Kickbacks: The Easy Way To Get Great Patients

It's been long established by the American Medical Association that it's unethical for a physician to give another physician money for a patient referral--what many would call a kickback.

In other words, let's say I go to Dr. Bob, my primary care doctor, complaining of back pain. He takes a look at me and says I should go see a back surgeon, Dr. Sue, who will likely perform an operation that my insurance will pay $50,000 for. Dr. Sue is grateful for the referral, and to show her appreciation she gives Dr. Bob $5,000 for his efforts.

This scenario is a huge ethical no-no in the practice of medicine, but it might not be entirely clear why it's viewed as such a serious breach of good conduct. After all, in most business ventures it would be perfectly acceptable for me to, say, give my friend over at Circuit City $100 for sending a customer to The Moral Guy's Electronics Emporium (where we're obligated to give you a great deal!) for an item Circuit City didn't have in stock. The common explanation for this prohibition is that giving doctors money for referrals leads to a lower standard of care to the patient: if the doctors care more about referring their patients and getting a big payday when the patient has an expensive procedure, they'll be less likely treat the patient more conservatively and avoid major operations. Back to our example, maybe my back pain could have been treated with a simple steroid injection by my primary care doc; but because Dr. Bob wanted the $5,000 from Dr. Sue, he referred me over to her and caused me to go through a difficult, painful operation I didn't really need.

But what about the argument that a customer could be taken advantage of in the same way in any business transaction? After all, most people have a story about how a mechanic demanded $600 for some brand new parts the car didn't actually need replaced; doesn't the Latin phrase caveat emptor ("let the buyer beware") apply to all business transactions?

Here's my take: medical practice is fundamentally different from just about any other profession because of the inherently unequal relationship between the doctor and the patient. The fact is, when you go to a doctor because you're sick you aren't in the same position as when you go into buy a stereo at a store: you're going to a person who's had four years of medical school and at least two further years of residency and knows more about medicine than you ever will; the doctor has seen and treated dozens, hundreds, perhaps thousands of other patients; you're expected to talk to a complete stranger about the most intimate details of your life; and most importantly, you're there to treat a problem which could permanently affect your well-being or even cause your death. Going in to see a doctor can be a terrifying experience where no one could reasonably expect you to be a rational consumer.

That's why I believe in the oft-repeated adage about the medical profession: Lawyers and whores have clients--doctors have patients.

To be fair, I think a lot of these issues come up in the legal profession as well--a person facing a felony conviction is in much the same situation as a patient going to see a doctor. But the basic point remains: given the nature of the relationship between the two, physicians have a greater obligation to the well-being of their patients.