprive their patients of care,
including clearly beneficial care that in other circumstances they would not
hesitate to provide? Just as the problem is new, so are the ethical justifica-
tions.
First, it is claimed that limiting care is what society wishes, and that the
medical profession has an obligation not only to accept the will of society
but to further it. Doctors are simply anticipating and delivering what is
expected of them by the body politic, despite the fact that individual patients
may want something else when they are sick.
Second, it is argued that because third parties now pay for nearly all
medical care, they have gained a legitimate voice—indeed, the overriding
voice—in how much medical care patients should receive. I find this a
peculiarly American argument. Essentially the message is that whoever pays
the piper calls the tune. The purest example of this view is the Oregon plan
for rationing the care received by Medicaid patients. This is often described
as a decision to allocate scarce resources rationally and justly, but it is, of
course, nothing of the sort. It is instead a matter of taxpayers deciding to
limit the care received by the poor, on the grounds that the taxpayers are
funding it. Those who drew up the priority list of medical services are not
those to whom it would apply. Even if we were to accept the idea that paying
for medical care confers the right to limit it, we should remember that most
patients do in fact still pay for their medical care, just as they always did.
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They simply pay in advance and indirectly, through their work or their
taxes. The third parties are not using their own money.
The third justification for doctors to be double agents is the most
compelling. It appeals to the doctor as good citizen or, more dramatically,
to the doctor as occupant of a metaphorical lifeboat with limited supplies.
According to this view, resources saved in denying patients expensive
medical care could be used to provide less expensive care to a larger number
of patients. Or it could be used for even more important public purposes,
such as education. This line of argument has been put forward most
persuasively by Dan Callahan (1990) who contends that Americans have
overvalued individual health care compared with other social goods.
ARGUMENTS AGAINST DOUBLE AGENTS

Despite these justifications, I see five serious problems with the view that
doctors should act to contain costs, patient by patient. First and most
simply, this view of the role of doctors is based on the premise that resources
in our health care system are in fact scarce. But, of course, they aren't. The
mere fact that we spend so much more on health care than all other advanced
nations is proof that our health care resources are plentiful. Given that in
1990 we spent about $2,566 on every man, woman, and child in the United
States, and Canada spent only $1,770, we can hardly claim inadequate
resources (Schieber, Poullier, and Greenwald 1992). And since Americans
and Canadians are subject to the same ailments and have roughly the same
outcomes, we must assume that our system is grossly inefficient. Clearly, the
answer to an inefficient system is not to stint on care, but rather to
restructure the system to make it more efficient.
Second, enlisting doctors as ad hoc rationers presumes that resources
saved by denying health care would be put to better use. But in our system
there is absolutely no reason to think that it would. As Norman Daniels
(1986) has pointed out, in the United Kingdom or Canada, resources saved
by denying care would be used for presumably more valuable health care,
but that is not the case here. In the U.S., we do not have a closed system in
which funds taken from one form of health care are diverted to another that
is deemed to be more important. Instead, funds not used for health care may
find their way into any sector of the larger economy, to be used for
anything—e.g., defense, education, farm subsidies, or personal savings.
Furthermore, even funds that remain within the health care system might
not be used for more effective care; instead, money saved on, say, heart
transplantation may very well find its way to a hospital's public relations
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office or to higher salaries for administrators. Under these circumstances, it

is very difficult to sustain an ethical argument for doctors acting as double
agents. The only principled way to ration health care is to close the system
and establish limits that apply to everyone—not just to the poor.
Third, asking doctors to be double agents overlooks an important
symbolic function of health care. Our society was founded on the principle
that individuals enjoy a set of basic rights that cannot be denied them. As
medicine has become increasingly effective in preserving life, medical care
has come to be counted among these rights. Thus, doctors are seen to
preserve a basic human right, namely life, just as criminal lawyers are seen
to preserve liberty by defending their clients. Lawyers do not decide part way
through a trial to call it quits because it's just too expensive to go on with
it. In both situations, there has been a consensus that the single-minded focus
on the patient or the client serves the broader interests of society. This
argument is particularly compelling in a society as unequal as ours. People
will tolerate the vast inequities in income and privilege in this country only
if they feel assured that their irreducible set of rights is truly protected. It has
been suggested that high technology medicine may serve precisely such a
reassuring function in our society. And public opinion polls tend to support
this view (Blendon 1991). The public, in contrast to the third-party payers,
does not feel that we are spending too much on health care, only that we are
not getting our money's worth.
Fourth, when doctors act as double agents, they are merely acting on their
own particular prejudices. They are deciding that this or that medical service
costs too much. This is not a medical judgment, but a political or philosophi-
cal one. Another doctor (or a plumber or electrician) might make quite a
different judgment. This is no way to allocate health care.
And fifth and perhaps most important, the doctor as double agent is not
honest. Sick people need and expect their doctors' single purpose to be to
heal them. The doctor-patient relationship would not survive a candid
statement by the doctor that only care that seems to the doctor to be worth
the money will be provided. Anything short of full efforts to heal the
individual patient, then, must involve a hidden agenda—an ethically inde-
fensible position.
CONCLUSION

In sum, we should be loath to abandon or modify the patient-centered

ethic, and we should be wary of ethical justifications for doing so. Unfortu-
nately, history shows us that ethics in practice are often highly malleable,
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justifying political decisions rather than informing them. Necessity is the

mother of invention, in ethics as well as in other aspects of life. For example,
in 1912, when the AMA thought salaried practice was a threat to the
autonomy of the profession, its Code of Ethics pronounced it unethical for
physicians to join group practices. Nov/, some 80 years later, we are again
hearing that it is a matter of ethics for the medical profession to carry out
what is essentially a political agenda. But ethics should be a little more stable
than that. Ethics should be based on fundamental moral principles govern-
ing our behavior and obligations toward one another. If a doctor is ethically
committed to care for the individual patient, that commitment should not
be abridged lightly. And it should not be nullified by a budgetary crunch.
Doctors should continue to care for each patient unstintingly, even while
they join with other citizens to devise a more efficient and just health care
system. To control costs effectively will in my view require a coherent
national health care system, with a global cap and a single payer (AngelÃ-
1993). Only in this way can we have an affordable health care system that
does not require doctors to be double agents.
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AngelÃ-, Marcia. 1993. How Much Will Health Care Reform Cost? New England
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