Question Is it ethical for surgeons to use economic considerations when setting their fees? For example, is it ethical for a surgeon who is known to have better results for a certain operation to charge more than a surgeon who has worse results? Likewise is it ethical for a surgeon who has a scarce skill in a region to charge exorbitant fees for that skill simply because it would be unaffordable for most patients to travel to another region to attend another surgeon?

Accepted:
June 19, 2007

Comments

This is a fascinating question because medical care is not a commodity like many others--for example televisions or ice cream. It is a service related to the most pround of human needs. For that reason, I answer your first question with a "no"--but with qualification. It really depends upon what you mean by "economic considerations." I think it would be wrong to use simple supply-and-demand considerations where the supplier (the surgeon) charged the highest price the market will bear. Why? Because higher prices will exclude those with less money from the service, and I don't think it morally defensible to distribute essential medical services on the basis of wealth. Moreover, people suffering from illness are not in a position to bargain for fees with medical providers in the absence of coercion. (Think of how little a surgeon would charge if he or she were at risk of dying if a prospective patient decided to seek care elsewhere.) For this reason, I find the American medical system on the whole to be morally deficient. A fairer and more equitable system of rationing and distributing services must be found.

On the other hand, I think that it is morally defensible to take the economic circumstances of the consumer (the patient) into account in the form of charging the wealthy more for medical services if that extra charge is used to subsidize providing medical sevices to the poor. Even in this case, however, the fee extracted from wealthy patients should not be excessive, since doing so would be taking advantage of people in desparate need.

As for your second question, for similar reasons, I think the answer is likely to be "no." Medical services are likely to be scarce in a region (e.g. Appalachia near my home) because the population is poor. A morally preferable course would be to charge less for those services in order to make them affordable for the population.

Now in cases, where medical services are paid for or subsidized by a third party (not the patient, perhaps the government), I think it morally permissible for that third party to offer higher compensation to regions where medical services are scarce in order to draw medics to the area. But, again, I'd qualify this claim by maintaining that those with medical skills would be morally wrong to extract excessive compensation for their services, even when a third part is paying, as doing so would be taking advantage of people's sickness and need to extract excessive wealth.

It may also matter what sort of operation we are talking about. If this is cosmetic surgery (beautifying belly buttons, say), then the service does seem quite similar to other commodities (face cream), and the reasons against the surgeon's charging what she will seem quite weak.

As we move to the other end of the spectrum -- to operations that are a matter of life and death -- Peter Fosl's points become ever more compelling. Such operations should not be rationed on the basis of wealth: A medically important operation that is routinely available to the wealthy should also be available, in roughly the same quality, to the poor. Call this the medical equity principle (MEP).

It does not follow from the MEP (here comes my second point) that it is unethical for the best surgeons to charge more. Societies that have organized themselves around the MEP need to have enough high-quality doctors to take care of the medical needs of all. To attract people into the profession of surgeon, and to entice them to become really good surgeons, such a MEP society may arrange itself so that the income of surgeons reflects their level of skill. Why should not a top surgeon who lives in a MEP society take the high remuneration available to her just as other surgeons with her outstanding skills are also doing in this society?

G. A. Cohen gives a reason against her doing this. See e.g. If You're and Egalitarian How Come You are so Rich?. But this reason applies to all highly-paid professionals. It is quite different from the ones Peter Fosl advances, which seem to me to be as inapplicable to a MEP society as they are to cosmetic surgery.

Our society -- not to speak of the world at large -- is very far from realizing MEP. Millions are spent on small improvements and extensions of the lives of the affluent even while poor uninsured Americans lack access to important medical services and millions of child deaths abroad could be avoided each year at the cost of a few Dollars per case.

These grotesque violations of MEP are a very grave injustice, in my view. An important aspect of your questions is then how one ought to behave in a context of grave injustice. By demanding from every patient what the market will bear for a medically important operation, a highly skilled surgeon would be both contributing to and taking advantage of a grave injustice: She would be contributing to the unjust segregation of patients by wealth, and she would be taking advantage of the fact that the social context is one in which patients must bid for top-flight medical treatment. What such a surgeon should plausibly do is to earn her living by charging the affluent what the market will bear and then giving equally good service to poor people for what they can comfortably afford (which may sometimes be $0).

Last point. It is not only top surgeons who, in an unjust social context, have responsibilities to shield people from grievous effects of injustice. Affluent citizens should understand that, if our society were just and thus in reasonable compliance with MEP, then people like themselves would have lower net incomes (as more of the social product would be spent on ensuring that all have access to important medical care). Understanding this, affluent citizens should not just pocket the fruits of injustice, but should spend some of their wealth on supporting political reforms or on protecting the victims of injustice. We all should help put access to medical care on the political agenda this primary season and help elect politicians who are firmly committed to moving this country and the world closer to MEP compliance.