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Journal of Business Ethics (2008) 83:127–131 DOI 10.


Ó Springer 2007

From Hippocrates to HIPPA: The Collapse Samuel Michael Natale of the Assumptive World

ABSTRACT. This paper studies the developments in the ethical concerns for physicians (Business Concerns) and job satisfaction contigent upon changes in Physicians’ assumptive world. KEY WORDS: Medical ethics, business assumptive values, shifting ethical values concerns,

‘‘Consilience,’’ a model articulated by Edward Wilson, argues that all knowledge and understanding is bound together by some as yet unknown common theory. He argues that there is one grand scheme to explain and unite all that we know and can know consilience/) (accessed 8/27/07). The whole concept of Consilience is that a decision is powerful and that its overall effect is seldom understood. This overall effect creates meaning for the many affected by a decision. When a large company lays off workers to increase its profits because of stockholder expectations, the effect is directly born by the laid off workers, and, indirectly, by the store owners in which these workers shopped; extend the analogy, if the workers go on some sort of unemployment, it will cause a demand on the treasury; it effects GNP, It effects well being, families, and shopping. It will ripple through an economy and affect an entire supply chain. If all knowledge is connected, so then are the decisions we base the information or knowledge that we have at our disposal. Decision Theory assumes that all decisions are based on one of three sets of conditions: certainty, uncertainty, risk. In the first case, certainty, an individual knows everything, and therefore the decision would be made easily and correctly. These are the easiest decisions from a consilient perspective. One example of a decision made with certainty would be the effect is constrained, sharpen the pencil or not, walk the dog or

not. Under conditions of uncertainty, a person is unclear about what is known and which results are best. These decisions can be at the Macro Level. An example of this type of decision is whether to raise revenue targets or not, increase taxes or not. In the risk scenario, someone would know a little about the alternatives, the things that he/she cannot handle and control and the effect of the decision. With the risk model, however, there is some sense of proportionate concerns and sense of success rates, etc. I would add a fourth to the traditional three criteria: a decision type, perhaps we can name it ‘‘reflex decision’’. An example would be one that physicians may often encounter: a decision which brings together in a single moment, the calculus of risk, the full knowledge of one’s training and the physician’s world view, to make a decision without a clearly defined ‘‘thinking’’ it through but, the decision is almost universally precise and correct. What I am arguing is that decisionmaking is all of one piece and, further, that decisions actually create meaning. Our decisions tie to our sense of legacy, that is, how we wish to be remembered whether it is Cleopatra, Toni Morrison, Bill Clinton, or George Bush. Each person make decisions based on how they understand the context of the situation and what they project their legacy will be. What a legacy actually is only history will judge, but all people act to create the meaning that they see as succeeding them. Even here the landscape is changing as Ann Nelson comments from her experience in Human Resources:
…The newest generation entering the workforce…are typically unconcerned with legacy, or more specifically they are concerned with family time to the point of rejecting a career that requires dedication/training/ personal sacrifices such as medicine. …What are the

In addition these choices appear to stem from one of two sources: those that ‘‘pertain to self. benign. privilege and an expectation of success. Students’ psychosocial characteristics as predictors of academic performance in medical school. that purpose often being viewed as noble. ‘‘the world is meaningful’’.) http://www. life and the world’’ and those that surround beliefs that may or may not include transcendence. and economically balanced by responsibilities equally significant and not for the faint of heart. personal correspondence. unless they are going to be highly paid or enjoy significant time off. Nelson. namely. Accordingly. this concept has been further refined by Janoff-Bulman (p. Glaser K.’’ Parkes (1975. p. committed personalities that see themselves as mission and vocation-driven rather than simply ‘‘working’’ at a given task. as well as the negative experiences reported by physicians around the world. or positive.128 Samuel Michael Natale others. and ‘‘the self is worthy’’. Center for Research in Medical Education and Health Care. they are dominant themes in the search for meaning that characterizes all of us in this 80 year journey. and pain. Jefferson Medical College. Far from being simply a theory. Challenges to the assumptive world The two most frequent challenges to the assumptive world have been loss and stress. accordingly. rewards. Philadelphia. Gonnella JS. stereotypically speaking… ( news/44_file/perspectives_winter%202007%20web. we call life. attitudes. they are rarely motivated to share great responsibility. p. Along with this vocational model originating even before Hippocrates and continuing until somewhat recently was status. behavior and cognition produce the character that arises from the personality.austenriggs. that social skills and world view are at least as important as knowledge base in predicting success in both medical school and practice. (Rando. The congruence of affect. This is nowhere more prevalent than in driven. In addition. Since these choices impact one’s entire life work. Damjanov I. morally. (Janoff-Bulman. 68(8): 635–7. 132). formed variously within different cultures. suffering. such as a desire to heal. 1993 Aug. one chooses a career with a purpose in mind. wherein justice. the assumptive world is the directly linked cause too much of the dissatisfaction in the world today. 5) who argues that these assumptions form the center point of our world and our consciousness. It is but a simple-step clinically to move to argue that the individual person and the world are in a meaningful and not random relationship. 1993) Important studies on the personalities of physicians have been replicated many times and emerge with the same result. planning and acting… Assumptions such as these are learned and confirmed by the experience of many years. and punishments occur not randomly but significantly. All of this. they are the composite that forms the physician’s personality and. 6). Veloski JJ. These specific beliefs about transcendence are not our concern here though the global assumptions regarding the self and the world remain paramount. 9/21/07) A step backward: the assumptive world I invite you this evening to journey with me a step further back in the decision chain… a journey into our consciousness that will reveal the assumptive world that each of us emerges from and lives within. Robeson M. Since there are different levels of and intensities of assumptions. In our particular effects of the generational cultural values on their assumptions and decision-making? In the business world. the behaviors that arise from the assumptive worldview of that personality. The assumptive world has been defined as ‘‘a strongly held set of assumptions about the world and the self that is confidently maintained and used as a means of recognizing. as it proceeded apace with an almost Elizabethan worldview with everything in its place and a place for everything. PA 19107–5083. pdf (accessed 9/20/07) What are these psychosocial measures that constitute success and from where do they arise? In fact. forms the bedrock of the person’s assumptive world with its values. . so that they are so much a part of us that we do not challenge them. One acts according to what one believes if they are psychologically healthy. needs and expectations. The concept is further expanded by JanoffBulman to suggest that the three most basic assumptions are: ‘‘the world is benevolent’’. 1992. Hojat M. Acad Med.

In health care. These can be divided equally into: Social and Economic. Entrepreneurship is acceptable as long as it does vacate the category of available care. eventually created an assumption that it could be done without training or high-level insight. as you know to the infrastructure an organization creates to manage its liabilities. the predominant issue is. that is. p. 69. psychological and moral environments were also changing. What we are saying here is that everything that are valued holds within it the possibility of ending or loss thereby producing a challenge to the assumptive world. Physicians were being distanced from the person they were treating as more specialization forced consultations and technological intervention rather than personal. surveys administered within the past 10 years have shown that 30 to 40% of practicing physicians would not choose to enter the medical profession if they were deciding on a career again. 2004. 2007. 1181) As a result of many of these simultaneous occurrences. government supported medical treatment. As roles and contact levels changed for the physician. at one medical convention. empathic interaction during the past few decades. The reduction was from professional discernment to task management. 40 percent of the doctors said they would not recommend the profession of medicine to a 129 qualified college student. and an even high percentage would not encourage their children to pursue a medical career. Underscoring all of these emergent questions is the growing (perhaps. In a telephone survey of 2000 physicians tat was conducted in 1995. Of course the changes were incremental and subtle with varying impact depending on the interpreter’s point of view. Within the extra-territorial format. In contrast. economic levels.From Hippocrates to HIPPA case. these changes are all subtly interactive and organically related. perhaps. Within the social frame of analysis.? What is the appropriate calculus to determine the costs of medical development as well as balancing this calculus against the law of supply and demand? These examples relate more directly to territorial concerns where we can assume a relatively common culture. Further. (Zuger. it would encompass the following (not an exhaustive list): . In 1973.S. and useful calculus of implementation. so did the perception of who the physician was…a role? A person? A concept? A task? Other events also impacted the assumptive world of the physician as litigation rose and specialization increased. Survey results suggest that levels of professional satisfaction have dwindled substantially in the past few decades. This is a consilient reflection of the mechanical world. Hearkening back to our premise of Consilience. Perhaps the clearest examples of this are held within the major ethical concerns in medicine in our day. Ironically. other economic. inappropriate) demand for unreasonable risk management. Concomitant movements As these social shifts were occurring to the physician’s world. Should the government and/or to what degree should the government provide access to medical care? What formulas exist that are both just and realistic without incurring massive entitlements. less than 15% of several thousand practicing physicians reported any doubt that they had made the correct career choice. all bets are off and a new model needs to evolve to accommodate the human need for healing where resources are impoverished and/or virtually absent. new levels of dissatisfaction in medicine are being reported and continue to grow significantly. Nor can this need be avoided without bankrupting the concept of medical professional and healer. what is the cost of medical treatment as a function of the average salary in the U. a group of doctors were complaining that they were limited in what they could or would attend as the language beyond their own area of interest had become increasingly technical and cultic such that general intelligibility was not available to them. which refers. governed by computer technology. Weinstein and Wolfe. the loss of status and responsibility has gone hand-in-hand with the paraprofessional system growth which made some of the discerning tasks of the physicians less than unique and. p. The loss was magnified and intensified by a growing alienation from the social system and its relationships as specialization and technology began to impact the practice of physicians’ decision making.

our ability. General liability. it is based on your knowledge. Striking a balance between moderate costs. gone are the ‘‘I am the partner of Dr. based on the relationship between costs. Gone are the stereotypes of being the Physician/king/powerbroker. Ph. Employee theft. (2004). 2004. It is inside of you.. takes one away from the primary concern of the healing work and requires valuing profit over service often simply to survive. cost.. The question a few years ago was asked. to reconstruct our assumptions may eventually lead to world more responsive to us and we to it. in the picture ‘‘Alfie’’: ‘‘what’s it all about Alfie?’’ You have the answer. under guidance. Since we are able to abstract. by the use of imagination. C. which allows us to thrive and dominate other species. and access (Montgomery et al. However. 2005). then neither will your actions based on your assumptions be acceptable to the world. You attempt to create a better world and you do this with . Perceptions of health are quality as mea- So how can one respond today? Beyond the normal psychological suggestions that tend to address very narrow adaptations. it is based on your assumptions of the world. Suzette. Suzette Sheth. your spirit. Intellectual property risk management. and D. and the realities that you face. if not the patient. If we see that the direction we have created in our minds is possible and desirable. providers. added to the Medicaid/ Medicare debacle effectively analyzed by Dr. Another critical economic factor to consider with regard to Medicare reimbursement is based on the fact the 60% of hospitals in the U. and access to care are all interrelated regarding patient satisfaction. If your perceptions are no longer supported by the world. high quality. Research malpractice. quality and access to care will suffer..S. This. Maintaining even a rudimentary conformity to these legal requirements along with HIPPA demands. by your actions you help those in difficulties.D. Directors and officers liability. However. present a daunting and negative picture. a virtual empire needs to be created to manage the social and legal demands. if the focus becomes too disparate on reducing costs. Medical malpractice.130 Samuel Michael Natale sured by the modified drain survey by Sheth. yes. It is based on understanding that every decision you make affects someone. the increasing utilization of Medicare is expected to bankrupt the program on or before 2030 (Feldstein. Capella University. and current veterans cohorts are continuing to utilize Medicare benefits in increasing numbers among all program parts A.e. Workers compensation. Jacobs & Rapoport. Dr Sheth writes: According to Montgomery The aging baby boomers in the U. your medicine. even the world at large. patients. quality. Earnest Becker has pointed out one possible response based on our brain capacity. slowly and painfully. and the government). The conclusions are these: All of our actions affect the world and the world affects each of us. X’’ what the new roles within a considerably more modest assumptive world will be yet remains to be seen. C. Life insurance and pension plans. the society he/she lives in. Bonding of finance staff. Likewise. et al. B. lose money on services provided to Medicare beneficiaries (AHA. of course. Key employee coverage (in case a major executive becomes incapacitated). In some ways you are the modern day Knights. As a result these and other factors. and moderate access to services is indeed most challenging. In short. if quality improvement becomes a disparate emphasis. costs and access to care will rise accordingly. While Medicare Parts C and D were designated to reduce Medicare expenditures and more efficiently utilize services. then we can begin to create it in the material world. quality. recreate the assumptive world as one better adapted to the changing social conditions.S. 2004). your practice. 138 pages. we are able to separate ourselves from our own consciousness and relate two orthogonal pieces of information and learning together so that we can imagine an event. 2007. 2004). objectify the self and project the self into the created environment. we can. All of these concerns.. there are certain actions that one can take to address the insults to one’s assumptive world. his/her family. containing healthcare costs (particularly Medicare costs) have become a priority among the stakeholders involved (i.

They may not be working for the world has changed and your assumptions about it have not. Jacobs. References American Heart Association 2005 Guidelines for CPR and ECC: 2005. A. I ask you to: • Focus on Consilience …for what you do affects all even if you do not know it. U.. Adelphi University. Li. Irish. and that we must open up our assumptions to understand that scheme which. H. E-mail: sammyMN@aol. risk and reward. and H. The Economics of Health and Medical Care (Aspen Publishers. problematically. H. Treated of Complicated Mourning (Research Press. Zuger. 2007. C. Vol. org/feldstein/aeajan8. we understand the way it is. and only if. New York 11530. I hope I have opened some small understanding in each of us. Parkes. Shattered Assumptions: Towards a New Psychology of Trauma (The Free Press. Janoff-Bulman. T. knowing the difference between national actions and international actions. R. J.: 1992. Rethinking Social Insurance. 1001. Boston. ‘What Becomes of Redundant World Models? A Contribution to the Study of Adaptation to Change’. 109. If I have done anything this evening. Retrieved October 10. The New England Journal of Medicine. E. as it should be if. The reality is that return is NOT what you may have thought it was. Rapport: 2004.: 1975. • Finally. 1.: 1993. from http://www.pdf. Iss. Journal of General Internal Medicine 19. IL). Chang. P. The Downward Spiral of Physician Satisfaction: An attempt to avert a crisis within by Obstet Gynecol. New York). L. Garden City. know that you can create (Becker) the world. W. Montgomery. Gaithersburg. • Focus on change to allow you to achieve what you are capable of. 1181–1183.jhtml?identifier=3035517. I. G. seem to be different for each one of us. Wolfe (2007). for the world is a different and changing place. So this evening. January 1. J. 131 Feldstein. Chanpaign. . 2007.From Hippocrates to HIPPA an expectation of return. C. Safran: 2004. and J. • Focus on social and economic issues—costs and benefits. Rogers and D.A.: 2004. B. • Focus on your assumptions. 350. These are not the same as you may have thought they were. M.americanheart. Dissatisfaction with Medical Practice. Retrieved October 10. (2004). that we must consider that there is one grand scheme that explains and unites all that we know and can know. Rando. Weinstein. T. 131–137. A. School of Business. Wilson. from http://www.nber. British Journal of Medical Psychology 48.S. MD).

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