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CAUT Bulletin Archives

June 1999

Conference Examines Academic Freedom in Medical Schools

The conference "Academic Values in the Transformation of American Medicine," sponsored by the American Association of University Professors (AAUP) and held last month in Boston, raised a host of problems affecting medicine practiced in universities and teaching hospitals. A panel discussion on "Corporate Funding and the Implications for Medical Research" was presented by Dr. Nancy Olivieri and CAUT president Bill Graham. The vast majority of the speakers denounced managed care in the United States, arguing that the advance of managed care (both the for-profit and the not-for-profit varieties) was in large measure responsible for driving academic medical centers into financial crises, mergers and bankruptcies. A number of academic medical centers have been sold to private operators and to nonprofit medical chains. Another factor was the effects of the federal Balanced Budget Act of 1997.

In 1965, for example, 54 per cent of the budgets of academic medical centers came from federal funding. By 1997 that had fallen to 20.3 per cent. In 1965, 34.8 per cent of revenues came from federal research grants and contracts. By 1997 that had fallen to 18 per cent.

Private practice physicians are being driven into managed care operations in ever larger numbers. Managed care, it was said, has been a disaster for medicine in the U.S. because it victimizes the poor, the chronically ill, and the elderly. Health management organizations make their money and cut costs by dumping the sick, the elderly and the poor, and retaining the healthy clients.

All but two of the managed care chains abjure teaching and research as a waste of resources. In spite of this, and because of the cutbacks in federal funding, academic medical centers have been making accommodations with managed care by importing HMOs into the hospitals themselves to operate the "practice plans." Hospital ownership is becoming a huge risk for universities, but if they give up ownership they also give up control of the medical curriculum and guarantees of scientific integrity.

Dr. Leon Eisenberg, professor of psychiatry at Harvard Medical School, and conference program chair, said that the U.S. health system is totally commodified. Health centers are shedding their "loss-making" clients (i.e., patients), physicians have lost control of their own working conditions, and doctor-administrators are becoming corporate managers and CEOs; there is a tendency to appoint accountants rather than physicians as hospital presidents.

A warning should go out to all and sundry, Dr. Eisenberg said, that "managed care is dangerous to your health!" Patients must be able to trust their doctors and doctors must be able to work in conditions which support scientific integrity.

"If I am paranoid, I am paranoid from experience ... Trust in physicians has been eroded." He quoted from Book IV of Plato's Laws to explain the difference between 'slave doctors' (i.e., commodified doctors) and 'free doctors.' He criticized Milton Friedman for placing market forces and fiscal efficiency above the social benefit of medicine: "if you trust everything to the wisdom of the market you might as well let anyone do brain surgery."

And he called on academic medical staff to take personal responsibility for their institutions. "Faculty must demand participation in the decision-making processes," and must "educate young doctors about what is happening." Finally, Dr. Eisenberg called for a government all-payer system of medicare as the only way to go.

In a panel discussion on "Collective Bargaining in Medical Centers" medical faculty were urged to reexamine their traditional aversion to collective bargaining and unionization. Confronted as they are now by term appointments, job insecurity, loss of professional autonomy, re-engineering and downsizing, absence of due process in disputes, the concentration of administrative power, and a growing culture of deference to power, medical faculty must devise plans for collective action and responsibility including collective bargaining and unionization, and tenure as the only real protection for academic freedom and scientific integrity.

The conference concluded with the adoption of a policy statement on "Academic Freedom in the Medical School." Main tenets of the policy are informed by such cases as those of Nancy Olivieri and David Kern. The policy statement asserts, in part: "The modern medical school has the attributes of a complex, money driven health care system with professors often acting as entrepreneurs in research and in patient care. It is marked by conflicting roles and responsibilities, both academic and non-academic, for faculty members and administrators alike. The intense competition for private or governmental funding can affect the choice of research subjects, and in some instances, scientists in academic medicine are finding it difficult to secure funding for unorthodox research or research on matters that are politically sensitive ... The freedom to pursue research and the correlative right to transmit the fruits of inquiry to the wider community -- without limitations from corporate or political interests and without prior restraint or fear of subsequent punishment -- are essential to the advancement of knowledge. Accordingly, principles of academic freedom allow professors to publish research findings that may offend the commercial sponsors of the research, potential donors, or political interests, or people with certain religious or social persuasions ..."

The full text of the policy statement will now go to the AAUP General Meeting scheduled for later this month.