Medical ethics since the time of ancient Greece, at least, have held that physicians must act in the best interest of his or her patient (fiduciary duty in ethics jargon). This is one of the most important elements when a doctor and patient agree to form a relationship (similar to ‘first do no harm’), and has deeply shaped the practice of medicine. For example, a physician could not prescribe a treatment for a patient with the benefit intended towards society at large, the king, their spouse, etc.. Their are numerous examples from history when this principle was violated, the eugenics movement being one not too distant, that had tragic consequences.

However, almost all physician care provided in modern times is in direct conflict with this principle. Today most of us as patients have contracted (a relationship) with either a medical insurance provider or governmental agency. In turn, most physicians (healthcare providers of every profession) have contracted with one or both or several of these entities to provide medical services. These contracts place a 3rd party between the doctor and patient, in other words. We provide a fixed payment to an insurance company, and they in turn pay the doctor. Why this occurred has to do with the evolution of hospitals in the US and, while interesting, will be taken up in another forum in the future. What is the problem with this arrangement?

Simply, as a doctor, I have contractual obligations to the insurer/governmental agency that may be in conflict with my opinion of what is the best course of treatment for my patient, my ethical duty. My patient, also, has contractual obligations that bar him or her, in many cases, from accepting what would be the best course.