Structural tensions between health policy and medical ethics: a qualitative study of physicians' experiences under...

Türkiye's Health Transformation Programme (HTP), launched in 2003, reorganised the country's healthcare system through interlocking mechanisms: a Performance-Based Revolving Fund (PBRF) - a pay-for-performance scheme - linking physician income to procedure volume; a Central Appointment System (CAPS) imposing daily patient quotas; and a General Health Insurance (GHI) scheme conditioning coverage on premium payment. No integrated qualitative analysis has examined the cumulative impact of multiple HTP mechanisms across all four principles of the Beauchamp and Childress framework using practice-level physician accounts.

An interpretive, constructivist qualitative design employing reflexive thematic analysis was used. Twenty-two specialist physicians participated across two phases: seven in a pilot phase for scenario development (not in the analytical dataset) and fifteen in the main interview phase, of whom twelve were retained for analysis after consensus review (n = 12 analytical sample; mean seniority approximately 25 years; criterion-based purposive sampling across five districts of Muğla, Türkiye). Data were collected via semi-structured interviews structured around four researcher-developed hypothetical scenarios. Primary coding was undertaken by the researcher and progressively validated through consensus discussion with the academic supervisor and a professor of medical ethics on the doctoral thesis monitoring committee. Transcripts were returned to participants for review (COREQ item 23).

Four primary themes and one cross-cutting pattern emerged. Participants described the PBRF as eroding beneficence and non-maleficence through patient-poaching, defensive clinical decision-making, and progressive normalisation of ethical violations. The hospital enterprise model was described as subordinating patient welfare to revenue priorities. Participants reported that CAPS quotas render genuine informed consent structurally difficult to achieve, while complaint mechanisms deepen perceived autonomy deficits. The GHI's premium-debt exclusion was described as transferring institutional injustice onto individual physicians. A cross-cutting theme captured participants' accounts of the transformation of professional identity from patient stewardship to a shift-completion mentality - consistent with the trajectory from moral distress toward moral injury described in the international literature.

Physicians in this study perceive HTP policies as creating cumulative tensions with the four-principle framework. These perceptions mirror patterns documented in neoliberal reform contexts across Australia, France, Iran, Botswana, and Canada. They constitute interpretive accounts drawn from a small purposive sample of senior practitioners in a single province, rather than structural diagnoses of the system. Findings argue for integrating practice-level physician accounts into health-policy ethical evaluation alongside efficiency metrics; the scenario methodology offers a replicable approach for practice-informed policy-ethics research rather than a direct structural diagnosis of the system.