The Obligations and
Limits of Fidelity: Physicians'
In a divided standard of care the physician's central duty under the standard of resource use (SRU) is economic advocacy. No longer do we view the physician, metaphorically, as a military general commanding medicine's "troops" and "tanks." Rather, we invoke metaphors of diplomacy.1 The physician is now the patient's "chief negotiator" in a complex concatenation of resource relationships.
Still, when we come to the other standard of care, the standard of medical expertise (SME), it might be supposed that we can nevertheless retain intact the traditional requirements that the physician devote personal attention and expertise to every patient in equal measure and that he always place the patient's interests above his own. Unlike costly technologies, the physician's own knowledge, skill, and caring are truly his to give. In a world where the physician is ever less able to deliver that which his patient needs, surely this obligation of personal, professional dedication must be more unstinting than ever.
So one might argue. In this chapter, however, we will see that even these traditional duties must be substantially modified in light of medicine's economic revolution. We must begin by recalling that economic changes have introduced new complexities into physicians' relationships with their patients. Physicians have always faced conflicts between their patients' interests and their own, of course, as for example where fee-for-service has rewarded excessive intervention. But as noted in Chapter 4, physicians' interests can now conflict with their patients' to a degree not witnessed before. While it is tempting to argue that the physician still should be unstintingly dedicated and should never place his own interests above the patient's, the matter is no longer so simple. No longer is professional altruism fulfilled merely by refraining from vulgar exploitation. Though physicians must of course remain faithful to patients' interests, at some point there must be a limit to the personal or professional sacrifices they