Regarding "standards of practice: carotid angioplasty and stenting".

our argument. The readiness of reproduction being equated with differentiation and market elasticity are loosely stated principles of economics, not the definition of commodity. Reducing medical care to the status of a commodity, the objection we find in boutique medicine, makes the practice of medicine a purely commercial transaction. Whether that transaction involves a differentiated or undifferentiated good or service is ethically irrelevant to our argument that doing so undermines medical professionalism. Our article did not predict a 2-tiered medical system emerging from the boutique model; we did intimate that it could result in a 2-tiered individual practice among physicians who adopt it. Our objection to this is that it would result in physicians who engage in boutique medicine treating the rich and poor differently, which, Dr Gregory pointed out more than 2 centuries ago, violates fiduciary professionalism. VIP medicine is arranged and administered by the individual physician; the tiers are within his practice. The easier access and closer observation he provides his premiumfee patients necessarily means that all other patientss are receiving less than his best efforts and attention. A multitiered medical system follows when these individual practices grease the slope toward normalization of socially acceptable multitiered insurance benefits, perhaps a boutique policy for the company’s top executives and a “standard plan” for the folks on the assembly line. The quality, quantity, and accessibility of medical care may show a normal range of variation consistent with skills and resources from 1 institution or physician to another. The systemization of these variations becomes unethical, however, when they occur within a structure that offers the physician special incentives to stratify the quality of care on the basis of the patient’s ability to pay, or willingness to pay an inflated premium, as in our boutique model. Drs Akbari and Henochowicz conclude that boutique medicine is ethically neutral, with doctors merely attempting “to differentiate themselves in the marketplace by providing perceived specialized services.” Boutique medicine does not differentiate the physicians, it differentiates the patients—and in so doing becomes ethically unpalatable. Drs Akbari and Henochowicz prefer “concierge” to “boutique” medicine. Neither of these terms of commerce reflects the special responsibilities of the medical professional, or the absolute trust with which every patient approaches his physician. Drs Akbari and Henochowicz have accurately described a “commodity” in economic discourse; if physicians begin to associate it with their patients, the “medical profession” will become an oxymoron.