Callousness and Legalism: Two Bad Behaviors in Medical Practice
Christy A. Rentmeester writing in the Winter 2008 ASBH Exchange, a bioethics newsletter, discusses the tendency for students and young physicians to be exposed to and learn from their mentors callousness and legalism as the way to evaluate and treat patients. Callousness is apparent when a physician does not “..recognize features of his patient’s situations that configure what they need from him.” In addition, he does not "define what the patient needs and deserves from him broadly (instead of narrowly) and generously (instead of meagerly)."
Think for example of a male patient who needs to consistently take a heart medication to prevent angina, a medicine to lower cholesterol and a blood pressure medicine to control the blood pressure. Suppose the physician simply writes the prescriptions and gives no attention to the financial and social status of the patient and whether the patient also has a wife who is also needs medication for her own high blood pressure and gout so that both, with limited income, will not be able to afford purchasing all the necessary medications. That behavior of the physician represents only consideration of the most narrowly defined needs (the written prescription) and no concern regarding how the patient is going to pay for the medications and whether the patient will not be compliant in taking the medications because of trying to support the medical needs of his wife and himself on that limited income. This behavior of ignoring the patient’s full needs represents a form of callousness.
Legalism is a form of practice in which the physician “orders tests, requests consultations or does procedures that are unlikely to benefit the patient or generate new clinical information that would help in caring for the patient more effectively. Such orders, consultations and procedures are done with the idea that doing these actions will make the healthcare professional appear ‘covered’ from an imagined legal point of view.” As Rentmeester suggest, “ …clinicians trained to think and see legalistically are taught to fear their patients and see them as threats.”
I would say that in both callousness and legalism, the there is the underlying behavior by the physician of only being minimally involved with the patient and making self-interest, not the patient’s interest, the major goal. Both Rentmeester and myself might be looked upon as being too harsh in our consideration of physician training. However, in view of the known “hidden curriculum” informally taught by those who train students and physician in their clinical years, there is a need be aware of distortions of clinical moral perception that can lead to callousness and legalism as the new doctors go beyond training. ..Maurice.