7
Economisation of healthcare and professional
ethics
The term 'economisation' is often used to describe the growing dominance of economic
motives and interests in the organisation and provision of healthcare. The consequence
of this for healthcare providers is that they must take account of economic as well as
medical aspects when considering treatments. This raises the question of what effect
economisation of healthcare has on the professional ethics of healthcare providers.
Should professional ethics change, or does the established system of professional
ethics have to be discarded? Do professional ethics offer protection against excesses in
the economisation of healthcare? This report shows that economisation puts pressure
on two key concepts in professional ethics: the importance of 'trust' and the importance
of professional standards. Professional ethics cannot be expected to offer sufficient
guarantees against risks of economisation. Other measures must be taken to guard
against these risks. The context of professional ethics is altered by the changing
circumstances of healthcare, and they must reflect this situation. This calls for a review
of current professional ethics.
7.1
Introduction1
The increasing focus on an economic approach to healthcare is often described by the
term 'economisation'. This is a collective term for a number of developments in
healthcare that appear to be closely linked. An analysis of the various meanings of the
term reveals two principal trends. On the one hand, economisation involves taking
initiatives to encourage the working of the market and a more businesslike approach, or
allowing healthcare with a profit motive. In this case, economisation really means
commercialisation of healthcare, and leads to a different way of working and thinking.
On the other hand, the term can also refer to financial measures, such as the recently
proposed no-claim system, from a cost control point of view. In this case, economisation
means an economically responsible attitude to healthcare. When used in this sense,
economisation often takes on a normative connotation: it is recommended as a way of
offering good-quality, accessible and affordable healthcare to everyone. An underlying
justification for this approach is a strong appeal to people to act responsibly.
This report mainly focuses on economisation in the sense of commercialisation of
healthcare and the changes that this will bring about in the organisation of healthcare.
Cost control issues will unavoidably also have to be addressed. This is not unusual, as
the market can also be used as an instrument of cost control. Economisation often
involves a mix of aims, one of which is cost control.
It is often said in the debate on economisation that the increasing attention paid to the
economic aspects of healthcare places doctors and other care providers in a moral
dilemma when it comes to exercising their profession. Their professional ethics,
conceived as a set of moral rules and principles that guide professional activity, may
come under pressure if they have to take account of different, and sometimes
conflicting, interests. Some people wonder whether the current system of professional
ethics is still adequate to meet these changing circumstances. Others take a different
view, seeing professional ethics as a buffer against the excesses of economisation.
1
This report was compiled by Dr. AJ Struijs, project coordinator for CEG/RVZ [Dutch Centre for Ethics
and Health/Council for Public Health and Health Care, and based on three background studies
carried out by third parties (these can be found at www.ceg.nl):
-
Dr MT Hilhorst, Doing good while making a profit. Towards an economisation of healthcare and
professional ethics? Erasmus Medical Centre, Rotterdam.
-
Dr FJ van Zuuren, The working of the market and ethics in clinical activity. Voices from the
field. Amsterdam University and Amsterdam FreeUniversity
-
Dr EJTh van Hout and Dr K Putters, The value of the norm. Effects of economisation on the action of
doctors and managers in hospital care. Tilburg University.
Economisation of healthcare and professional ethics 153
This report examines the effect of economisation of healthcare on the professional
ethics of healthcare providers, particularly hospital doctors. Section 7.2 starts by
defining economisation and the trends that have led to it becoming more important.
Section 7.3 then looks at professional ethics. What do we mean by this? What trends
affect them? We then go on to investigate the consequences of economisation for
professional ethics. What is the position of professional ethics in this changing situation?
Does the influence of economisation make them vulnerable, robust or flexible? Various
answers can be given depending on the view the respondent takes of professional
ethics, and this discussion raises ethical issues. These issues and their significance for
public policy are addressed in section 7.4.
7.2
Economisation of healthcare
Features of economisation
The key features of economisation are a management approach, quantification, marketfocused operation, an entrepreneurial attitude, productivity as a norm and remote
2
management (Grit 2000, Van Hout and Putters 2004). Engelen (Expert meeting, 2004 )
adds the following to this description: professionalisation of the organisation, marketing
and profit orientation. He considers that economisation in the healthcare system is
principally manifest as professionalisation of the organisation, and also in the form, of
marketing.
Van Hout and Putters (2004) agree with Grit (2000) in their definition of economisation,
and also support his contention that economisation is associated with three types of
changes. These relate to professions (arrival of management), systems (the effect of the
market is felt more strongly) and ideologies (neoliberalism). These point to two important
developments in healthcare that follow from economisation.
PRIVATISATION
The first of these developments is that healthcare is offered on a commercial basis. Privatisation
of healthcare means, for example, that private clinics carry out specific procedures and that
outpatients’ clinics run by medical insurance firms on behalf of private companies ('company
clinics'), production lines (for inguinal hernias, for example) and shops selling home care products
are set up. These are independent firms, or firms associated with normal institutions, that offer
part of the healthcare chain on a commercial basis.
COMMERCIALISATION OF OPERATIONS
Economisation also affects the non-profit sector, where profit is not the goal. It leads to
changes in the way organisations work. Market principles, such as efficiency, strategic
policy and human resources management (HRM), which are common features of
private enterprise, are deployed to bolster public interests such as solidarity, equality
and suitability of care (Grit 2000, RVZ 1998; 2002). We see this form of economisation
reflected even in the language that is used, with terms such as HRM, production lines
and diagnosis-treatment combinations (DTCs).
Economisation also affects the demand side. Market incentives, such as the increase in
patient contributions and the proposed no-claim system, are examples of the
commercialisation of healthcare. These arrangements are designed to increase client
responsibility, curb the use of healthcare, combat unnecessary consumption of
healthcare and save costs.
Public policy has to deal with both developments. On the one hand, the authorities want
to encourage economisation of healthcare. The working of the market is an instrument
that enables healthcare to be more efficiently organised. Healthcare policy has shifted
2
An Expert meeting was held to prepare this report. The minutes can be found at the CEG website:
www.ceg.nl
Economisation of healthcare and professional ethics 154
from control of supply to a demand-led approach. The patient is the 'customer' and can
obtain the product, 'healthcare', from a variety of providers. Healthcare is a 'product' that
can be profitable or loss-making. Medical insurance providers act as brokers for the
customer, negotiating with healthcare providers on price and quality, and buying in
healthcare. The idea is that a demand-led system leads to more freedom of choice for
the patient/customer.
Consumerism and commercial principles have therefore become more dominant in the
way the sector thinks and operates. However, the authorities also have to monitor the
quality, affordability and accessibility of healthcare.
Reasons for economisation
Economisation cannot be seen in isolation from other trends. Influences inside and
outside the healthcare sector play a part in the increasing focus on commercialisation.
The most important issues are discussed below (Van Hout and Putters 2004).
Higher costs
Ever-increasing costs are an important factor in the economisation of healthcare by
means of privatisation and a more commercial approach to management. Two trends
contribute to this persistent rise in costs. The first of these is the ageing population,
leading to a greater demand for healthcare. Older people form a steadily growing
proportion of society, and need more and specialised care. In relative terms, older
people make most use of hospital care, which increases the pressure on this sector.
Furthermore, technology is continually creating opportunities, leading to more demand.
Developing technology is an expensive process, and new technologies are extremely
costly when they are first introduced. For example, expensive drugs have been
developed that are very effective in treating rheumatism (Van Zuuren 2004). This also
puts pressure on healthcare budgets. It is true that new technologies may eventually
lead to savings. For example, diseases can be detected earlier, or research might
produce better or cheaper drugs. The application of these innovations will eventually
produce huge savings, and it will be possible to treat more patients for less money.
"The demands placed on medicine by older people are increasing, and this is quite
understandable. Indications for hip surgery, for example, have been relaxed. It is now possible
to perform a hip replacement operation on people over 80, as the risks of anaesthesia are
reduced." "In the case of cataract surgery, for instance, and hip surgery as well, the boundary
for establishing an indication for treatment is continually shifting in the direction of consumer
care: performing procedures that are less necessary from a medical point of view. This makes
the totality of healthcare more expensive." (Van Zuuren 2004).
Individualisation
Privatisation and commercialisation of healthcare also fit in well with the trend
towards increasing individualisation. The ability of individual patients to make an
independent choice as to the medical care they receive is increasingly seen as
important. People want more freedom of choice and flexibility to buy in their own
healthcare. This is not limited to essential treatments. Some people also want to be
able to choose to undergo procedures that are not medically necessary, such as
cosmetic surgery (face-lift, liposuction) or refractive surgery to replace spectacles or
contact lenses (Van Zuuren 2004).
A plastic surgeon has opened a private clinic with colleagues from the same region. People
here pay for their cosmetic surgery themselves. "Not everyone can pay for this, just as not
everyone can afford to stay in a five-star hotel. It would be unfair to have others contribute to
procedures, such as an expensive face-lift, via their medical insurance premiums."
(Van Zuuren 2004).
Reaction to deregulation
Deregulation is another trend that has contributed to the commercialisation of
healthcare. Excessive legislation and regulation have bogged down the healthcare
Economisation of healthcare and professional ethics 155
system, and deregulation therefore is needed to allow entrepreneurship to flourish. The
thinking is that encouraging innovation, creativity and efficiency will be more beneficial
to the public interest in healthcare than the current way of doing things. However, not
everyone agrees with this view. Lack of government intervention might lead to less
effective protection of the public interest (Expert meeting 2004). The question is whether
the commercialisation of working methods, deregulation and commercialisation of
healthcare can actually offer adequate support to key values such as solidarity, equality
and accessibility, and to professional values such as medical urgency and professional
autonomy.
Conclusion
Economisation is a complex term and relates to a range of economic initiatives in the
healthcare sector, which in turn have a variety of goals. Economisation is sometimes
used to refer to the commercialisation or privatisation of healthcare. Private clinics,
'company clinics' and shops selling home care products are examples of this. These are
independent firms that offer parts of the healthcare chain on a commercial basis.
Economisation also refers to a method of operation (commercialisation) in which market
principles are used in guarding the public interest. The action of the market is a specific
form of economisation. It is an instrument of control that organises healthcare in
response to demand and aims to increase patients' freedom of choice.
Economisation cannot be seen in isolation from other trends that also influence changes
in the emphasis of healthcare. For instance, individualisation increases patient
autonomy. The ageing population leads to higher costs, and so also has an effect on
equality, accessibility and solidarity in healthcare. Technological progress raises the
issue of whether everything that can be done must be done.
7.3
The influence of economisation on professional ethics
Characteristics of professional ethics
We need to have some insight into professional ethics before we can decide how far the
economisation of care influences the professional ethics of healthcare providers. It is
true that this report only considers the influence of (certain aspects of) economisation on
professional ethics. Other trends are taking place at the same time, such as
juridicisation and informatisation, that are currently exerting a strong influence on
healthcare and therefore also on professional ethics. These trends will be addressed
when they are relevant.
Professional ethics has been briefly described above as a set of moral rules and
principles that guide professional activity. This report mainly focuses on the professional
ethics of hospital doctors and the dilemmas they face as a result of economisation.
Members of other professions, such as nurses and care assistants, also face
comparable dilemmas (Van Dartel at the Expert meeting in 2004):
We know from the nursing and care sector that a minimum threshold is set for the quality of
professional activity: if the quality of care does not come up to scratch, these professionals
leave. The problem is how the profession and the institution should react to what is, at the
personal level, a negative experience. This is because the effect is to keep complex patients
out.
What are the unique features of professional ethics? Professional ethics refers to
good action by healthcare providers. This good action comprises a number of
characteristics that are briefly described here (for more details, see Hilhorst 2004).
A healthcare provider can be expected to act with a view to the (best) interests of the
individuals in need of care who are referred to him or her. Individuals in need of care
must be able to have complete trust in the commitment, expertise and disinterest of the
healthcare provider. Trust, and patient interests, are essential features of good
healthcare provision.
Economisation of healthcare and professional ethics 156
Healthcare providers also have their own specific expertise that they put to the service
of both individual interests and the public interest. They undertake to protect these
interests by making a promise (taking an oath) in public. Specific expertise also requires
healthcare providers to organise themselves (professional autonomy and more farreaching professionalisation). Public trust is an essential condition for self-regulation
and professional autonomy. Professional freedom should also be regarded as a
conferred freedom.
What constitutes good care is generally a matter for expert opinion. Care providers
inevitably put their own interpretation on it. They need to have sufficient room for
manoeuvre (discretionary powers) in order to exercise their own responsibility. This
room for manoeuvre requires transparency and responsibility.
Conclusion
Professional ethics therefore relates to good care provision. Trust is an important basis
for this. Certain rules of behaviour pertain to good care provision. These have been
enshrined in the form of professional codes, standards and protocols, but are also liable
to change. Social and technological developments lead to a debate on what constitutes
good care, and this in turn affects professional ethics. Professional ethics are not set in
stone, but are a dynamic concept.
Professional ethics and the influence of control instruments
Good care cannot be provided without a good structure to organise that care. The
provision of good care partly depends on the context in which it is performed. The
healthcare sector has various control instruments used to organise care in the best
possible way. Market instruments and legal instruments are currently very influential,
and make their mark on the way healthcare is organised. This in turn affects the way
healthcare providers carry out their professional activities and influences their
professional ethics. What are the consequences of this for our view of what constitutes
good care, professional action and professional ethics? This is the central point
addressed by this section.
The issue of what constitutes good organisation of healthcare can be examined in
various ways. One approach takes a view as to what constitutes good care as the
starting point and then looks to see what kind of organisation is most appropriate for that
care. After all, changes to systems are not an end in themselves but are carried out in
order to improve care (Jochemsen at the Expert meeting in 2004). Another approach is
to take current trends as given and then to examine the ethical consequences of these
trends.
Hilhorst (2004) favoured the latter approach and assumed that economisation of
healthcare is a fait accompli. His interest was in tracing the positive and negative effects
of this fact. He set out the advantages and disadvantages of various control instruments
on the organisation of healthcare. He then examined the shifts in values brought about
by this process and the possible consequences for professional ethics. His findings are
summarised in this section.
He considered the market instrument and the effects of legislation and regulations,
professionalism and professional ethics. Given the links, and in some cases overlaps,
between these control instruments, he analysed all four in the context of economisation.
Influence of the market instrument
The market as an instrument puts a particular interpretation on, and lends a particular
direction to, healthcare and the definition of good healthcare. The market determines in
its own way what 'quality' is. Hilhorst based his ideas on the views of Cherry. Cherry
(2003) put forward the idea that the market enables people to co-operate peacefully; it is
sufficient for them to agree on what healthcare must be provided. The market lends its
moral authority to this decision. Agreement is not needed on other issues (such as
Economisation of healthcare and professional ethics 157
morality, underlying considerations, and the importance of good health alongside other
goods). He also concluded that the market permits many things that it does not strictly
speaking endorse. It allows people to buy things in healthcare that others hold to be
abnormal, and perhaps even morally reprehensible.
What might this comprise? Common examples might include abortion, euthanasia,
plastic surgery and live organ donation. But they also include less obvious or even
controversial forms of care, such as paying to be seen more quickly in a 'company
clinic', provision of stimulants that are damaging to health, and the creation of embryos
for medical research.
Healthcare takes on a certain perspective in the market. In terms of values, this can be
described as follows.
— Intrinsic versus instrumental: the market sees only instrumental values. What this
means is that the value of life, the integrity of the organism or the importance of
health, which many people see as intrinsic to medicine, are not the highest values
on the market. What counts is the patient's wishes, or satisfying the patient, rather
than the medical judgement.
One ophthalmologist working in a private clinic is a supporter of market involvement:
the point is to satisfy the customer. The operation of the market in this sector must be
seen as competition between the various ophthalmology clinics, and the question of
what the customer is willing to pay for treatment. Market involvement is not good if it is
purely and simply there to cut costs. A clinic might easily claim that it can provide a
service at lower cost by using poor materials (for instance, the cheapest lenses). You
have to compete with each other on the basis of quality, and the customer must be
able to see where the differences in quality lie. This means that market involvement
can boost quality (Van Zuuren 2004).
— Equality and justice. Justice (particularly equal access to care) is also not a
sacrosanct value on the market. Market operators can make money by offering
certain scarce forms of care, and individuals with money will take priority. A certain
idea of 'fairness' then has to be sacrificed in favour of 'efficiency'. Everyone is better
off in that everyone is helped 'more quickly', but some are helped more quickly than
others. This raises the question: How strongly do healthcare providers and
individuals in need of healthcare feel about this inequality?
A clinical psychologist working in a regional psychiatric centre reported: "Towards the
end of the year, staff are put under pressure to concentrate on intake and diagnosis at
the expense of treatment. This is because the budget for intake and diagnosis had not
yet been exhausted, in fact, far from it. Staff get the impression that they are working to
no good purpose." (Van Zuuren 2004).
— From an ethical point of view, a narrow moral basis for agreement is sufficient on
the market. Anything that is accepted by those directly concerned is 'good'. Selling a
kidney, or helping someone who no longer wants to live to commit suicide, is not
morally dubious so long as the actions are voluntary (and do not harm anyone else).
So the market does not impose any particular idea as to care for individuals. Those
concerned can decide for themselves how they want to interpret their vision of
healthcare. Demand can affect supply, as with other goods on the market (safety,
education or food). The question of whether vulnerable patients can be offered
sufficient protection on the market is, of course, an important one. Additional
instruments (such as legislation and regulation) are often needed in order to achieve
such protection.
The operation of the market therefore changes what is seen as good healthcare and
professional action. It brings about a shift in values, offering greater options for patients
and doctors from various points of view. On the market, a narrow moral basis for
agreement is sufficient (demand leads supply). Instrumental values take precedence
(patient satisfaction is what counts), and equality and justice are seen in a different light
(efficiency is more important than justice). This latter aspect has damaging
Economisation of healthcare and professional ethics 158
consequences for equal access to care. The market cannot prevent risks such as
unequal access, poor quality care and patient selection.
Influence of the legal instrument
The legal instrument aims to protect the parties involved in healthcare, but also
determines the form that healthcare takes. We must therefore take the legal perspective
into account when considering economisation, as legal instruments are also used in
bringing about changes in respect of increased cost-awareness, demand management
and the involvement of the market.
The Agreement to Medical Treatment Act reinforces the legal status of patient autonomy
(Legemaate 1995, Macklin 1993). The Act is based on the idea of a contract model. If
healthcare is expressed in economic terms when the market is involved, then healthcare
is formulated in terms of contractual undertakings with mutual rights and obligations
when the legal instrument is used. 'Agreement' is another key concept here. The Act
aims to bring about a more balanced, less asymmetrical relationship in the provision of
healthcare. The model is intended to change the way in which healthcare is regarded
and carried out, though it is as yet difficult to say how this will happen. The contract
model contains opportunities and risks.
What are the risks of this legal instrument to the vision of healthcare and professional
ethics? First, we need to consider whether the unique features of healthcare provision
can be expressed in legal terms. Second, we need to address the question of whether
this approach will not result in more (unilateral) emphasis being laid in practice on legal,
rather than moral, norms. The following aspects have a role to play:
— Asymmetry in practice. The Act has a symbolic significance. The desirability and
need for a more equal positioning of healthcare providers and healthcare users is
held up before our eyes, but inequality remains in practice. This is equally due to the
skill and expertise of the doctor as it is to the often dependent, vulnerable position of
the patient.
— No free market. The doctor-patient relationship is one that can only to a limited
extent be characterised as taking place in a free market. Patients' options when it
comes to entering into 'contracts' are often limited by geography, the details of their
insurance cover and psychological factors.
— Minimalist intervention. The patient is no longer dependent on the goodness or
benevolence of the doctor. Their cooperation is based on clearly understood selfinterest. But doctors can practice medicine only if patients and society at large are
willing to provide medical practitioners with the resources, training and infrastructure
that they need to perform their tasks. The profession is evolving into a job like any
other, in which neither altruism nor doing good have to be regarded as core values.
This is not, of itself, a serious matter. However, if both parties only pay attention to
their own self-interest, then this could have damaging consequences for the quality
of healthcare.
— A broad ethical vision. An ethical vision of the relationship between providers and
recipients of healthcare usually goes beyond morally reductive calculations of
mutual benefit. Will 'juridicisation' lead to defensive medicine, to an impoverished
relationship between providers and recipients of care, and to doing only the bare
minimum? To moral erosion? Will values such as personal attention, a caring
attitude and mutual trust retain their significance? Is not care often provided in
situations in which the patient is dependent and vulnerable?
— Not all norms are the same. In ethical terms, the legal logic, 'the vocabulary of
rights', must never become the predominant norm (Huibers and Van der Burg
1994). Professional norms and ethical norms are not identical. A good medical
practitioner has the responsibility, and must have the freedom ('autonomy', Den
Hartogh, 1997) to provide the care that is needed according to the professional
standard governing medical practitioners. This care goes beyond what is laid down
in rules and standards.
So the use of the legal instrument is based on agreement, just like the market
instrument. In legal terms, this is the 'contract'. The advantage of the legal instrument is
that it can enhance the position of the patient and restrict that of the doctor. On the other
Economisation of healthcare and professional ethics 159
hand, this is an ideal that is little reflected in practice. The Act thus has a mainly
symbolic effect. One danger of juridicisation is that it can lead to defensive medicine and
minimalist intervention, a situation in which the interests of doctors and patients do not
coincide. Another risk is that legal norms could overrule or replace moral and
professional norms.
Influence of professionalism as an instrument
This section addresses the question of how far professionalism can serve as a guide
and control in the current circumstances. Can doctors and other healthcare providers
fall back on 'set' values and norms?
The report 'Operation of the market in specialist medical care' (RVZ 2003) sees major
benefits from the working of the market, such as greater accessibility and the provision
of more suitable care. However, it does also recognise that there are some limitations
and shortcomings. For example, self-regulation within the sector and the medical
profession may come under pressure. The Council also thinks that patient selection is
not just an illusion. There is selection of healthier patients who are cheaper and easier
to treat. The Council sees professional ethics and the social function of hospitals as a
sufficient counterweight to patient selection:
"There are counterweights, such as the norms and values of the involved parties. Professional
ethics should continue to oppose patient selection. Hospitals, which present themselves as
social enterprises, should also want to avoid selection." (RVZ 2003: 49v).
Hilhorst, in contrast, wonders whether this confidence in the profession is justified.
Professional ethics as an anchoring point? The medical profession picking up where the
market leaves off? Is this not expecting too much of a counterweight from professional
ethics and management ethics ('social enterprise')? He finds it odd that practitioners are
mentioned in the same breath as institutions such as hospitals. The management ethics
that fit a 'social enterprise' (as is the focus of the Council's activity) does not necessarily
coincide with the professional ethics of healthcare providers. Hilhorst thinks that this is
the wrong starting point. And the assumption that both - healthcare institutions and the
medical profession - should be on the side of the patient and not on the side of the
market is not one that can be accepted without question.
The voices of protest and frustration expressed by practising healthcare providers must
be taken very seriously. Be they right or wrong, their experience bears consideration.
The views expressed not only reflect their frustrations (Miles 2002) but also their
motivations. These motivations reflect a view of healthcare. Their experiences point to
the complex array of forces and interests in which they feel that they are placed. It is
difficult to uphold an ideal of healthcare in the face of this array of forces (Hilhorst 2004,
Tonkens 2003, Expert meeting 2004).
To take an example, teenagers with scoliosis (abnormal curvature of the spine) can undergo
surgery at a couple of sites in the Netherlands. This is a day-long, loss-making operation
requiring a bed in paediatric intensive care. The orthopaedic surgeon who was interviewed is
allowed to perform 15 of these procedures a year. The waiting list is enormous, and he wants
to carry out more of these kinds of operation, but the hospital manager says: "This is too
expensive for us, do more hip or knee operations." So the surgeon has to let down the
concerned and outraged parents who ask him when it will be their child's turn, and in the
meantime he has to carry out other types of surgery. He regards this as an ethical dilemma
(Van Zuuren 2004).
To the degree that money takes on a more significant role in routine medical care, the
providers of this care are placed in a situation where various interests come into conflict.
The risks to healthcare will increase as strategic action becomes more tempting. Acting
rationally means considering not only the patient's interest, but other interests as well
(Rodwin 1993). Money has to come into the equation alongside the benefit of action.
Healthcare providers rightly express concern as to this conflict of interests. Their
warnings are in themselves a form of professional ethics. They are a sincerely felt
expression of their moral and professional view of healthcare trends. Strategic action is
Economisation of healthcare and professional ethics 160
in conflict with professional action. It is unclear whether healthcare providers will be
able to resist the temptation to engage in strategic action. In general, it would not be
reasonable to press too hard for virtuous values such as integrity, benevolence or
altruism. After all, healthcare practitioners are only human: "You can't do without people
of integrity in organisations, businesses and politics. But, ideally, you should need as
few of them as possible" (Musschenga 2004).
Another essential point for professional ethics is that healthcare providers are guided by
the requirement to provide 'good care'. This is a professional motive from which
considerable personal and professional satisfaction can be derived: 'the feeling that
you've done a difficult job well'. Here, 'good' is used in the sense of good according to
the rules of medicine and healthcare provision, in line with both the rationale of the
specialism and in accordance with the justified expectations of the patient and society at
large.
Healthcare providers need a certain degree of professional freedom in order to act
independently and autonomously. (Professional) bodies are needed to guard this
independence (as mentioned in the quotation from the Council above), and they require
certain powers (for instance, in respect of education and training, ongoing medical
research, professional self-regulation, quality assurance, and testing, sanctions and
discipline).
It is clear what is at stake. If more 'healthcare products' are offered via the market, then
the question is whether this professional independence will continue to be strong
enough. We also need to consider whether it will be possible to maintain professional
standards in the interplay of interests, and whether they can continue to play the central
role that they have played in the past. Finally, some thought needs to be given to
whether a sufficient basis for trust in the actions of healthcare providers remains under
the changed circumstances.
Effect of professional ethics as an instrument
A number of features have been listed above to describe professional ethics. We will
now address the issue of professional ethics in rather more detail. We will then look at
the question of how professional ethics operate to guide professional action, and what
effect they have on what constitutes good healthcare provision.
What are the unique features of ethics and professional ethics? Before looking at
professional ethics, let us first briefly examine the unique features of ethics. Moral rules
(which may or may not be written down) are learned and passed on when bringing up
and educating children, and are often regarded as self-evident. It is true that ethics
cannot be imposed in the same way as legal rules, but they do have their own authority.
How do professional ethics evolve and function? The rules for medical intervention are
becoming increasingly explicit, in ethical terms as well as from other points of view.
Professionalisation is the issue. The medical profession 'internally' regulates matters,
reaches mutual agreements and so binds individual practitioners to professional norms
(guidelines, standards and protocols). Modern efficiency requirements and the need to
save on costs also provide a further impetus in this direction. Medical interventions are
increasingly circumscribed by legislation: social norms thus determine how healthcare is
to be provided. The Agreement to Medical Treatment Act and the Medical Research on
Human Subjects Act are examples of this. We thus see that the situation is fluid, with
constantly adjusting norms.
Professional ethics are formulated in two ways:
1. in the oath, professional codes, rules of conduct, standards and protocols. These
reflect the internal professional ethics of and for the profession and are the
traditional route of internal self-regulation. Healthcare professionals themselves
determine what constitutes good care and formulate it in guidelines and codes.
2. it is an evolving conception of good care that fits into a broader social context, which
is the modern, outward-looking route. In this approach, there is not one single set of
professional ethics. Professional ethics are instead dynamic and embedded in
Economisation of healthcare and professional ethics 161
social trends. Alongside consensus, there is considerable difference of opinion as to
what constitutes good care (Hilhorst 2004).
THE OATH
The oath taken by Dutch doctors since 1878 requires newly qualified doctors to
undertake to respect the law. The doctor promises to respect professional secrecy.
Anything that a doctor learns in confidence in the practice of medicine must be kept
confidential (unless otherwise required by law). However, this matter is also regulated
by law and the oath does not add anything to or take anything away from this obligation.
The symbolic value of the oath is important in that the doctor gives a public undertaking
to accept the responsibilities arising from the skill and expertise that he or she has
acquired.
It is clear from the foregoing that sincere engagement, good intentions and personal
commitment are regarded as vital. Good care cannot exist without all these elements.
These principles conceal ideals regarding the good practice of medicine that are not
captured in the rules and are not the same for everyone. This remains the case in the
revised oath drawn up in 2003. The oath assumes personal freedom and responsibility.
Without these, the doctor-patient relationship loses its moral (and professional)
character. This moral character must be expressly seen as an aspect of quality.
CODES OF CONDUCT AND HONOUR
The codes of conduct devised for many professions are much more specific, taking the
form of a set of clear rules. The oath drawn up in 2003 is formulated (much more than
the 1878 oath) as a list of rules. A particular feature of codes is that they are devised as
a kind of internal 'hallmark', and are generally created by and for the profession itself.
Codes currently exist alongside or as a complement to legislation, with examples
including the rules of conduct of the KNMG (the Dutch Medical Association) or the
doctor-patient model scheme of the KNMG and the LPCP (the Dutch Association of
Patients and Consumers).
A closer investigation of current professional codes leads us to conclude that
professional ethics are not a fixed and eternal set of rules, but that they are inherently
dynamic. To the same degree, they do not reflect perfect consensus either.
Contradictory views reaching to the very heart of professional ethics cannot be excluded
by formulations in professional codes. Though there is broad agreement in many areas,
there remains considerable 'intervariation' in healthcare. This (partly) arises from the
different interpretations that practitioners place on their professional role. Ideas as to
what constitutes good care differ, and this occurs just as much among practitioners as
among recipients.
Summing up, Hilhorst sees current professional ethics in the following way:
— We have to take a nuanced view of ethical values such as altruism and doing good
in the provision of medical care. In the present context, practitioners provide
services in accordance with professional norms with a view to the patient's best
interests, and are appropriately paid in exchange. Good, exemplary action should
ideally attract (additional) payment. Patients do not generally want to rely on charity
and goodwill.
— The idea that professional norms inherent to healthcare are threatened by an
invasion of non-medical, or even anti-medical, norms is incorrect and exaggerated.
Modern norms include good, equal accessibility; appropriate use and just
distribution; transparency and responsibility. These norms also represent a moral, or
more accurately, a professional duty.
— Healthcare does not exist in isolation from place and time. The image of a
healthcare practitioner with his own age-old morality is a romantic, ahistorical image
that can therefore not be elevated so as to become a norm for today. Medical
practitioners must use their time and take account of the expectations placed on
their actions.
— Good healthcare depends on good organisation of healthcare. The role of
practitioners must not be ignored in this. They have specialised skills and expertise,
first-hand experience through their contacts with patients, and stand on the front line
Economisation of healthcare and professional ethics 162
of action. Practitioners must be aware of the modern context within which they
provide healthcare and are given (partly collective) resources to do so. Professional
norms take precedence over individual practice and comprise the whole of
healthcare, include its complex structures.
The position of professional ethics
What is the current position of professional ethics? Can it withstand the pressure of
current changes in healthcare? Do professional ethics offer protection against excesses
in economisation? There are, according to Hilhorst (2004), three types of responses to
these questions:
1
The changes are good, not threatening
Professional ethics have changed, and many see this as a gain and not a loss. The
provision of healthcare is still focused on the best interests of the patient; that is the
constant, but the answer to the question of who is responsible for protecting the
patient's interests has changed. This is seen as a threat only by the adherents of oldstyle professional ethics. Of course, the debate on the ethical emphasis on 'patient
autonomy' is not yet over. Professional ethics are evolving. The important thing is to find
the right balance between being in authority and being subject to authority that is
appropriate to the times and circumstances. If healthcare is seen as 'cooperation based
on agreement' between the provider and the recipient, then the involvement of the
market is not an immediate threat to healthcare or ethics. Things may take place on the
market that some people oppose (buying a kidney or re-implanting more embryos), but
that does not mean that ethics have been abolished. Commercial healthcare providers
will have their own norms of good care and will want to guarantee their quality.
However, setting these norms is not a matter for government or the profession alone.
2
The end of (shared) professional ethics
Issues of life and death, reproduction and embryo research are surrounded by
fundamental differences of opinion, so that it is impossible to speak in terms of one set
of professional ethics shared by all. Practitioners are divided on matters that go to the
very heart of traditional professional ethics. They differ on how to interpret concepts
such as 'respect', 'sanctity' and 'deserving of protection' as regards life, exactly those
issues that should be extremely important to medical practitioners. Some see these
modern trends as ‘the end of professional ethics', or in any case (but perhaps this is the
same thing) the end of professional ethics 'shared' by all (Cameron 1991). Increasing
involvement of the market will merely accentuate this situation. Ethics will in future only
be encountered in a fragmented way, perhaps organised in segregated or privatised
institutions. This vision would mean that everyone would withdraw to the island of their
own convictions, values and standards, where everyone would provide healthcare in
line with their own individual ethics (Hilhorst 1999-1). A communal approach will be hard
to find.
3
Competition makes an ethical and professional code impossible
Others take the view that many rules of conduct will disappear as a result of certain
market developments (Polder, Hoogland and Jochemsen 1996). Competition will no
longer allow healthcare practitioners to form a united front. That is, different prices will
be introduced, doctors will try to poach on each others' territory, and practitioners will be
less willing to share their skills and expertise with their colleagues and will not
necessarily be prepared to take over other practitioners' patients. All this is in conflict
with the rules of conduct that are (still) in force, such as those of the KNMG. In future,
healthcare providers will also compete for the favours of patients and insurance
companies. Past professional autonomy, regarded as 'inherent' to the profession and to
professional ethics, and claimed to be in the patient's interests, will disappear.
Practitioners will feel less bound by professional rules obeyed by the sector. The
profession will become divided and will no longer be jointly answerable to a universal
ethical and professional code. "The traditional content of the way the medical profession
is understood will be handed over to free market forces in order to improve healthcare
and at the same time reduce costs". The problem is clear, since nobody can be
Economisation of healthcare and professional ethics 163
opposed to 'reducing costs'. What we have here is a tension between 'profession' and
'profit', the difficult task of balancing such different concepts.
Polder et al. (1996) took a negative view of these developments. In a situation
dominated by different interests and the conflicts between them, fundamental values are
pushed into the background. An array of different services will become available, and
this could undermine confidence in healthcare providers. The risks of discontinuity of
care and opportunistic intervention are real. It will be hard to demonstrate actual
differences in quality. Promotional activities will lead to excessive expectations and
increased demand. More expensive services will become scarce. A more commercial
attitude on the part of healthcare providers may have a knock-on effect on contacts with
other healthcare providers. Conflicts of interest may arise in various ways when it
comes to referring patients. In short, behaviour will become strategic and partly
motivated by factors other than the patient's immediate interests. This will come about
as a result of the discipline of the market; the spirit of competition, at pain of bankruptcy.
Profit (benefit) is in conflict with profession (benevolence and beneficence). The
conclusion here is that the profit motive will eventually undermine responsible medical
intervention.
These three differing reactions show that the (future) position of professional ethics is by
no means agreed. The reactions range from a positive to a negative view of the
influence of economisation on the position of professional ethics. Looking at these three
types of reaction together, we are forced to conclude that professional ethics certainly
do not have enough counterweight to resist the excesses and risks of economisation.
Towards a different form of professional ethics?
Will professional ethics have to change as a result of the changing healthcare
environment? Does more market mean less professional ethics? Or the other way
around: will professional ethics need to strengthen their position in response to the
influence of the market and other 'non-medical' influences?
It has become clear in the meantime that we cannot expect an unambiguous answer to
these questions. The answer depends on whether we assume a set of professional
ethics based on a minimum moral consensus, or professional ethics based on a more
'complete', broad morality. In this context, Hilhorst described professional ethics as
either thin or thick (Hilhorst 2004).
Polder et al. (1996) defended a system of professional ethics based on a broad moral
vision. According to them, the meaning of the term 'profession' is difficult to reconcile
with competition. They consider that a number of elements are of critical importance to a
healthcare structure, and that these must be implemented at all times.
— Quality: this is (partly) an ethical concept, the content of which cannot be
determined by the market.
— Allocation: this must be based on need, not on market demand or purchasing
power.
— Trust: a healthcare provider uses his or her skills to the patient's benefit and gives
honest, complete information.
— Professional norms: these must not be abandoned for opportunistic reasons.
In theory, the involvement of the market is possible to a limited degree, provided that the
market is structured in such a way that it can serve the actual content of the term
'profession' referred to above.
Polder et al. choose a different point in shaping their ideas. They took a view of what
constitutes good care as a starting point and conclude that the choice of organisational
model must be subordinate to this.
According to Polder et al., the only question that then remains is whether the market
itself (by regulated competition) or with some government control (via legislation) can
Economisation of healthcare and professional ethics 164
counter the risks that are inherent in the trend towards greater market involvement.
They are not optimistic in this respect. Asymmetry is a characteristic of the doctorpatient relationship and trust is therefore a fundamental and vital concept. Juridicisation,
based on the contract model, is just as real a risk as economisation, as it does not take
account of the unique nature of healthcare provision, that is, the specific character of the
doctor-patient relationship and the purpose of the practice of medicine. The purpose
involves a particular value (health) that is not up for debate.
Hilhorst took the view that Polder et al. attach too much weight to the uniqueness of the
(medical) profession. Trust in the profession is closely associated with this. Individuals
in need of care are clear and essential in that approach. They therefore locate 'true'
professional ethics at the 'heart' of healthcare, which they relate to essential medical
care, the undisputable goal of medicine and healthcare. The expertise of healthcare
providers is a decisive factor here, as they are best placed to know how to act in order
to meet the need for care.
Their view of healthcare provision is expressed from an ethical point of view in moral
terms that are quite content-rich. The organisation of care has to serve 'the purpose of
the practice of medicine'. The question arises as to the circumstances in which
healthcare can best fulfil its purpose, enabling it to be what 'is in its nature' or what it
'should' be. Formulations such as these make it clear that strong moral/normative
considerations are present in the background and play a part in determining what
medicine and healthcare 'are'. And what they are not.
Hilhorst opted for a system of professional ethics based on a narrow or minimal
morality. He agreed with Cherry (2003) who took 'cooperation on the basis of
agreement' as the starting point for healthcare. The argument put forward by Hilhorst is
that there is no longer one single conception of what health is. Discussions over the
past few years have shown that it is not easy to define what constitutes care (both
necessary care and good care). Healthcare is no longer what it once was, or rather it
comprises much more than it ever did before. The broad moral vision of Polder et al.
may still be valid for the more 'objective', scientific side of medicine, but it no longer
seems appropriate for much of modern medical care. There is no longer one single form
of healthcare, one single profession, one single medicine.
The concept of health is embedded in many different views of the body and the
individual. It is difficult to see how this plurality of moral considerations can be brought
back to one single, clear concept of healthcare or health, and to a fixed, universal
system of professional ethics. Hilhorst therefore concluded in the light of this outline that
the 'buoy' to which it was hoped that professional ethics could be attached by means of
a morally robust interpretation of the practice of medicine no longer has any clear
anchor in the modern era.
Professional ethics take on a different context when they are guided less by the
profession and more by the market. This changes professional ethics, but does not
necessarily make them worse. These new ethics must be actively given form and
content, a development that will not come about by itself. Hilhorst, who defends this
view, here chooses the line of what was described as the first reaction in the preceding
section.
Professional ethics 'on the market' have their own character and entail new risks for
healthcare. These ethics need to be protected by guarantees if good care is to be
assured. Strict regulations are also needed for these professional ethics within an
environment that supports them. In terms of quality, it is even more difficult than in the
past to have confidence in the consensus and standards reached by the profession.
Where internal (self-) regulation was once sufficient, external review is now needed.
What risks to healthcare are we talking about? Independence of attitude and purchasing
power are not equally distributed. Those in need of care are recognised on the market
when purchasing power comes into play. Who will act on behalf of those who lack
independence and purchasing power?
Economisation of healthcare and professional ethics 165
— patient selection: patients who are easier to treat and have a straightforward
requirement are better off and are treated earlier. What
should be done about
unprofitable patients? (unjust distribution, unequal treatment);
"When a patient is admitted, it is no longer medical urgency in the new situation but the
question of whether certain targets are met that determines what action is taken. If the hip
operations purchased by insurer A are nearly all used up, but there are still plenty left for
insurer B, then patients insured with company B will take precedence when it comes to hip
surgery. This situation contradicts the principles of equal access to healthcare. The
professional ethics of doctors are put under pressure, as financial arguments outweigh
medical arguments in deciding whether someone can be treated." (Van Zuuren 2004).
— trust in the healthcare provider as a condition can be undermined if organised
mistrust (conflict of interests) holds sway as a result of competition;
— The market leaves the door open to unnecessary or high-risk treatments carried out
in private clinics, such as total body scans.
A gynaecologist gives the example of a private IVF clinic abroad that treats well-to-do
women aged 45, who are highly unlikely to conceive, in return for payment (Van Zuuren
2004).
This means that professional ethics are placed in a different context and must adapt to
the new situation. A system of professional ethics founded on a minimum moral basis of
agreement does not, of itself, offer sufficient guarantees against the risks of
economisation. Additional external measures are needed to prevent or restrict such
risks as patient selection, a fragile relationship of trust between doctor and patient, and
unnecessary health risks.
7.4
Conclusions and recommendations
Conclusions
We can now offer the following answer to the question of what economisation means to
healthcare, and particularly to the professional ethics of healthcare providers:
'Professional ethics' do not in themselves stand in the way of the drive to a greater
market involvement in healthcare. Adapting to new circumstances requires a different
set of ethics, which will not evolve by themselves but need to be actively given form and
content.
Further investigation is also needed into whether 'the sector' (doctors and others
working in healthcare) is ready to change (see also Van Zuuren 2004, Van Hout and
Putters 2004). Economisation is more than market involvement, in that it includes a
complex movement that is not evident to all and the outcomes of which remain unclear.
This report is a first attempt at mapping the influence of economisation on the
professional ethics of doctors. The complexity of the topic and the responses from the
profession show, however, that further research is needed.
Policymakers must clarify the opportunities and risks associated with economisation.
Their task should be regarded from two points of view:
— In terms of measures: the objections that exist must be considered, and the dangers
and risks of 'more market' must be overcome. Professional ethics are not of
themselves able to offer protection against the risks of market involvement, such as
patient selection and self-regulation of the professional grouping that will be put
under pressure. Other measures are needed to counter these risks.
— In terms of vision: a different healthcare structure must specify, in terms of
'fundamental values', what choices are to be made in healthcare and what is the
normative view of future healthcare.
Two key values relating to professional ethics for doctors and other healthcare
providers seem to be brought into play by economisation. First of all, there is the
Economisation of healthcare and professional ethics 166
importance of trust and secondly the importance of a professional standard (quality
standards, in particular). Economisation, broadly expressed as 'money can play a part
in healthcare', puts these values under pressure.
Trust can no longer be assured in the same way if economisation increases. More
regulated competition implies more organised distrust. Professional standards will
become increasingly variable, whereby quality and costs will be weighed up against
each other, and each factor may detract from the other.
Additional instruments that are less internal (self-regulating) and more external (social)
are needed. If traditional professional ethics are mainly regarded as an internal
instrument, then they should play a minor role as economisation increases. The
alternative is more external guidance and control to guarantee 'quality' and 'trust'. The
market has not yet come to any firm conclusion as to what the term 'quality of care'
should mean, and it is open to many different, but not necessarily worse, interpretations.
If the patient, rather than the practitioner, is to become the focus of healthcare, then
healthcare will have to be differently organised, with the starting point being the patient's
need for care (a 'demand-led' system). Patients are often unable to themselves decide
what constitutes good care, and others have to ensure that the care is of good quality.
The question now is whether determination of quality should be left to healthcare
providers. Are they best placed to take on this task? Caregivers might stand in each
others' way.
The medical profession is not a single, homogeneous entity, but is instead made up of
many different disciplines. It sometimes looks more like a divided house of diverging
specialisms and areas of care, with all the compartmentalisation and competition that
this entails. This should lead to a more external system of quality assessment, but does
not necessarily imply poorer quality and less care.
Recommendations
— The increased economisation of care and the influence of this on the professional
actions of doctors require further investigation of the position and function of
professional ethics. This report is merely an initial assessment.
— The significance of economisation must be principally reflected in professional
standards, and especially quality standards.
— This report focused largely on hospital doctors. However, other professional groups
face similar problems and dilemmas in the exercise of their profession. Nurses and
care assistants are known to face economic pressures in terms of the quality of the
care they provide. For that reason, the influence of economisation on professional
ethics in other disciplines must also be investigated.
— Research is needed into how vulnerable factors (risks) such as 'trust' in the doctorpatient relationship and patient selection can better be guaranteed. The professional
ethics of healthcare providers cannot offer the whole answer to this. Other
measures should therefore be taken to prevent or restrict the risks and excesses of
economisation. Attention must be paid to the influence of economisation on
professional ethics and the changes that it will bring about in the current,
conventional professional, not only of ethics in scientific and political research, but
also in terms of education.
Economisation of healthcare and professional ethics 167
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