Private practice is unethical—and doctors should give it upBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2299 (Published 05 May 2015) Cite this as: BMJ 2015;350:h2299
- John Dean, consultant cardiologist, Royal Devon and Exeter NHS Foundation Trust Hospital, Exeter EX2 5DS
Ask any smoker: the last person they want to be with when lighting up is someone who has just quit. I sense a similar discomfort among some of my colleagues now that I have given up private medical practice. Like a lapsed Catholic shunned by the priesthood, I have become an apostate.
I have always been ambivalent about private practice, and I had become increasingly uncomfortable about my own involvement. I realised that, in all conscience, I could not go on with it. No matter how high I set my own moral and ethical standards I could not escape the fact that I was involved in a business where the conduct of some was so venal, it bordered on criminal—the greedy preying on the needy.
The business of medicine and the practice of medicine are at odds. Private medicine encourages doctors to make decisions on the basis of profit rather than need. When confronted with a choice between two treatment pathways in equipoise—one that earns the doctor no money and the other with a fat fee attached—that conflict is stark. I cannot say, with hand on heart, that I have never chosen the second option.
Money is at the root of it all
So why did I do it? To begin with, I decided that I needed the money to renovate the house, educate the children, and so on. And I was sure that I could keep the private work separate from my NHS work. I saw private patients after hours and slotted in operations in my free time. But it became increasingly difficult to keep the lid on the private jar as the contents expanded, and some spillage was inevitable.
I wasn’t so much earning a living as earning an earning. Of course, the rewards from private practice were not entirely financial; I could spend more time with these patients, and I met some colourful characters and made good friends, which would not have happened if I had restricted myself exclusively to NHS work. But the inescapable fact is that money was at the root of it all. This is strange, because I never hankered after a Maserati car or a chalet in the Swiss Alps. And I’m not attracted by the promise of “fine dining”—I’m more of a chicken balti man.
Private work also has direct adverse effects on the NHS. A consultant cannot be in two places at once, so time spent in the private sector deprives the NHS of a valuable resource. Private medicine is a lonely place; you do not have the support of a team, as you have in the NHS. It is also difficult to discuss problems with colleagues—after all, the problems are yours, and you are being paid to sort them out. In the private sector your NHS colleagues are usually your competitors.
And, let’s face it: the whole business is largely a con. Patients think that paying must mean higher quality medicine, but—like paying more for shampoo with added vitamins—the promise is far greater than the reality. Rich and famous people may use private facilities to shelter from the public gaze; for most “ordinary” private patients, though, the main advantage is simply to jump the NHS queue. Private hospitals are like five star hotels, but for the most part they are no place to be if you are really sick.
The most pernicious aspect of private medical work, however, is the indirect effect it has on a consultant’s NHS practice. It is difficult to justify subjecting private patients to unnecessary tests and treatments if you avoid doing the same to NHS patients. So, to ease the stress of this cognitive dissonance, you have to operate the same system in both wings of your practice. Also, private practice creates a perverse incentive to increase your NHS waiting times—after all, the longer they are, the more private practice will accrue. Hence, specialties with short waiting times, such as oncology, offer little private work. Jealousy over private income is a major source of conflict between consultants in many hospitals.
I know what some will be thinking: what’s wrong with doing extra work in your own free time? If I had done a paper round or taken a Saturday job, wouldn’t that have been the same? Well, the work might have worn me out, but there would be no other conflict with my main business.
I don’t miss private practice. The release of the burden is liberating. And I find that the time I have gained is much more valuable to me than the money was. Is it a crass hypocrisy, though, for me to sit atop the pile of money I earned and pretend to have the moral high ground? Maybe, but I wish I hadn’t done it. Perhaps it would have been easier if I had not been allowed to. Perhaps the rulers of healthcare should draw an uncrossable line between private and public medicine and tell doctors to choose: namely, that they cannot work on both sides of the divide.
Cite this as: BMJ 2015;350:h2299
Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: None; I have previously carried out private medical work as an NHS consultant, but I no longer do so.
Provenance and peer review: Not commissioned; not externally peer reviewed.