This may seem like a strong statement, and it is—for good reasons. These threats to the profession are great enough that such clear and unambiguous language is needed. Bailey's analysis, "Asklepios: Ancient Healer of Medical Caring," in a recent issue of this journal [2] exactly identifies the core value that the Covenant affirms: the fiduciary ("founded in trust") responsibility of the physician to the patient. Bailey also—and interestingly enough, given the 3000 years since Asklepios practiced—identifies in ancient times the same threat that confronts us today: pecuniary inducements to put self-interest before the values of the profession.

Much of the discussion among physicians about the current tumultuous changes in the environment of medical practice relates to the increasing penetration of managed care. Medical gatherings abound with complaints about the bureaucratic intrusions into the physician-patient relationship and the pressure on physicians—in some cases, in the form of direct financial incentives—to withhold indicated diagnostic or therapeutic measures to keep costs down.

The Covenant does not oppose managed care. Physicians do share with the rest of society the challenging responsibility to make health care affordable for all. Current trends are toward increasing numbers of uninsured persons, decreasing eligibility for Medicaid, and increasing beneficiary costs for Medicare. All of these lead to decreasing rather than increasing access to health care. More responsible cost containment could lead to broader access, and managed care, if done openly and with maximal concern for patient welfare, can actually improve collaboration among specialists and primary care physicians, leading to rational clinical decisions based on cost-effectiveness [3].

Managed care is not the problem; profit is the problem. Before the days of widespread health insurance, physicians such as William Carlos Williams dealt daily with patients who could not afford medical treatments. Their only source of reimbursement was out-of-pocket payment. Williams used restraint when ordering diagnostic tests, hospitalization, and other interventions because of the limited resources of his patients. In these difficult decisions, which are chronicled so poignantly in The Doctor Stories [4], it is clear that Williams' concern is caring for patients, not enhancing profits for himself or for shareholders investing in a profit-making corporation. This is where the real challenge to the soul of the profession is being engaged.

The Covenant is now being circulated among medical societies, who are being asked to endorse it. It has recently been endorsed by the American College of Physicians, the American Board of Internal Medicine, and numerous other societies. Why ask professional societies to affirm this document? Precisely because self-regulation is considered a defining feature of a profession [5]. Professionalism requires enough independence to sustain intrinsic moral values and to represent those values to society [6].

Organized medicine has responded to these threats from the changing environment in health care in many ways. One of the major responses has been to urge physicians to take control of the business of health care. This measure may provide some protection for the patient, because physicians are more knowledgeable about the clinical implications of various cost-containment strategies, but it is not enough to protect the soul of the medical profession. Accepting the "business" paradigm, especially in a profit-centered corporate setting, turns the physician away from concern for the patient and toward concern for the bottom line [7]. More than 9 billion dollars were generated as profits in health care in 1995; this is money that is unavailable for medical needs at a time when policymakers solemnly agree that we "can't afford" universal access to health care.

Physician control addresses only one characteristic of a profession: autonomy. The other characteristics of the profession of medicine, outlined by social scientists as well as ethicists [8], include the physician's clear responsibility to advocate for the sick and the most vulnerable, to put the patient's welfare before his or her own, and to be accountable to the public, from whom professional prestige derives. None of these latter characteristics are inherent or indeed even visible in the modern corporate structure of health care. The Asklepian motive has disappeared when health plans consider themselves to be like supermarket chains. The supermarket has no explicit or corporate responsibility to provide food for someone who is hungry but cannot afford to pay. The corporate business model in health care behaves the same way, so that growing numbers of uninsured and underinsured people will have nowhere to go once market forces have taken over. What, then, is the responsibility of the profession that traces its roots to Asklepios? This is the moral question that faces us so starkly.

Responsible physicians must consider the prudent use of health care resources because of their accountability to society and their awareness that health care access for all depends on a considered containment of cost. Corporate motives do not include the return of savings to enhance access to the underserved. On the contrary, the rise of corporate health care has paralleled an increase in the number of uninsured Americans [8]. The most successful of the corporate medical models now considers a 70% medical loss ratio to be a successful target. This means that 30% of the dollars put into the health care system go not to the provision of health care but to private gain.

What is the message for the physician? There are billions of dollars to be made, and that temptation is difficult to resist. Like Asklepios, modern physicians must be either physicians or profiteers; they cannot have it both ways. As described by Plato [2], "If he was the son of God, he was not avaricious ... and if he was greedy of gain he was not the son of a God." Modern physicians no longer consider themselves gods, but the conflict between the sacred trust of the patient–physician relationship and the destructive force of greed remains as clear as it was in the days of the ancient Greeks. Many young persons are attracted to medicine because it promises meaning, a transcendent significance to the activities of healing that goes beyond the need to make a living. This is more than a job, physicians often still say. It is a way to help people, to contribute to the improvement of the human condition. Families or patients who have had a "good doctor" will affirm the human significance of that relationship, especially if they have faced serious illnesses. Although the physician's role in the lives of patients may not be godlike or divine, at its best it can and ultimately does have spiritual dimensions. Like the clergy, medicine requires public accountability. The trust of the patient and the public may be irreparably damaged if personal gain and corporate profit become primary concerns. Zeus struck Asklepios with a thunderbolt because the healer agreed to use his talents to raise someone from death for the promise of gold. Zeus was angered because the physician infringed on the territory of the gods and did so because of the lure of riches rather than his vows to serve humanity.

Are physicians in the United States vulnerable to this same thunderbolt? Clearly, yes. Is all lost? Not yet. We must understand that we have a responsibility to use medical resources wisely precisely because health care is a public good. As our power to heal grows, the cost of care increases, thus increasing the importance of prudent purchasing. But the reason to contain cost must be to grant expanded access to the vulnerable and the needy and not to enrich ourselves or investors.

The Covenant is reprinted with permission. Crawshaw R, Rogers DE, Pellegrino ED, Bulger RJ, Lundberg GD, Bristow LR, Cassel CK, Barondess JA. Patient-physician covenant. JAMA. 1995; 273:1553. Copyright 1995, American Medical Association.