HEC Forum

This article explores the association between medical professionalism, revenue enhancement, and self-interest. Utilizing the sociological literature, I begin by characterizing professionalism generally and medical professionalism particularly. I then consider “pay for performance” mechanisms as an example of one way physicians might be incentivized to improve their professionalism and, at the same time, enhance their revenue. I suggest that the concern discussed in much of the medical professionalism literature that physicians might act on the basis of self-interest is over-generalized, and that instead we ought to argue about ways to distinguish permissible and impermissible self-interested actions. Also, I argue that financial incentives for medical professionals ought to be permissible but considered as “by-products” of doing what physicians are expected to do as professionals in any case. Nevertheless, I conclude that, even if a positive association between increasing professionalism and revenue enhancement can be established, in the long term it may not be an unambiguous good for physicians as professionals in that this association may tend to reduce their professional discretion.

In the United States, there is no consensus about who should make decisions in acute but non-emergent situations for incapacitated patients who lack surrogates. For more than a decade, our academic medical center has utilized community volunteers from the hospital ethics committee to engage in shared decision-making with the medical providers for these patients. In order to add a different point of view and minimize conflict of interest, the volunteers are non-clinicians who are not employed by the hospital. Using case examples and interviews with the community members, this paper describes how the protocol has translated into practice over the years since its inception. Members reported comfort with the role as well as satisfaction with the thoroughness of their discussions with the medical team. They acknowledged feelings of moral uncertainty, but expressed confidence in the process. Questions raised by the experience are discussed. Overall, the protocol has provided oversight, transparency, and protection from conflict of interest to the decision-making process for this vulnerable patient population.