As we ponder the destructive changes unfolding today in health care and medical practice, we find ourselves questioning whether the government push and attempted takeover of the health care industry was truly repulsed by the American people following the consummation of the great health care debate of 1993 and 1994.
Despite all the media hullabaloo about a growing medical marketplace and the supposedly conservative changes brought about by the November 1994 Republican revolution, corporate socialized medicine is making headway, becoming a reality, step-by-step under the rubric of managed care and a mislabeled "free market." The fact is that we still face an ominous threat from those who seek to destroy the noble profession of medicine, enslave the healers, and dispose of those whose quality of life they deem not worth living.
The supremacy of the patient-doctor relationship, and the ability of physicians, including practicing dermatologists, to do all they can for their patients is being increasingly challenged (and likely will continue to be challenged in the uncertain future of the 21st Century), unless we prevail in derailing the juggernaut of managed competition and corporatism.
Today, many of the major health care corporations with their burgeoning networks are acting in collusion with government bureaucrats to impose managed competition/managed care and to change the time-honored ethics of the medical profession. Where once the supreme medical ethic dictated that physicians place their individual patients' interest above their own (and above that of the state) in the spirit of true altruism and charity, today's ethics of corporate socialized medicine and managed competition propound that the physician place cost considerations and the interest of third-party payers above that of their patients.
For the first time in the history of medicine, American physicians are being coaxed or coerced, whatever the individual case might be, to ration health care by restricting their patient's access to specialists or expensive treatments - that is, forced, involuntary rationing for the sake of cost containment, and as to make their HMOs more efficient and profitable.
Cicero and the Fall of the Roman Republic
Thirty years ago, Millard F. Caldwell, a Justice of the Supreme Court of Florida, drew parallels between what was happening to the United States in 1965, at the time of the Great Society of Lyndon Johnson, and the series of events that took place at the time of the dissolution of the Roman Republic in the 1st Century B.C. at the time of the great orator, statesman, and patriot, Cicero.
Likewise, a generation later, I would like to draw further historic parallels between what is happening in our country today, and quoting Cicero, illustrate and bring to your attention the fateful events that took place at the death knells of the Roman Republic.
Even before the inception of the first millennium, Marcus Tullius Cicero (106-43 B.C.) the great orator and statesman, decried and eloquently spoke against the politics of envy and growing confiscatory taxation, while trying to explain the reasons for the general dissatisfaction of the population - this, at a time when Rome had reached its zenith in both wealth and power. He went on to presage civil strife, and the violent overthrow of the Republic, after the populace had traded in their votes and their vigilance for panem et circenses (bread and circuses), and their rights and liberties for false security and the yoke of oppression.
Cicero pleaded to his fellow lawyers: "None of you will challenge the lawmakers and cry to them, this is unconstitutional, and an affront to a free people and it must not pass!" He asked, "Will one of these, your own, lift his eyes from his ledgers long enough to scan the Twelve Tables of Roman Law, and then expose those who violate them and help to remove them from power, even if it costs their lives? These fat men. Will six of them in this city, disregarding personal safety, rise up from their offices and stand in the Forum, and tell the people the inevitable fate of Rome unless they return to virtue and thrift and drive from the Senate the evil men who have corrupted them for the power they have bestow?"
To paraphrase Judge Caldwell, does that sound like 1996 and our indifference to the growth of government into every aspect of our lives? Does it remind you of our preoccupation with our personal affairs and our unwillingness to "rock the boat?"
As the Roman situation continued to deteriorate, and the people traded their voices and their votes for state benefits, Cicero again asked: "Are we not free? Shall a man be denied his right to speak under the law which establishes that right?...It is not freedom which permits the Trojan Horse to be wheeled within the gates...He who is not for Rome and Roman Law and Roman liberty is against Rome...He can not ride two horses at the same time...Though liberty is established by law, we must be vigilant...."
Again, does that sound like the moderate politicians who straddled the fence in 1996 and betrayed the trust of their fellow citizens and professional colleagues by making compromises that violate our constitution and the codes of ethics of our profession in exchange for a filigree of political and personal power. Does it ring a familiar bell with your friends and complaisant colleagues you deal with in your day to day walks of life?
As time passed, Cicero, the patriot, continued his personal struggle for liberty and finally became Consul of the Republic. It seemed that for a time the corruption of those who were subverting the constitutional rule of the Republic had ceased. But, behind the scenes, "moderate" politicians and the establishment were seeking to silence and banish Cicero. To defend himself, Cicero appeared before the Roman Senate to plead his case: "The Senate, in truth, has no right to censure me for anything, for I did but my duty and exposed traitors and treason against the State. If that is a crime, then I am indeed a criminal."
The future members of the First Triumvirate (60 B.C.), Marcus Crassus, Julius Caesar, and Pompey the Great, were present. They did not come to Cicero's assistance, but rather, turned their faces against him. "You have succeeded against me. Be it as you will. I will depart...For this day's work, lords, you have encouraged treason and opened the prison doors to free the traitors. A nation can survive its fools, and even the ambitious, but it can not survive treason from within."
Cicero was indeed banished from Rome, but he was not exiled from his conscience. The Roman general Sulla once told Cicero the middle class-the merchants, lawyers, and physicians - were too timid to stand up for their natural rights and justice. Now, his former friends who had deserted him, the ever acquiescent lawyers, the complaisant doctors, and the bustling businessmen told him: "We do not meddle in politics. Rome is prosperous and at peace. We have our villas in Caprae, our racing vessels, our houses, our servants, our pretty mistresses, and our comfort and treasures. We implore you, Cicero, do not disturb us with your lamentations of disaster. Rome is on the march to the mighty society for all Romans."
Cicero was in anguish and despair, but he continued to fight for the natural rights of man and honest government. He began to write a book to further plead his case. His publisher then asked him, "But who will read it? Romans care nothing for law any longer, their bellies are too full."
When Marcus Junius Brutus came to Cicero complaining that Caesar had betrayed the Republic, Cicero responded: "Do not blame Caesar, blame the people of Rome who have so enthusiastically acclaimed...him and rejoiced in their loss of freedom and danced in his path and gave him triumphal processions...Blame the people who hail him when he speaks in the Forum of the 'new, wonderful good society' which shall now be Rome's, interpreted to mean 'more money, more ease, more security, more living fatly at the expense of the industrious.' Julius was always an ambitious villain, but he is only one man." And yes, the Republic had been betrayed and the public trust violated.
Shocked to Reality
So, my confreres, what has been done to our profession and what is now taking place in our country, not just in health care but in every aspect of our lives, occurs with our tacit consent. We are reluctant to stand up and be counted, as the medical profession is destroyed piecemeal from within and from without. We are reluctant to call managed care for what it is, "corporate socialized medicine." We are reluctant to expose the ethics of managed competition, a perversion of Hippocratic ethics, harnessed for the institution of rationing as to achieve the bottom line for the health care mega-corporations. The dedicated and devoted physicians in the trenches, the honest healers, the busy and competent physicians, have always been an easy mark because we have been laboring in the trenches, putting our trust and livelihood in the hands of the purported leadership - the moderates and the compromisers - who have repeatedly betrayed our trust and our profession from within the gates.
As forewarned by Cicero, the Roman Republic after nearly four centuries of glorious constitutional rule, triumphant conquests, and enormous expansion, fell prey to populist demagogues who claimed to speak for the people and the lower classes, but spoke for their own selfish ends and their unquenchable thirst for political power. They promised land, bread and circuses; instigated riots and insurrections; and preached class hatred and warfare. Yet, they had forgotten Aristotle's axiom, "inferiors revolt in order that they may be equal, and equals that they may be superior." How many times have we heard class warfare rhetoric, demagogic calls for wealth redistribution using, for example, the politics of envy mantra: "The Republicans are seeking to cut Medicare by $270 billion dollars to pay for a $245 billion dollar package of tax breaks for the rich." When in reality, the differences in the "cuts" (that is, only reductions in the rate of growth of Medicare) between the Democratic and Republican packages are virtually insignificant (in terms of government largesses) - a mere $40 billion over 7 years. But, for populist politicians, perception is reality and that is what counts, not facts or figures. To correct the alleged inequalities, they call for more government and pass seemingly innocuous legislation like the Kassebaum-Kennedy Bill that threatens to criminalize the practice of medicine.
A long, bloody civil war ensued. Cicero was assassinated. Chaos reigned in Rome. Law and order and the ancient Roman precept of the rule of law were discarded. For all intent and purposes, the Republic was transmogrified first into a motley mass democracy, with populist politicians currying favor with the unruly masses and threatening to establish a tyranny of the government-dependent majority - a majority which, no longer informed and vigilant, could be manipulated on the promise that they would be given other peoples' money, land, and wealth. This chaotic situation could not stand, and it too quickly degenerated into virtual mobocracy (the rule of the mob). The time was fast approaching that would ring the death knell of the Republic.
In the end, as is well known from the pages of history, when law and order disintegrate, the citizenry yearn for peace and security, and unfortunately, especially if misinformed, end up giving up their liberties and handing power over to a strong man, a dictator, who promises to give security and re-establish law and order. That is just what happened when Julius Caesar crossed the Rubicon, seized power after a bloody civil war, and formally overthrew the Republic in 44 B.C. Roman citizens gave up their votes and their time-honored constitutional, republican principles happily, quid pro quo, public largesse and other panem et circenses, to which they had become immorally inured. This included getting on the public dole for bread and other government subsidies, and being given free gladiatorial entertainment in the many Roman arenas.
Great men, statesmen, philosophers, and republican leaders like Pompey the Great (106-48 B.C.), Cato the Younger (95-46 B.C.), Marcus Tullius Cicero* , and later, Seneca the Younger (3 B.C.-A.D. c.65), died honorably for their republican sentiments and their firm beliefs in the natural rights of man, the rule of law, and the tenets of the Roman constitutional Republic.
In our own day, likewise, the final battle for the survival of the private, independent practice of medicine and dermatology represents more than just a struggle between two sectarian factions attempting to dictate the mechanism of health care delivery; more importantly, philosophically, it is a struggle that symbolizes the titanic conflict between two rival ideologies: One vision believes in the ethics of Hippocratic medicine, restores the sanctity of the patient-doctor relationship (based on genuine compassion, charity and trust); respects private contracts and free associations; and advocates individually-based, free market incentives in the form of MSAs in which patients are empowered and physicians are free to practice Hippocratic medicine. This vision, sadly, is quickly fading under managed care and the direction that we are headed.
The alternative view represents corporate socialized medicine centered around the concept of managed care/managed competition, whereby HMO bureaucrats dictate patient care from afar, claiming to rely on the false "ethics of caring," but in reality basing their policies on what is actually closer to the Swiss philosopher Ernest Truffer's veterinary ethics, an ethic that forces physicians to act in the interest of the corporate entity as third-party payer, rather than in the interest of their patients; mandates coercive compassion; responds only to pressure by politically-powerful special interests; and insists on statism and collectivism, rather than voluntary individual incentives. Medical care becomes a right rather than a mutually beneficial professional relationship based on ancient Hippocratic principles and ethics. Physicians are no longer dedicated independent practitioners, but docile, complaisant employees of the networks that employ them.
In short, gentlemen, the Vandals are not over the top, nor have they been repulsed; they remain battering at the gates with their minions are, however, within the gates, subverting the walls of the House of Medicine.
For vigilant and informed physicians, there is no longer room on the sidelines. If we are not successful in our efforts, our fate will be the catastrophic stumble and inevitable plunge down the bottomless pit of corporate socialized medicine, and the enslavement of the medical profession under the yoke of managed care. This plunge would signify the commencement of a New Dark Age of medical care regression and your enslavement as caring dermatologists; health care rationing for your patients; and perhaps, in the not-too-distant future, a brave new world of government- or corporate-imposed, active euthanasia - rationing by death - as the ultimate and most efficient form of cost control. You can be sure the brunt of this cataclysm will be borne out, and the responsibility placed squarely on your shoulders. You and your patients will be the biggest losers.
Judge Caldwell's contemporaries believed in 1965, at the time of Johnson's Great Society and the inception of Medicare, that America, then, was going through a second American Revolution, a revolution of a destructive generation that would saddle us with government dependency and welfare; rampant crime; gigantic, intrusive government; and politicized medicine. Alas, they were correct. Moreover, the children are yet to be devoured by the flames of their misguided revolution. I assert, today, we are still going through this trial by fire. It's time to counter-attack and restore the true ideals of our nation and our profession.
Miguel A. Faria, Jr., M.D.
* Cicero sided with the Senatorial republican forces led by Pompey the Great and after Octavian (Augustus) took Rome, Cicero was executed by order of Mark Antony (c.83 B.C.-30 B.C.)
(This was also a speech delivered to the members of the Georgia Neurosurgical Society, May 24-26, 1996. The oration was inspired from the writings of Dr. Faria's book, Vandals at the Gates of Medicine---Historic Perspectives on the Battle Over Health Care Reform and other essays.)