Introduction
My goal this afternoon is threefold: first, to explain why the integrity of the professions in general and medicine in particular is so important to my vision of an open society; second, to explore with you why the integrity of the medical profession is so endangered today; and third, to share with you the details of a new program that my foundation has launched to foster professional, as distinct from market, values in health care. The program will have a difficult task and I want to take this opportunity to discuss the strategy that the program intends to follow with a qualified audience like this one.

My Commitment to Open Societies
As you may know, I have been deeply committed these past twenty years to promoting open societies in countries, particularly in the former Soviet Empire, that lack such a tradition. One of the most extraordinary moments in 20th century history was the breakup of the Soviet system, which, in many countries, brought with it the demise of what were closed societies, and initiated a process, in some countries more successful than others, to achieve more open societies.

What do I mean by an open society? A society based on the recognition that perfection is unattainable and we must be satisfied with the next best thing: a society that holds itself open to improvement. This is just a fancy way of describing a liberal democracy; one that seeks to achieve the greatest degree of freedom compatible with social justice. Open societies are characterized by the rule of law, respect for human rights, and a division of power. In open societies we find a commitment to active political participation by citizens, a free exchange of ideas, respect for minorities and minority opinions; a critical mode of thinking in politics, in the press, in the schools, and in society in general.

Open societies are also characterized by a market economy. Markets are not perfect but they are certainly preferable to state controls when it comes to the allocation of scarce resources among competing individual needs. When it comes to the fulfillment of social needs, there is an indispensable role for government, even if the political process is less efficient than the market mechanism.

It may be asked whether the US qualifies as an open society by these standards. My answer is a definite yes because it is inherent in the concept of open society that no society is perfect and that includes open societies as well.

When I established my foundation in 1979, I defined its goals as opening up closed societies, helping to correct the deficiencies of open societies and fostering a critical mode of thinking. For the next fifteen years I became progressively more involved in opening up closed societies until it became practically a full time job. When the earth-shattering changes wrought by the collapse of the Soviet system began to abate, around 1994, I decided to devote more thought and money to the second part of the agenda, correcting the deficiencies of our own, open society.

I settled on three major themes. First, correcting the unintended adverse consequences of mistaken policies and attitudes; second, confronting the penetration of market values into areas where they do not properly belong; third, reducing the inequities and iniquities prevalent in our society.

The first theme has led me to the project on death in America and to drug policy reform. There are problems that cannot be solved in the sense of making them disappear. Death is such a problem and so is the drug problem. But the way society tackles these problems can make them worse than they need to be. In our society there is widespread denial of death and zero tolerance towards drugs. Both attitudes have brought unnecessary harm and suffering.

The second theme has led me to the professions: law, medicine, journalism. These professions ought to be guided by professional values, but when the professions are turned into businesses, professional values are superceded by market values.

By market values I mean the profit motive. The profit motive has come to play an excessive role in our contemporary open society. There is a widely held view that the common interest is best served by everyone pursuing his own self-interest, that the market mechanism can take care of all our needs, but that view is false. There are both social needs and individual needs that cannot be satisfied through the market mechanism. We as individuals need to have a sense of right and wrong and we as a society need to share some common values. The profit motive is not sufficient to provide a sound basis for our life either as individuals or as a society. Yet it has come to dominate our lives. Market values are supposed to be a means to an end; yet they have become an end in itself. We are so engrossed in competition, in the pursuit of success measured in terms of money, that we have little time or energy left to figure out our intrinsic values. In a traditional society those values are given; but in society characterized by choices we do need to figure them out for ourselves. And it is not easy. There are too many choices, too many enticements. What is worse, holding certain principles can become a hindrance in the pursuit of success. Why bother, then, especially if other people will judge you not on the basis of your principles but on the basis of your success in the marketplace. No wonder that our society suffers from a deficiency of intrinsic values.

In some areas we are just confused; in others, established values are eroding. Professional values that ought to guide professional behavior fall into the latter category. On this occasion, I will focus on medicine—although I have been told that there is no better way to warm a medical audience's heart than by telling anti-lawyer jokes or by spelling out in detail all the problems that lawyers are confronting.

The marketplace is threatening medicine in very specific ways. Clinical care is now dominated by for-profit corporations that place the interests of shareholders above the interests of patients and often disregard the ethical obligations of doctors. Health care companies are not in business to heal people or save lives; they provide health care to make profits. In effect, in the necessary effort to control health care costs through the market mechanism, power has shifted from physicians and patients to insurance companies and other purchasers of services.

I recognize that not all of the problems of marketplace and medicine begin with managed care. All was not well with medicine in the days of fee-for-service, when doctors were paid by the government or by insurance companies for whatever tests they ordered or interventions they took. Such a system was bound to lead to too many tests and too many procedures. When medicine had a blank check, it is not surprising that it filled in big numbers. In fact, it was only after the passage of Medicare, when the government assumed the medical bill for everyone over 65 and placed no limits on what it would pay for, that medicine became a lucrative profession. So I have no doubt that even in the pre-managed care days, professionalism could be subverted by the temptation to do more medicine in order to make more money.

I remember as a child in Hungary that doctors used to add to their referral letters the initials B.S. which stood for bene solvens, well paying, and that was a license to do—and charge—as much as possible.

Nevertheless, the rise of managed care has created a crisis in the medical profession because there is no escaping its influence. It was one thing for individuals to face the temptations that came with fee-for-service and to resist them. It is quite another to confront the overwhelming presence of managed care. It is the HMO that pays the patients' bills and controls much of the personal financial fate of its physicians. It is the HMO that makes contracts with hospitals and may control the economic fate of the institution. Let those who hold the trump cards order doctors to do less tests or make fewer referrals to high priced specialists, to prescribe cheaper drugs, and to discharge patients from the hospital more quickly, and let them provide financial incentives to reward compliance and penalize non-compliance, and the integrity of the profession and patients' best interests are in trouble. There is unanimity among doctors, deans, historians, and health economists that money has never been so much in the forefront of medicine or potentially so powerful in determining medical decisions. Today more than ever we need professional ethics to stand against marketplace forces.

It is not only managed care that pits money against professional ethics. Take, for example, the role of drug companies. According to one study funded by the Open Society Institute, many medical schools, but not, I am happy to say, Columbia—allow pharmaceutical companies to give medical students books, stethoscopes, lunches, and dinners, in this way starting a habit of expectation that may last throughout a career. The presence of pharmaceutical companies is even more intrusive among medical residents—and the gamut of gifts runs from food to Christmas presents to travel to conferences. Is it any wonder that by the time residents become doctors they are accustomed to the largesse of the pharmaceutical companies—with gifts growing bigger as the career and responsibilities advance? Does every physician who accepts a three-star dinner or a first-class flight and hotel inevitably do the company's bidding by prescribing its drugs above others? Not necessarily. But it stretches the imagination to believe that the companies are not buying something for their investment—or more surely still, that the profession is not damaged in its public standing by being seen as too ready to take drug company money.

I know that hospitals are not flush with funds, nor are medical schools. But there must be ways of insulating medical students and residents from pharmaceutical companies. We should be particularly careful to insulate newcomers to the profession from contamination with marketplace values during their training period. Medical school and residency are times when students and young doctors are acquiring their professional obligations, learning what it means to be a doctor and what values the profession upholds. Surely this is a process that should be guided as little as possible by the marketplace in the form of the drug companies.

But we need to do more than that to safeguard professional values. We must find ways that allow medical students and young physicians to express the altruism and sense of service that brought some of them into medicine in the first place. At the same time, they must also be encouraged to learn the skills of advocacy. American physicians are exceptional in their political passivity; European doctors are far more engaged in public service and politics. Young medical professionals in this country should be encouraged and taught how to serve and how to advocate for their patients and how to promote public policies that will protect vulnerable populations.

Most importantly, we need to understand what professionalism should mean for the 21st century. It is too facile to talk about recreating or restoring an ethic of professionalism, not only because it is questionable just how effective this ethic actually was in the past, but also because new circumstances require a new response. Professional ethics for the 21st century will have to confront the need to promote equity in health care while recognizing that there must be some limits on the use of medical resources. It is easy to ration the medical care that someone else is to receive. But how do we ration the medical care that we are to receive? Professional ethics will also have to define what physicians owe to their employers and to their society as well as to their patients—an unusual question that may well require new paradigms in professional ethics.

These are the considerations that led me to want to establish a Program on Medicine as a Profession in my foundation. I had the questions but I did not have the answers, and even if I had them, I would have considered it contrary to the principles of open society as we practice them in the foundation, to impose it on the program. Instead, we convoked a group of experts and asked them to propose a strategy for the program. On the first occasion I did not like the answers they came up with. So we asked a different group. Eventually, I attended a workshop where I found both the analysis and the proposed strategy convincing. Based on that experience I gave the go ahead, and I am now happy to announce that the OSI has established a new Program on Medicine as a Profession with an initial budget of $15 million for the next three years. The advisory board for the program is headed up by a member of your College of Physicians & Surgeons faculty, David Rothman. Sitting on the board are David Blumenthal of Harvard, Norman Daniels of Tufts, Eli Ginzberg of Columbia, Jerome Kassirer the editor of the New England Journal of Medicine, Robert Lawrence of Johns Hopkins, Susana Morales of Cornell, Marc Rodwin of Indiana, Kenneth Shine the president of the Institute of Medicine, National Academy of Sciences, James Tallon the president of the United Hospital Fund and Gerald Thomson also of Columbia. You may note with pride that three members of the board are from Columbia.

We already have a program dealing with the legal profession. In that program we have found it easy—and gratifying—to provide support for public interest and public service work. We intend to do the same in medicine, using Baltimore and New York City as the initial sites. But that is the easy part. In law, it has proven much harder for the foundation to affect the core, or mainstream, of the profession. In medicine, the board thinks that it has identified an effective strategy. The program will use its resources to bring to the table two groups that have rarely joined forces together, that is, medical organizations and consumer organizations. Until now, doctors and patients in their collective capacities have been more hostile to each other than cooperative. But under the truly revolutionary challenges that medicine now faces, it is possible that their common interests will bring them together and make them effective in bringing about a change for the better.

Hence, we are issuing a Request for Applications whose aim is to promote professionalism through physician-consumer alliances. We imagine these alliances will work to monitor and promote quality of care; set priorities in the allocation of medical resources; strengthen the accountability of health care to the community, including setting up mechanisms to evaluate physician competency; and address such critically important ethical issues as the protection of patient privacy in an era of computer data bases.

Medicine is too important to be left to the mercy of marketplace values. Physicians must work to make certain that this does not happen and patients and consumers must join with them in this effort. Together, they may be able to accomplish what neither of them could do alone.

As I have said before, I have found the arguments in favor of this strategy convincing and I am ready to back it. But I am not an expert and I will be interested to hear how you react to it.