by Paul H. Ward, MD
It is an honor to be asked to deliver the 21 st Annual Daniel Baker Lecture.
My thanks to President Neel, the Committee, and the Officers of the American
Laryngological Association for selecting me for this honor.
In 400 BC, Hippocrates introduced, for his followers,
an oath that has served as the basis of medical ethics. (1) The
timeless purpose was to guide physicians in their caring for patients and
their relationships with each other. The oath specifically outlines the
fiduciary responsibilities between the physician and patient, the responsibility
for caring for the poor, end the interrelationships between physicians.
It has served, over 2,000 years, as a template in times of doubt about
what being a physician really means. Times change, waves move from sea
to shore, and our ethics have shifted over time, just as the sand dunes
move in the desert from the blowing winds.
Many new influences, including explosive technological and pharmaceutical
developments, are agents of change. Hippocrates did not have to deal with
the current population explosion, problems with resources and reimbursements,
interference with medical decision-making by third-party payers, and bureaucratic
dictates. This communication cannot give lengthy consideration to most
of the new ethical dilemmas currently confronting society and physicians,
but will discuss the shifts of behavior that are eroding devotion to the
Hippocratic principles.
Many medical schools now require courses in medical ethics. Their goals
are to help students recognize ethical issues, stimulate moral reasoning,
and develop a sense of moral obligation and personal responsibility. As
seen from papers written by the medical students, they are obtaining a
good grasp of the many ethical dilemmas such as acquired immunodeficiency
syndrome, abortion, euthanasia, death and dying, holding and denying life
support, and the current lack of access to and inadequate distribution
and unfair allocation of medical personnel and resources. They are familiar
with the principles of autonomy, patient rights, economic constraints,
utilitarianism, beneficence, malfeasance, and justice in much greater depth than
previous generations of physicians. (2)
The courses in medical ethics are usually taught by philosophers, lawyers,
psychiatrists, and theologians. Regardless of the competency of these teachers,
ethical principles are preferably best learned at the patient's bedside,
in the clinics, and in the operating rooms, from mature ethical role models.
Men and women have developed, as a basis for ethical decisions, certain
eternal immutable values, many of which form the basis of an ethical society.
These universal traits, such as respect for the dignity of others, loyalty,
honesty, integrity, and caring for their fellow man,
have been described as representing the foundation of moral character and
behavior. (3)
The founder of the Joseph and Edna Josephson Institute of Ethics designed
the Institute to gather and focus the moral energy of people who want to
do something to make society more honest, free, accountable, and caring.
Founded in 1987, the Institute has maintained that our American culture
was built upon a foundation of 10 consensual signal values that form the
basis of an ethical society: honesty, integrity, respect, caring, fairness,
promise-keeping, pursuit of excellence, civic duty, accountability,
and loyalty. (4) While based upon Judeo-Christian and
Islamic or Muhammedan traditions, they transcend cultural, religious, and
socioeconomic diversity. Many, if not all of these, are tenets characteristic
of all ethical physicians and surgeons.
How have we as physicians gone astray? This communication attempts to
analyze the results of failures in commitment to Hippocratic medical ethics.
Considerations of possible solutions are discussed that may restore respect
and honor to our sacred profession. Perhaps the entire disarray of society,
overpopulation, overexpansion of our present obsolete and paralyzed government,
and excessive numbers and maldistribution of physicians play a significant
part in the shifting sands of medical ethics.
Before the early 1960s the majority of physicians and surgeons felt an
obligation to care for the medical needs of the poor and needy. This was
demonstrated by donating a half-day or day working at the city or county
hospital or absorbing the cost of caring for the disadvantaged in our offices.
Early during the second half of this century, the government decreed that
equality of medical care for all of society was not a privilege but a right.
To secure this right at least for the elderly and the needy, Medicare and
Medicaid were established. To make this fair for physicians, the government
began reimbursement for the care of older citizens, impoverished children,
and the other needy members of society. Initially the rate of remuneration
was marginally adequate to cover expenses. The physician's pro bono contributions
were eliminated. Instead of donating time and services, the medical profession
warmly embraced the concept of being paid.
The rapid development of new technology (ie, computed tomography, magnetic
resonance imaging, organ transplantation, etc) resulted in rapid escalation
of national medical expenditures, countered by governmental cutbacks in
reimbursement to a level inadequate to cover expenses. Many physicians,
who had become prosperous and greedy after being paid, forgot some of their
Hippocratic oath. The old expression that "he who pays the piper calls
the tune" became applicable. Government, with its camel's nose under the
tent, entered its full body of power and began the economic control of
medicine. The government stimulated managed care by subsidizing health
maintenance organizations and other experiments designed to cap uncontrollable
medical costs. New technology developed in almost every area and specialty
of medicine, further escalating the cost of medicine. Incompetent legislatures
could not determine who should receive the new technology, preferring to
allow such issues to be decided by default by a vacuum of leadership, and
approved everything for everybody. They soothed their consciences by allocation
of resources, and along with managed care, have forced physicians into
the position of being the rationers of medicine. This position is very
uncomfortable for us and violates our Hippocratic oath. Organized medicine
and contemporary practitioners let this apparently irreversible plague
occur.
What have been the actions of physicians in response to the changes or
shifts in our ethical behavior? The behaviors by members of our profession
that have displaced us from the position of honor and esteem are preoccupation
with financial gain, greed, inattention to the principles of altruism,
loss of devotion to a way of life, and failure to be a friend and advocate
to our patients and to share with them the decision-making in their care
and treatment.
Physicians have allowed the government, through the Federal Trade Commission,
to mandate the acceptance of advertising, previously considered unethical
by reputable physicians. The government's alleged purpose was to increase
competition by charging medicine with restraint of trade and let market
forces decrease the cost of medicine. Advertising since 1983 has been practiced
widely, primarily by marginal physician entrepreneurs and hospital administrators.
It has done nothing to reduce the cost of medicine, but has enriched and
enlarged the practices of pseudoscientific charlatans. This has helped redefine
medicine and the physicians as a morally neutered technician for hire. (5) To
quote R. J. Feinstein, "The medical profession began its decay during the
second part of the 20th century. A once noble and esteemed profession first
began to come apart when physicians started advertising
their services like common merchants or tradespeople." (6)
Another grievous offense is failure to monitor and discipline the abusive
members of the medical profession. We have "minded our business," tolerating
incompetence, cheating, deception, dishonesty, and lack of caring for patients.
In spite of extensive talk and posturing, punishments for violations of
medical ethical standards have been nonexistent to relatively minor punishments
and reprimands.
The system of governmental reimbursement has encouraged the dishonest
physicians to set up fraudulent schemes to steal from the government insurance
companies and, in turn, society. With the involvement of governmental and
third-party payers, many physicians no longer follow the Hippocratic tenets
of caring for colleagues and their families pro bono. Turning over the
responsibilities and the business part of practice to billing agencies
has dissolved this sacred opportunity to serve and receive the rewards
and honor of caring for our colleagues. We fail to be the patient's advocate
when we tolerate the introduction of new, unproven technology (de, endoscopic
surgery from sinuses to abdominal), generally at exorbitant fees and the
performance of marginal surgery. Physicians must stop unnecessary and marginal
surgery, developing outcome studies that will eliminate ineffective, marginal
surgical procedures. Let us chastise those among us who submit outrageous
bills for unbundled procedures that defraud the system and bring reproach
upon our profession. The treatment of patients with expensive proprietary
drugs when equally effective generic drugs are available does not suggest
that our patient's interests are primary. The rewards from the drug companies
have been "vacation trips to meetings," trinkets, and free lunches. How
can we resist these attempts to influence and alter our Hippocratic principles
of honesty and patient advocacy? Just say no, or don't use their drugs
until scientifically tested and proven to be superior. It does not benefit
the patient to order drugs that cost more than the patient is able to pay.
As our patient's friend, confidant, and advocate, we must be cognizant
of the cost of what we do, what we order, and the patient's ability to
afford the action taken. The most expensive way is not always the best.
Physicians continue to maintain that fee-splitting is unethical, as proclaimed
widely in our oaths, yet we practice it in health maintenance organizations,
large group practices, and full-time academic medicine settings. The solution:
let's become honest, and if we are going to condone and participate in
these situations, let's remove these concepts from our oaths and thereby
remove the hypocrisy.
As patient advocates, physicians have failed by passively allowing the
government to allocate medical resources; allowing insurance companies
to balloon their massive profits by accepting only healthy clients; and
allowing corporate managed care and hospital administrators to hire only
doctors who will ration medical care according to their dictates.
Too many physicians have been enticed by money to participate in our
corrupt legal system by serving as hired guns. Let's be honest with ourselves:
no lawyer is going to pay you to tell the whole truth, as you see it, unless
it corresponds to their plans for the case. While lawyers profess to seek
truth, their ethics are to win at all costs. We have medical-legal prostitutes
among us who sell their souls to the devil, testifying for either side
and allowing the "shysters" to place words in their mouths or stop testimony
short of telling the whole truth. How can this be managed? Ostracize them
from our medical fraternity. I have found it very effective not to testify
unless I am subpoenaed by either plaintiff or defense, including the prosecuting
district attorneys. When subpoenaed, I go as a "friend of the court" at
no charge and even pay for my own parking. I request the judge to allow
me to testify briefly, giving my own opinions, which may be right or wrong
but are my honest perceptions. Then I will answer the questions. It is
amazing how neither side bothers me or wants my services anymore! The eventual
solution is to participate in reinvention of our obsolete legal system.
Both the American Academy of Otolaryngology-Head and Neck Surgery and the
State of California have task forces to review cases and act as expert
witnesses. In California, those who participate are regional volunteers,
from all specialties, who accept $75 to $100 per hour and modest travel
expenses. How effectively these systems will function is yet to be proven.
I predict that without control of the expert witness, the lawyers won't
want any part of the "search for the truth."
Physicians have passively tolerated the abuse of drugs and alcohol by
our colleagues who have dulled their intellects and decision-making ability
while they are caring for patients. These cripples reflect poorly upon
our profession. Punishment, unless disaster occurs, is minimal: a short
probation or slap on the wrist. We excuse it as a disease or genetic defect
and stay uninvolved for fear of legal consequences. According to many studies,
a number of physicians violate the Hippocratic oath and the trusted position
of the "white coat" and healer by taking advantage of patients in vulnerable
positions and engaging in sexual relationships. (5) We
excuse it as a sickness that with the assurance of our psychiatric colleagues
can be attributed to repressed memories of parental child abuse or some
other flimsy excuse. Legally it may or may not be consensual, but it is
rape, if not of the patient, then of our professional image. These physicians
are accepted back into the physician fellowship while the patient suffers
in silence and the black eye to medicine's image slowly fades. Let's flush
these untrustworthy scum from our fellowship.
Some physicians think nothing of Iying to their patients or the patient's
family. An author of many articles on medical ethics, Sissela Bok, feels
there is no evidence that patients are debilitated by presentation of truthful
information on their conditions. Actually, much has
been learned recently of the benefits of truthful information being presented
to the patients. (7) Physicians must create an atmosphere
of honesty and openness. The undermining of the traits of honesty, integrity,
loyalty, courage, and respect and care for the dignity of our patients
represents a disintegration of the very foundation of medicine.
Many of the ethical issues we face today are excessive in number, more
tenuous than before, and often amorphous, sometimes defying ethically correct
answers. This appears to be the case in the development of a national health
plan. The current and previous national administrations have not succeeded
in devising a plan to take care of the health of our nation's citizens.
Physicians must actively help formulate such a plan, ethically considering
that in a democracy, if any group is treated unfairly, the plan is morally
and ethically wrong.
As a nation and particularly as physicians, we are frustrated in the
decision-making process that thrusts us into an adversarial position as
to what we can afford versus what is indicated and fair. Dr LeSalle Leffall,
President-Elect of the American College of Surgeons, states, "We must be
even more vigilant in listening to the entreaties of our conscience to
do what is in the best interest of our patients. " (3) Pellegrino
indicates that a fundamental difference between a business and a profession
is that at some point in a professional relationship, when a difficult
decision is to be made, you can depend on the one who is the
true professional to efface his or her own self-interest. (8,9) This
enduring principle must be reinstituted and remain inviolate if we are
to maintain the trust of our patients. Respect and trust are not given
in perpetuity, but must be earned each day of our lives.
Inevitably, times and mores change. Medicine and medical ethics cannot
remain stagnant, nor ever again return to what they were. If physicians
are to regain a portion of the respect and elevated status previously accorded
them, there is a need to shed avarice and greed while regaining the virtue
of modesty. We must provide leadership and become involved in the decision-making
process of meeting societal needs. Our patients cannot be allowed to remain
as ciphers in large, interpersonal, business dominated groups.
Physicians must remove themselves from the wooden-paneled boardrooms
and carpeted consultation suites and spend designated time in community
outreach programs. We must become familiar with problems, dangers, and
realities that face our patients and their communities. There is a need
for physicians to reinstate Hippocratic principles and participate in the development
of a comprehensive health system that will provide caring service for all
our citizens. Physician responsibility must be extended to include not
only our individual patients, but the communities from which they come. (10)
In 1910 Flexner concluded, "The physician's function
is fast becoming social and preventive rather than individual and curative." (11) Eighty
years later, Nuland echoed Flexner, arguing that it is time to turn our
thoughts to a new model for physicians, because the day is past when physicians
can think only of their individual patients to the exclusion of other patients,
future patients, and the rest of mankind. (12) The next
several decades will see a new type of medical practice dedicated to public
health, devoted to providing healthy lifestyles and healthy patients, and
preventing and correcting the predisposition to disease by the technologies
of immunology, molecular biology, and genetic engineering. In the next
decade we will see many forms of heart disease and some types of cancer
eliminated. The physicians of the next century face new challenges accompanied
by even greater opportunities to learn, to grow, and to personally better
serve their patients.
Our redemption lies in rededication to the precepts of being more caring,
more compassionate, and more sensitive to patients' needs. It may be expressed
best in the words of French Jesuit philosopher Pierre Teilhard de Chardin: "Someday
after mastering the winds, the waves, the tides, and gravity, we shall
harness for God the energies of love and then for the second
time in the history of the world man shall have discovered fire." (13) It
is that love and that fire that the ethical physician exemplifies so well.
The American health care system is unique, but in need of some reinvention.
It dynamically strives to be technologically advanced while attempting
to be a compassionate system that simultaneously is socially equitable.
It can ill afford to be lost.
In conclusion, let me paraphrase the remarks of Peter Drucher in characterizing
the current plight of medicine and, I believe, the "shifting sands of medical
ethics": We are the problem. We are the resource. We are the solution.
1. Hudson WB. Ethics in a competitive profession.
Trans Am Laryngol Assoc 1986:8-9. Return
2. Shapiro J, Miller R. How medical students
think about ethical issues. Am Med 1994;92:591-3. Return
3. Leffall LD Jr. Medical ethics in today's
society. Bull Am Coll Surg 1994;79:6-11. Return
4. Josephson M. Making ethical decisions.
Los Angeles, Calif: The Josephson Institute, 1992. Return
5. Kass LR. Professing ethically on the
place of ethics in defining medicine. JAMA 1983;249:1305-10. Return
6. Feinstein RJ. A view from the century:
how medicine met its demise. Acad Med 1982:28-9. Return
7. Bok S. Lying-moral choice in public and
private life. New York, NY: Pantheon Books, 1978. Return
8. Pellegrino ED. Toward a reconstruction
of medical morality: the primacy of the act of profession and the
act of illness. J Med Philos 1979;4:32-56. Return
9. Pellegrino ED. Thecommon devotion-Cushing's
legacy and medical ethics today. J Neurosurg 1983;59:567-73. Return
10. Greenbeck MR. Educating physicians
for the twenty-first century. Acad Med 1995;70:179-85.Return
11. Flexner A. Medical education in the
United States and Canada. A report to the Carnegie Foundation for
the Advancement of Teaching. Boston, Mass: Updyke, 1910. Return
12. Nuland S. Doctors: the biography of
medicine. New York, NY: Vintage Books, 1988. Return
13. Teilhard de Chardin P. On love and
happiness. San Francisco, Calif: Harper and Row, 1984. Return
top |
