The Original Massachusetts Call to Action
The Call to Action was published in the December 3rd issue of the Journal of the American Medical Association, along with the names of 2300 Massachusetts
endorsers. The "Call to Action" has since been endorsed by people in several other states. Some state CDHC's have altered slightly the text in their state Call to Actions, but they have all closely resembled this original in both spirit and basic principles.
We are Massachusetts physicians and nurses from
across the spectrum of our professions. We serve patients
rich and poor, in hospitals and clinics, private offices
and HMOs, public agencies and academia. Mounting shadows
darken our calling and threaten to transform healing from
a covenant into a business contract. Canons of commerce are
displacing dictates of healing, trampling our professions'
most sacred values. Market medicine treats patients as profit
centers. The time we are allowed to spend with the sick
shrinks under the pressure to increase throughput, as though
we were dealing with an industrial commodity rather than
afflicted human beings in need of compassion and caring.
The right to choose and change one's physician [or nurse],
the foundation of patient autonomy and a central tenet of
American medicine, is rapidly eroding.
Doctors and nurses are being prodded by threats and
bribes to abdicate allegiance to patients, and to shun the
sickest, who may be unprofitable. Some of us risk being fired
or "delisted" for giving, or even discussing expensive
services, and many are offered bonuses for minimizing care.
Listening, learning, and caring give way to deal-making,
managing, and marketing. The primacy of the patient yields to
a perverse accountability - to investors, to bureaucrats, to
insurers and to employers. And patients worry that their
doctor's and nurse's judgment and advice is guided by the corporate
Public resources of enormous worth - non-profit
hospitals, visiting nurse agencies, taking once a day, even hospices -built over
decades by taxes, charity and devoted volunteers, are being
taken over by companies responsive to Wall Street and
indifferent to Main Street. Communities find vital services
closed by remote executives; savings are committed not to
more pressing health needs, but to shareholders' profits.
Not-for-profit institutions, forced to compete, must also
curtail unprofitable activities like research, teaching and
charity, or face bankruptcy. Hospital chains' profits reach
$100 per patient per day(1); a single HMO president nets $990
million in a take-over deal(2); and insurers' overhead consumes
$46 billion annually (3).
At the same time, the ranks of the uninsured continue
to grow, while safety-net public hospitals and clinics shrink,
and public health programs erode. Even many with
insurance find coverage deficient when they need it most;
care or payment are too often denied for emergencies or
expensive illnesses. The sick are denied skilled nursing
care, rushed out of hospital beds and hurried through office
visits. Increasingly, patient comfort, the special needs of the
elderly, infirm, or disabled are ignored if they conflict with
the calculus of profit.
The shift to profit-driven care is at a gallop. For
doctors and nurses, the space for good work in a bad system
rapidly narrows. For the public, who are mostly healthy and
use little care, awareness of the degradation of medicine
builds slowly; it is mainly those who are expensively ill who
encounter the dark side of market-driven health care.
We criticize market medicine not to obscure or
excuse the failings of the past, but to warn that the changes
afoot push medicine further from caring, fairness
and efficiency. We differ on many aspects of reform, but on
the following we find common ground:
- Medicine and nursing must not be diverted from their primary tasks;
the relief of suffering, the prevention and treatment of illness, and the
promotion of health. The efficient deployment of resources is critical,
but must not detract from these goals.
- Pursuit of corporate profit and personal fortune have no place in
- Potent financial incentives that reward overcare or undercare weaken
doctor-patient and nurse-patient bonds, and should be prohibited. Similarly,
business arrangements that allow corporations and employers to control the
care of patients should be proscribed.
- A patients' right to a clinician of choice must not be curtailed.
- Access to health care must be the right of all.
Before the values we cherish are irretrievably lost,
we invite members of the health professions and the public to
to join in a dialogue on health care's future. The headlong rush
to profit-driven care has occurred without the assent of patients
or practitioners, through a process largely hidden
from public scrutiny and above citizen participation. This
must be replaced by an open and inclusive process that is not
dominated by the loudest voices - those amplified by money
and political influence.
America's history is replete with examples of
powerful social movements kindled by initially unimposing
moral voices: in the eighteenth century the Boston Tea Party;
in the nineteenth, abolitionism, and in the twentieth century,
appeals for civil rights and nuclear disarmament. Only a
comparable public outcry can reclaim medicine. We believe
that our professions' voices can gain extraordinary resonance
when we speak selflessly in patients' interests. From
Massachusetts we pledge the following initial steps:
- We have petitioned our Governor, Legislature and
Attorney General for a moratorium on for-profit
takeovers of hospitals, insurance plans, HMOs,
physicians' practices and other health care institutions.
We expect public officials to oppose such takeovers and
not to abrogate their duty to safeguard indispensable
community resources. We urge colleagues in other states
to join in the call for a moratorium, pending the
development of comprehensive and national policies
addressing these issues.
- On the publication date of this Call physicians and nurses
will convene in the historic heart of Boston. This open
meeting will call the public's attention to the deterioration
of care and caring, and initiate a colloquy on a future for
health care guided by science and compassion, rather than
greed. We have invited colleagues across the nation to
gather simultaneously at similar meetings, linked by
- These events will launch an ongoing series of teach-ins
and meetings in hospitals, clinics, HMOs, offices,
nursing and medical schools to discuss the health care
crisis. We ask that each health institution throughout the
nation devote a major conference such as Grand Rounds
to the moral crisis facing our professions. These
conferences should review national and local data, and
draw on each group's clinical experience to assess the
impact of the corporate takeover; the fundamental values
that are at risk; elements of reform necessary to meet the
needs of patients and communities; and strategies to resist
and reverse the onrush of for-profit systems. Such
discussions must acknowledge the realities of funding as
well as caring. Our group is prepared to assist in the
preparation of these conferences by offering evidence-based
syllabi, slides and other materials.
- We invite public endorsement of this Call by additional
colleagues, and by medical, nursing and lay groups. The
Harvard Medical School Class of 1997, voting at a
convocation held on "Internship Match Day," was the first
group to offer its formal endorsement.
Our goal is not endorsement of a pre-specified program
for health care reform. Indeed, we believe that a number of
programmatic solutions could provide the humane,
comprehensive and equitable care that our nation deserves.
We seek an inclusive and empowering dialogue with patients
and the public to formulate a caring vision true to the
community roots and samaritan traditions of American
medicine and nursing.
- Columbia HCA Healthcare Corporation. 10Q Report
filed with the Securities and Exchange Commission
November 19, 1995.
- Managed Healthcare Market Report. June 30, 1996;
- Levit KR, Lazenby HC, Sivarajan L. Health care
spending in 1994. Health Affairs 1996; 15(2):130-44.
The following individuals participated in drafting this call:
Joan Agreelis, R.N., Jerry Awrn, M.D., Charles M. Blatt,
M.D., Susanna E. Bedell, M.D., Sasan E. Bennett, M.D.,
David H. Bor, M.D., Emile Frei III, M.D., Ernesto Gonzalez,
M.D., Suzanne Gordon, Thomas Graboys, M.D., Charles
Hatem, M.D., David U. Himmelstein, M.D., Timothy H.
Holtz, M.D., Barry S. Levy, M.D., Bernard Lown,
M.D., Robert J. Master, M.D., Timothy B. McCall, M.D.,
Mitchell T. Rabkin, M.D., Jeffrey Scavron, M.D., John D.
Stoeckle, MD., Lee Swislow, RN., John Walsh, M.D.,
Steffie Woolhandler, M.D.