More On Weeding Out Medical Ethical Misfits
"Finding oneself in the hands of an unethical physician can be a terrifying experience. How can we know whether the physician to whom we entrust our bodies and our confidences seriously lacks medical ethics? Are government and medical community safeguards effective in weeding out unsafe doctors?" So writes Philip R. Alper,Robert Wesson Fellow in Scientific Philosophy and Public Policy at the Hoover Institution in the Hoover Digest titled "Why Medical Ethics Matter". It is worth reading as we continue the discussion of the topic of weeding out medical misfits. Alper contrasts the various approaches through the centuries to establish professional behavior from the threatening Code of Hammurabi to the motivating Oath of Hippocrates and to the perhaps legally scripted American Medical Association's Code of Medical Ethics and finally to the complex recently developed Charter of Medical Professionalism. The latter, according to Alper "created by three preeminent internal medicine organizations in the United States and Europe, ... speaks in near-religious terms of 'three fundamental principles and ten commitments' (the latter actually total 36 by my count when compound sentences are teased apart) that would challenge a genius to comprehend and a saint to perform." Do you think these literal guideposts to ethical behavior accomplish what they were intended? Can you suggest other approaches to this issue? ..Maurice.
posted by Maurice Bernstein, M.D. @ 7:09:00 AM
7 comments
7 Comments:
As an occasional patient and a frequent witness to the physician patient relationship (RN), I think the answer lies in changing the nature of that relationship. Not blaming physicians entirely for this, but the inequity in the relationship makes it difficult for patients to question and easy for physicians to abuse. Taking down the pedestal would enable patients to identify that doctors might be unethical. I believe it would also make self policing more effective, since the need to maintain that mystique contributes to the reluctance to tattle. I also think it would decrease rather than increases medmal issues b/c the expectations of patients would be more realistic. Of course, true malpractice would have fewer places to hide.
5in9years
But 5in9years, how do you propose to take the physician down off the pedestal? Lets talk about the pedestal itself. Why is it present? Difference of knowledge? At the outset of a physician-patient relationship, it is the patient who is going to the knowledgeable physician to get diagnosis and treatment for symptoms and a disease about which generally the patient has no knowledge. The patient is looking up for help by someone who knows more than the patient. This already creates an unequal relationship. It is only later in a good relationship when the physician needs the cooperation of the patient to obtain needed historical information and to perform appropriate examinations and tests to complete the physician’s challenge and responsibility and finally compliance with the treatment to reach the physician’s hoped-for cure that the two become more equal. But is the doctor still on the pedestal?
Another reason that the pedestal may be present is that allegedly the physician stands tall because of his or her high moral/ethical beliefs and behaviors. The physician is one that the patient can look up to, in addition to knowledge, but also for trust. A person who is sick needs to have trust in their doctor and to feel that the doctor is perhaps even more trustworthy than themselves. If the physician appears on a pedestal to the patient due to the physician’s knowledge and ethical behavior, one could argue that removal of the pedestal could lead to disillusionment of the patient about the doctor and this would not be therapeutic.
Now if this all sounds like paternalistic doctor talk, it well may be. But I fear that it will be most difficult to take doctors down off their pedestal for the way as I described the patients look at their doctors but also because standing on a pedestal has been part of the culture of medicine for centuries and seems to be part of the way physicians look at themselves and their profession. ..Maurice.
Is the pedestal based on knowledge? If so, then anyone with knowledge in an area unfamiliar to me should share the pedestal. To be honest, I'm much more in awe of my mechanic than my doctor. When I go to the doctor, I at least speak the language; when I take my car to the mechanic, I am at his mercy. The doctor knows more about medicine than the patient, but perhaps much less about parenting or about birth, or about repairing air conditioners. Each person has unique gifts to share with the others. Some of them require a lot more effort to complete-medicine or law, for example-but none of them is all important. I find it interesting that the relationship becomes more equal only when the physician needs the patient to comply with exams/history/treatment/etc. That doesn't seem more equal to me. If the relationship starts out on equal footing, the doctor is providing information and treatment at the request and continued consent of the patient. If it starts out on an inequal basis, it is much more likely that when the doctor needs the patient's cooperation to perform his function, he will manipulate or coerce. So, for me, either the pedestal is there or it is not.
If the pedestal is based on an assumption of ethical behavior, the patient better have chosen his physician wisely. Doctors, on the whole, are no more or less ethical than any other humans. The results of their morals-or lack therof-is perhaps more critical. The patient who assumes ethical behavior based solely on the initials M.D. is lost already. The system should do its best to protect that person from unethical doctors, but the system-whether at the educational or the provisional level-will always have some failures. I do understand that you think some patient's need to believe in their doctor's morality in order to feel secure, but I'm not sure that disillusionment would be a negative in that situation. Frightening, certainly, but in the end beneficial in that the patient is free to choose a physician who truly is ethical. I've used ethical and moral more or less interchangeably here, though I know that isn't entirely correct.
With your final paragraph I completely agree. It is not only in the culture of physicians, but of patients. I shudder when I hear women say "my doctor wouldn't do anything to endanger the baby" History teaches differently, if only we will learn. I don't think the difficulty of the task, however, makes it less worthy as a goal.
5in9years
btw-completely unrelated, but I was interested in your take on this:
http://online.wsj.co.....JYY_20060510,00.html?mod=tff_main_tff_top
5in9years, check the URL again, it doesn't seem to go to a page. It may be incomplete. Why don't you summarize what it is about? ..Maurice.
maybe this one will work. It's a discussion of the sall street journal article in the other link.
http://www.mppllc.com/pages/2005/05/3-problems-and-solution.html
It's about research studies published in medical journals unflattering information about meds ommitted. The article goes into the influence of pharma companies on even the professional literature of medicine. Are professional journals an important means of keeping up to date for doctors (my impression was always that they are) And are there any unbiased sources of information out there for practicing physicians?
5in9years
Uggh-sorry for that typo-the first line refers to a Wall Street Journal article
5in9years
5in9years, your last URL works and takes us to the Health Business Blog. The blogger there links to the Wall Street Journal article but also comments on the conflict of interest by the publishers of the medical journals. And if that is affecting which articles to be published, including publishing those with incomplete information, physicians will be adversely affected since the journals represent a source of information for practicing physicians. ..Maurice.
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