Marc A. Rodwin

Rodwin argues that there has always been a tension at the heart of medicine between the self-interest of the physician in making a profit and the professional ethos that calls on the physician to act in the interest of her or his patient and the general public good. Historically, societies have managed this tension by arranging the economic structure of medical care differently than other services. The medical profession is granted a monopoly over medical practice, to set standards for entry into medical practice and to regulate itself. The idea is that there is not only a special expertise but a moral core at the center of medical professionalism that justifies physician authority, and provides the basis for effective self-regulation.

But, Rodwin argues, developments in recent decades have severely undermined the efficacy of professional ethics as a means of managing conflicts of interest. Rodwin sketches out the historical development of the political economy of France, the United States and Japan to explore how differences in the roles of organized medicine, markets and state regulation affect the creation and management of conflicts of interest for physicians. At the beginning of the twenty-first century, all three countries sought to control spending and promote efficiency; to increase the pace of therapeutic innovation and improve the quality of care; and to rationalize the organization and of medicine and the delivery of health care. But in pursuing these goals, policy makers neglected to consider the ways in which policy changes would exacerbate physicians’ conflicts of interest. As a result, these policies not only failed to achieve the intended goals, but eroded the fragile trust between physicians and patients.

Rodwin concludes by recommending a number of aggressive policy strategies that should be pursued to manage conflicts of interest:
-- Increase medical care outside of private, fee-for-service practice (e.g., expansion of public sector physicians along the model of the Veteran’s Administration, or non-profit prepaid group practices).
-- Restrict entrepreneurship within private practice
-- Regulate payments incentives (e.g., balancing capitation vs fee-for service).
-- Restrict and regulate ties with third parties (e.g, ban kickbacks, gifts and financial support for CME and professional meetings from Pharma).
-- Protect Professional judgment (e.g, creation of independent review organizations empowered to create and enforce standards and guidelines for accepted treatments).

Rodwin’s method is a straightforward comparative historical policy analysis of the USA, France and Japan from the origins of modern medicine in each country through the first decade of the twenty-first century. There is not much in the way of ethical or social theory employed in the book, beyond the core assumption that professional medicine, like other professions, articulates a set of ethical ideals and aspirations that are internalized by physicians, but that these will be balanced by the tendency of physicians to pursue the maximization of profits like any other rational economic actor.

The theoretical framework of this book is limited, failing to make the connections to broader social and cultural factors that are frequently made by historians, sociologists and anthropologists. But Rodwin provides a clear and insightful account of how health care policy and practice have worked out in different national contexts, and his analysis of the problem of conflict of interest in the clinical practice of medicine is important to consider. His policy recommendations will seem compelling to academics, but might be seen as unrealistic given the valorization of private markets in contemporary politics, at least in the United States. His implicit counter-argument is that, it is perhaps more unrealistic to think that medical practice can continue to enjoy wide popular support and trust for much longer while it is plagued by such blatant and distorting conflicts of interest.… (meer)