Background: Although much has been written about the ethics of new methods
of health care financing, little is known about the extent to which physici
ans experience these cost-control arrangements as ethical problems.
Method: A cross-sectional telephone survey of 1549 physicians, 8 to 17 year
after residency, randomly selected from 75 US metropolitan service areas (
response rate, 74.0%).
Results: Only 17.0% believed that financial incentives to limit services ar
e ethically acceptable. Although 52.9% thought that physicians should try t
o abide by guidelines discouraging the use of interventions with possible b
ut unproven benefit, only 14.5% thought such guidelines should be enforced
by payers. Only 5.7% thought that it was morally acceptable for payers to d
iscourage physicians from telling patients about their personal financial i
ncentives, and only 9.1% found compliance with such restrictions morally ac
ceptable. Changes in the health care system in the past 5 years were believ
ed to have had a negative impact on their own patients' trust in them by 50
.6%, and 80.8% believed that changes in the health care system in the past
decade have diminished physicians' commitment to an ethic of undivided loya
lty to patients. In multiple regression analysis, physicians who reported t
hat the overall personal financial incentives in their practices encouraged
them to reduce services were significantly more likely to have ethical obj
ections to such incentives, to believe their own patients' trust in them ha
d diminished, and to believe that the ethic of undivided loyalty to patient
s had diminished.
Conclusions: Many of the methods now commonly used to influence medical dec
ision making are considered ethically objectionable by most midcareer physi
cians. Whether their ethical disquiet about these arrangements is justified
cannot be answered from these data.