When I was growing up the economy was terrible. The recession of the 1970s (with effects lasting until 1983) was characterized by both high unemployment and high inflation, leading to the presidency of Jimmy Carter and subsequently the presidency of Ronald Reagan. The last 30 years have been characterized by economic growth but at the expense of an increase in the wealth of the top 10% of the population and a concomitant decrease in the incomes of the bottom 50%. When this trend began, those who were the recipients of the increase were unapologetic in the display of their wealth, with Madonna’s Material Girl becoming an anthem of sorts. Acquiring wealth and displaying it was encouraged.

When I entered medical school in the 1980s, although it was understood that we would do well financially, financial incentives were not supposed to influence our decision making. Doctors made money but making money was not what being a doctor was about. We were told by our mentors to do the right thing by the patient and the money would follow. We were not guaranteed entry into the top 1%.

Today the top 1% of American households make more than $380,000 (US). As you can see from this survey, this level  income is easily within the reach of most non-primary care specialists. As chronicled by Atul Gwande, in ways subtle and not -so-subtle, physicians are able to influence patients (consumers?) to purchase health care such that today THEY ARE THE 1 PERCENT.

I have my own set of thoughts regarding the discussions of wealth redistribution, progressive taxation, and the value to society of certain types of work as measured by income. I (probably selfishly) believe that physicians deserve to be valued by society. I worry that physicians (like Wall Street executives) confuse income with value to society. I discussed the spectacle of Michael Jackson’s life previously but really had convinced myself that this was a “one-of” episode. Conrad Murray and his obsession with money and willingness to (allegedly) commit murder to maintain a client was an aberration, right?

Today’s news brings more evidence that physicians are willing to be participants in harming people in exchange for money. Reported by Bloomberg and picked up by the AP, the market for stealing solid organs for transplant has moved from an urban legend status to reality:

[B]rokers use deception, violence and coercion to buy kidneys from impoverished people, mainly in underdeveloped countries, and then sell them to critically ill patients in more-affluent nations. The middlemen form alliances with doctors in leading hospitals who do these transplants for a fee, no questions asked.

Although the real bad guys are the gangs who kidnap the potential donors, the article lets the doctors off VERY EASY. In describing one transplant evaluation:

They took him to Metropolitano Hospital, where kidney specialist Gustavo Salvador sat down with Yafimau. Salvador, who did his medical training at Central University of Ecuador, says Yafimau showed him the document saying he wanted to donate a kidney.

“If someone comes to me and says, ‘I come to voluntarily say that I want to donate,’ then that’s as far as we go,” says Salvador, sitting in an office adorned with Salvador Dali prints. “I can’t investigate the life of the person. That’s not my job.”

Salvador says he was paid $800, his normal fee for referring a patient to a surgeon.

This scandal is not, for the most part, American in origin in the traditional sense. I do believe we have some culpability. First, in the same way those who trained the pilots who flew on 9/11 should have asked about the purpose of the training, our Graduate Medical Education system trains physicians with little to no discussion of manpower needs and ultimate outcome of training. If we train an excess of transplant surgeons they are going to have to practice somewhere and their skill set is limited. Our training should reflect manpower needs. Second, medicine as a commodity leads to poor decision making on the part of the physician and on the part of the patient. Third, physicians apparently need a set of rules imposed to prevent them from behaving badly. It was the Nazi atrocities that led to the reform of research ethics. What is it going to take to reform the ethics of clinical practice?