The ethical questions regarding "custom" or "boutique" medicine are diverse; some are readily apparent and others are more subtle. Custom medicine involves the provision of medical services that extend beyond typical office visits. For example, persons with this type of health care arrangement may be provided with their physician's cell phone number and given the freedom to contact him or her day or night. They also may host their physician in their home to discuss child-rearing or other matters and/or may request that their physician attend various conferences at their children's schools. Such extended privileges are granted for an annual fee—ranging from just over a thousand dollars per year to $20,000 per year or more. Higher fees are typically associated with greater access to physicians and increased physician involvement in patients' lives. In custom medicine arrangements, the physician still bills patients' insurance carriers for traditional services rendered (such as office visits), but such services constitute a smaller percentage of the physician's income.
In August 2002, the Boston Globe ran a story on the emerging trend of custom medicine. It appears that the main impetus for this shift in the nature and provision of health care lies primarily with physicians, rather than patients. Boston pediatrician Michael McKenzie, who announced in June plans to close his thriving practice of 2,500 children, stated that his new custom medicine practice would "improve [his] work life immeasurably [by leaving him with] fewer patients and...more time and greater interactions with those patients." Other physicians cited factors such as increased productivity demands and restrictive insurance systems as reasons for their departure from traditional practice. While some physicians and patients are embracing "custom medicine," others view this latest shift in health care delivery as (at best) unnecessary or (at worst) as serving to widen the gap between rich and poor in terms of health care received.
It is important to state at the outset that such an inequality is not new; rather, custom medicine is merely a newly defined wrinkle in health care. The question is not whether rich and poor are treated differently with respect to health care (they always have been), but whether the differential treatment implicit in custom medicine is right—and how much of a difference is tolerable. For years hospitals have had "VIP wards" (e.g., the Phillips House at Massachusetts General Hospital and the 7th floor at Cleveland Clinic Foundation Hospital) that have housed wealthy patients who have desired better services and are willing to pay for them. Mission hospitals also often have private and semi-private room wings that cater to paying patients such as wealthy natives or expatriates with health insurance. These rooms often generate the funds to pay for health care for the poor who fill the vast majority of beds in these hospitals. Furthermore, physicians have for years selected the type of patients they wanted to serve based on the location of their office and the choice of insurance plan(s) they will accept. custom medicine is therefore not much different from many of the health programs that have long been offered by medical centers and physicians around the country.
Having established that custom medicine is not entirely new and that it is already practiced to a certain extent even in mission hospitals, we must ask: is this practice ethical? There are several levels to consider in this discussion: health policy, the patient's perspective, and the physician's perspective. From a health policy perspective, U.S. Health and Human Services Secretary Tommy Thompson has determined that nothing is wrong with this approach to health care as long as patients are not required to pay for standard medical care out-of-pocket. Some health insurance companies have chosen to remove custom care providers from their networks, a move which seems vindictive and short-sighted. Nevertheless, it is likely that wealthy patients will easily find another insurance plan that will allow them to stay with their "boutique" physician.
Patients' participation in custom medicine is an ethical issue for only the few that can afford this type of health care. In the general sense, this is an issue of priority of spending. For the Christian patient who is able to afford these services, there is the larger issue of stewardship. He or she must ask if this is the best use of the funds that have been given to them by God or whether they could find a less expensive way to access high- quality medicine (such as paying for a more generous traditional insurance package that allows more open access to physicians and services). It might also be possible to obtain the desired amount of health information through other reliable sources without paying for custom medical services.
For physicians to elect to become custom medical providers there are several issues at stake. Certain types of procedures (such as cosmetic surgeries) are not reimbursed by insurance carriers; charges here are paid in cash and are equal to what the market will bear and dependent upon the surgeon's reputation. Many plastic surgeons receive the majority of their fees from cash payments and are already custom physicians but with open access to those able to pay their procedural fees out-of-pocket. Many physicians would not consider this possibility because of other considerations. Surgeons need to do many procedures to remain competent and to have the reputation to attract wealthy patients. For them to limit their patient volume and procedures would decrease their market value with time.
For those who view medicine merely as a business, there is nothing ethically wrong with the change from traditional to custom medicine. For those who view medicine as a mission and as a calling, however, choosing to practice custom medicine is much more than a business decision. For the Christian physician, there are several additional considerations. First, the Christian physician must ensure that such a change in practice style is submissive to the Lordship of Christ. Philippians 2:3 admonishes believers to "Do nothing out of selfish ambition or vain conceit, but in humility consider others better than yourselves." The Christian physician contemplating a change in practice must not only think of his or her own needs but also the needs of his or her patients, colleagues, and community. Moreover, as James, Peter, and John exhorted Paul in Galatians 2:3, the Christian physician must remember the poor. Custom medicine carries the intrinsic danger of isolating physicians from the poor. It is hard to remember the poor when you do not see them.
In summary, custom medicine is not an entirely new concept, but merely a variation on widely-accepted methods of health care delivery. It is not wrong in itself; however, the motivations and implications of endorsing this emerging trend should be carefully considered—especially by Christian physicians and patients.