Saint Martin of Tours in a new world of medical ethics.
I end with another parable, but it is also a true story. Harvey Cushing, the famous surgeon after whom the Cushing Lectures are named, made an international reputation in his allegiance to quality. He badgered his profession to a higher standard of self-effacement and railed against the debasement of clinical skills and overemphasis on research and pursuit of personal gain. We honor him to this day because those were, and remain, important points. Yet, Harvey Cushing served as a surgeon during World War I and at Ypres. Although the Allied mortality was as much as 50,000 soldiers a day, not counting the wounded, Cushing refused to operate on any more than two patients each day, arguing that to do so would have lowered his standard of care for his patients--a standard that made sense in one time but that became strikingly insensitive, and I suggest even unethical, in another when confronted with a different reality. The ethical claims for professional autonomy based on such standards of professional ethics has had the effect of supporting widespread distributional inequities. These inequities are clearly a form of rationing that have been condoned implicitly by the professional ethics in the name of professional autonomy. Many of the condemnations we hear today of prospective payment systems and how they will "ration" medicine contain a similar sense of unreality. The high standards are laudatory, but they should not be used as an excuse to not meet other pressing needs. High standards should never be used to make a problem worse.(ABSTRACT TRUNCATED AT 250 WORDS)