Moral Medicine: Professionalism on East Tennessee Medical News

Moral Medicine: Professionalism

By: DAVID STEVENS, MD, MA (Ethics)

As a child, I was scared to go to the doctor. It seemed there was always a nurse lying in wait with a big syringe attached to a bigger needle dripping some syrupy liquid ready to cause me pain. No matter how much my mom reassured me it wasn't going to hurt much, it never turned out that way.

Fear of physicians is not only common among children but adults, too. Even doctors devise to disguise their discomfort when they are in a patient gown sitting on the exam table. As a patient, you feel vulnerable.

It used to be much worse. Twenty-five hundred years ago when you sought out a physician, you did not know whether he would cure you or kill you. If your enemy paid your physician enough, they would abuse their knowledge of drugs, administer an overdose, and no one would be the wiser.

Talk about being nervous to see the doctor!

Hippocrates changed all that. He realized that the foundation of the doctor-patient relationship is trust. Unless the patient knows that the doctor will only do what was in their best interest, trust cannot exist. Physicians should only heal and never intentionally harm a human being.

The fulcrum of this radical change in medical practice was apprentices taking a moral oath. Before medical education was imparted, students stood before their future colleagues, teachers, and communities to solemnly profess their commitment to how they would use the powerful knowledge that was going to be given. They swore by the gods they recognized with the promise of blessings if they kept their word and curses if they did not.

It worked. People voted with their feet and soon the non-Hippocratic physicians went out of business. This moral foundation of medicine has let Western medicine flourish and develop for millennia.

This is also the reason why doctors and other healthcare personnel were called "professionals." Each one "professed" a standard of conduct. They had established a solemn agreement with God, a covenant, to hold them accountable. They also had a covenant relationship with their patients that governed their actions and priorities. A physician sacrificed and got up in the middle of the night to care for a patient, not because they were paid to do so, nor because they feared being sued, but because that is what a doctors' covenant does. Because of their compassion and sacrifice for the good of others, professionals were revered and respected. They were allowed to govern themselves in large part through professional societies that provided mutual accountability.

Sadly, our professionalism is in decline. Few medical schools require any kind of public profession. Those that do have radically changed the commitment required. Some schools even ask their graduating medical students to come up with their own "oath" as if four years of medical school imparts the wisdom of the ages!

Other pressures have been brought to bear. Our profession is becoming a business. Think about it: We are no longer called professionals but "providers," and patients are called "consumers." Doctors are seen as units of production--vending machines dispensing pills, procedures, and services. Our patient relationships are governed by contracts not covenants, as if to say, "You give me so much money, and I will give you so much service." I don't know about you, but I don't want a doctor who decides to get up in the middle of the night when I have my first heart attack based on the brand of insurance he or she accepts or the amount I promise to pay.

To their credit, some professionals resist this insidious commoditization of healthcare; but the pressure to conform is almost overwhelming. Many doctors have lost their autonomy. Some of it is our own fault. We did not self-govern ourselves well, costs went out of control, business and the government stepped in with regulations, standards of care, reimbursement rates, and much more. Those that control the money call the shots.

The result: collegiality has been replaced by competition. Our professional associations act like labor unions. New doctors are much more concerned about lifestyle and income than in serving the sick. They want to work less, make more, and find their fulfillment outside their "job."

Some of the things we use to swear to never do are now done every day. Trust is eroding, the foundation is crumbling, and many healthcare personnel find little contentment trying to stand on the shifting sand.

Don't despair. There is a solution. We just need to wake up and stand up.

We know what works, so we need to get back to the fundamentals. We need to restore our covenants, refocus our priorities, and resist those that want to strip us of our professionalism. With individual commitment, collegial resolve, and a clear vision of what medicine should be, we can restore our foundations.

David Stevens, MD, MA (Ethics), is CEO of the Christian Medical & Dental Associations. For more information, please visit their Web site at www.cmda.org