In a recent article in America (Patient No More, 7/16), Kevin W. Wildes, S.J., our friend and colleague at Georgetown University, celebrated a requiem for the traditional, patient-centered ethic of medicine. In its place he proposed a new ethic of social contract, one oriented to societal need rather than the need of the individual patient. In this Father Wildes joins a growing cadre of bioethicists who want an ethic more responsive to the commodification, institutionalization and cost containment now reshaping the American health care system.
As physicians who have practiced and taught medicine for a collective total of 110 years, we think the protagonists of the new ethic are neglectful of the realities of the predicament of illness and the centrality of the personal relationship between the sick person and the physician. We regard their proposed new ethic as another step in the progressive depersonalization and dehumanization of the human experience of illness. It imperils not only the sick but the society that fosters it.
Father Wildes argues that the traditional model of care is focussed too narrowly on individual patients. He says it cannot address questions of allocation of resources or access to health care. He rejects it as paternalistic, neglectful of preventive medicine and too concerned with acute care. The traditional model, he concludes, must be replaced by a model more sensitive to economics and the organizational aspects of health care; that is, it should be a social community model.
We have observed at first hand the profound changes in health care that worry Father Wildes, and we agree with his précis of the issues to be addressed. We cannot, however, agree that dissolving, weakening or replacing the traditional patient-physician relationship will do anything but exacerbate the situation. Our reasons are as follows.
To begin with, Father Wildes’s depreciation of the patient-physician relationship flies in the face of the fact that most Americans cherish dearly their freedom to choose their own physicians. Anyone who is ill, or has been ill, recognizes that the relationship with one’s physician cannot be encompassed in a contract or a commodity transaction.
How can a contract cover the vulnerability, dependence and anxiety of the sick person? How can it encompass the ineradicability of trust the patient must ultimately place in the physician’s character or competence? The physician invites the patient’s trust and in doing so solemnly promises a technically correct and morally good decision taken in the patient’s interests.
The sick person is a patient, not a consumer, client or customer. A patient, as the etymology of the word indicates, is one who bears a burden, one who suffers. The patient brings his burden to the physician, asks for help, is offered help and expects to be helped and not injured. In this vulnerable state, patients are morally entitled to protection from exploitation of their vulnerability by the person who invites their trust.
In the traditional model, the patient expects fidelity to trust from an identifiable person. In a social contract, or social community model, the patient must trust a faceless organization. Anyone who has tried to identify the person responsible for the quality of service in any of today’s commercial or public utility enterprises will comprehend why illness cannot be treated like a telephone, airline or government service.
In any case, sick persons cannot enter contracts because contracts (individual or social) are drawn between equals. A sick person is hardly in a position to negotiate or bargain for favorable terms. The covenantal model of traditional ethics places the burden on the physician to efface his or her own self-interest, at least to some degree, to balance the inequality of power.
Contracts, moreover, are minimalistic and legalistic in spirit, drawn between people who do not trust each other. They allow for the pursuit of self-interest and competitive advantage. They are oriented to non-maleficence rather than beneficence. They are built on the market notion of caveat emptor, scarcely the principle to rely on when one is sick, dependent and anxious.
A second problem with Father Wildes’s line of argument is a misunderstanding of the intimate relationship between the epidemiological approach to disease, which he so reveres, and the individual patient-physician encounter he so reviles. Our knowledge of the ecology and epidemiology of illness in any community is a statistical summation of data collected over the course of a large number of individual patient-physician interactions. Individual patient-care records provide information about the clinical features, pathogenesis, natural history, prevention, treatment outcomes, morbidity and morality of illness. Epidemiology, therefore, is only as reliable as the accounts of the individual patient encounters that it summarizes statistically.
Individual clinical medicine and epidemiology are therefore mutually dependent. Establishing the connection between smoking and cancer depended on a careful study of the records of individual patients. The same is true of the statistical evidence we now possess about the causes and prevention of heart disease, diabetes and lung disease. We agree, therefore, with the importance that Father Wildes places on a community’s experience with disease, but we decry his abnegation of the source of that experience in the encounter of physicians with individual patients.
A third misconception is Father Wildes’s assumption that in a managed care system the patient-physician relationship is somehow abrogated or replaced by a communal decision-making model. This ignores the fact that H.M.O.’s operate by consciously limiting the physician’s clinical choice of procedures, drugs and tests to those the H.M.O. deems most economical. Clearly cost containment can work only if the patient-physician encounter is at the center of health care. This is why managed care organizations deliberately pit the physician’s self-interest against the patient’s. They reward physicians for cost containment and punish them for cost overruns.
Managed care organizations recognize the centrality of the patient-physician encounter to such an extent that they strive to prevent physicians from advocacy on their patients’ behalf. Some ethicists think managed care organizations could ethically provide financial incentives to physicians for not fighting for their patients. This is a clear violation of the covenantal relationship between doctor and patient. It makes the physician a double agent and raises genuine doubts about his primary responsibility.
Father Wildes seems unaware of the physician’s inevitable moral complicity. In the end the physician writes the order to treat or withhold treatment. He or she is responsible for the moral status of that order and for its benign or malign effect on the patient. No contract, managed care organization or financial reward system or team approach can excuse the physician from moral complicity.
The laws of torts, contracts and fiduciary relationships still recognize the special responsibility of the physician for the standard of care the patient receives. At the moment, these laws apply to physicians but not to managed care corporations. The matter is currently before the Congress. We hope that body will recognize the moral impropriety of relieving managed care organizations of complicity for harm done to patients by the restrictions they place on physician decisions.
Father Wildes’s catalogue raisonné of the sins of the traditional model includes every defect of our health care system. He accuses it of failing to assure cost containment, equity of access and preventive medicine. He even says it destroys the common good. Were Father Wildes to argue his case in a court, he would be hard put to provide evidence for such a potpourri of charges.
Good medicine has always been economical medicine. It is scientifically irrational and morally indefensible to use tests, procedures and medications that are not effective, beneficial or proportionally costly. Preventive medicine has been part of a good patient-physician relationship ever since the Hippocratic physicians emphasized the importance of diet, environment and style of living as elements of disease causation and cure. Access to care for the poor has been integral to a morally valid patient-physician relationship ever since the Hippocratic ethic was incorporated into the charitable traditions of Judaism, Christianity and Islam.
There is no incompatibility between prevention, care and cure; there is nothing in the centrality of care for individual patients that precludes access, availability and affordability of health care. Nor is the common good violated by solicitude, compassion and ethical emphasis on the care of individual persons. Fidelity to trust in the patient-physician relationship in no way precludes the exercise of societal responsibility. What it does mean is that a physician bound by a covenant of trust to an individual patient must do his best for that patient. When not bound to an individual, the physician is not only free to enter into discussions of public policy, rationing and financing of a health care system but morally bound to do so.
That physicians and their organizations do not always fulfill the obligations of a traditional patient-centered ethic is a serious indictment. But there is little likelihood that a system based on a social contract or a community model will prove the salvation theme Father Wildes envisions it to be.
When patients ask, Whom shall I trust? we contend they will be better served if they can identify a human beingfallible, no doubt, but still an identifiable and ethically accountable individual person. Patients will not disappear, nor will illness and disease. The shortcomings of today’s health care system are as much a condemnation of our society and its values as they are of the ancient ethic of care that is responsive to the vulnerability of the sick person. To replace that ancient ethic with trust in an organization, a community or a system is to substitute an ethic of diffused responsibility for one unmistakably centered on a trusting relationship between identifiable human beings.
We would suggest that even with its fallibilities, the traditional ethic is a sounder safeguard of both the individual and the common good than the proposed new ethic.