introduction Larry R. Churchill and Joshua E. Perry
T
he ethical tensions between market forces in health care and professional claims about the priority of service are long-standing. Many readers may think of Arnold Relman’s New England Journal of Medicine article as a convenient beginning point for the contemporary debate about how to manage these tensions.1 In the more than three decades since Relman’s article, “the medical-industrial complex”2 has become even more pervasive and the tensions between a business model for health care and a professional service model have increased proportionately. Market forces have always been an element in American medicine, but recently they have become pervasive and, some would argue, dominant. While physicians have always sought to portray themselves as trustworthy guardians of a scarce and important social good, in the U.S. they have traditionally functioned as small businesses — a cottage industry with a professional service ethos and varying degrees of entrepreneurial impulse. In the past most medical corporations were owned by physician groups or non-profit organizations governed by boards of local citizens, operating with a community orientation and responsiveness driven by local needs. In 2014, large sectors of the health care landscape are corporatized, with a Wall Street orientation and responsiveness driven by market-share and profit margins. Increased public funding for services, combined with private, corporate delivery of those services, is the U.S. pattern Larry R. Churchill, Ph.D., is the Ann Geddes Stahlman Professor of Medical Ethics, Center for Biomedical Ethics and Society, Vanderbilt University. Joshua E. Perry, J.D., M.T.S., is an Assistant Professor of Business Law and Ethics and a Research Coordinator in the Center for the Business of Life Sciences at Indiana University’s Kelley School of Business.
408
over the past 50 years. This hybrid pattern accentuates both the professional and public sense of moral dissonance about the status and meaning of health services and the appropriate roles of those providing services at the point of individual patient care. Thus have long-standing questions around this basic tension between market and service models grown in intensity and importance. What are the implications of this tension for health professionals, such as physicians, nurses, or pharmacists? Is health law adequate to the task of increased complexity of relationships between physicians and health care institutions and drug and device manufacturers in the life sciences industry? Can medicine any longer claim to be the fiduciary of a social contract aimed at caring for the sick? Is the business of health care, along with its marketing practices and financial models, different from other industries, and if so, in what ways, and how should this difference result in practices, policies, and regulations? And what is at stake in finding some acceptable equilibrium between market and professional service paradigms for health care, particularly given the scope of government funding, influence on the economy, and impact on individual patients and the public? Some contributors to this issue of JLME present new research findings to refine or shift the focus of these issues. Others examine the Affordable Care Act (ACA) as the latest embodiment of the commercial/professional tensions, and probe its passage and its provisions as indicators of American health care values, and as a bellwether for future policy. Other authors carefully examine current pressures on professional practices that have been under-emphasized, and still others argue for new concepts or even a different paradigm for framing the issues. journal of law, medicine & ethics
Churchill and Perry
The first two articles present very different overviews of the basic quandary. Ted Marmor and Robert Gordon3 trace the demise of self-regulation in medicine and the assault on professionalism since the passage of Medicare. They distinguish between financial and professional autonomy, arguing that the Canadian experience shows that these are separable and that relinquishing financial independence can be a road to greater clinical autonomy. They also detail some of the important ways that the ACA embodies the classic
between liberal aims and market mechanisms perpetuates the moral tensions rather than resolving them. While Oberlander’s focus is on the broad political framing of health policy, Sam Halabi’s article “Selling Hospice,”6 continues a conversation stirred-up in these pages a few years ago7 and presents a sharply focused analysis of the fast growing for-profit hospice movement. Halabi analyzes the corporate, investment, and regulatory history of Vitas Hospice Care, arguing that the commercial dimension of this and other for-profit
In 2014, large sectors of the health care landscape are corporatized, with a Wall Street orientation and responsiveness driven by market-share and profit margins. Increased public funding for services, combined with private, corporate delivery of those services, is the U.S. pattern over the past 50 years. This hybrid pattern accentuates both the professional and public sense of moral dissonance about the status and meaning of health services and the appropriate roles of those providing services at the point of individual patient care. Thus have long-standing questions around this basic tension between market and service models grown in intensity and importance. mechanism and techniques of a market model, with little or no evidence for their effectiveness. By contrast, Andy Wicks and Adrian Keevil4 are skeptical that the usual ways of thinking about the business model of medicine and health care can be productive. They see the conventional exchanges about business vs. professional ethics as proceeding from flawed assumptions and employing a model of business ethics that is prejudicial and inaccurate. They argue that stakeholder theory will provide a different paradigm for sorting the business/professional tensions, and specifically they claim that focusing on stakeholders and their responsibilities will illuminate the neglected “meso-level” — as well as the macro- and micro-level of analysis — where much of the morally important action resides. Several contributors focus their analyses at the health systems level. Among these is Jon Oberlander.5 He argues that while the ACA expands the government’s role in the regulation of insurance and enfranchises many more citizens, it largely relies on a health market consumer paradigm to achieve these ends. Thus “a pluralistic health financing system riddled with inequities and coverage gaps beget a pluralistic health reform law that reduces but does not eliminate these inequities and gaps” and produced some additional gaps in the process. The ACA as a balance the buying and selling of health care • winter 2014
hospice providers poses a threat to patient autonomy and overall patient care. Rather than focus exclusively on the for-profit features, Halabi argues that there has been too little attention to “the corporate and investment structures that surround hospice provision including overlapping directors between hospice and other healthcare providers; contracts between hospice firms and other providers especially in the pharmaceutical, nursing home, and home health sectors.” He concludes with a call for greater regulatory attention to merger and divestiture activities. Jamie Fletcher and Jane Marriott,8 two legal scholars working in the U.K., provide the last contribution to the policy section of this volume. These researchers describe recent healthcare reforms in the U. S. (Affordable Care Act) and in the U.K. (Health and Social Care Act of 2012), and assess them on a metric of “revolution” or “evolution.” With detailed accounts of the legislative processes in both countries, they argue that the constitutions of both play a critical but neglected role in the amount and kind of reform that can occur. They contend that an off-shoot version of the evolution model, viz., convergence, is the more accurate picture of current reforms, and that constitutional law in both countries is a critical vehicle for shaping and containing health reform policies.
409
INTRO D UCTION
Several contributors to this forum give primary attention to the ways that commercial influences affect the identity of professional service providers, as well how these professionals are viewed by the public. An imaginative study by Josh Perry, Dena Cox, and Tony Cox9 uses a provision of the ACA as an occasion to test public perceptions about physicians’ relationships with pharmaceutical firms. The Physician Payment Sunshine Act, included within the ACA, requires that pharmaceutical and device companies report their financial relationships with physicians. The authors report on a patient survey to gauge the way this new requirement for transparency might affect public trust, measured by a variety of scenarios, such as drug samples, speaking fees, free lunches and owning company stock. The results are indicative of a public accepting of some financial relationships, but very skeptical about others, and bespeak a range of social assumptions about professional and business norms that merit further investigation. While Perry, Cox, and Cox are concerned with the influence of what patients may learn about pharmaceutical perks and payments, Matt Lamkin and Carl Elliott10 are focused on what patients do not know, in this case about the growing prevalence of drug company “adherence programs.” Everybody admits that patient adherence to prescriptions is a problem, often leading to ineffective care and increased morbidity. In “Curing the Disobedient Patient: Medication Adherence Programs as Pharmaceutical Marketing Tools,” Lamkin and Elliott probe the more commercially driven and worrisome aspect of adherence programs, especially when health professionals, such as nurses, are hired by pharmaceutical manufacturers to coach and befriend patients as a strategy for boosting sales and creating brand-loyalty for products. The authors describe in detail how this occurs and why it is morally troublesome. They, too, are concerned that the hardwon public trust for health professionals can be easily dissipated by commercial ambitions. In “Economism and the Commercialization of Health Care,”11 Howard Brody couches his critique of commercial forces within the pervasive American cultural assumption about the virtues of markets generally, a phenomenon he terms “economism” — the assumption that all aspects of life should be understood and managed on economic terms. He argues that little headway can be made on problems of excessive commercialism of health care until public culture and political discourse shift to loosen economism’s quasi-religious hold on the social imagination. Brody takes specific aim at pay-for-performance measures for clinical work as a recent example of an economist ideology at work. 410
Lois Shepherd, in “The Hair Stylist, the Corn Merchant, and the Doctor,”12 challenges the accepted views about the special moral virtue of altruism that the public often attributes to physicians and that physicians frequently claim for themselves in their professional codes. Shepherd is concerned about the moral elitism this social attribution and professional claim implies, and argues that special claims to altruism are not simply false, but potentially detrimental. Attributing a special altruistic identity to doctors, she says, obscures the ordinary moral obligations that physicians share with other professions and occupations, such as hairstylists and corn merchants. Indeed, the special status often claimed by physicians for selfless motives and actions may well stand in the way of their recognizing the corrupting influences of commercialism, and lead to the neglect of the truly important physician virtues, such as compassion and humility. In an extensively researched report Liz Chiarello13 turns the focus to pharmacists and the professional contingencies that affect their role as medical and fiscal gatekeepers. As a sociologist, Chiarello is concerned with the organizational and institutional structures — the rules and routines — that surround the work of pharmacists and shape the way they navigate their gatekeeping duties. Thus she portrays a nuanced and much needed contextualization for the impact of commercial forces on professional work. Her work shows the importance of whether health professionals are in a private clinic or a public hospital, in a flat or a hierarchal organization, or working within a for-profit or not-for-profit setting. Among her other conclusions she contends that “we should examine how shifts in inter-professional relationships mediate the effect of commercialization,” thus calling for more detailed attention to these and other social factors if we are to correctly gauge the impact of commercial forces on professional life and work. Finally, Bill Sage and Kelley McIlhattan14 invite us “upstream” from the current fixation on medical care and the medical care industry to consider what health law might be like when it is truly focused on health, that is, on consumers of health services and products before they develop illness and are classified as “patients.” The authors describe a variety of current and potential upstream products and services, such as self-monitoring devices, health consults, and mobile management systems, highlighting the existing and future role of health law on matters like malpractice, informed consent and product liability. They conclude that changes associated with the ACA present an opportunity “to bring health care products back into line with other sectors of the economy” where the justification for products is not efficiency to the medical system but value to consumers. journal of law, medicine & ethics
Churchill and Perry
These eleven articles reflect a diversity of institutional and disciplinary perspectives, each of which offers an important contribution to the discussion of legal, ethical, and policy issues raised by the business of health care and contemporary ecology of medicine. It is our hope that this symposium will be a catalyst for future dialogue among patients, physicians, and policymakers, as well as additional analysis by scholars working at interdisciplinary crossroads in schools of business, medicine, law, and public health — both in the U.S. and beyond. The questions and concerns we and our contributors have raised are rooted in debates dating back to the Ancients, and yet they remain among the most vexing of 21st century social issues. May the conversation continue with renewed vigor. References
1. See A. S. Relman, “The Medical Industrial Complex,” New England Journal of Medicine 303, no. 17 (1980): 963-970, and his subsequent writings on this topic: “The Health Care Industry: Where is it Taking Us?” New England Journal of Medicine 325, no. 12 (1991): 854-859; and “Medical Professionalism in a Commercialized Health Care Market,” JAMA 298, no. 22 (2007): 2668-2670. 2. The concept “medical-industrial complex” was introduced in 1970 by B. Ehrenreich and J. Ehrenreich in The American Health Empire: Power Politics and Profits (New York: Random House, 1970). 3. T. R. Marmor and R. W. Gordon, “Commercial Pressures on Professionalism in American Medical Care: From Medicare to the Affordable Care Act,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 412-419.
the buying and selling of health care • winter 2014
4. A. C. Wicks and A. A. C. Keevil, “When Worlds Collide: Medicine, Business, the Affordable Care Act and the Future of Health Care in the U.S.,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 412-419. 5. J. Oberlander, “Between Liberal Aspirations and Market Forces: Obamacare’s Precarious Balancing Act,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 420-441. 6. S. Halabi, “Selling Hospice,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 442-454. 7. J. E. Perry and R. C. Stone, “In the Business of Dying: Questioning the Commercialization of Hospice,” Journal of Law, Medicine & Ethics 39, no. 2 (2011): 224-234. 8. J. Fletcher and J. Marriott, “Beyond the Market: The Role of Constitutions in Health Care System Convergence in the United States of America and the United Kingdom,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 455-474. 9. J. E. Perry, D. Cox, and A. D. Cox, “Trust and Transparency: Patient Perceptions of Physicians’ Financial Relationships with Pharmaceutical Companies,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 475-491. 10. M. Lamkin and C. Elliott, “Curing the Disobedient Patient: Medication Adherence Programs as Pharmaceutical Marketing Tools,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 492-500. 11. H. Brody, “Economism and the Commercialization of Health Care,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 501-508. 12. L. Shepherd, “The Hair Stylist, the Corn Merchant, and the Doctor: Ambiguously Altruistic,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 509-517. 13. E. Chiarello, “Medical Versus Fiscal Gatekeeping: Navigating Professional Contingencies at the Pharmacy Counter,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 518-534. 14. W. M. Sage and K. McIlhattan, “Upstream Health Law,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 535-549.
411
Copyright of Journal of Law, Medicine & Ethics is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
T
he ethical tensions between market forces in health care and professional claims about the priority of service are long-standing. Many readers may think of Arnold Relman’s New England Journal of Medicine article as a convenient beginning point for the contemporary debate about how to manage these tensions.1 In the more than three decades since Relman’s article, “the medical-industrial complex”2 has become even more pervasive and the tensions between a business model for health care and a professional service model have increased proportionately. Market forces have always been an element in American medicine, but recently they have become pervasive and, some would argue, dominant. While physicians have always sought to portray themselves as trustworthy guardians of a scarce and important social good, in the U.S. they have traditionally functioned as small businesses — a cottage industry with a professional service ethos and varying degrees of entrepreneurial impulse. In the past most medical corporations were owned by physician groups or non-profit organizations governed by boards of local citizens, operating with a community orientation and responsiveness driven by local needs. In 2014, large sectors of the health care landscape are corporatized, with a Wall Street orientation and responsiveness driven by market-share and profit margins. Increased public funding for services, combined with private, corporate delivery of those services, is the U.S. pattern Larry R. Churchill, Ph.D., is the Ann Geddes Stahlman Professor of Medical Ethics, Center for Biomedical Ethics and Society, Vanderbilt University. Joshua E. Perry, J.D., M.T.S., is an Assistant Professor of Business Law and Ethics and a Research Coordinator in the Center for the Business of Life Sciences at Indiana University’s Kelley School of Business.
408
over the past 50 years. This hybrid pattern accentuates both the professional and public sense of moral dissonance about the status and meaning of health services and the appropriate roles of those providing services at the point of individual patient care. Thus have long-standing questions around this basic tension between market and service models grown in intensity and importance. What are the implications of this tension for health professionals, such as physicians, nurses, or pharmacists? Is health law adequate to the task of increased complexity of relationships between physicians and health care institutions and drug and device manufacturers in the life sciences industry? Can medicine any longer claim to be the fiduciary of a social contract aimed at caring for the sick? Is the business of health care, along with its marketing practices and financial models, different from other industries, and if so, in what ways, and how should this difference result in practices, policies, and regulations? And what is at stake in finding some acceptable equilibrium between market and professional service paradigms for health care, particularly given the scope of government funding, influence on the economy, and impact on individual patients and the public? Some contributors to this issue of JLME present new research findings to refine or shift the focus of these issues. Others examine the Affordable Care Act (ACA) as the latest embodiment of the commercial/professional tensions, and probe its passage and its provisions as indicators of American health care values, and as a bellwether for future policy. Other authors carefully examine current pressures on professional practices that have been under-emphasized, and still others argue for new concepts or even a different paradigm for framing the issues. journal of law, medicine & ethics
Churchill and Perry
The first two articles present very different overviews of the basic quandary. Ted Marmor and Robert Gordon3 trace the demise of self-regulation in medicine and the assault on professionalism since the passage of Medicare. They distinguish between financial and professional autonomy, arguing that the Canadian experience shows that these are separable and that relinquishing financial independence can be a road to greater clinical autonomy. They also detail some of the important ways that the ACA embodies the classic
between liberal aims and market mechanisms perpetuates the moral tensions rather than resolving them. While Oberlander’s focus is on the broad political framing of health policy, Sam Halabi’s article “Selling Hospice,”6 continues a conversation stirred-up in these pages a few years ago7 and presents a sharply focused analysis of the fast growing for-profit hospice movement. Halabi analyzes the corporate, investment, and regulatory history of Vitas Hospice Care, arguing that the commercial dimension of this and other for-profit
In 2014, large sectors of the health care landscape are corporatized, with a Wall Street orientation and responsiveness driven by market-share and profit margins. Increased public funding for services, combined with private, corporate delivery of those services, is the U.S. pattern over the past 50 years. This hybrid pattern accentuates both the professional and public sense of moral dissonance about the status and meaning of health services and the appropriate roles of those providing services at the point of individual patient care. Thus have long-standing questions around this basic tension between market and service models grown in intensity and importance. mechanism and techniques of a market model, with little or no evidence for their effectiveness. By contrast, Andy Wicks and Adrian Keevil4 are skeptical that the usual ways of thinking about the business model of medicine and health care can be productive. They see the conventional exchanges about business vs. professional ethics as proceeding from flawed assumptions and employing a model of business ethics that is prejudicial and inaccurate. They argue that stakeholder theory will provide a different paradigm for sorting the business/professional tensions, and specifically they claim that focusing on stakeholders and their responsibilities will illuminate the neglected “meso-level” — as well as the macro- and micro-level of analysis — where much of the morally important action resides. Several contributors focus their analyses at the health systems level. Among these is Jon Oberlander.5 He argues that while the ACA expands the government’s role in the regulation of insurance and enfranchises many more citizens, it largely relies on a health market consumer paradigm to achieve these ends. Thus “a pluralistic health financing system riddled with inequities and coverage gaps beget a pluralistic health reform law that reduces but does not eliminate these inequities and gaps” and produced some additional gaps in the process. The ACA as a balance the buying and selling of health care • winter 2014
hospice providers poses a threat to patient autonomy and overall patient care. Rather than focus exclusively on the for-profit features, Halabi argues that there has been too little attention to “the corporate and investment structures that surround hospice provision including overlapping directors between hospice and other healthcare providers; contracts between hospice firms and other providers especially in the pharmaceutical, nursing home, and home health sectors.” He concludes with a call for greater regulatory attention to merger and divestiture activities. Jamie Fletcher and Jane Marriott,8 two legal scholars working in the U.K., provide the last contribution to the policy section of this volume. These researchers describe recent healthcare reforms in the U. S. (Affordable Care Act) and in the U.K. (Health and Social Care Act of 2012), and assess them on a metric of “revolution” or “evolution.” With detailed accounts of the legislative processes in both countries, they argue that the constitutions of both play a critical but neglected role in the amount and kind of reform that can occur. They contend that an off-shoot version of the evolution model, viz., convergence, is the more accurate picture of current reforms, and that constitutional law in both countries is a critical vehicle for shaping and containing health reform policies.
409
INTRO D UCTION
Several contributors to this forum give primary attention to the ways that commercial influences affect the identity of professional service providers, as well how these professionals are viewed by the public. An imaginative study by Josh Perry, Dena Cox, and Tony Cox9 uses a provision of the ACA as an occasion to test public perceptions about physicians’ relationships with pharmaceutical firms. The Physician Payment Sunshine Act, included within the ACA, requires that pharmaceutical and device companies report their financial relationships with physicians. The authors report on a patient survey to gauge the way this new requirement for transparency might affect public trust, measured by a variety of scenarios, such as drug samples, speaking fees, free lunches and owning company stock. The results are indicative of a public accepting of some financial relationships, but very skeptical about others, and bespeak a range of social assumptions about professional and business norms that merit further investigation. While Perry, Cox, and Cox are concerned with the influence of what patients may learn about pharmaceutical perks and payments, Matt Lamkin and Carl Elliott10 are focused on what patients do not know, in this case about the growing prevalence of drug company “adherence programs.” Everybody admits that patient adherence to prescriptions is a problem, often leading to ineffective care and increased morbidity. In “Curing the Disobedient Patient: Medication Adherence Programs as Pharmaceutical Marketing Tools,” Lamkin and Elliott probe the more commercially driven and worrisome aspect of adherence programs, especially when health professionals, such as nurses, are hired by pharmaceutical manufacturers to coach and befriend patients as a strategy for boosting sales and creating brand-loyalty for products. The authors describe in detail how this occurs and why it is morally troublesome. They, too, are concerned that the hardwon public trust for health professionals can be easily dissipated by commercial ambitions. In “Economism and the Commercialization of Health Care,”11 Howard Brody couches his critique of commercial forces within the pervasive American cultural assumption about the virtues of markets generally, a phenomenon he terms “economism” — the assumption that all aspects of life should be understood and managed on economic terms. He argues that little headway can be made on problems of excessive commercialism of health care until public culture and political discourse shift to loosen economism’s quasi-religious hold on the social imagination. Brody takes specific aim at pay-for-performance measures for clinical work as a recent example of an economist ideology at work. 410
Lois Shepherd, in “The Hair Stylist, the Corn Merchant, and the Doctor,”12 challenges the accepted views about the special moral virtue of altruism that the public often attributes to physicians and that physicians frequently claim for themselves in their professional codes. Shepherd is concerned about the moral elitism this social attribution and professional claim implies, and argues that special claims to altruism are not simply false, but potentially detrimental. Attributing a special altruistic identity to doctors, she says, obscures the ordinary moral obligations that physicians share with other professions and occupations, such as hairstylists and corn merchants. Indeed, the special status often claimed by physicians for selfless motives and actions may well stand in the way of their recognizing the corrupting influences of commercialism, and lead to the neglect of the truly important physician virtues, such as compassion and humility. In an extensively researched report Liz Chiarello13 turns the focus to pharmacists and the professional contingencies that affect their role as medical and fiscal gatekeepers. As a sociologist, Chiarello is concerned with the organizational and institutional structures — the rules and routines — that surround the work of pharmacists and shape the way they navigate their gatekeeping duties. Thus she portrays a nuanced and much needed contextualization for the impact of commercial forces on professional work. Her work shows the importance of whether health professionals are in a private clinic or a public hospital, in a flat or a hierarchal organization, or working within a for-profit or not-for-profit setting. Among her other conclusions she contends that “we should examine how shifts in inter-professional relationships mediate the effect of commercialization,” thus calling for more detailed attention to these and other social factors if we are to correctly gauge the impact of commercial forces on professional life and work. Finally, Bill Sage and Kelley McIlhattan14 invite us “upstream” from the current fixation on medical care and the medical care industry to consider what health law might be like when it is truly focused on health, that is, on consumers of health services and products before they develop illness and are classified as “patients.” The authors describe a variety of current and potential upstream products and services, such as self-monitoring devices, health consults, and mobile management systems, highlighting the existing and future role of health law on matters like malpractice, informed consent and product liability. They conclude that changes associated with the ACA present an opportunity “to bring health care products back into line with other sectors of the economy” where the justification for products is not efficiency to the medical system but value to consumers. journal of law, medicine & ethics
Churchill and Perry
These eleven articles reflect a diversity of institutional and disciplinary perspectives, each of which offers an important contribution to the discussion of legal, ethical, and policy issues raised by the business of health care and contemporary ecology of medicine. It is our hope that this symposium will be a catalyst for future dialogue among patients, physicians, and policymakers, as well as additional analysis by scholars working at interdisciplinary crossroads in schools of business, medicine, law, and public health — both in the U.S. and beyond. The questions and concerns we and our contributors have raised are rooted in debates dating back to the Ancients, and yet they remain among the most vexing of 21st century social issues. May the conversation continue with renewed vigor. References
1. See A. S. Relman, “The Medical Industrial Complex,” New England Journal of Medicine 303, no. 17 (1980): 963-970, and his subsequent writings on this topic: “The Health Care Industry: Where is it Taking Us?” New England Journal of Medicine 325, no. 12 (1991): 854-859; and “Medical Professionalism in a Commercialized Health Care Market,” JAMA 298, no. 22 (2007): 2668-2670. 2. The concept “medical-industrial complex” was introduced in 1970 by B. Ehrenreich and J. Ehrenreich in The American Health Empire: Power Politics and Profits (New York: Random House, 1970). 3. T. R. Marmor and R. W. Gordon, “Commercial Pressures on Professionalism in American Medical Care: From Medicare to the Affordable Care Act,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 412-419.
the buying and selling of health care • winter 2014
4. A. C. Wicks and A. A. C. Keevil, “When Worlds Collide: Medicine, Business, the Affordable Care Act and the Future of Health Care in the U.S.,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 412-419. 5. J. Oberlander, “Between Liberal Aspirations and Market Forces: Obamacare’s Precarious Balancing Act,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 420-441. 6. S. Halabi, “Selling Hospice,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 442-454. 7. J. E. Perry and R. C. Stone, “In the Business of Dying: Questioning the Commercialization of Hospice,” Journal of Law, Medicine & Ethics 39, no. 2 (2011): 224-234. 8. J. Fletcher and J. Marriott, “Beyond the Market: The Role of Constitutions in Health Care System Convergence in the United States of America and the United Kingdom,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 455-474. 9. J. E. Perry, D. Cox, and A. D. Cox, “Trust and Transparency: Patient Perceptions of Physicians’ Financial Relationships with Pharmaceutical Companies,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 475-491. 10. M. Lamkin and C. Elliott, “Curing the Disobedient Patient: Medication Adherence Programs as Pharmaceutical Marketing Tools,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 492-500. 11. H. Brody, “Economism and the Commercialization of Health Care,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 501-508. 12. L. Shepherd, “The Hair Stylist, the Corn Merchant, and the Doctor: Ambiguously Altruistic,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 509-517. 13. E. Chiarello, “Medical Versus Fiscal Gatekeeping: Navigating Professional Contingencies at the Pharmacy Counter,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 518-534. 14. W. M. Sage and K. McIlhattan, “Upstream Health Law,” Journal of Law, Medicine & Ethics 42, no. 4 (2014): 535-549.
411
Copyright of Journal of Law, Medicine & Ethics is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
