The Covert Rationing Blog

What DrRich Means By the “Once Ethical” Medical Profession

October 3rd, 2007 by DrRich

Yesterday, Dr. James Gault of the Retired Doc’s Thoughts blog noted DrRich’s habitual use of the adjectivals “once proud, once ethical” to refer to the medical profession. He says:

I certainly do not WANT to believe that the modifier “once” is correct. However, there seems to be much awash in the land to push the vectors in the direction of less pride and less ethical behavior.

Dr.Gault then goes on to recount, particularly poignantly, some of the ways in which doctors are indeed suffering from a dearth of professional pride in recent years. Reluctantly, he concludes, the “once proud” modifier is probably justified.

While he does not address very much in this essay the “once ethical” modifier, Dr. Gault does link to an equally insightful article he posted a couple of months ago that - if a bit circumspectly - gives his answer.

It is on this point - Has the medical profession truly abandoned its ethical principles? - that DrRich would now like to elaborate. For, as Dr. Gault has reminded him, it would probably be inadvisable to continue referring to the medical profession by the inflammatory and insulting modifier “once ethical,” without explaining what he means.

So here is what DrRich means by “once ethical:”

Until 2002, the medical profession “officially” operated under two ethical precepts.

The first, The Principle of Patient Welfare (also called the precept of beneficence) has been described in many ways (most famously, “First, do no harm”), and underlies the classic doctor-patient relationship. The physician must always behave in a way that accrues to the benefit of the patient. The patient comes first, and must be the doctor’s primary concern, above, for instance, personal and financial considerations.

The second, The Principle of Patient Autonomy, was added after World War II in the Nuremberg Code, and confirmed by the Declaration of Helsinki of which the United States, as well as the rest of civilization, are signatories. (It was felt necessary to add this ethical precept after the abominations performed on “imperfect humans” by Nazi doctors were “justified,” by twisted logic, as being consistent with patient welfare and thus with medical ethics. As it turns out, only patients themselves can be relied upon to determine what best serves their own welfare; hence, the precept of autonomy.) Under the princle of autonomy, patients are acknowledged to have the right to self-determination regarding their own healthcare. Fundamentally, this means that patients have the right to know, and the doctor is obligated to inform them, of any and all information that might help them make their decisions regarding their own healthcare.

As anyone can see, under a system of covert rationing doctors simply cannot follow these two precepts. It is not possible to ration covertly, at the bedside, and honor patient welfare and patient autonomy at the same time.

The problem was explicitly recognized as early as 1998, in an article by Hall and Berenson in the Annals of Internal Medicine (volume 128, p 395) which stated:

It is untenable for the medical profession to coninue asserting an idealistic ethic that is contradicted so openly in clinical practice. . .We propose that devotion to the best medical interests of each individual patient be replaced with an ethic of devotion to the best medical interests of the group [of patients] for which the physician is personally responsible.

This article, among other things, led to the formation of a commission to study the issue (the issue being, apparently, that if it becomes difficult to follow ethical precepts, one ought to change them). Represented on the commission were all the heavy hitters: the ABIM Foundation, ACP-ASIM Foundation, and the European Federation of Internal Medicine (hereafter this august group of groups will be referred to as the Millenialists, for reasons that will be clear in a moment). In 2002, this great commission made their formal pronouncement, which they titled: Medical Professionalism in the New Millenium: A Physician Charter. In it, the Millenialists proclaimed a third ethcial precept: The Principle of Social Justice.

The Principle of Social Justice dutifully states that physicians should not withhold medical services from patients based on race, ethnicity, gender, etc., etc., but that’s just window dressing. The real purpose of this new precept is to charge physicians with “the fair distribution of healthcare resources.” That is, it specifically and directly justifies bedside rationing.

(The Millenialists did not adopt the idea of Hall and Berenson - that doctors should base their rationing on their own individual patient population. Instead, doctors should aim for the equitable distribution of resources across all of society. DrRich counts this as too bad. Just think of all the extra hockey tickets and baked goods doctors would get if their patients knew they were competing specifically with all the other people in the doctor’s office for healthcare services.)

At the risk of being redundant, DrRich calls your attention to the main point. The reason this third ethical precept was deemed necessary is explicitly because doctors cannot any longer adhere to the other two. (”It is untenable. . .to continue asserting an idealistic ethic,” according to Hall and Berenson. “Indeed, the medical profession must contend with complicated political, legal, and market forces,” (emphasis DrRich’s) according to the Millenialists.)

Ostensibly, the Third Precept gives doctors who are too introspective (admittedly, not a big problem with many of us) an out. “Sure, I’m violating Precepts One and Two,” they can now tell themselves, “but I’ve got to do that to honor Precept Three.”

DrRich thus broadcasts his disgust with many medical ethicists for promulgating arcane twists of logic by which they seem to be able to justify almost anything. By their definition, of course, the medical profession is still ethical.

DrRich still likes the first two precepts. They have been and remain, in fact, the real and true definition of medical ethics, whatever the Millenialists might try to sell us. And these are unarguably the precepts by which patients still think doctors are operating. But reality and truth aside, the first two precepts have been officially suborned by the leaders of the medical profession in favor of one that is more, well, practicable.

So with this explanation but without apology, DrRich will continue to use the modifier “once ethical” to describe today’s medical profession.

Posted in General Rationing Issues

2 Responses to “What DrRich Means By the “Once Ethical” Medical Profession”

1. James Gaulte wrote on 10/4/07 at 2:20 pm :

   Dylan has a line in “One too many Mornings” that goes “Everything I’m saying you can say it just as good”.Or in this case better.
   Thanks for an excellent exposition of this issue.
   James Gaulte

2. The Covert Rationing Blog » Blog Archive » Patients, Doctors, and Remote Third Parties wrote on 12/22/07 at 10:56 am :

   […] this is the reason why patients (according to traditional, though now quaint, medical ethics) are also supposed to have an advocate, an individual who is charged to take their […]

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