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DrRich Initiates A Medical Ethics Smack Down With The ACP

Yesterday, DrRich noted (with his usual affecting humility, modesty, self-deprecation, &c.) that the Covert Rationing Blog has been named a Finalist in the 2009 Medical Weblog Award Competition, in the category of Best Health Policy/Ethics Blog. He now calls to his readers’ attention the fact that, among the other two finalists – both of which are of very high quality and undoubtedly are more deserving of this award than DrRich – is none other than the ACP Advocate Blog.

The ACP Advocate Blog, written by Bob Doherty, is a publication of the American College of Physicians, and its purpose is to explain, elaborate on and advocate for the ACP’s positions on important matters related to health policy and medical ethics that affect its members, namely, internal medicine specialists.  Doherty – who DrRich does not know, but of whom he has heard many very complimentary things – is an insightful analyst of matters related to healthcare policy, and to boot he is an excellent writer. DrRich is a loyal reader of the ACP Advocate Blog, which in fact has habitually led off DrRich’s blogroll.

Here’s why this is interesting. While both the ACP Advocate Blog and DrRich’s blog are finalists in the medical ethics category, it so happens that DrRich and the ACP are far apart on that very issue. DrRich (himself formerly a proud member of the ACP for over 30 years) has been a vocal critic of the ACP’s stand on medical ethics, ever since it joined a group of professional organizations a few years ago to formulate “Medical Ethics for a New Millenium.” DrRich believes that this “new medical ethics” is harmful to patients and to the medical profession alike, and has not been bashful about saying so.

So here we are – DrRich and the ACP Advocate Blog – both selected, as fate would have it, as co-finalists in the venerable Medical Weblog Award Competition in the category of medical ethics, when, regarding this very topic, the former has been quite vocal and persistent about criticizing the latter. Meanwhile, DrRich’s effusions on the subject have been completely ignored by the ACP in general, and by Doherty in particular. Now let’s be clear – DrRich does not blame them in the least for failing to respond to his criticisms, since they are very likely completely unaware of his existence (being, as he is, merely one tiny voice in a great sea of blogospheric pontificators). Also, truth be told, even if they were aware of DrRich’s criticisms, prestigious organizations such as the ACP do not owe a debt of response or recognition to every lone crackpot who criticizes them or their policies. If they had such an obligation, then how would they ever get any work done?

But still and all, here we are, fellow finalists.

So what, prithee, is the correct etiquette here? Quite likely, the correct thing for DrRich to do would be to avoid disharmony, to ignore the tension built-in to this unasked-for situation, to pretend there is no major point of contention over medical ethics between himself and one of the other medical ethics finalists, to spend the next couple of weeks writing about some other of his favorite subjects – how fat people prevent global warming, say, or on the most politically correct way to move old farts expeditiously into the next life – and, for propriety’s sake, to simply leave contentious medical ethics alone for another time.

But really, where’s the fun in that?

Plus, medical ethics is important. In fact, DrRich believes that the very point of contention, between the ACP’s conception of medical ethics and his own, is of such critical importance as to define the ultimate viability of the medical profession itself, and more importantly, the actual, physical (life-and death) viability of patients. And this being the case, it would be a shame – and possibly unethical – to let the subject just lie there, at the very time when taking it up might at last engender some of the give-and-take the subject sorely needs, and failing that, at least might gain a broader audience than it has had to date. (For DrRich has discussed this all before, but to little avail.)  Such a broader awareness could be useful, since doctors and patients who fully understand the danger in which this new system of ethics has placed them can take the steps necessary to protect themselves (and each other).

And so, at the risk of being impolitic, impolite, boorish, boring, incorrect or incorrigible, and quite likely at the risk of rendering himself completely unworthy of his status as a finalist in the Medical Weblog Award Competition, and possibly even at the risk of forfeiting his status as same (though he has not been apprised of any particular rules he may be about to violate), DrRich hereby lays down the following proposition, and cordially invites the ACP Advocate Blog (or any other interested or offended party) to reply:

A Proposition

The New Medical Ethics, as espoused by the ABIM Foundation, ACP-ASIM Foundation, and the European Federation of Internal Medicine (hereafter referred to collectively as the Millennialists), and as laid out in a tract entitled, “Medical Professionalism in the New Millennium: A Physician Charter,” (Annals of Internal Medicine, February 5, 2002, vol. 136, pages 243-246), is deficient in the following ways:

  • it undermines the foundation of the doctor-patient relationship,
  • it threatens to fundamentally destroy medicine as a legitimate profession, and
  • it places patients at grave personal risk whenever they encounter the healthcare system.

Just so.

What’s Wrong With the New Ethics?

To see how the “New Ethics” declared by the Millennialists is harmful, it is useful to first review old-fashioned, or “classic” medical ethics.

Classically, doctors have been obligated to recognize two ethical precepts: Patient Welfare and Patient Autonomy.

The precept of Patient Welfare (also called the precept of beneficence, or “first, do no harm”), obligates the doctor to always behave in a way that accrues to the benefit of the individual patient. The needs of the individual patient come first, and must be the doctor’s primary concern, above, for instance, personal and financial considerations.

Under the precept of Patient 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.

So classically, doctors were obligated to do whatever they must to assure that their individual patients were fully informed about all their medical options, and to act to assure that their individual patients got the care they needed (as long as, fully informed, they agreed to it).

By the late 1990s, however, the Millennialists – quite correctly as it turns out – detected a severe problem with this classic medical ethics. Namely, modern physicians were, to a very large extent, unable to comport with it.  Quite simply, this is because  under a system of covert healthcare rationing (such as was in full bloom even by that time), doctors cannot follow these two precepts. It is not possible for doctors to ration healthcare covertly, at the bedside, and at the same time fully honor their patient’s welfare and autonomy.

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 continue 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. . .”

This influential 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, then one ought to go ahead and change them). And this commission led to the Millennialists and their New Ethics.

The innovation of the Millennialists was to proclaim a third ethical precept: the precept of Social Justice. The precept of Social Justice charges physicians with effecting “the fair distribution of healthcare resources.” That is, it directs doctors to decide which patients ought to get those limited resources, and which ought not to get them.  It specifically and directly justifies bedside rationing by doctors.

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 Millennialists.)

Ostensibly, the precept of Social Justice gives doctors who are too introspective (admittedly, not a big problem with many of us) an out when they find themselves having to place the interests of payers ahead of the interests of their patients by, say, failing to mention certain medical options that might be available.  “Sure, I’m violating Precepts One and Two,” they can now tell themselves, “but I’ve got to do that to honor Precept Three.”

The bottom line is that, having been coerced by the the insurers and the government (who utterly control the doctors’ professional viability) to place the payers’ needs ahead of the needs of patients, doctors found themselves in utter violation of their fundamental ethical precepts. The proper response of physicians (and their professional organizations such as the ACP) would have been to reassert those ethical obligations, to push back against the payers, and enlist the cooperation of their patients (who, after all, have a particularly vital interest in the matter) in doing so. Instead, they have taken a path of lesser resistance, re-defining medical ethics to comport with their new, coerced behavior.

What Does This “New Ethics” Do To the Doctor-Patient Relationship?

The addition of the precept of Social Justice to the ethical obligations of the physician renders the doctor-patient relationship inoperative.

The doctor-patient relationship is critical to the professional survival of the doctor, but it is critical to the actual survival of the patient. Consider that patients – especially when they are sick – are no more capable of navigating a complex healthcare system (whose chief concern, increasingly, is minimizing spending at any price) than are, say, accused felons a complex legal system. And patients are no less in peril than the felon if they run afoul of that system.

Society explicitly recognizes the right of the accused felon to an advocate, a professional whose job it is to protect his individual interests against the conflicting aims of the “system,” and who is expected to leave no stone unturned in guaranteeing his rights and prerogatives under the law.  A patient’s need of a similar advocate is no less acute than that of the felon. (When you are sick, you should be entitled to at least the same protections as when you rob a gas station.)  And the doctor-patient relationship is supposed to see that you have such an advocate.

Over the ages the doctor-patient relationship has been defined, through rules of ethics and rules of law, as a fiduciary one. When a patient seeks a physician’s help and the physician agrees to give that help, a special covenant is made.  The patient agrees to take the physician into her confidence, to reveal to him even the most secret and intimate information related to her health.  The physician, in turn, agrees to honor that trust, and to become the patient’s advocate in all matters related to her health, placing her interests above all others – including the doctor’s own personal or financial concerns.

The New Ethics breaks that covenant from the outset. It renders “ethical” the divided loyalty of the physician. Today, when patients go to a doctor for medical advice, they do not know – and cannot know – whether that advice is being given to advance primarily the patient’s own well-being, or the well-being of the society that desires a “fair distribution of healthcare resources.” With the formal adoption of this New Ethics, patients have been essentially cut loose, and set adrift to fend for themselves in an increasingly hostile healthcare system, without being able to rely on the kind of personal advocate they’ve been conditioned to expect, the kind of advocate an accused murderer is awarded without question or hesitation.

Less obvious, but no less profound, are the consequences of this New Ethics to the profession of medicine.  Abandoning their primary obligation to the individual patient means that physicians have committed the “original sin.” They have abdicated their traditional, ethical, and legal roles as patient advocates; they have broken a sacred pact. They have fully compromised themselves as professionals; indeed they have become professionals in name only, and not in fact.  And as a result, to their utter frustration, they find themselves standing naked before their enemies, the very insurers and regulators who forced them to abdicate their sacred obligation in the first place.

DrRich finds it exceedingly sad that the ACP and other professional organizations, in an honest effort to protect their membership, and thus to devise a form of medical ethics which comports to the realities of the day, have ended up wrecking the doctor-patient relationship, and in the process have done great material harm to patients, and fatal professional harm to the very physicians whose ethical sensibilities they sought to protect.

DrRich does not imply evil intent to anyone here – not even to the insurance companies and the regulators (whose actions to coerce covert rationing are, really, just an effort to fulfill the job our society has assigned to them). Indeed, DrRich assumes all parties involved are sincerely trying to do the right thing. And so DrRich (ever your cheerful optimist!) sees a way out of the ethical dilemma.

That way out requires a new way of thinking about medical ethics – the “right” way, if he may be so bold – and in his next post DrRich will describe it.

In the meantime, DrRich is a bit distressed over his violation of the traditional civility of the blogosphere, for his possibly having abused the honor bestowed on him in his selection as a finalist in the Medical Weblog Competition, and indeed, for exposing himself to the accusation of initiating a Medical Ethics Smack Down.

As penance, DrRich invites his readers to go ahead and cast a vote for his competitors. They are both extremely worthy, and neither of them are (yet) behaving as immoderately as DrRich. You may do so here.

*This blog post was originally published at The Covert Rationing Blog*

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