The doctor in the company

What happens when medical and business ethics collide?

As the number of healthcare companies grows and healthcare systems operate more and more like businesses, the number of physicians managed by these for-profit and not-for-profit companies has increased. Some healthcare organizations are led by physician CEOs and others have physicians in other leadership roles, such as Chief Medical Officer. What are the obligations of doctors in companies? How do they resolve situations where business motives and patient care obligations conflict?

After graduating from medical school, physicians are expected to take some form of the Hippocratic Oath and adhere to the professional standards set by their specialty associations and licensing bodies. While these oaths may differ in specific content, an underlying principle that most agree on is “first do no harm.” Physicians are expected to advocate and support the well-being of patients and, where possible, prevent illness and take action to support their health. Modern medical education reinforces these expectations through ethics, licensing, and board certification courses focused on appropriate behavior.

When a doctor becomes an officer of a company, he takes on a completely different set of obligations. While not codified into something as well-defined as an “oath,” there is a fundamental expectation that an officer of a company will always act in the best interests of the company. This edict usually means that they will do whatever it takes to make a profit. The corporate physician is routinely presented with situations where responsibility to the company and responsibility to patients conflict. If you listen carefully, the shrill sounds of moral tension can be heard.

The temptation to “code-switch” for doctors who join corporate leadership is high – and many resolve the tension between patients and profits by establishing a clear hierarchy: In most situations, fiduciary duty trumps oath of Hippocrates. The reason for this hierarchy is clear. Most other individuals in organizational leadership have not been fully trained in a “patient motive” (apart from a hastily concocted corporate pablum) and have self-assuaged any ethical tension with platitudes such as “no margin, no mission.” Put another way, if we can’t make money, we can’t operate and we can’t achieve our patient care goals. So making money – and not patients – becomes the most important principle underlying decision-making within the company. Even if the way the money is made – profiting from illness, rather than promoting good health – is questionable.

And perhaps this superficially resolved tension is why we have a healthcare system that seems to have no real regard for patients whatsoever, despite the visible presence of physicians in leadership. Significant copays that create a barrier between patients and life-sustaining medications like insulin. Utilization management protocols that routinely prioritize inferior outdated treatments over better new ones. The never-ending rush to discharge patients, often before they are ready. Clinical networks that require patients to place their trust in the hands of doctors and institutions that we would never visit if given the choice. Medicines whose price is beyond everyone’s reach. Healthcare systems that aggressively bill people and put them in debt. All these decisions were made in consultation with the doctor in a senior role within the company. And yet they remain silent when they get the chance to say something or speak out. Or worse, they bend their minds to believe that the wrong thing is the right thing. Somehow they have become complicit.

That’s because the cost of standing up for the doctor in the company can be high. Failure to toe the company line involves quick and predictable action. In these times when more and more doctors are moving from clinical medicine to a non-clinical career, there is a long line of people ready to replace you from within or without. Speak your mind or speak out at your own risk.

And so the corporate doctor – who usually starts out with the best intentions of being the voice of what is best for patients – usually falls into a game of corporate conformity or survival or self-aggrandizement. Moral certainty fades into an alignment with and toxic positivity for otherwise questionable corporate goals. The company uses the doctor as a spokesperson when the company’s morality is questioned. “Our lead physician believes” is an oft-repeated response when the integrity of a clinical process is questioned—when what the physician actually believes has been replaced by what is expedient for the company at the time.

And so the corporate doctor has two paths: 1) acquiesce to the corporate demands, or 2) if he or she decides to stick to his or her primary moral compass, he or she is largely thrust into the fray. A lone voice forced to learn the subtle art of corporate politics to make the right thing happen for patients every now and then. Plagued by a persistent sense of moral unrest and always wondering, “How did I get here?” and often weary because they have to be the last bulwark against the company’s innate tendency to make profits at the expense of what is good for patients. Could it be that a position as a manager and staying true to your training as a doctor are only partially compatible? I’m not so sure.

What I am certain of is that as more and more physicians move into corporate roles, the importance of building a robust agreement on one’s mandate is paramount. The doctor must ask himself more than once – and with more than a few real example situations – how will we resolve situations where what is good for patients and profit come into conflict? This question – as existential as it is – must be a steady dialogue that is considered normalized and acceptable. If the answer is unsatisfactory or incomplete, or if there is discomfort or smoothness, one should take a deep breath and ask themselves whether the opportunity is worth it. Because what is at stake and what is in danger of being lost is something that we as doctors can almost never get back. Our professionalism. And our soul.