I. This presentation examines larger cultural and philosophical background issues framing medical ethics and concerns for medical professionalism.
A. Since the early 19th century, codes of ethics have served to establish medical professional identity and give it focus and content.
B. The content of codes of medical ethics has changed to reflect the moral fashions of the age.
C. This presentation will sketch the large-scale cultural and conceptual geography that sets the context of contemporary codes of ethics and current challenges to the medical profession
II. In a post-modern, post-traditional culture, the challenge to physicians is to maintain and enhance a sense of medical professionalism, and a moral self-identity. This presentation focuses on the task of enhancing a sense of medical professionalism, taking as an example the particular situation in the USA.
A. A cardinal mark of a profession is its self-regulation and distinctive moral identity, which was once reflected in medicine as a quasi-guild with special knowledge and skills, as well as with a fiduciary responsibility to patients and society nurtured by the accountability of
1. individual physicians (medical professionals in Western Europe possessed an individualism born of solo-practice and individual accountability) within
2. the profession as a self-governing association of learned and skilled practitioners,
3. guided by its own moral framework not fully open to outsiders.
B. In the 20th century, medicine in the USA was deprofessionalized by being transformed from
1. a self-regulating quasi-guild with its own moral framework and identity to
2. a trade overseen by regulators (i.e., overseers) both public and private,
3. responsible to customers and subscribers (i.e., marginalization of patients as patients),
4. whose professional ethics needed to conform to the requirements of bioethics.
C. A proposed response to the moral identity crisis of contemporary physicians:
1. physicians should challenge bioethics: all content-full moral perspectives are a view from “somewhere”, so that the claim of bioethics to speak from “nowhere” is false,
2. the moral somewhere of clinical experience is essential to providing good health care,
3. and physicians can offer a set of unique insights into the finitude characterizing the human condition, an understanding necessary for contemporary societies.
4. The medical profession must once again appreciate that its medical ethics need not conform to the requirements and aspirations of a general secular bioethics.
III. The deprofessionalization of medicine in the USA was the result of a number of factors.
A. The moral revolutions of the 1960s and 1970s challenged traditional values.
1. USA society moved from being de facto and de jure Christian to being de jure secular.
2. Medicine changed from being shaped by traditional social structures to becoming partially post-traditional. These developments engendered the contemporary culture wars.
3. The moral authority of the professions was challenged and in part deconstructed: traditional authority figures (e.g., fathers, husbands, and physicians) were questioned.
B. A major social, legal, and political reshaping of medicine occurred in the 20th century, so the AMA could no longer state, “All features of medical service in any method of medical practice should be under the control of the medical profession.”
1. Medical ethics and codes of medical ethics possess a substantial history. See, for example, Giovanni Codronchi, De Christiana ac tuta medendi ratione libri duo (Ferrara, 1591); Rodericus Castro, Medicus-Politicus: sive de officiis medicopoliticis tractatus (Hamburg: Frobeniano, 1614); Wolfgang Thomas Rau, Gedanken von dem Nutzen und der Nothwendigkeit einer medicinischen Policeyordnung in einem Staat (Ulm: Stettin, 1764); Johann Peter Frank, System einer vollständigen medicinischen Polizey (Mannheim: C.F. Schwan, 1779); John Gregory, Observations on the Duties and Offices of a Physician (London: Strahan, 1770); Thomas Percival, Medical Ethics (Manchester: Russell, 1803); Medical Association of North Eastern Kentucky, A System of Medical Etiquette (Maysville, KY: Maysville Eagle, 1839); Samuel A. Cartwright, “Synopsis of Medical Etiquette,” New Orleans Medical and Surgical Journal 1, no. 2 (1844): 101-4; and American Medical Association, Code of Medical Ethics (New York: H. Ludwig, 1848). For an overview of this history after the establishment of the American Medical Association, see Donald E. Konold, A History of American Medical Ethics, 1847-1912 (Madison: State Historical Society of Wisconsin, 1962). See also Robert Baker (ed.), The Codification of Medical Morality (Dordrecht: Kluwer, 1995.
2. The profession’s capacity to control the ethos of medical advertising was attenuated: American Medical Assoc. vs. Federal Trade Comm’n, 638F.2d 443 (2d Cir. 1980).
C. The bioethics revolution placed medical ethics within a moral account by laymen. Claims for the authority of clinical moral knowledge were often globally and pejoratively labeled paternalist. Physicians were denied “special” moral knowledge.
1. Bioethics effected a profound change in medicine’s moral identity: bioethics claimed to offer a moral perspective from “nowhere”. Bioethics denied the legitimacy of a professional moral perspective from the thick “somewhere” of clinical experience.
2. Bioethicists entered the vacuum created by the marginalization of physicians and religious ethicists to become the new secular moral theologians and priests; bioethics attempted to become the defining moral perspective for medicine and for medical professionals.
3. Medicine’s internal values derived from clinical experience were explicitly
a. rendered in conformity with the new societal ethics (e.g., bioethics), so that
b. medical-moral specialists are no longer experienced, reflective physicians, but
c. bioethicists, with the result that the moral authority of physicians is discounted.
D. These changes involved both advantages and disadvantages, costs and benefits.
1. Medicine benefited from important reflections on the professional life.
2. Medicine recaptured a sense of its place as integral to the humanities.
3. However, medicine has yet to recapture its own professional moral identity.
E. Challenge: Restoring a medical professional moral identity so as to sustain and nurture the life of the physician as a special moral calling with its own moral integrity.
IV. These changes in moral assumptions that recast the medical profession arose against a background of scientific and technological developments altering medicine’s content and language.
A. The profession had already been reshaped by the new sciences of the 18th-19th centuries.
1. The clinical practice of medicine became dependent on the laboratory (e.g., Giovanni Morgagni, De sedibus et causis morborum per anatomen indagatis, 1761)
2. Sciences such as anatomy, physiology, and bacteriology became basic in the sense that clinical reality was redescribed in basic scientific terms. A new scientific language or medical discourse of medicine emerged, which recast the language of the clinic.
3. Complaints by patients in order to be bona fide required pathoanatomical and pathophysiological truth value; they had to be vindicated by the basic sciences.
4. Observer bias was recognized as a problem to be addressed by means of
a. clinical pathological correlations (the autopsy became central),
b. controlled experiments (the laboratory came to define the clinic), and
c. the statistical analysis of findings (statistics came to guide clinical choice).
5. The Art of medicine became dependent on the Science of medicine.
B. The latter part of the 20th century witnessed the information revolution: the advent of artificial intelligence allowed the rapid accumulation and analysis of data so that
1. a new evidence-based medicine endorsed treatment only when legitimated
a. by an acceptable likelihood of benefit, along
b. with an acceptably low level of morbidity and mortality risks.
2. Detailed quality assessment of health care by non-professionals became possible. Institutions and individuals can often access medical information as well as physicians can.
V. These changes were occurring in the social fabric of medical practice.
A. Physicians have ceased to be primarily solo practitioners. The independent medical professional, largely self-accountable, is being replaced
1. not simply by physicians working in group practice settings, but by
2. physicians often located within institutional settings controlled by large corporations, both for-profit and not-for-profit or governmental, with the result that
3. physician treatment choices are ever more managed by non-treating physicians or non-physicians: increasingly, third parties manage and control medicine.
B. These changes in the physician/patient relationship have made the physician/patient dyad largely anachronistic. Between physician and patient there are now usually
1. payers other than the patient (e.g., the patient’s employer or the government),
2. fiduciaries (e.g., private and governmental insurance systems holding funds from payers for patients), who are stewards of funds and obligations,
3. large-scale health care institutions within which health care is increasingly provided,
4. regulatory governmental agencies seeking to contain costs and protect patients, and
5. managers passing judgment on the appropriateness of medical interventions.
VI. Economic forces have also been reshaping the character of the medical profession.
A. Growth in expenditures proved difficult to curtail because
1. an egalitarian ideology committed medicine to the impossible task of providing
a. the best of care to all (doing all possible to extend life and decrease suffering), and
b. equal care to all (in the face of irreducible biological inequalities),
c. while preserving physician/patient choice
d. and still controlling costs.
2. Only the state of Oregon in the USA could admit that one had instead to be committed to
a. less than the best care for most (termed as at least “adequate” care for all),
b. unequal care (recognizing that nature has created all unequal), and
c. limited physician/patient choice without extra payments, so as
d. effectively to control costs (additional benefits were available only with payment).
B. Because most physicians, politicians, and patients did not wish to admit the impossibility of the egalitarian medical ideology, it became necessary to impose constraints on access to desired and beneficial diagnostic and therapeutic interventions so as to contain costs while nevertheless claiming, contrary to the facts of the matter, that
1. access to important beneficial care was not being significantly limited and that
2. cost restraints have no important impact on health outcomes, and
3. the quality of care could be maintained by management despite resource limitations.
C. Managed care, prospective payment, and other such approaches to cost containment have involved a shift in treatment paradigms undertaken in order to contain costs.
1. Under full indemnity retrospective reimbursement, likely beneficial diagnostic therapeutic interventions for which someone wants to pay are innocent until proven guilty.
2. Under limited prospective reimbursement, expensive interventions (even if associated with few risks) are guilty until proven innocent (i.e., shown statistically to be effective).
D. Note that no health care system can provide “all available” care to all; see Article 57, Brazil’s Code of Medical Ethics.
VII. How in the face of these profound changes can the profession of medicine recapture a substantive moral identity and a sense of professionalism? What can physicians in Brazil learn from what occurred in the USA? One possibility is for physicians and medicine as a learned profession is to be centrally involved in educating society and patients regarding the limits of the human condition. John Kitzhaber, M.D., as governor of Oregon pursued this goal in developing the Oregon Plan.
A. The profession of medicine should help guide public policy and patient choice prudently and honestly so as better to take account of the human condition.
1. As a learned profession, medicine should remind society regarding the intractable diversity of moral visions and the failure of the Enlightenment hopes reflected in the emergence of the original American bioethics; there is disagreement about the meaning of the major passages of life, from sexuality and reproduction to suffering and death. There are disputes about the authority and integrity of the family. These circumstances provoke the culture wars. We do not share one morality. For example, it is not morally self-evident that physicians should not inform parents regarding the diagnosis and treatment of their minor children (see Chapter IX, Article 103, Brazil’s Code of Medical Ethics, 1988).
2. The medical profession should remind society that bioethics did not find a neutral moral vision from “nowhere”.
3. The profession of medicine should inform society that medicine, not bioethics, best understands the moral significance of the character of human finitude as it marks health care. Physicians should be the educators regarding the nature of the human condition. They should be teaching society and patients about the limits of human powers and possibilities:
a. all will die (no amount of resources can prevent this);
b. most will suffer before they die (no amount of resources can prevent this);
c. empirical knowledge (e.g., medical) is probabilistic;
d. resources are limited; and therefore
e. all life is a gamble and therefore medicine is a gamble, in which
f. one generally gets what one pays for (and humans are dramatically unequal).
B. The profession of medicine should recapture its moral self-identity and preserve its own internal moral commitments by not serving the political agenda of hiding the consequences of limited resources or by endorsing a particular view of justice in health care allocations.
C. The medical profession, because it is focused on suffering, dying, and death, should see its moral identity depending on frank disclosure of the limits of human finitude, including the limits of secular morality and bioethics. The medical profession should seek its own moral voice.
VIII. In summary, physicians are members of the profession that deals with human suffering, dying, and death. Physicians can find a professional wholeness and integrity realized through aiding our culture in facing human finitude, our unavoidable limits and inequalities.
A. Physicians should not reduce their moral perspective to the supposed anonymous and universal aspirations of the bioethics that took shape in the 1970s.
B. Physicians should rebuild a moral vision grounded in the somewhere of clinical experience.
C. Physicians should not uncritically accept the bioethical fashions of the age.
