I just returned from a clinical ethics consult. The scenario was all-too familiar: an elderly, very ill patient, who can no longer communicate his wishes; the patient’s family, whose goal seems to be to keep the patient alive as long as possible at any cost, insisting, over the protests of doctor and nurse, that “everything” be done; a physician who is distressed because she knows that the care she is providing at the family’s behest, while featuring the latest high-tech, gizmo- and gadget-heavy treatment, is also disproportionately burdensome to the patient compared to any benefit it might possibly give. In short, the physician feels compelled by the family to give inappropriate care, to violate the basic principle of “First, do no harm.”
I don’t have statistics to prove it, but it seems to me that this type of ethical dilemma, a conflict between patient (or family) and physician — in particular, a conflict manifested as mistrust of the physician — is becoming more and more common. Why?
There are many possible reasons, but one of the most concerning is that patients may not trust that doctors are always acting in their best interests. In other words, they may see physicians as technicians rather than professionals.
Since Hippocrates, medicine has possessed the special status of Profession, with all of the privileges that go with that title. One of those privileges has been professional autonomy: unlike the trades or technicians, which are compelled for their survival to provide whatever the market demands or will bear, the Profession of Medicine was allowed to set its own limits based on a code of ethics. Even if the market demanded that physicians provide the means to kill a person, medicine was implicitly granted the right to say, “We will not do this. We will give no deadly drug, even if asked. We will not give an abortive remedy.”
Now, however, that state of affairs seems to be changing. Some of us physicians have demonstrated that we are willing, in pivotal situations, to act in ways that, instead of adhering to the professional code, acquiesce to society’s demands for everything and everything: from eliminating the unwanted fetus, to questionable enhancement procedures, to deliberately hastening death in terminally ill patients. Because of this, I fear that our profession’s status as a profession is eroding, and along with it, our privilege of doing only what we know to be best for our patients. The more we are perceived as willing purveyors of medical techniques to the highest bidder (or the person with the best insurance), the more we will run into the ethical dilemmas rooted in the suspicion that we cannot adequately govern ourselves to do what is best for patients.