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 bottom line.

Public resources of enormous worth - non-profit hospitals, visiting nurse agencies, 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:

1. 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.
2. Pursuit of corporate profit and personal fortune have no place in caregiving.
3. 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.
4. A patients' right to a clinician of choice must not be curtailed.
5. 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:

1. 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.
2. 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 satellite.
3. 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.
4. 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.

References:

1. Columbia HCA Healthcare Corporation. 10Q Report filed with the Securities and Exchange Commission November 19, 1995.
2. Managed Healthcare Market Report. June 30, 1996; 4(12):1.
3. 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.