Conflicts of Interest and the Future of Medicine: The United States, France, and Japan

Abstract

As the promise of health care reform in the United States continues to face political and legal hurdles, few questions evoke as heated a debate as those surrounding cost control. Though most stakeholders agree that too many dollars change hands in the U.S. health care economy, politically tenable solutions to the problem have been elusive, as evidenced by the paucity of substantive cost-control measures in the current reform efforts. At the heart of the debate are fundamental tensions between patient choice and societal cost, between autonomous physician decision-making and adherence to clinical guidelines, and between free healthcare markets and government oversight of those markets. This past spring, the Independent Payment Advisory Board (IPAB) was introduced in the United States as a key component of the deficit reduction plan and was designed as a neutral body with the authority to cut Medicare spending if the federal health insurance program exceeded certain targets. A predictable backand-forth ensued. Opponents invoked the “rationing” defense, arguing that clinical care would suffer as independent physician decision-making was limited by government intervention, while supporters maintained that Medicare cannot afford to keep paying for health care at its current levels (Pear 2011). Though reform efforts such as the IPAB have focused on payment, critical to this discussion is the contribution of physician behaviors to the cost of care (Krugman 2011). Specifically, while most people assume that physicians are ordering only what is necessary for patients according to their professional ethics, sometimes other factors, including financial incentives, drive their decisions (Grande et al. 2009; Wazana 2000). Some of the more powerful financial incentives in medicine include financial ties to companies (for example, honoraria, consulting fees) and the payment incentives from fee-for-service clinical practice. The existence of these incentives— and the conflicts of interest they create—is the subject of Marc Rodwin’s new book, Conflicts of Interest and the Future of Medicine. In his history-heavy analysis of the growth and symbiosis of medicine and industry in the United States, France, and Japan, Rodwin chronicles the cultural, legal, and institutional factors that have contributed to each country’s current landscape of financial incentives in clinical medicine. Each tells a different story of how organized medicine, professional self-regulation, market competition, and payers affect contemporary physician behavior and provides insight into the relationship between this behavior and health care cost. Bioethical Inquiry (2011) 8:383–386 DOI 10.1007/s11673-011-9326-y