Last week the US Ambassador visited the Medical School to meet with Maltese doctors to discuss the US health plan. He came across as a humble person, actually asking us about our system and how they, as Americans, can learn from Europeans, who have managed to create health care systems which are based on a social justice system different from that in the US.

I do not see us as morally superior to the American people. Even in Europe we have a long way to go and in fact, if we do not listen to the US experience, may find ourselves in the same waters they find themselves today. In the United States if you are not covered by adequate health insurance, you may find yourself in a situation were you have no health care at all. It is mostly a private-based, insurance-funded system. Conversely, many European countries have sought to develop plans which are more social-oriented; perhaps it is because, although socialism has been mostly shunned, the democratic counterparts have always based their values on religious institutions which in turn preach a system of social solidarity. Be this as it may, I wish to look at why health care plans should be in a different ball game than normal business and perhaps where we can learn something ourselves.

President Obama (and I have to admit my great admiration for the gentleman) wishes to rescue health care. Among one of his suggestions we gather that he is asking the large insurance companies to throw back something into the system. What makes health care what it is after all? Health care starts with empathy. We empathise with the plights of the sick. If we see an injured person, we instinctively go over to give some help. This philosophy extends into the broader aspect of society. Most European states tax specifically for health care. When health care is privately based you may easily fall into a parasitic relationship whereby business takes advantage of the ill.

If insurance companies, which assess risk, treat human beings as they treat cars, then we are simply treated as objects. When you enter the field of health care you must play the game of health care. But you cannot do this unless the main players of the field, the health care professionals, do the same. When doctors earn millions, or at least, a proportionately large amount of money, then they become stake-holders with a great conflict of interest. They themselves may not wish to see a social system in which they are mere employees of the state. Whilst this may be fair to an extent, a balance has to be found. Certainly, the external good of money and success is not to be undervalued, even as a value in itself for some, but unless there is, to follow Alistair Macintyre’s definition, ‘internal goods’, that is, the inherent volition of benevolence – that of wanting to do something for the sick, then the values which doctors found in their youth which made them go into health care in the first place, gets lost along the way.

Even in bioethics we see that in the US beneficence was lost as a value to be upheld above all else and was indeed associated with paternalism. What became more important was the autonomy of the individual. Authors like Robert Veatch even insist that the Hippocratic Oath is outdated and gives the impression that doctors are nothing but over-exalted service providers. The ‘care’ in health care must be seen. As in justice, it must be done and seen to be done. If from health care people simply become rich and it stops there, then there is something wrong.

But another key factor which made health care in the United States less viable is their highly litigation system. A video was shown of a doctor who participated in President Obama’s discussion, who admitted that all the doctors present were guilty of the expense of the system because they daily order tests which are not needed. If they do not, they can miss out on a rarity which will lead to litigation. This ‘defensive practice’ is deadly to any health system, and I shall have more to say about it further on in this article when we consider what we are contemplating locally. Moreover there are situations in which ordering tests can even bring in more money to the doctors and therefore it is difficult for a society not to contemplate remotely whether there is any conflict of interest. But even if there was, their litigation system would disallow doctors not to do tests which may be avoided. Moreover if you have an insurance which is going to cover all the costs, you, as a patient, do not really care about how much it costs, even if it is a false sense of security. We need not do a Chest X-ray every time someone presents with a cough, even though there is a rare chance it be something else.

The hard facts about the US system is that a lot of money which can be spent on health goes into corporate profits of large insurance companies, and into the pockets of lawyers – money which has to be recuperated from patients as well. Then there is the hard fact about pharmaceutical companies. A pharmaceutical company invests millions to produce drugs. It legitimately requests patents and a number of years in which only they can produce the drug. This is where we must study further the relationship between medicine and industry. Let’s face it, when it comes to drugs and investigations, doctors and medicine rely on industry. But this relationship can be curbed into being a symbiotic one rather than a parasitic one, and here is where governments have to come in. They must guide people in the game, doctors and industry alike, that when it comes to health the rules must change. To make profits from sick people does not even sound right. It is fine for a doctor to charge for a fee, but that is why most medical councils overlook the fees being charged. There must be a similar procedure which looks over industry and asserts that the final price of the drug can be reached by the average pocket. Health insurances can be allowed to continue to exist but they must provide something in return, such as a guarantee that if a company closes down, someone will not remain without health insurance.

So while America looks to Europe, including Malta, our success is based on historical and market forces as well. Many a GP in Malta would like to earn more. We are the ‘cheapest’ GPs in Europe, not to mention that facts show that we are also amongst the best. But although there are few doctors working in health centres, there are plenty in private practice. Moreover many in private practice are not even GPs themselves but dabble for an hour or two in the evening in a pharmacy whilst they do a more specialised job during the day in the government hospital. Not only they are not vocationally trained, but they even choose which work they do not want to do. They simply take that work which is easy and makes quick money. They would not take on the responsibility to enter into the merits of detecting and acting upon domestic violence or child abuse. They will not enter into a professional relationship with a drug addict. Some do not even touch babies, let alone have a child development programme or a diabetic clinic. If we were to implement a philosophy that to enter a field, you must be ready not only to take the easy work and the easy money, but provide a comprehensive service, then family doctors and patients would all be better off.

From this micro dynamic to such a macro dynamic as the US system, ethics journals discussing the principle of Justice in health care all point towards this – that health care starts with an altruistic attitude. If this is lost it becomes a money-making machine. Like all money making machines, it will try to curb anything which tries to undercut its profits, and that includes any government welfare system. To change things, the rules must be changed. Commitment to health care must be tied to a commitment to comprehensiveness. I can give a Neolithic site to an agency and give it full rights to make profits. But unless it is tied to take care of that site and to allow, for example, discounts to locals, and free access to schools, then it will be unjust on the people who as a country own that site.

As a people we empathise with each other when we are sick. We also know that many make huge profits from this mere fact. We can fight through our governments for good deals. Businesses, by default, rarely enter this field for altruistic reasons. So mentalities must change and I augur that President Obama manages to do just that.

But one interesting fact needs to be delved into as it may soon touch us. I quoted above the physician who admitted that health care costs a lot because of extra tests which are done simply as a defensive practice. When a patient visits a doctor, a legal contract is established. The law recognises that as soon as a doctor accepts to see a patient, the doctor takes on professional obligations which if breached will make him or her liable for negligence. This tort part of the law exists locally each and every time a patient visits my practice. But since patients can shop around, they form contracts with different doctors all the time as well. A consultation need not necessarily finish when the patient leaves the office. He may call me in the evening to follow on the morning visit or may want to enquire about a medication. But after the episode, it finishes. Even for chronic illness, such as my taking care of a diabetic person, it is very doubtful how ongoing the contractual relationship is. There may be a file, but the patient may default by visiting other professionals.

All this will change with registration. When someone is registered with me, we now need to ask whether as a doctor I am taking on an ongoing contractual relationship. At the end of the day it is this that has to be clarified. Doctors have already argued about the implausibility of the 24/7 coverage and the Minister has accepted that it will not be in the next proposal. But we still need to work out what form of contractual relationship we are taking on. After all the government is asking private doctors to take on something at which it has failed over the years to provide adequate coverage for, and at no extra income for doctors. In fact, with means testing, many may earn less. So for any system to work there has to be a give and take; or else it will break.



Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta. He is also former president of the Malta College of Family Doctors.