Recent posts by Drs. Gibes and Haack state that a recapturing of the ends of medicine—what medicine is about—is urgent, and any reassertion of those ends should be led by physicians. I agree (even if some of our exchanges expose areas of disagreement, particularly about specifics of public policy). When we say that the ends of medicine must be reclaimed, what do we mean?
This question prompts me to ask about a philosophy of medicine. Dr. Pellegrino articulated the fullest such philosophy I’m aware of: medicine is a true calling, a profession, not a job or a business; it is characterized by a covenantal relationship between physician and patient; duty requires the physician, from time to time, to efface his self-interest in favor of the patient’s interest; and so on. (I do not hope to write an adequate summary of Dr. Pellegrino’s philosophy here, I simply mean to remind us that he has spent a lifetime developing it.) I also recall, again, the characterization I heard from Dr. Samuel Thier, years ago, of members of a “learned profession”: they are committed to lifelong learning, they police one another, and they value performance over reward.
It seems to me that everyone whose name is followed by the letters M and D (present writer included) must come to terms with these viewpoints, regardless of where he is stationed within the sprawling enterprise we call modern medicine. It also seems to me that the sprawl invokes a thicket of often-competing duties that can complicate efforts to step back and unpack the proper ends of medicine. It further seems to me that the task of restating the ends of medicine might be simplified by starting with the perspective of the individual practitioner—a perspective that I invite my fellow bloggers, who take care of patients (I don’t, any more) to take the lead on.
How might this project proceed? I take the perspectives of Drs. Pellegrino and Thier to be axiomatic. I also take as axiomatic a commitment to the life and dignity of each individual patient, a commitment to human exceptionalism, and a commitment to defend what bioethicists call “the therapeutic boundary.” That said, I suggest that a renewed discussion of the ends of medicine might break out such specific questions as:
1) As Dr. Haack seems to be asking, what is the scope of medical care that mercy requires we advocate be offered, at equal practical opportunity, to all humans?
2) If choices must be made among the items included in 1), which of their costs ought to be socialized (through public or private means)? Or, conversely, are there any medical costs that ought not be socialized? In other words, what should the physician demand his healthy neighbor pay for, on behalf of his patient, and what are the limits of that authority?
3) If “good medicine” is, as seems self-evident, an “end” of medicine, how much does good medicine require or permit an individual physician’s judgment as opposed to following treatment guidelines that are at least claimed to be “evidence based,” or to managing for disease outcomes? How do we approach—and who interprets—“the data?” (Last week, Dr. Gibes provided a link to the excellent collection, found at the ABIM’s “choosing wisely” website, of lists of questionable procedures. Each list that I reviewed was followed by a disclaimer—“see your doctor”—yet the evidence is believed definitive for these cases!)
4) What is the physician’s relative duty to her individual patient as opposed to the public health, or more elusively, the public good? A case study in last year’s Hastings Center Report posed the case of a 56 year-old woman with treatable soft-tissue sarcoma who visits her physician carrying a supply of an effective medicine that is in such short supply that public policy calls for it to be used primarily for pediatric cases. Is the physician obligated to administer the drug to the woman, the case asked? Incredibly [to me], the [eminent] discussants said, “no.” Correct?
5) What constitutes an ethical practice arrangement in the 21st century? To be sure, obvious profiteering or conflicts of interest are out of bounds, and arrangements that create the potential for conflicts of interest (such as certain ways some specialists are paid) should be re-arranged. But are certain kinds of physician group structures ethically preferable, and if so, what is the proper role of people skilled at managing money or organizations? And is it ethically substandard for a physician to be an employee of, say, a hospital system? And how can a physician-employee make sure he is advocating for his patient?
I hope that my fellow bloggers will take up these or other relevant issues further, systematically, brick by brick.