We are happy that Dr Goldstein finds our article interesting and that our findings demonstrating widespread moral disquiet among physicians corroborate his own personal experience. We concur with his suggestion that physicians will react in a variety of ways to the new moral pressures introduced by changing financial incentives and other cost-containment measures.
While some physicians may more readily adapt to the new system, it remains unclear whether such adaptation should be considered an ethically appropriate response to a changing moral environment, or co-optation by a morally flawed system. Data cannot settle this issue. However, we found that physicians practicing in settings in which their overall personal financial incentives were to limit tests and treatments were more likely to find such incentives ethically unjustifiable, more likely to believe that the profession's ethic of undivided loyalty to patients was changing, and more likely to believe that their own patients' trust in them had diminished in the last 5 years. This suggests that such adaptation does not happen quickly. But because we studied only 1 cohort of physicians who finished residency 8 to 17 years ago, we cannot test Goldstein's hypothesis that recent graduates are more likely to adapt. This would require us to repeat our survey.
Sulmasy DP, Bloche MG, Mitchell JM, Hadley J. Cost-Control Arrangements and Misdirected Loyalty—Reply. Arch Intern Med. 2000;160(16):2546. doi: