The Calling of Saint Matthew and Pharmaceutical Money: The Dialectic Between Mission and Profit in Contemporary Healthcare
Tetsuya Tanimoto, M.D. Medical Governance Research Institute, Tokyo, Japan
On November 2, 2025, the "20th Symposium of the Association for Promoting Healthcare Reform from the Frontlines" in Tokyo convened a session examining conflicts of interest and the flow of pharmaceutical money — such as lecture fees or manuscript compensations — from pharmaceutical corporations and medical device manufacturers to physicians. Drawing upon my presentation delivered at this symposium, this article interrogates the contemporary trajectory of escalating healthcare expenditures in Japan, the structural pathologies engendered by the suppression of medical reimbursement rates, the high-profit architecture of pharmaceutical enterprises. Finally, I would like to revisit the classical theme of medicine’s “mission” — the ethical and philosophical foundation of why we heal — by reflecting on it through the lens of Caravaggio’s paintings and the moral tensions they reveal.
The Paradox of Expanding Medical Expenditures and Constrained Reimbursement—Understanding Frontline Deficits
To establish a foundation for this analysis, we must first examine the fundamental dynamics of healthcare expenditure. According to the "Overview of National Medical Expenditure" promulgated by the Ministry of Health, Labour and Welfare on October 10, 2025, aggregate national medical expenditure in fiscal year 2023 attained 48 trillion 915 billion yen ($326 billion USD), representing a 3.0% increase from the preceding year. Per capita expenditure reached 386,700 yen ($2,578 USD) — a 3.5% year-over-year increase — while the GDP ratio maintained relative stability at 8.08%.
International comparative analysis reveals that healthcare expenditure as a proportion of GDP approximates 10% across advanced European nations, while the United States registers at 17% — nearly double Japan's rate. While Japan's healthcare expenditure can be characterized as moderately contained, the demographic transition toward an aging society ensures the persistence of an inexorable upward trajectory. https://www.oecd.org/en/data/indicators/health-spending.html
The universal health insurance system in Japan was instituted in 1961, sixteen years following the conclusion of World War II. In the intervening six decades, profound transformations have occurred across demographic composition, epidemiological patterns, medical technologies, and cost structures. The fiscal sustainability of universal health insurance confronts mounting challenges.
Under the universal health insurance framework, medical reimbursement rates function as government-regulated prices subject to systematic suppression. The overall situation after the COVID-19 pandemic precipitated the acute manifestation of deficit problems across healthcare facilities. However, Japan's healthcare delivery system — particularly primary care clinics — has long operated under conditions necessitating high-volume, abbreviated consultations to forestall financial losses. This represents an economic consequence wherein pricing mechanisms fundamentally determine clinical behavior.
A particularly illuminating international comparative study published in BMJ Open (2022) empirically demonstrates the relationship between pricing structures and clinical practice patterns.
The study documents that Japan's consultation fee stands at 720 yen ($4.80 USD) (the re-consultation fee at the time of investigation; currently 750 yen / $5.00 USD), yielding a ratio of 0.8 relative to minimum wage. Conversely, the United States' consultation fee reaches $75.08 USD), with a minimum wage ratio of 10.3. Consider a hypothetical scenario wherein a physician conducts consultations for one hour without ancillary examinations or diagnostic procedures. Under Japanese reimbursement structures, compensation would fall below minimum wage, whereas American physicians would receive remuneration exceeding minimum wage by more than tenfold.
While this simplified comparison does not account for the complexity of examination fees and management charges, it serves as a powerful indicator of reimbursement inadequacy. Critically, these pricing differentials manifest in observable clinical behaviors. Mean consultation duration in Japan is 6 minutes, compared to 21 minutes in the United States. South Korea and Taiwan, with reimbursement structures analogous to Japan's, similarly exhibit consultation times of 5-6 minutes. Nations with elevated consultation fees demonstrate proportionally extended consultation durations, with data revealing consistent correlational relationships.
Thus, cross-national evidence substantiates the proposition that pricing mechanisms (consultation fees) systematically determine service delivery patterns (consultation duration). Under Japan's reimbursement architecture, fiscal viability for clinics necessitates maximizing patient throughput within abbreviated timeframes while generating revenue through ancillary diagnostic procedures and examinations.
This structural constraint imposed by inadequate reimbursement extends beyond primary care to encompass major academic medical centers. At an October 27 press conference convened by leadership of the National University Hospital Council, projections indicated that the 42 constituent national university hospitals would collectively incur ordinary deficits exceeding 40 billion yen ($267 million USD) in fiscal year 2025, potentially establishing an unprecedented record. Conference participants characterized the situation as "an existential crisis of unprecedented magnitude."
Even tertiary care institutions providing advanced medical interventions confront structural deficit conditions. This phenomenon reveals that the fragility of revenue models generated by price-setting under universal health insurance transcends organizational scale.
The Destination of Healthcare Expenditure Growth—Pharmaceutical Sector Profit Concentration
This situation engenders a fundamental paradox: while healthcare institutions struggle with deficits, aggregate medical expenditure continues its upward trajectory. Where, then, does this incremental capital flow? The "Data Book 2025" published by the Japan Pharmaceutical Manufacturers Association provides crucial insight into this question.
Examination of pharmaceutical corporations ranked by operating profit margin reveals exceptionally elevated levels of 20-30%, with net profits ranging from 100 billion yen ($667 million USD) to exceeding 1.1 trillion yen ($7.3 billion USD) among leading firms. These extraordinary returns are predominantly driven by high-cost pharmaceutical innovations including immune checkpoint inhibitors such as Ono Pharmaceutical's Opdivo, Shionogi's COVID-19 therapeutics, and other oncological agents, emerging infectious disease treatments, and orphan drugs for rare conditions.
Consequently, a significant proportion of healthcare expenditure growth is captured not by clinical delivery systems but by the pharmaceutical sector's profit accumulation. An analogous phenomenon occurs under the rubric of healthcare digital transformation (DX), wherein capital flows not to frontline medical facilities but to ancillary industries including medical device manufacturers and electronic health record vendors.
Of particular concern is the reverse flow of pharmaceutical capital from peripheral industries back to clinical settings. Consider the case of a hospital director who participated in the aforementioned crisis deliberations. This individual delivered 40 industry-sponsored lectures annually, receiving pharmaceutical payments exceeding 4.5 million yen ($30,000 USD) — approximately 110,000 yen ($733 USD) per engagement.
This compensation structure reveals a profound distortion of professional incentives. Rather than dedicating effort to patient care with reimbursement of 750 yen ($5.00 USD) per re-consultation, a single pharmaceutical industry lecture as corporate spokesperson generates income exceeding 100,000 yen ($667 USD) — a dramatically more efficient return. This architectural distortion in compensation design creates powerful inducements toward pharmaceutical industry engagement. The pricing asymmetry renders non-clinical activities relatively lucrative, thereby influencing physician labor allocation. Indeed, aggregate pharmaceutical payments to physicians reached 29.8 billion yen ($199 million USD) in fiscal year 2021 (per yenfordocs.jp compilation).
Global Healthcare Commercialization: Insights from The Lancet
The tensions between healthcare and capital are not confined to Japan but represent a global 21st-century phenomenon. An editorial published October 25 in The Lancet—arguably the world's most influential medical journal — addresses the relationship between pharmaceutical pricing and drug development in the United Kingdom.
The editorial cites evidence that pharmaceutical industry aggregate profits from 2000 to 2018 approximated more than $8 trillion USD, positioning pharmaceuticals among the world's most profitable sectors. Concurrently, the United Kingdom confronts concerns regarding pharmaceutical industry exodus in response to the Trump administration's tariff policies, given the UK's comparatively modest drug pricing.
However, the editorial advances a crucial analytical insight: pharmaceutical investment location decisions are predicated upon factors including human capital availability, fiscal policy, and research infrastructure — demonstrating no correlation with drug pricing structures. In other words, elevated pharmaceutical prices do not necessarily attract research investment.
The editorial further elucidates pharmaceutical business model evolution. Research evidence indicates that approximately 80% of major pharmaceutical companies' flagship products originated through acquisition of innovations developed by academic institutions or small biotechnology firms. The dominant paradigm has shifted from internal drug discovery to acquisition and commercialization of external innovations.
While expensive novel therapeutics are frequently justified through rhetoric about investment in high-risk innovation, empirical reality diverges substantially. Since the turn of the 21st century, pharmaceutical research investment has stagnated while internal reserves have expanded dramatically. From 2000 to 2018, assets among 27 major pharmaceutical corporations increased substantially. Profit allocation demonstrates pronounced bias toward shareholder returns rather than research investment, with the editorial characterizing prevailing business models as prioritizing "shareholders over patients."
A review article on the United States healthcare system, published in The Lancet's October 21 online early edition, adopts an even more provocative title: "Healthcare in the USA: Money Has Become the Mission."
Within Christian cultural contexts, "mission" carries semantic weight exceeding the Japanese conceptual equivalent of "shimeі" (calling/duty). While contemporary professional ethics has secularized the term to signify service to society, its etymological roots in the Latin "missio" (to send) retain theological implications of divine purpose and sacred obligation.
The review article offers a trenchant critique of American healthcare's progressive subordination to market mechanisms, wherein insurance corporations and financial investors exploit public funding to extract profits. The commercialization wave has penetrated hospitals, outpatient facilities, and long-term care institutions. Empirical evidence demonstrates that this transformation has precipitated deterioration in healthcare quality and access while exacerbating socioeconomic disparities.
The second Trump administration's transactional approach to healthcare policy—exemplified by Medicare privatization initiatives — accelerates the marketization of social insurance programs. Compounding these structural challenges, anti-vaccination advocacy by figures such as Robert F. Kennedy Jr. undermines public confidence in scientific institutions.
The review articulates a fundamental ethical interrogation: Does healthcare's mission prioritize revenue generation or the protection of patient health and life? While the manifestations and degrees of commercialization differ between market-driven American healthcare and public systems such as the UK's National Health Service or Japan's universal health insurance, certain phenomena transcend systemic boundaries: for-profit corporate penetration of healthcare delivery and pharmaceutical industry profit concentration with shareholder return prioritization. Given historical patterns wherein American developments subsequently diffuse to Japan with temporal lag, escalating attention to healthcare-capital relationships in Japan appears inevitable.
Caravaggio's Chiaroscuro — Reconsidering Healthcare's Fundamental Mission
The question of professional mission extends beyond healthcare to constitute a perennial philosophical inquiry into human purpose. The classical medical aphorism "Is medicine benevolent art (仁術) or calculating commerce (算術)?" captures this enduring tension. To reexamine healthcare's mission, I invoke imagery from religious art as a hermeneutic framework.
Consider "The Calling of Saint Matthew" (1599-1600) by the Italian Baroque master Michelangelo Merisi da Caravaggio, housed in the Contarelli Chapel of the Church of San Luigi dei Francesi in Rome.
This masterwork employs Caravaggio's signature chiaroscuro technique — dramatic tenebrism that creates stark contrasts between illuminated and shadowed spaces. The composition depicts Jesus Christ, crowned with a nimbus and accompanied by Saint Peter, extending his call to Matthew, a tax collector who occupied a morally degraded status in ancient Jewish society, to join his discipleship.
Art historical scholarship debates Matthew's identification within the composition. He may be either the bearded middle-aged figure in the central left grouping, or the young man at the far left counting currency with downcast gaze. Some scholars suggest Caravaggio deliberately cultivated ambiguity: does the bearded figure gesture toward himself in incredulous self-reference ("You summon me?") or toward the youth in identification ("This one?").
Regardless of iconographic interpretation, the painting embodies a binary existential proposition: the choice between dedicating oneself to monetary accumulation or to service for humanity's collective welfare. Saint Matthew ultimately elected discipleship with Jesus, committing to a life of service. Yet contemporary reality presents an ironic inversion: precisely within Western Christendom, the emphasis on financial calculation in healthcare intensifies.
We must resist reductive binary thinking that frames profit-seeking as categorically problematic. Healthcare's operational reality requires some degree of profitability for institutional sustainability. Pure volunteerism proves unrealistic, and absent adequate financial incentives, neither healthcare organizations nor pharmaceutical enterprises can recruit exceptional talent. The critical concern lies in money's potential transformation from instrumental means to ultimate end — the elevation of profit maximization to paramount organizational objective.
As this analysis demonstrates, pharmaceutical industry payments constitute both an ethical and policy challenge integral to healthcare system design. A causal chain emerges: pricing mechanisms determine clinical behavior, which influences organizational financial performance, which shapes industrial profit structures, which subsequently affects governance decisions regarding shareholder returns versus research investment. This interconnected dynamic manifests across clinical practice and medical industry globally, including Japan.
Conclusion
Returning to Caravaggio's composition: the dramatic illumination pierces darkness, revealing the decisive moment of choice. Light's presence accentuates shadow's depth. Healthcare similarly exists within this interplay of illumination and obscurity—the light of confronting disease and the shadow of profit-driven imperatives.
No singular optimal solution defines the appropriate relationship between healthcare and capital. However, we retain the capacity and obligation for sustained interrogation: As healthcare expenditure escalates, are these resources genuinely deployed for patient benefit? Does pharmaceutical industry influence distort clinical judgment? Do shareholder returns constrain research investment?
Humanity's relationship with money constitutes a challenge extending to antiquity, unlikely to achieve definitive resolution. Precisely for this reason, those engaged in healthcare bear responsibility for continuous critical dialogue, perpetual redefinition of sustainability parameters, and ongoing reexamination of medical ethics. Like the illumination in Caravaggio's masterwork, we perpetually confront moments of existential choice.
The original Japanese version of this article was published on November 4, 2025, in the MRIC email newsletter.
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