Abstract
In this article, the authors attempt to build a bridge between economic theory and medical ethics to offer a new perspective to tackle ethical challenges in the physician–patient encounter. They apply elements of new institutional economics to the ethically relevant dimensions of the physician–patient relationship in a descriptive heuristic sense. The principal–agent theory can be used to analytically grasp existing action problems in the physician–patient relationship and as a basis for shaping recommendations at the institutional level. Furthermore, the patients’ increased self-determination and modern opportunities for the medical laity to inform themselves lead to a less asymmetrical distribution of information between physician and patient and therefore require new interaction models. Based on the analysis presented here, the authors recommend that, apart from the physician’s necessary individual ethics, greater consideration should be given to approaches of institutional ethics and hence to incentive systems within medical ethics.
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Notes
As one of the three fundamental analytical instruments of the new institutional economics in which the primary aim is to examine contract relationships between the players with respect to information asymmetries and the resulting agency problems (adverse selection, moral hazard, hold up (cf. Rees 1985, p. 3).
The agency problem of ‘moral hazard’ deals with the asymmetrical distribution of information between the players after having fixed the contract, namely that the principal cannot adequately observe or monitor the actions of the agent. The question whether the agent will stick to the contractual arrangements or not and what incentives they have to do so, forms a central element of the PA model. The so-called “hidden action” phenomenon describes the information problem, whether the assigned activities have actually been carried out or whether the assigned competencies are purposefully used. “Hidden information” means that the actions of the agent are observed, however the principal has difficulties in assessing it. The PA theory discusses mechanized possible solutions to reduce the information asymmetries in the form of “monitoring” (introducing or increasing concrete performance controls), “signalling”(the agent makes his or her services or performance transparent) or “screening” (the principal researches the agent’s characteristics). Within a trust-relationship the agency problem of “hold-up” (Ripperger 1998, 67ff) becomes a pivotal issue.
Relationships of trust can principally be described as being principal–agent relationships (Ripperger 1998, pp. 63). In the semantics of economic barter, trust is described here as goods. Only the advance investment of the trust giver and the reward by the trust taker constitutes a trust-based relationship. Here the specific everyday and sociopsychic incentive and sanction mechanisms of the relevant atmosphere of trust are decisive for the analysis of the coordination und motivation problems of the players involved.
Reasonable trust will require good grounds for such a confidence in another’s goodwill, or at least the absence of good grounds for expecting another’s ill will or indifference. Trust, then, on this first approximation, is accepted vulnerability to another’s possible but not expected ill will (or lack of goodwill) toward one” (Baier 1994, p. 99).
In comparison to some structural problems of the health system “online health seeking” is a marginal phenomenon. Yet, the analysis of these problems sheds light on two elements of the structural problems: Firstly, a dominance of expert knowledge in the past has systematically reduced self-responsibility of patients for their own health care. Secondly, the legitimisation of expert knowledge seems to change from paternalistic expertise to transparent consulting and enabling of patients to be able to choose between alternatives. “Online health seeking” and benevolence are maybe marginal, but represent exemplary future trends for the health system.
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We are grateful to the helpful comments by one of the reviewers.
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Langer, A., Schröder-Bäck, P., Brink, A. et al. The agency problem and medical acting: an example of applying economic theory to medical ethics. Med Health Care and Philos 12, 99–108 (2009). https://doi.org/10.1007/s11019-008-9138-y
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DOI: https://doi.org/10.1007/s11019-008-9138-y