ON THE DIMINISHED STATE OF THE MEDICAL PROFESSION

Note to fellow Ricochet members: I have had to take my Ricochet account back from Dr. Publius at this time. As it happens this post (Number 4 of Dr. P’s Medicalist papers), was inadvertently leaked, prior to publication, to a physician colleague, who took umbrage. Regrettable words were subsequently exchanged between Dr. P and this unnamed colleague (obviously, on a site with a less restrictive CoC than one finds here), and as a result the two have agreed to settle the matter in the way of gentlemen, on the Field of Honor. 

I am hopeful Dr. P. will conclude this matter satisfactorily, despite the fact that his old eyes are perhaps not the precise instruments they once were. I have agreed to post this, and the remaining Numbers of his Medicalist papers (which he has fortunately completed), in case the outcome should be unsatisfactory. (Due to my own infirmities of age, I was obligated to pass up his offer to serve as his second.)

The irony is that, in a later Number, Dr. P takes a much more charitable and sanguine view of his fellow physicians than he does here, and had his antagonist read the entire tract (or had Dr. P not been too stubborn to say as much), this gentlemanly discussion they have undertaken might not have been necessary. There is a useful lesson here for those Ricochet members who count themselves among the Whippersnappers: When you become an Old Fart, try not to be too cranky.

Finally, in my role as Dr. P’s amanuensis, I have taken the liberty of revising the title of the Medicalist, to more accurately describe its intent; namely, to explore whether there’s something about the healthcare plan being considered in Congress that makes it worthy of the support of most conservatives.

To the People of Ricochet:

BEING a physician himself, DR PUBLIUS considers it an obligation, in advancing this tract on the healthcare plan being proposed in Congress, to say something about his own profession’s role in healthcare reform. After all, doctors are among the primary actors in the healthcare system, and their professional recommendations go a long way toward determining how much money is spent on healthcare. What doctors believe about the proposed reforms, one might assume, should carry substantial weight.

This will be a relatively brief Number, because as it turns out there is little to say.

For the medical profession, there is one ethical obligation that surpasses all others. It is the very obligation that defines a classic profession, and once it is abandoned, members of that so-called profession no longer have any claim whatsoever to any of the special regard, respect, perquisites, or considerations that commonly accrue to true professionals in our society.

Physicians have referred to this obligation as the doctor-patient relationship. Like the lawyer-client relationship and the clergy-parishioner relationship, the doctor-patient relationship is supposed to be a sacred, protected, fiduciary one, in which the patient can feel safe in disclosing private information they may not even willingly tell their spouses, and in return the doctor agrees not only to keep that information private, but also to act on that information in such a way that furthers and optimizes the individual patient’s own best medical interests, without regard to which actions or recommendations might be to the doctor’s interests — or to society’s.

The abandonment of this sacred, fiduciary obligation (honored by physicians for over 2000 years) cannot be blamed on Obamacare. It was formally abandoned years before most of us had ever heard of Mr. Obama. The doctor-patient relationship, never as pure in practice as it was in concept, began to significantly erode in the 1990s. This, of course, was the heyday of for-profit HMOs, when the insurers used extreme coercion to make certain that doctors learned who their real customers were. Doctors who did not place the payers first had their reimbursements slashed, and often found themselves excluded from panels, and therefore from access to patients. In a surprisingly short time doctors by the thousands were signing “gag clauses,” in which they agreed to withhold from patients certain information that might be adverse to the interests of the HMOs.

It would be wrong to say that doctors did not mind these things. It troubled many of them deeply. Indeed, by the turn of the millennium many members of the profession were feeling, and occasionally publicly expressing, tremendous guilt for having had to abandon their chief ethical obligation to their patients, in order to continue practicing medicine.

Faced with an ethical dilemma which was increasingly difficult for them to tolerate, an outcry arose from within the medical profession demanding that their leadership take up the problem, and do something about it. Most doctors had in mind some sort of organized action by which the profession would attempt to reclaim its ethical grounding. And so, conferences were convened, debates (of a sort) engaged in, and at last, action taken.

What doctors in the trenches failed to realize was that the physicians who dedicate their careers to leading professional organizations are almost always Progressives, because this is what Progressives do. So the action that was finally taken was the official adoption of a new set of medical ethics, which was published in 2002: “Medical Professionalism in the New Millennium: A Physician Charter. “(Annals of Internal Medicine, February 5, 2002). This document described a new ethical precept which was to be formally adopted by the medical profession. That new precept was, of course, “Social Justice.” Under the precept of social justice, doctors, in making medical decisions at the bedside, suddenly became obligated to take the equitable distribution of healthcare resources into account. Covert rationing at the bedside at the behest of payers (who presumably knew more about equitable distribution of resources than individual physicians did), was not only acceptable, and not only a positive good, but an ethical requirement.

During the intervening years this new charter of medical ethics was indeed formally adopted by virtually every medical professional organization in the world.

Adding social justice to the ethical obligations of physicians or course did nothing to ease the discrepancy between the needs the patient and the needs of the payer. But its addition at least assuaged some of the guilt of some of the doctors who chose not to think too deeply about it.

This modernized, progressive version of medical ethics was not the result of Obamacare, but it has served Obamacare well. It was a matter of mere moments before doctors noticed that it would behoove them to shift their efforts from making the insurers happy to making the government happy.

Today, when a doctor makes a medical recommendation to a patient, that patient can no longer be confident that the recommendation is truly the one the doctor believes is best for him or her. For it may instead simply represent what the doctor has decided the patient deserves, given his/her needs in relation to the needs of all the other patients in the Accountable Care Organization, the state, the country, or the world. (The range of patients encompassed by the directive to “fairly distribute” resources turns out to be quite fluid.)

If we Americans ever do regain control of our healthcare system, and are successful in redirecting its efforts away from the benefit of the herd and back to the benefit of individual patients where it belongs, our physicians (most of whom, by this time, have been trained in the New Ethics from the beginning of their careers), will need to attend some type of re-education camp. (Our Progressive friends can probably help us in setting these up.)

In the meantime, having abandoned their defining ethical obligation, doctors and their opinions on healthcare reform, or on any other matter of public importance, can be listened to politely if we are feeling generous. But we should feel no real obligation to take them seriously, and we are free to proceed without them.

DR PUBLIUS

For anyone interested, here are links to all seven Numbers of Dr. Publius’ Medicalist papers:

The Medicalist No. 1 – ON WHY WE SHOULD CONSIDER A DISAPPOINTING PLAN

The Medicalist No. 2 – ON THE THREAT POSED BY THE COST OF HEALTHCARE

The Medicalist No. 3 – ON THE RELUCTANCE OF THE HEALTH INSURANCE INDUSTRY

The Medicalist No. 4 – ON THE DIMINISHED STATE OF THE MEDICAL PROFESSION

The Medicalist No. 5 – ON THE REQUISITE FEATURES OF AN ACCEPTABLE PLAN, PART 1

The Medicalist No. 6 – ON THE REQUISITE FEATURES OF AN ACCEPTABLE PLAN, PART 2

The Medicalist No. 7 – ON WHY CONSERVATIVES SHOULD, AFTER ALL, SUPPORT THIS PLAN