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In the present climate of investor owned for profit hospitals, medical clinics, laboratories and pharmacies, there is significant commercialisation of the health care delivery systems. As a consequence, the medical profession is now confronted by various business and marketing practices to attract patients and to use medical services. 

The ethical issues of doctors involvement in ‘privilege cards’ and ‘discount cards’ promoted by commercial companies and insurance agencies have recently become topical. What may seem to be a simple private arrangement between clinics and these third parties has far reaching implications and raises the question of whether medicine is a business or profession. Are all these marketing strategies compatible with the ethics of the medical profession? 

There is no doubt there is a business aspect of a medical practice. Doctors should always practise sound financial policies in running their practice. However, for its own survival and progress the practice of medicine must still be in the context of a profession. What then is the difference between a profession and business? A profession or professional is characterised by 3 main features, namely: 

1.  A professional holds special skills and knowledge in a special field of knowledge that is socially important and significant. The professional should have mastery or hold authority in the field that he practises. This means continual study and professional improvement. 

2. A professional has a certain authorisation to practise in that field. The profession should have certain autonomy and responsibility to establish credentials; standards of practice; ethical standards and professional behaviour. A profession must self regulate. Breach of standards of practice or behaviour leads to censure. The professional must at all times be responsible for his decisions and answerable for his actions if demanded by his colleagues or society (in our case, our patients). 

3.  A profession accepts social responsibility and has a strong service orientation. In the cases of the medical profession the interest of the public health and the patient supersedes any self interest of the profession. 

In other words the profession is pursued largely for the benefit and greater good of the society and not for their own selfish financial interest. In a profession, the accepted measure of success is not the amount of financial return but by the level of professional reputation, recognition and social contribution. 

Buy cheap and sell high  
The practice of medical profession is not based on the first business principle of “buy cheap and sell high”. A business is an economic activity that is conducted for maximising profits for the owners; not necessarily for the greater good of society; not governed by any ethical codes and need not possess special skills or mastery over a field of knowledge. A businessman is governed by the common laws of the country or special business regulations. A businessman’s responsibility ends when he closes or sells his business. A professional is still liable for his work even though the project has ended or the piece of work has been completed. 

The Singapore Medical Council (SMC) Ethical Code (P 19) states that “The promotion of practitioners’ medical services, as if the provision of medical care were no more than a commercial activity is likely to both undermine public trust in the medical profession and over time, to diminish the standards of medical care which patients have a right to expect”. 

Reasonable Remuneration 
However, a profession is not a charity. In the practice of medicine, doctors should receive remuneration for services personally rendered by them or by professionals under their supervision. 

The remuneration is based on the complexity of skills exercised or time and effort expended in rendering the service. The range of fee again, is to a large extent, regulated by the professional peers. 

The medical profession should endeavour to provide high quality, cost-effective care. Financial remuneration should not be the motivating influence behind the type of medical management. A professional is not expected to over-charge or under-charge. Physicians fees should commensurate with the services rendered. The medical doctor should neither pay nor receive commission or discounts for referral of patients. 

The SMA Ethical Code (Chapter Two P 12, Section F3) clearly states that “Participation in any form of marketing schemes, involving free gifts, discounts and other forms of inducements to attract patients is considered unethical and unprofessional”. “A doctor is expected to build his or her professional reputation based on ability (e.g. medical skills and knowledge), integrity and good professional conduct”. 

Waiver or reduction of fees 
That does not mean that medical doctors should not reduce or waive the professional fees at all times. On the contrary, the medical profession is expected and encouraged to reduce or waive the professional fees if financial constraints impede the patient receiving or continuing his medical care. In times of epidemics, natural disasters or emergencies, the medical doctor is expected to volunteer his or her services spontaneously. This is distinct from the discount scheme in which the benefits of the reduced charges are not based on means test or infirmities, but are rewards for participation in commercial arrangements. 

Commercialisation erodes away the essential ingredient of the patient’s trust which is extremely important in the successful practice of medicine. No doubt doctors could learn from some marketing practices, especially those which make us aware of our patients needs and preferences. However, let us keep away from other marketing practices which have succeeded in persuading the public to purchase goods and services that they do not want and which they later find that they did not ever need. 

In spite of all these commercial onslaughts, one can take comfort in that the majority of our medical colleagues share in the philosophy that the ability to practise as a medical doctor is a privilege given to us by our patients and society; taught to us by our teachers, colleagues and patients; acquired by our diligence and intelligence which was endowed and blessed to us by the Great Physician of the Universe. In keeping it this way there is more fun, joy and harmony. 
 
 

Profession

Business

1.  Holds special knowledge, skills and       training  2.  Must maintain mastery in the field  3.  Registered by law in a special register as       an individual based on credentials 4.  Governed by ethical code, self regulated       behaviour by profession. Governed by       Courts of Law and Government  5.  Profession responsibility for actions       Subject to answer for actions when       demanded by clients and society  6.  Service orientation       Greater good of society

Has business skills    No need to master any special knowledge  Business is registered. Owners and directors may change    Special business regulation in selected cases      Responsibility ends on selling business      Profit maximisation  For owner and managers’ profit