Professional Functionality within a Moral Framework
As it pertains to the broad issue of physician behavior in the practice of medicine, it is both fair and appropriate to question whether medicine represents a higher calling, and if so, shouldn’t doctors be held to a higher standard of morality / behavior than other members of society? To answer these questions, we should first look at the medical world as it functions in these rapidly changing times.
The eminent Georgetown University bioethicist, the late Professor Edmund Pellegrino, once described the practice of medicine in the current social climate as challenging and often demoralizing. Policy makers want physicians to be gatekeepers of society’s resources and instruments of the bureaucratic apparatus; patients seek autonomy and see physicians increasingly as instruments of their wishes; ethicists question the value of the physician’s fiduciary role—suggesting to some extent the adoption of a contractual arrangement between patient and physician; and administrators of managed care systems want physicians to be entrepreneurs, competitors, and instruments of profit (1).
The capabilities of the physician are demeaned on the one hand as being too technological, while at the same time they are unrealistically expected by patients to have magical powers that in effect render them liable for the everyday fallibilities of nature - often unforeseeable and sometimes unavoidable. To state the obvious, in treatment, things don’t always go as planned, no matter the correctness of the plan. This or the skill with which it is implemented; yet the physician often shoulders the blame. Essentially, medicine is practiced in an atmosphere in which all that goes wrong must be blamed on someone. This is not dissimilar to the societal tendencies for legal gratification, only more intensely so. Furthermore, incentives and disincentives are used as levers to modify physicians’ behavior, and then the latter is chastised for responding. Finally, patients have come to feel little if any fiscal responsibility to the doctor, instead viewing the payment as a matter between a third-party payer and the physician—the care being an entitlement. Right or wrong, good or bad, it is the system in which we function.
Other forces are also at work in this kaleidoscope of interweaving demands that have been imposed on the practicing doctors. Underlying the turbulence of a fluid medical system is the obvious economic pressure created by the increasing cost of health care. As this essay is written and distributed, the Affordable Care Act is and will continue to change the dynamic. A discussion of what is needed to stabilize these problems is not part of the mission of this essay; however, clearing up certain misconceptions certainly is. Thus, my need to point out that the steady rise of health care cost is to a large extent unrelated to a physician’s fees. Doctors currently work as intensively as ever, but many do so for less money despite the same effort. Considering the huge expense of a medical education, the long and arduous training required, and the many sacrifices and demands of the life style, when coupled with the extraordinary responsibility for human life, it is absurd for physicians not to be paid well, and before relegating the average doctor to a substantially lessened income, the public should contemplate the consequences. I certainly concede that, with some obvious exceptions, doctors make a good living. Why shouldn’t they? If a young person seeks wealth, however, I would not recommend the medical profession. To state the obvious, other careers are more financially attractive, and furthermore, attaining wealth should not be the reason for becoming a physician.
Physicians must deal with all of these influences, and all in a society with a compromised trust of authority figures, a tendency for social cynicism, and even moral pluralism. Why is it surprising to anyone that such an atmosphere potentially distracts from a doctor’s primary mission of rendering service and care for sick people? As a sequel to this line of thinking, it seems reasonable to ask whether moral integrity can ever be rescued from such an unpromising climate. Pellegrino believes the answer to this question is obvious. He contends that rescue it we must, and the relationship between physician and patient ought to serve as the moral fulcrum—the Archimedean point, if you will—from which the balance between self-interests and high medical standards must be struck (1). Unfortunately, that very visceral thing – that human connection - seems to be slipping from our grasp.
I submit that in order to improve this state, we must think of the profession as being in a higher realm—not in an elitist, but an idealistic way—than the rest of society. Accordingly, we must require a higher level of morality and behavior for its members than for the rest of society. Some physicians resent being held to a different standard. Given what they believe to be the unwarranted and unfair infringements on the profession, they feel that survival behavior ought to be geared more to ground-level combative interaction. My contention, however, is that it diminishes the profession to respond negatively by allowing our standards and especially our behavior to become average in attempting to “work the system.” Rescue of moral integrity can only lie in taking the high ground. So, answering the question that I posed in the first sentence of this chapter: yes, the public should hold physicians to a higher standard, and furthermore, we should be honored by that distinction.
How might the quest for such a standard translate into practical language? For starters, there should be specific actions that make the goals of our profession clear: the leadership must somehow convince the public that the flawed system in which we labor is actually as much to the detriment of patients as it is to us. The inability of the profession to communicate this basic message has been a major failure on our part. It is fundamental that patients understand that we are in this together. The profession as a whole should stand for what is good, and follow a code that consistently recognizes that right is always right, and wrong is never right. The profession should admit complicity in some of what ails us—to some extent, in attempting to “work the system,” we have forfeited the high ground and thus have brought some of our difficulties on ourselves. The profession should refute all attempts to devalue the lives of the vulnerable that happen to have mental or physical compromise, and we should resist the desensitizing of our society to the sanctity of life. I predict that this trend will accelerate, as health care rationing becomes a reality. The profession should promote care for all of the sick and wanting—should provide care for the uninsured (this is part of the evolving health care system)—and should universally accept Medicare and Medicaid. Finally, and very importantly, all physicians and especially the leadership of the profession should consistently and unequivocally condemn our colleagues who function as moral pygmies by fraudulently exploiting the system, or by the ethically compromising in charging exorbitant fees and collecting them by manipulation of the coding systems to gain larger-than-warranted insurance payments.
The dishonor of physicians should be viewed with the same revulsion reserved for any betrayal of sacred trusts. For these individuals, the respectability automatically afforded by membership in the profession is but a transparent fig leaf covering unworthiness. Unless our stance on this is strong and steady, the ideals Pellegrino cited will not be realized. And although most of what I have said relates to medicine in general, because the thrust of these essays concerns the psychic forces between cancer physicians and cancer patients, I should point out that because this terrible disease is associated with a unique patient fear and vulnerability, any ethical breach while caring for this group of patients is especially despicable.
In order to function effectively in this world of materialism and self-gratification, the physician must strike the proper balance—on one hand avoiding naiveté and behaving realistically while also refusing to surrender those high ideals to which I have referred. The search for this balance has, to a large extent, been responsible for many of the vibrations in what ought to be a smoothly operating system. Despite the vibrations, however, I believe that moral standards are actually what will keep the system going, vibrations and all.
Roy B. Sessions, MD, FACS
References:
(1) Pellegrino, Edmund D.; “The John Conley Lecture”, delivered to the Annual Meeting of the American Academy of Otolaryngology/Head and Neck Surgery, San Diego, Ca; September 8, 1990.