 |
 |
|
|
One-hundred and fifty years ago a code of medical ethics was developed by the American Medical Association in response to a crisis of integrity within the profession, brought about in part by the social transformations wrought by the Industrial Revolution.
Is a similar transformation overtaking American medicine today?
As for-profit health care pushes physicians into the unfamiliar terrain of business, and the reality of limited resources seems to undermine the doctor's traditional allegiance to the individual patient, are the old guideposts for ethical behavior still useful?
Those were the questions posed by APA leaders and other representatives of the Council of Medical Specialty Societies at a three-day conference in Chicago last month titled "Contemporary Health Care and the Ethics of Medicine: What Is a Physician to Do?"
The conference, organized in part by Sara Charles, M.D., APA representative to the council and chair of the council's Task Force on the Ethic of the Profession, brought together representatives from 17 specialty societies.
"A working conference," is how Charles described the meeting, and work groups labored throughout the conference to develop a set of principles to guide physicians in three broad areas of ethical concern: the physician-patient relationship, the physician-physician relationship, and the relationship of the physician to society.
Those principles, presented at the end of the meeting to the conferees, will be sent to all of the specialty societies within the CMSS--including APA--for review and revision.
Discussion of the work group statements at the conference was moderated by APA Assembly Speaker-elect Jeremy Lazarus, M.D., and APA Medical Director-designate Steven Mirin, M.D., in an effort to achieve consensus around the ethical issues posed by changes in the health care market.
Lazarus, who is also a former chair of APA's Ethics Committee, said that the conference was a landmark occasion for a diverse group of specialties--some of which have been, from time to time, at loggerheads--to come together in agreement on a set of ethical principles.
In addition to Lazarus, Mirin, and Charles, speakers at last month's conference included Edmund D. Pellegrino, M.D., of the Center for Clinical Bioethics at Georgetown University Medical Center; Joseph J. Fins, M.D., director of medical ethics at New York Hospital; George D. Lundberg, M.D., editor of the Journal of the American Medical Association; and the Rev. James L. Connor, S.J., director of the Woodstock Theological Center at Georgetown University.
Also speaking were Christine K. Cassel, M.D., professor and chair of the department of geriatrics and adult development at Mt. Sinai Medical Center, and the Rev. Monsignor Kenneth Velo, president of the Catholic Church Extension Society of the United States, who spoke on behalf of the late Joseph Cardinal Bernadin, S.J., archbishop of Chicago.
Speaking on behalf of the "patient's perspective" was Nobel Prize-winning novelist Saul Bellow.
Consensus was easy to reach in some areas, particularly the conviction that for-profit medicine is eroding the traditional physician-patient relationship.
Pellegrino voiced this consensus when he stated that physicians "must not do the Pontius Pilate act"--that is, wash their hands of the transgressions of for-profit health care. Rather, physicians must summon the "courage to say, 'I will not do certain things,' " he said.
Yet if resources for health care are finite-as they arguably are in an aging society with rapidly expanding technology and a culture of individualism that ensures a virtually unlimited demand for health care--where do the ethical physician's loyalties lie: with the individual patient or with the larger community? Around this question there was greater ambivalence.
Lazarus, Mirin, Pellegrino, and others insist that the physician's first allegiance is to the individual patient, and that individual doctors cannot be placed in the position of "rationing at the bedside." It is up to the larger society and its leaders, with the advice and input of physicians, to make the difficult decisions about allocation of resources, they said.
Yet Cassel argued that American medicine's exclusive devotion to the individual patient--as codified in the Hippocratic oath--is the result of what she called a "divergence" nearly 100 years ago from the discipline of public health. As a consequence, she said, most physicians don't think about "population-based health," which in other cultures forms an integral aspect of the doctor's education.
Cassel challenged the audience by suggesting that the Hippocratic oath may need to be revised to reflect a commitment to population-based health.
While that view may not have met with unanimous agreement, Cassel did reflect a concern that lies at the heart of the modern medical-ethical dilemma: that the ethical physician caring for the individual patient cannot at the same time be heedless of the millions of Americans who go without any health care.
The ethical conundrums implicit in today's health care environment were made strikingly real with a series of vignettes that called on participants to choose between sometimes conflicting values: the rights and wishes of an individual patient or the needs of a larger community.
Choices registered by physicians at the conference were seldom unanimous, seeming to confirm what was echoed by speakers throughout the conference: that the practice of health care has moved into a transformative era, where traditional truths have been rendered questionable.
Charles, at the opening of the conference, summed up the vexed condition of the modern physician.
"Physicians today are overwhelmed and demoralized not only by the complex demands placed on them by specialty-specific technological advances, increasingly sophisticated information systems, and participation in and use of a wide range of quality-assessment parameters, but also and most acutely by changes in the financing of medical care, which are designed to unabashedly influence their behavior," Charles said.
She asked: "Is the current environment even hospitable to a traditional ethic, or should the latter be adapted in some way or complemented to fit the new realities?
"Although positives may emerge from some of these developments, uneasiness persists about whether or not in the long run something central to the work [that physicians] do is being compromised, transformed, or even lost," Charles said.
Further coverage of last month's conference will appear in the next issue of Psychiatric News.
(Psychiatric News, May 16, 1997)