MEDICINE, MONEY, AND MORALS

A convincing case for resolving financial conflicts of interest that compromise the judgment of doctors and that bias the clinical choices they make. Whereas lawyers, certain financial professionals, and government officials are considered by law to be fiduciaries- -i.e., obligated to work for the benefit of those they represent- -there's as yet no effective policy to hold doctors accountable in this way. The medical profession has never developed a framework to address this problem, and, according to Rodwin (Law and Public Policy/Indiana University-Bloomington), it's unlikely to do so. Here, Rodwin examines seven activities that lead to significant conflicts of interest among physicians: kickbacks; referral to facilities in which physicians have a financial interest; the selling of medical products that they themselves prescribe; hospital purchases of private practices; payments by hospitals for patient referrals; gifts by pharmaceutical firms; and risk-sharing in health-maintenance organizations (HMOs). Disturbing examples of each of these activities dot the text and dramatize how patients can be adversely affected by them. Rodwin draws on the regulatory approaches of other professions to offer recommendations for solving the medical establishment's conflict- of-interest problems. He argues for setting up new institutions and rules to hold physicians to fiduciary standards, with legislatures taking the lead in laying down the ground rules, and with courts, regulatory agencies, third-party payers, and state attorneys general enforcing them. One interesting concept the author examines is the regulation of the medical industry by a federal commission, similar to the regulation of the securities business by the SEC. A constructive contribution—featuring a well-presented analysis as well as concrete proposals for reform—to the ongoing discussion of our national health-care crisis.