The Dire Implications For Doctors Of the New Medical Ethics

DrRich | October 19th, 2010 - 7:34 am

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In his last post (and in several past discussions) DrRich asserted that the Hippocratic Oath has been declared formally and officially obsolete by the medical profession itself, and that as a result of this action, the medical profession has voluntarily placed the professional viability of all physicians entirely into the hands of the government. Hence, DrRich has postulated, the Amish Bus Driver Rule is thereby activated, which permits (and probably compels) the government to use the leverage of medical licensure to control and direct the behavior of physicians – even their ethical behavior.

Lest anyone think DrRich is exaggerating about this, let us listen to the words of some of the physician-intellectuals who now hold positions of official responsibility, within the Central Authority itself, for determining the behavior of American doctors. DrRich asks his readers to notice both the content and the tone of these words, as both are important.

First, listen carefully to Donald Berwick, MD, recent recess-appointee to the position of head of CMS, in a passage from his ominously-titled book “New Rules,” (co-written with our old friend Troyen Brennan, MD):

“Today, this isolated relationship [between doctor and patient] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care…Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority…Health care is being rationalized through critical pathways and guidelines. The primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making.”

(Thanks to Dr. Gaulte of the excellent blog, Retired Doc’s Thoughts, for pointing us to this valuable passage.)

Dr. Berwick’s views on the need to constrain individualized decision-making in the practice of medicine is echoed by none other than Ezekiel Emanuel, MD, PhD. Dr. Emanuel is a bioethicist at the National Institutes of Health, and a fellow at The Hastings Center (a bioethics research institution). He is the brother of former White House Chief of Staff Rahm Emanuel (himself an expert in political ethics). Dr. Emanuel was brought in to the Obama administration as a high-ranking adviser on healthcare reform, and is widely expected to have a strong hand in determining who will sit on the GOD panels and how those panels will operate.

Regular readers will recall that Dr. Emanuel is also the co-author of that infamous paper recently accepted for publication in the Annals of Internal Medicine (and whose editors, thereby, formally auditioned for seats on those GOD panels) which called upon American physicians to abandon their ancient tradition of primarily serving their patients, and instead embrace their true destiny, which is assimilating into the Borg.

DrRich has found two instances in Dr. Emanuel’s writings in which he specifically commented on the obsolescence of the Hippocratic Oath.

In the May 16, 2007 issue of the Journal of the American Medical Association, in an article entitled, “What Cannot Be Said on Television About Health Care,” Emanuel expresses the following complaint about American physicians: “Reasoning based on cost has been strenuously resisted; it violated the Hippocratic Oath, was associated with rationing, and derided as putting a price on life, akin to the economist who knew the price of everything but the value of nothing.”

In the June 18, 2008 issue of the same journal, in an article on healthcare “overutilization,” he discussed seven factors that drive the overuse of medical services. He identifies one of these factors as a “culture of unwarranted thoroughness” on the part of American doctors, which serves to drive up cost. “This culture is further reinforced by a unique understanding of professional obligations, specifically, the Hippocratic Oath’s admonition to ‘use my power to help the sick to the best of my ability and judgment’ as an imperative to do everything for the patient regardless of cost or effect on others.”

Thus, Emanuel finds that it is a stubborn adherence to outdated medical ethics, which causes doctors to strictly place their individual patient’s interests above society’s interests, that accounts for a substantial proportion of unnecessary healthcare costs.

These passages from the very physicians who are directly driving healthcare policy through the auspices not of professional medical organizations, but through the auspices of the Central Authority itself, are striking in two ways.

First, their directness is striking. Doctors no longer work for the good of their patients; they work for the good of the collective. And heretofore they are obligated to follow the rules which are promulgated centrally, rules backed by the righteous force of the Central Authority, rules whose primary function is to make sure that decisions on medical care will be directed centrally, rather than at the doctor-patient level.

Second, the indignation these passages reflect is striking. The obligation of physicians to follow central directives is not an item of negotiation or persuasion – it is a DONE DEAL. Physicians’ own elected leadership of their own professional organizations – all of them – have formally signed on to the New Ethics, ethics which obligate doctors to practice medicine in a way that follows the dictates of remote panels guarding the interests of the collective  (rather in a way that jealously guards the needs of individual patients). And while this abandonment of an ethical precept that had been in force for over two millennia was promulgated with little fanfare, and while most practicing physicians seem not to realize that it has even happened (though we can be sure that all medical students everywhere are being steeped in it), it is a DONE DEAL.

And doctors who persist in practicing the “old way,” are not only acting in a manner that is “no longer tenable or possible,” but they are also violating the very ethical precepts which their own profession has now voluntarily adopted. They are behaving unethically. They are being evil.

No wonder our physician leaders are indignant. No wonder they have little choice but to divine the necessary “rules with authority” to force these recalcitrant physicians to do their self-admitted duty to the collective. By persisting with their old fashioned ideas in the face of that which medical ethics now prescribes, doctors are forcing the Central Authority to take strong action. Fortunately, since (we all know) our government is a benign entity, it will begin gently, with tough central rules and regulations (backed by authority) to “constrain decentralized individualized decision making.” The Central Authority will only invoke the Amish Bus Driver Rule (or worse) if these kinder, gentler steps fail.

As for the doctors who do not like this new reality, DrRich has a harsh message. You brought this on yourselves, by allowing your professional organizations to propose, write, and adopt these “New Medical Ethics.” For all the statements of Berwick, and Emanuel, and other health policy experts, castigating you for your inadherence to these new ethics, are predicated on the fact that you have a formally-adopted obligation to follow them.

It does no good to protest that you yourself were unaware that your profession has taken this formal action. Just as President Obama is your President whether you voted for him or not, the New Ethics is your formal rule whether you agreed with it (or were aware of it) or not.

And if you do not like the idea that the details of your behavior as a practicing physician are going to be handed down from on-high, and that you are not to be permitted any longer to primarily advocate for your patient, against the competing interests of the slavering Central Authority, you have nobody to blame except yourself.

And what this tells us is that if you are going to change things, you cannot hope to seek relief from legislators, or from your medical leadership (which has already assimilated with the Borg). Your only hope is to begin by reclaiming your profession yourselves, and re-asserting your primary obligation to your patient. There are several ways to undertake such a course, all of which will require standing up to the government and to your own leadership, and all of which will be difficult and dangerous at this late stage.  But it is the only path that remains open to you for your professional salvation.

Just keep this undeniable fact in mind: Obamacare, or any other form of centralized control over the practice of medicine, can only be achieved with the active acquiescence of physicians themselves. If physicians decide they simply will not allow themselves to be coerced to unethical medical actions, and insist on reestablishing the doctor-patient covenant as the guiding precept of their profession, the entire house of cards will fall. Physicians are far from powerless, if they would only dare to act.

We will still need healthcare reform, to be sure, but physicians have the power to insist that it can only be a kind of healthcare reform which fully honors and guarantees that covenant.

5 Responses to “The Dire Implications For Doctors Of the New Medical Ethics”

  1. Epoetker says:

    Once again, I would agree that physicians do, in fact, have power. But I do not believe that their inability to exercise it is due to moral failure or silent assent. Words like ‘preoccupied’, ‘harried’, ‘burdened’, or perhaps even ‘jaded’ come to mind when thinking about most physicians I’ve seen. Maybe those that have ‘arrived’ in their practice or residency are exempt, but complaining about the assent of physicians to these rules is increasingly looking like the old vs. the young. And I don’t expect old heads on young shoulders.

    • DrRich says:

      Epoetker,

      If you are accusing me of being old – guilty as charged.

      The thing about ethical precepts is, one is supposed to follow them whether or not one is preoccupied, harried, burdened, jaded, or young. Otherwise, why bother articulating them in the first place?

      Also, if we decide it’s too inconvenient (or dangerous to our livelihoods or our freedom) to reclaim our ethical obligation to always place the interests of our patients first, then shouldn’t we take pains to notify our patients of that fact? They are, after all, relying on us to do so. If they know they are on their own, perhaps they can make other arrangements for a personal healthcare advocate (as I described in my book).

      Rich

  2. cory says:

    “There are several ways to undertake such a course, all of which will require standing up to the government and to your own leadership, and all of which will be difficult and dangerous at this late stage. But it is the only path that remains open to you for your professional salvation.
    Just keep this undeniable fact in mind: Obamacare, or any other form of centralized control over the practice of medicine, can only be achieved with the active acquiescence of physicians themselves. If physicians decide they simply will not allow themselves to be coerced to unethical medical actions, and insist on reestablishing the doctor-patient covenant as the guiding precept of their profession, the entire house of cards will fall. Physicians are far from powerless, if they would only dare to act.”

    Sorry, that train left the station ten minutes ago.

  3. Jupe says:

    I don’t think the train has left the station. In fact, come to think of it, we might be approaching a unique opportunity.

    The price of insurance is probably about to increase dramatically, and the tax on not having insurance isn’t going to be high enough to act as a deterrent to going without insurance. It seems far more likely than not that a whole lot more people will find themselves uninsured in the near future, and they’ll be paying for care to PCPs out of pocket. It seems that this might make it easier for PCPs to move to direct-pay practices. With so many people NEEDING to just pay their doctors directly, moves to ban such arrangements might be met with widespread outrage, too.

    • DrRich says:

      Jupe,

      This is an interesting point, and one I hadn’t thought of. If patients themselves have to “drop out,” that will create a unique (and one-time) opportunity for doctors who want to drop out.

      Rich

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