While recognizing that all these economic changes will profoundly affect health care, many physicians and bioethicists insist that physicians can and should avoid compromising their patients' welfare in the name of raising revenues or even containing costs. "Physicians are required to do everything they believe may benefit each patient without regard to costs or other societal considerations"1; "asking physicians to be cost-conscious ... would be asking them to abandon their central commitment to their patients."2 While the physician might assist in creating public or institutional resource policies, and while he occasionally must ration, as where there are too many patients for too few intensive care beds, in this traditional view he must never voluntarily say "no" to his own patient simply in order to honor third parties' economic concerns.
There are good reasons for this traditional view. It arises through a pervasive belief that physicians have special obligations of fidelity because patients are vulnerable. Health is a precondition of most life goals and projects, after all, and thus is of central importance to any autonomous person. Illness and injury often represent not merely a physical impediment to doing what one wishes, but an obstacle to clear reasoning and reflection. They can be an ontological assault on the unity of body and self, a wounding of personhood.3
Medical assistance renders the patient still more vulnerable. He must expose himself both physically and psychologically, laying bare the intimacies that he would otherwise reveal only to loved ones.4 And in the process of diagnosis and treatment he may risk further harm, including permanent disability or even death, in order to regain what health he can.