Politiques et Management Public : Article pp.83-101 du Vol.28 n°1 (2011)

*Auteur correspondant : Philippe.Batifoulier@u-paris10.fr

doi:10.3166/pmp.28.83-101 © 2011 IDMP/Lavoisier SAS. Tous droits réservés

La déontologie médicale face aux impératifs de marché

³ Philippe Batifoulier

, Franck Bessis

et Olivier Biencourt

a EconomiX, Université Paris Ouest Nanterre La Défense, Philippe.Batifoulier@u-paris10.fr

b Triangle, Université Lumière Lyon 2 ; fr.bessis@gmail.com

c GAINS, Université du Maine, Olivier.Biencourt@univ-lemans.fr

Résumé

Les médecins, au nom d’une déontologie qui leur serait propre, bénéficient du « privilège

» de s’organiser en profession, c’est-à-dire comme un anti-marché. Déontologie et marché seraient donc supposés s’opposer. Dans cet article, nous développons une autre concep- tion de la déontologie des médecins au moyen d’instruments d’analyse de l’économie des conventions et interrogeons les vertus supposées du marché. Nous montrons alors, les effets pervers de la pénétration de la mentalité marchande en santé. Le contexte normatif marchand, créé par la politique publique, influence la conception d’une activité médicale adéquate. Elle peut donc produire des effets non désirés : augmenter les dépenses et ac- croître les problèmes d’accès aux soins. © 2011 IDMP/Lavoisier SAS. Tous droits réservés

Mots clés : profession, déontologie médicale, économie des conventions, marchandisation, système de santé français.

Abstract

Medical deontology driven by market-based health care reform. Because of deon- tology, medical profession is an historical construction against market. In this paper, we develop an original conception of the medical deontology with the tools of the French school of the economics of conventions. We show how market reform in the French health sector modifies the definition of legitimate behaviour and impacts deontological rules.

However, the development of a market-based normativity is the source of unexpected effects: more spendthrift behaviour and inequalities, contrary to the declared objective of health insurance governance. © 2011 IDMP/Lavoisier SAS. Tous droits réservés

Keywords : profession, medical deontology, convention theory, marketisation, French health system, perversity effect.

04

Introduction

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1 Notamment, Salais et Thévenot (1986) ; Favereau (1988) ; Revue économique (1989) ; Batifoulier (2001) ; Orléan (2004) ; Eymard-Duvernay (2004 et 2006) ; et Diaz-Bone et Thévenot (2010) pour une explicitation des liens avec la sociologie pragmatique.

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2 La thèse de l’effet pervers identifiée par Hirschman (1991) comme l’un des trois éléments principaux de la rhétorique réactionnaire est donc ici retournée contre les partisans du marché autorégulateur pour lesquels toute intervention de l’Etat dans les « lois » du marché serait contre-productive. Ce retournement tient simplement au fait qu’il apparaît clairement ici que l’Etat intervient dans la mise en place des marchés eux-mêmes.

3 De manière synthétique, nous pouvons retenir que la culture professionnelle « évolue sous la contrainte de sa propre histoire » (Champy, 2011, p.142). La substance de chaque profession peut alors être objectivée sans perdre de vue l’idée qu’il s’agit de construction sociale (mais par là-même plus complètement arbitraire).

4 Voir Champy (2009), pour la mise en perspective sociologique de ce « troisième regard » et la présentation d’autres travaux pouvant lui être associés.

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5 En l’absence d’un ensemble complet d’états du monde, l’agent ne peut pas optimiser. L’axiome de Savage (1954) qui postule un préordre complet sur les préférences n’est pas respecté.

6 Les limites de nos capacités cognitives nous empêchent par exemple de dresser la liste exhaustive des stratégies possibles lors d’une partie d’échec mais cet ensemble de stratégie est bien complet, contrairement à la trajectoire d’évolution d’organismes vivants qui donne à penser un ensemble ouvert de possibilités.

7 Qu’il s’agisse de mobiliser des règles de science médicale ou des règles déontologiques.

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8 L’exemple des journalistes, où l’autonomie apparaît aussi comme une « nécessité de la pratique » (Lemieux, 2010, p.25) montre que d’autres formes d’organisation peuvent se substituer à l’ordre professionnel, qui appellent dans tous les cas un renforcement des dispositifs démocratiques (Lemieux, 2010b, p.128).

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9 L’Etat peut donc faciliter ou au contraire restreindre l’accès à certains mondes de production et principes supérieurs communs. Voir Salais et Storper (1995), partie IV, chapitre 1, pour une présentation plus détaillée (et moins schématique !) de cette idée.

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10 La technique de la convention médicale, à l’image d’une convention collective, habilite les syndicats de médecins et les caisses de Sécurité sociales à négocier les tarifs des soins. Ce tarif s’impose aux médecins et sert de base aux remboursements des caisses aux assurés sociaux.

2. De nouveaux fondements normatifs à la rationalité médicale. Les effets pervers de l’orientation marchande

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11 Voir Bénabou et Tirole (2003) pour la présentation modélisée d’un argument similaire, mais dans le cadre d’une relation principal agent, qui génère alors une tension entre les hypothèses de rationalité retenues et le principe même de l’argument : parler de motivation intrinsèque ne revient-il pas à sortir du cadre de l’action instrumentale modélisée par la théorie du choix rationnel (Da Silva, 2011)?

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12 Voir Narcy (2007) pour une revue des expériences réalisées à partir de cette distinction.

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13 Dans une configuration de « locus-of-control » interne, l’agent croit que sa propre action détermine la récompense.

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14 Celui que doit fixer le médecin en interprétant le « tact et mesure » du code de déontologie et le tarif opposable des conventions médicales, en fonction de caractéristiques diverses comme le revenu supposé du patient, son niveau de couverture complémentaire, le type d’acte ou sa durée, etc.

15 Date à partir de laquelle les médecins déjà en secteur 2 qui le souhaitaient y sont demeurés, tandis que les autres ne pouvaient plus y accéder (à l’exception des anciens chefs de clinique-assistants).

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16 Voir aussi l’article de Abecassis et Domin dans ce numéro

17 La raison donnée est que tout médecin doit avoir reçu par courrier le règlement conventionnel minimal de 1998, suite à la dénonciation de la convention. Or, la CPAM ne peut pas faire la preuve de l’envoi de ce règlement à la plaignante. Dans ce cas, le règlement ne s’applique pas. Voir Prétot (2004) pour un développement.

18 Le nombre de consultations donnant lieu à un dépassement d’honoraires a été multiplié par deux en 2002 et les dépassements ont majoré les honoraires de 8 % en moyenne en 2002 (CNAMTS, 2003).

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19 L’acte est gratuit pour le patient mais fait l’objet d’une rémunération pour le médecin au tarif de la Sécurité sociale. Il s’agit donc d’une gratuité différente de celle de l’acte non lucratif où le médecin refuse de percevoir des honoraires.

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Conclusion

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