Safeguarding Our Stories, Our Selves

While having a “sit-down-family-meal” with a son and his family over the recent holiday weekend–something that happens far too infrequently in families today—our six-year-old grandson attempted to leave the table during the post-meal conversations but was restrained by his mother. “Conversations are boring,” was his frustrated response to his unpleasant imprisonment. His response brought to mind a similar attitude in another 10-year-old grandson who refuses to talk on the phone—he will only text, because “talking is boring.” This appears to be a disturbing mark of the future generation, a generation that cannot and will not converse but only connect using sound-bites, ungrammatical phrases, and acronyms. One can only wonder: what will their future relationships be like?

This generation has more opportunities for communication than any in the history of the world, yet this communication lacks authenticity, for there is no sense of communing in such interactions, no sharing of stories or stepping into the story of another. There are faces and images, but no conversations–and no stories.

But we are a storied people. Whether that story is individual or corporate, stories are vital to who we are as individuals and as a society. Stories do more than simply recount—they create identities and engender meaning. It is stories that give meaning to our lives, for without stories there is no meaning.

As social beings, our personal identity is forged in the perichoretic dance of selfhood, a reciprocal encounter of the self and the other (and of course, for Christians, that ultimate Other is God). Our storied lives cannot be disentangled from the stories of others for our sense of self is determined by our narrative interaction with and response to the other–our self-understanding is shaped by our encounter with the stories of others.

This is no less true in medicine where our professional identity is fashioned in the encounter with the narrative of the embodied other. But scientific, business and industrial models of health care have distorted the professional model of patient care: the other is now dissected, systematized, quantified, and placed into diagnostic boxes and treatment algorithms. Narrative identity is lost in the binary operations of electronic medical records, where there are “faces”–but no story. Technocratization has objectified the other; and as Buber has stated, the I-Thou relationship of encounter has become the I-it relationship of experience. Strict reliance on experience to the exclusion of encounter induces interpersonal meaninglessness, angst, and loss of trust. And there can be no authentic relationship where there is no trust. The objectification of the other has also tainted the professional identity, impeding the necessary sense of response-ability of the physician to the other. The result is service, not care.

Industrialized modern medicine strives for efficiency; it seeks standardization and reduction, eliminating specifics, reducing all to generalities. It is, in fact, a microcosm of our social maladies. But narratives are not efficient. Narratives, like flesh and bones, do not fit into algorithm and template boxes. They cannot be standardized or reduced. They are racemose, intertwined, interconnected webs of experience that simultaneously serve to distinguish us as individuals and bind us together in community. And they are vital to the experience of empathy and compassion.

And so was my grandson’s retort merely childish bravado or a painfully prescient prophecy? Will relationships of future generations be based on experiential façades or meaningful encounters with the other? If there is no encounter of dialectical narratives, who will we understand ourselves to be? Will medicine be any different? Can the “care” in health care survive the objectification of the other? Most importantly, is there nothing that can be done to preserve our narratives and safeguard our stories, whether in health care or in life?

Objectifying Patients, Roboticizing Physicians

One of the things I have always enjoyed about teaching is the fact that in the process of doing so, I, too, learn. Concepts that are vaguely understood become clear; relationships between circumstances and events become more well-defined. That was true again as I recently led a workshop on Transitions in Clinical Medicine for CBHD’s summer conference, where it became apparent that the primary experiential change occurring in medicine today is the loss of the physician-patient relationship; and that the two primary forces driving that change are the loss of physician independence and a shift in medical focus from the health of the individual patient to population health.

The physician-patient relationship (and here I will use the traditional terminology, although in today’s health care market that is often expressed as “provider-consumer”) has traditionally been the heart and soul of medical care; and independent physicians, by proclaiming and maintaining the sanctity of this covenantal relationship have been able to deter much governmental interference in the profession, and more specifically, in the care that they render to their patients. In recent years, however, there has been a move of physicians from private, independent practice to group practices, and now to hospital employment, a move that has been motivated by increasing regulatory requirements linked to reimbursement. But this move has had profound consequences for the physician-patient relationship, for that relationship is no longer primary: physicians now have a new master—and it is not the patient; they are now beholden first and foremost to their employer, who is subject to governmental regulatory control. A wedge has been driven in the physician-patient relationship; its sanctity has been violated.

Secondly, but not unrelated, whenever governmental money is involved in any issue or problem, the government must first define the problem and then mandate the solution. In medicine, this has taken the form of redefining the physician-patient relationship and objectifying the patient. Traditionally, the primary focus of a physician was the relationship with the person who presented for care, always keeping responsibility to the greater society as the horizon against which the current relationship was set. But no longer is our relationship primarily with the individual; the government is redefining our primary relationship and responsibility as population health. We are to practice, not according to the needs of the individual patient but according to statistics; we are not to focus on improving the health of the population one person at a time (which is too inefficient), but to focus our efforts on improving the health of the population in the hope that it will “trickles down” to the individual.

But population statistics correspond poorly to any particular patient for patients are persons, not statistics. Their lives are defined by stories, not facts. And yet that is increasingly what our template and algorithm boxes force us to obtain: “Just the facts, ma’am; just the facts.” In the electronic medical record (EMR) we have “faces,” not stories: there is no place for narrative in the EMR.

These two forces are changing medical care as we have known it. The EMR—a governmental requirement–has been an instigating factor—the leading edge of the wedge—forcing us to turn our backs on the patient and our faces to the computer. One can only wonder at the future of medicine as technological progress marches on in the light of governmental control, as narrative is reduced to facts, as relationships are subordinated to data, as quality of care is depreciated to value, as complex problem-solving skills are lost to clicking buttons and filling in boxes, as medical care becomes roboticized. Will robots be our replacement? Or will that, indeed, be what we become…?

Making Babies; the New “Normal”

Once upon a time in a fairy tale land that now seems far, far away, young people fell in love, got married, and started a family. But the idea of “starting a family” has taken on new meaning as pregnancy has come under the rubric of technological control. Increasingly, it is not about having children but about “making babies.” With the advent of technology and its encroachment into the world of prenatal care, “tests” and “prevention” have replaced “touch” and “protection,” and pregnancy has become an aggressively managed 9-month illness that culminates in delivery. A time of joyous anticipation has been transformed into a period of anxiety-laden responsibility—responsibility for producing a perfect product.

This phenomenon is about to escalate as leaders in the American College of Obstetrics and Gynecology are now advocating a new addition to the armamentarium of obstetricians: universal prenatal genetic counseling. In an article in this months Obstetrics and Gynecology entitled, “The Case for Universal Prenatal Genetic Counseling,” the authors argue that the array of available genetic information and testing is expanding exponentially and far outpacing the ability of an obstetrician to keep abreast and to provide accurate prognostic information to expectant parents (note that the adjective “expectant” also takes on a new ring of anxiety). Therefore, prenatal genetic counseling should be part and parcel of every pregnant woman’s prenatal care package, as is the current prenatal screening.

Indeed, we do indeed have lots of data, and an increasing number of tests and options for providing us with even more data, but skepticism queries: do we have knowledge? The two are not the same. Do we truly know which of the many genetic variants that we might be able to identify are meaningful or significant? Furthermore, what recourse is available at this point for addressing any of the variants that might be identified? The answer: none but destruction of the potentially imperfect specimen.

No doubt these recommendations are spawned from legal considerations: the desire to protect practitioners from litigation for an inability to give adequate informed consent and resultant charges of wrongful birth that might ensue. Such a desire is noble, but then one must ask: who are we in fact treating? Are we treating babies or our own professional and parental anxieties?

No doubt, technology has benefited many expectant parents and their children, but this once again becomes an issue of boxes—of putting everyone into the same undiscerning “prenatal box.” It is certainly “democratic;” but it is unlikely that every parent needs or desires such information. Furthermore, we will be laying enormous and overwhelming responsibility and guilt on the heads and hearts of many parents unnecessarily, and in the process, will be stealing from them the anticipatory joy of child-bearing–or have we done so already? And how many discarded healthy babies will be left in the wake, when, in the midst of uncertainty we err on the side of responsible caution, allowing our anxiety to rule by eliminating potential problems?

The eternal ethical question arises: just because we can, should we? Yet, is it possible for us to ignore what we “know” or think we “know”?

Will our children never know the joy of a “normal” pregnancy? Will they never again have the luxury of having children in blissful ignorance? I fear that this new anxiety- and responsibility-ridden micromanaged way of making babies–rather than having children–will, for them, become the “new normal.”

Autonomy and Moral Status Revisited

While Steve Phillips and I have been giving this issue a lot of recent “air time,” I want to continue the discussion from my last post of an article in Obstetrics and Gynecology entitled “The Fetus, The ‘Potential Child,’ and the Ethical Obligations of Obstetricians,” examining some of the ethical assumptions contained therein.

The underlying presupposition of the authors is rational (and radical!) reductivism: the fetus is merely what we can see with our eyes and measure with our scientific tools. Curiously, they mention the “dual status” of the fetus, but quickly redefine that duality, not as consisting of both body and soul, but as consisting of both an objective and subjective nature: objectively it is (nothing more than) a “non-viable mammal in a uterus;” subjectively, it is “the spark of a future son or daughter” to its parents. In other words, the distinguishing feature and value is not something inherent in the fetus but ascribed to it by a third party, in this case, the parents.

Sadly, we have learned to see with our enlightened, scientific eyes, eyes that are blind to the meaning and significance of what is seen; for our scientific eyes have lost the ability to behold. Parenthetically, the word “behold” is a fascinating one: it occurs over 1200 times throughout Scripture, but is often perceived to be an idiosyncratic expression that is hastily retranslated. Given the importance of “sight” in Scripture, however, the term often has far deeper significance. And what is it that we have lost the ability to behold? We have lost the ability to behold the moral beauty of nascent human life—that created beauty mentioned by Steve Phillips.

There is a repugnantly selfish and utilitarian calculus embedded in such thinking, one that is contra-Kantian as well: this being is only of significance if it somehow beneficial or useful to us.

This entire issue is grounded in a misappropriation of autonomy—the autonomy of the mother. Parenthetically, again, one should note that this is a term that is never used in these discussions–the disaffected term “woman” is used instead–for “mother” implies relationship, and it is that very relationship that is being denied and rejected. But autonomy, in the original Kantian sense, involved conducting oneself in the light of truth and acting as a responsible member of a moral community. To our diminishment we have rejected that understanding of autonomy in favor of the Humean version: autonomy as the capacity to act on selfish needs, wants, and wishes informed by instrumental reasoning.

Perhaps that is the only way that those who wish to preserve a “right” to abortion can morally justify their position: by denigrating the moral and material status of the fetus.

It is true that our personhood is contingent and relational; it is derived from our relationship to our Creator whose care and concern extends particularly to the weak and vulnerable. As humans we are beings-in-relation, and that primary relationship is with our faithful God in whom we “live and move and have our being.” It is a relationship that precedes any other and exists whether any other human acknowledges it or not. Hence our personhood and moral status is contingent not upon the fickleness of other humans but on the faithfulness of our loving Creator God.

Autonomy, Moral Status, and Consequential Conundrums

At times our unreflective declarations, pronouncements, and moral positions made without adequate forethought consequentially lead to moral conundrums, with which we are then left to wrestle. A recent article entitled “The Fetus, the “Potential Child,” and the Ethical Obligations of Obstetricians,” in Obstetrics and Gynecology exemplifies an effort to reframe just such a conundrum. In this article, the authors attempt to justify a physician’s obligation to deny maternal requests that jeopardize her unborn child without rationally jeopardizing her right to abort the unborn child if she so chooses. Secondarily it addresses the issue of how an obstetrician is to define his or her moral responsibility to a being in utero.

Quickly setting aside the issue of abortion, which is stated to be grounded on the essentially unassailable right to bodily integrity (“negative” autonomy) and supported by “mainstream” ethical opinion, the issue of “positive” autonomy is addressed: are there limits on the right of a woman to demand treatment that negatively impacts her child? Acknowledging that physicians also possess negative autonomy rights and consciences (defined as “professional integrity”), on what basis can a physician refuse a maternal demand for treatment or care that is not in the unborn child’s best interests? The answer: distinguish “fetus” (having “value” but no interests) from “potential child” (having anticipatory interests that will “evolve and ultimately attain at delivery”). According to the authors, the fetus has no independent moral status because the issue is “irresolvably disputable,” confirming the arbitrary nature of that determination. So what is it that determines this distinction in moral status? Maternal choice. By the decision to eschew abortion and continue the pregnancy a woman grants moral standing to the child within while simultaneously constraining and limiting her own affirmative autonomy. This decision also enables the physician to resume the fiduciary role to the unborn that has traditionally been entailed in the care of pregnant women.

And so in an attempt to keep previous moral proclamations from overflowing their banks and being carried to their logical conclusions—conclusions which would invalidate our standing as providers of obstetrical care–they are shored up by creating new categorical boxes. But as I am so fond of saying these days, flesh and bones do not fit into boxes without remainder; embodied life is not that simple. Having created the box labeled “potential child” it is then poked full of “subjunctive” holes that make room for contingencies: “the interests of the potential child might infringe on a pregnant woman’s right…”; and “as those interests (of the fetus) rise to a level at which they can be considered…” Oh, what tangled webs we weave!

Life is fragile; and from this particular perspective, so is our moral standing as human beings, contingent as it is upon the good graces of those upon whom we are relationally dependent. Our moral agency becomes not something inherent in our nature as beings created in the image of God, but a goal to be attained–not by any act of our own but by the circumstantial whims of another.

Treating the concept of moral standing with irreverence has greater implications for other vulnerable humans as well, dependent as they often are on the grace of others for their care. Their moral standing is also now jeopardized, hanging in the balance.

And so we must return to the basic questions, as difficult and painful as they might be: What is the source and meaning of our moral standing? Who has the authority and right to determine the moral standing of another human being—and on what moral ground?

In playing with the concept of moral agency, we play with our human nature and identity; and we do so to our own detriment. In our efforts to distinguish grounds for granting degrees of moral status to the unborn in order to support our own changing personal and political agendas, we dehumanize ourselves. Moral agency has become so capricious, arbitrary, and contingent as to be meaningless.

Unyoking Employer-based Health Care Benefits

It is amazing how quickly a benefit becomes an expectation becomes a right. Our immersion in the present blinds us to the recent past from which we have just emerged. The phenomena to which I am referring are employer-based health care–and contraceptive–benefits.

The idea of social insurance originated in the late 19th C in Europe, but took root more slowly in the US. Here the most popular form of social insurance in the early 20th C was “industrial” life insurance, providing funds to cover the expenses of the final illness and burial. “Sickness” insurance, where it existed, arose primarily for purposes of financial stabilization during illness, and were initially offered as a benefit by employers to enhance worker loyalty. Actual “health” insurance was a later addition.

But even with the advent of health insurance, “health” and “health benefits” were narrowly defined. It is only within the last decade that insurers have begun to include contraceptives in their benefit package. Prior to that the only form of contraceptive covered was sterilization. But that benefit has morphed quite quickly in the social rhetoric to an expectation and a right.

An editorial in the NEJM, January 2014, entitled “Contraception at Risk,” cites the two cases currently before the US Supreme Court arising from the ACA mandate: Sibelius v Hobby Lobby Stores, Inc. and Conestoga Wood Specialties Corp. v Sibelius. While the editorial avoids explicit use of the term “right” in reference to the provision of contraceptive benefits, the idea is implicit in the it’s reference to contraception as a “compelling public health need” and as an essential ingredient in “high-quality medical care” (others, like R. Alta Charo, J.D. are not so nuanced). Furthermore, the authors make the lofty and vaporous claim that “the welfare of the patient must trump the religious convictions of her employer…for after all, it is the woman, not her employer, whose health is at risk.” Such claims fail to acknowledge that while some contraceptive agents are an option for treating some medical conditions, the primary indication for their use is not medical care but life-style management.

But this raises a provocative question: why do businesses remain in the health care benefit business? Why should businesses, many of whom are struggling to maintain financial solvency during these times of economic uncertainty, continue to subsidize health care for their employees? Why should health insurance remain yoked to employment and employers? In reality, that is one of the factors contributing to the high percentage of un- and under-insured in this country—the fact that those who are unemployed or part-time employees are denied benefits. Perhaps it is time in this country to sever health insurance from employment and make it true “social insurance” putting it in the hands of the government or government-subsidized insurance plans. That would end part of the controversy over contraceptive coverage, allowing businesses to focus on their business, not health care coverage, and allowing persons to purchase subsidized plans that met their needs, eliminating questions of conscience. Such a move would lay to rest an area of considerable political strife that divides us all.

What would be required? A voluntary and consensual agreement on the part of all businesses (or alternatively, a governmental mandate–the former is preferable) to cease provision of such benefits to their employees, returning those savings to them in the form of higher wages which employees could then use to purchase their own plan. For those businesses that refused to do so in an attempt to maintain a competitive edge, there could be governmentally-imposed financial penalties.

Employer-based health care benefits has been just that–a beneficent benefit, not a right. But now, as an expectation, it is no longer a gift. It was a good idea in its time, but one whose time in the sun has come to an end. So it is time to shift the responsibility for this expectation elsewhere, and the only other logical entity is the government. “But,” some would argue, “that would allow too much governmental intrusion into the health care—into the profession of medicine!” To that I would say, “Wake up, Goldilocks. There is not only an intruder in your house; he’s already sleeping (and snoring loudly) in your bed.”

Reflections on the Metaphors We Live–and Die–By

Images powerfully impact how we think and how we live. Metaphors, those images we use to describe the indescribable, to portray the unfamiliar and mysterious, are particularly so because of the identity relationships they create. In my last post, I commented on an article in the NYT entitled, “A Tumor: the Embryo’s Evil Twin,” which described the similarities between embryogenesis and the cellular behavior of malignancies. But the article alluded to more: to the metaphors we use to understand the two—to metaphors of life and death.

The article referenced Susan Sontag’s metaphorical description of her tumor as “alive,” as a “demonic pregnancy,” as a “fetus with a will.” Sontag used metaphorical images of life to portray the powers of death, but the tables turned quickly as others used images of death to portray life, making a mockery of the fetus by comparing it to an invading, parasitic tumor, images which gave rise to such movies as “Invasion of the Body Snatchers,” “The Blob,” “Alien,” and “Rosemary’s Baby.” No longer were death-producing forces described in terms of life, now a life-giving process was identified with death, supported by powerfully gruesome imagery, imagery that unfortunately remains semi-permanently burned into our minds’ eye.

Ironically, the use of these metaphors has the paradoxical effect of personifying tumors (“a fetus with a will”) while simultaneously depersonalizing the fetus (“a blob of cells). And if we can use warfare imagery located in such terms as “battle,” “fight against,” “survivor,” to depict our treatment of death-producing personified malignancies, how easy it is to carry those same metaphors over to the control of life-giving depersonalized ones (the meaning of the Greek root, metaphoro is, indeed, “to carry over” or “to carry between”). We utilize similar chemotherapeutic substances to control both. But control is the best we can accomplish: we can destroy life, but cannot give it. We can “win” some marginal “skirmishes” and postpone death, but cannot destroy it…

In truth, we are enslaved by our fear of death (Heb 2: 15), and we are not skilled in concealing our chains. Our lives are marked by our futile attempts to gain some measure of control over it by associating it in our minds with what we can control—and destroy. But in the process we create undesirable images of life, images that mock and devalue it.

The article emphasizes the genetic similarities between processes that lead to life and those that lead to death. Life, however, is not reducible to death; yet, life gone awry does lead to death. It is therefore not surprising that the same processes that are purposely designed for life can, in our fallen world, mindlessly destine death. For the processes of death are not a matter of an evil “will,” as Sontag states, but rather of our corporate fallen human will.

Yet ironically and hopefully, in God’s world life comes from death. For it is through the death and resurrection of Jesus of Nazareth, Jesus the Christ, that we humans have life, true life, life free from our enslavement to the fallen life-giving processes that now bring death.

This holy weekend when life and death hang in the balance, may we realize that death is not the final word; that the One who gives life has also brought life from death. He alone has destroyed death for us and offers us freedom from slavery to our greatest fear.

The Genetics of Life and Death

Having long been fascinated with embryology, a recent article in the New York Times entitled “A Tumor; the Embryo’s Evil Twin,” captured my attention. The article delineated the similarities between the genetic processes that govern both embryological development and tumor growth, also alluding to the metaphors we use to describe the “mysterious.”

The article referenced Susan Sontag’s 1978 book, “Illness as Metaphor,” as well as her unfortunate descriptions of her cancer as a “demonic pregnancy” and “a fetus with its own will,” metaphorical descriptions that she ironically decried in her book. There are, however, many sobering similarities between the processes involved in the embryological creation of new life and the malignant destruction of established life including the rapid proliferation of cells, the ability to invade host tissues, the capacity for angiogenesis for establishment of a blood supply for nourishment, and the ability of cells to “metastasize” (forming new body parts or spreading destruction through body parts). But there is also a crucial difference: the processes that create new life are orderly, controlled, and limited; those that destroy life are not. The process of apoptosis, the dying off of superfluous cells, a process that shapes and limits the proliferation of cells in the developing person, setting boundaries on growth, is one such factor in embryological growth absent from tumor growth. Furthermore, the ultimate “invasive” growth of the unborn human being is bounded by complex processes that result in its expulsion into semi-independent extra-uterine existence; such is not the case with malignant processes where untrammelled growth is bounded only by the destruction and death of the host.

But it seems that there is something more: there is something inherent in the organism as a whole that promotes, directs, and limits cellular growth, something we’ve known for some time but chose to ignore a few years ago in all of the media hype surrounding the “promises” of embryonic stem cell therapies. Such hype “apoptotically” died out when it was discovered that embryonic stem cells—cells originally destined to become part of a human being—lost their direction and purpose when removed from the developing person, growing uncontrollably, and resulting in tumors and malignancies. Cells capable of purposeful development into a living person, when removed from the person, were capable of malignant destruction.

It is curious that Sontag described her cancer as a “fetus with its own will,” when the possession of a “will” is characteristic of the human person and has been historically linked to the presence of a soul. In fact, a cancer is not even metaphorically “a fetus with its own will,” but cellular growth run amok without direction, purpose, or a will.

What is it about the organism—the developing person–that controls cellular growth; that directs and limits the formation of new life from a cluster of undifferentiated living cells; that allows purposeful growth, enabling an unborn person to draw life from the mother for a time without destroying her? Could it, perhaps, be the soul?

When Guidelines Become Mandates and Means Become Ends

A recent report in the NEJM reviewed and extrapolated the new guidelines of the American College of Cardiology and the American Heart Association for the “treatment of cholesterol,” guidelines which would expand the numbers of U.S. adults “receiving or eligible” for statin therapy by 12.8 million—a nearly 30% increase. The increase would occur on the basis of a calculated–not real–10 year risk of cardiovascular event and would be greatest among those in the older age group (60-75). The authors of this article merely calculated data; they made no comments on the costs or ultimate outcome of implementation of such guidelines on morbidity, mortality or overall health of the U.S. population.

Guidelines and algorithms are a good thing, especially given the increasingly dynamic complexity of health care, and I am grateful for them. They are essential tools for assisting physicians and providers in navigating the ever-changing alternatives for treating many conditions encountered by their patients. In fact, a copy of the most recent document containing 20 pages of algorithms for management of abnormal pap smears AND one for management of abnormal cytology–algorithms which seem to change annually at least—occupy sacred space beside the computer in my office.

But the concept of “guideline” is changing rapidly. Guidelines were intended to be an adjunctive tool, an instrument to be used in conjunction with clinical judgment and considerations of patient context for management of various health conditions; as such they were to be ONE means to the end of patient care. However, clinical judgment as well as patient context is abolished by such management plans; and guidelines suddenly become not a means to optimal patient care, but the end of care itself. And as an “end” they slip surreptitiously into the murky waters of “mandate.”

Serving on several hospital committees has illuminated how this works. Once a guideline is established, and a “stamp of approval” is placed on it by the specialty colleges, there arises an expectation that it will be implemented and followed. On the heels of expectations come studies that evaluate “compliance,” studies that generate editorials in major journals that chastise those who fail to comply. From there the stage is set for third parties to link reimbursement to compliance with those “guidelines.” The first “third party” is almost always the government, and from there all other payors follow suit. Suddenly what was intended to be a means–a tool–has become an end in itself; what was intended as a guideline becomes a mandate. This scenario is exacerbated by the increasing change of physician status from private practitioner to hospital employee: hospital purchases of private practices has increased 30-40% in the last 5 years, a move promoted by the ACA. Physicians and providers are now increasingly subject to third party bureaucratic management of hospitals and hospital reimbursement issues.

What is the problem with mandates? First of all, “flesh and bones” do not fit into algorithm boxes without remainder, and that remainder—the person who presents for care–is always significant. Secondly, mandates eliminate more than clinical judgment; they eliminate informed consent. HPV vaccination is an odd example. Immediately after its release by the FDA, there was an egregious move to mandate HPV vaccination that failed. Despite the mandate failure, however, the expectation was so powerfully set that it was lumped into a set of vaccinations to be administered at a particular childhood age. And when that happened, like all other mandates, there was no longer any effective informed consent given for the vaccination. After all, does any practitioner really have time for a thorough discussion of what we know and DON’T know about HPV and HPV vaccination? In patient populations where socioeconomic levels are higher, patients often have the resources to be informed about treatment options—if they can wade through all of the media spin and hype. But in more impoverished populations, where patients are not already informed, their options are going to be limited by provider compliance with moneyed mandates, and informed consent will be absent.

Guidelines are but one tool in the doctor’s bag, in our armamentarium for the “war against disease and death.” It cannot and should not replace all other tools. We would not expect our auto-mechanic to be restricted to only one tool, nor would we be pleased if he was forced to relinquish his expertise and judgment. Why do we treat our own health differently, allowing third parties limit our tools, jettison clinical judgment, eliminate informed consent, and mandate our health care? Answer: money.

I confess that I am torn. I do not believe that health care is a right: I believe that it is a responsibility. As a wealthy nation, we have a responsibility to see that all citizens have a basic level of care. I believe that the “we” originally referred to the profession; but “we” dropped the ball when third parties entered the game with deeper pockets; now the only player that can pick up the ball is the government. As I mentioned in a response to a post on 1/27/2014 regarding infertility, when governmental money is involved in any issue or problem, the government must first define the problem—and mandate the solution. But, as stated in the NYT article above, in a government run health care chess game, both the physicians and the patients are nothing more than pawns. Is there no other solution?

Codes and Contracts: Democratizing Professional Ethics

What exactly is the nature of a professional code of ethics? That is the question raised by a recent editorial in JAMA which affirmed recommendations for the development of a new, unified code of ethics for health professionals by the Institute of Medicine’s (IOM’s) Global Forum on Innovation in Health Professional Education workshop. But perhaps more significantly, what the IOM proposed is not a new, transdisciplinary code of ethics, but a “social contract” that will govern the work of health care professionals and their roles and relations in society. While the former is, in part, appropriate and commendable, the latter is not; for the IOM has misapplied the concept of social contract and disemboweled the concept of a profession.

Citing Rousseau as a prime example, the authors of the editorial define social contract “an agreement among members of a society to cooperate for social benefits,” maintaining that “professions also require social contracts, wherein professional groups acquire social prerogatives in exchange for promises regarding expertise, group self-regulation, and service.“ But then they err in linking codes of ethics with social contracts, averring, “Professional obligations under these social contracts are often expressed in codes of ethics.”

A social contract as originally defined was a political theory that concerned the legitimacy and authority of the state over the individual: individuals consented to surrender some of their freedoms in submission to an authority in exchange for protection of their rights. It entailed a relinquishment of natural rights and freedoms to obtain benefits of the political order. It had—and has–nothing to do with “codes of ethics.”

So where did the authors come up with the erroneous association of codes of ethics and social contracts? Perhaps from the AMA itself: a precedence was set when the AMA used the term “social contract” in their 2001 Declaration of Professional Responsibility—the subtitle of which is “Medicine’s Social Contract with Humanity.” But in fact, the Declaration is no social contract at all, but a global code of ethics.

What both the AMA and the authors have done is confound the concept of a code of ethics with a social contract. But to reiterate, a code of ethics is NOT a social contract. The profession of medicine, as traditionally understood, is a moral endeavor—a moral art—necessarily entailing the activities of moral agents. Historically these activities have been bounded by internally-derived moral constraints and virtues determined by the profession itself or by its nature, not externally-imposed rules and regulations. A professional code of ethics is the conscience of a profession, a delineation of these internally-derived values for conduct and behavior of its members, entailing the standards of excellence and honorable behavior expected of its members. These intrinsic values and moral commitments involve more than minimalistic prohibitions; they are integral to the character of the physician and shape the professional relationship, supplying its bounds, and guiding the employment of technique in the service of the patient.

Moreover, moral obligations can only be accepted by free choice; they cannot be mandated or imposed on a moral agent, for as long as one is not directing their own activity, they are not responsible, and hence they are not a free moral agent. A professional code of ethics is not and cannot be an externally imposed set of rules and regulations.

The term “enforcement” also appears in the IOM’s recommendations, further evidence of their confusion about the nature of a profession and of a professional code of ethics. They recommend development of new institutional frameworks for enforcing these standards—standards determined by the public, not by the moral agent themselves. In other words, they are not talking about “codes of ethics” at all, but about laws.

A final “insight” from the IOM workshop was the “principle of reciprocity” as the foundation of the code of ethics: reciprocity would determine “what health professionals should expect of each other, what society and individuals should expect from health professionals, and what health professionals should expect from individuals and society.” But can a society really commit to reciprocity in health care? Caring for the sick and vulnerable is not a reciprocal arrangement. It could theoretically entail refusing to care for those who didn’t meet the standards set for individual responsibility in health care.

While the IOM’s recommendation of a transdisciplinary code of ethics to govern all health professionals is commendable, their concept of it as a social contract is not. Social contract theory applies to the legitimacy of governmental authority over individual freedom, not health care. As such it belongs to the arena of licensure, not codes of ethics, which are distinct entities. As a moral art, a profession is bound by its commitment to a set of intrinsic values and moral convictions in the exercise of its skills. In medicine, this is distinguished by the concept of an oath by which the physician professes total commitment of their medical skills to the well-being of the patient within the bounds set by the profession. Confounding codes of ethics with social contracts and instituting regulation of moral determinations will irreparably alter professional obligations and further threaten the profession of medicine as it has been historically understood.