Who does the doctor serve? When we lived in a society with common values, the answer was easy—the patient. Today, not so easy.
Now, doctors sometimes are asked to take lives, not just save them. And there is a push within organized medicine to create a destructive dual mandate for physicians, to care for patients yes, but to also concomitantly look out for the interests of society—a prescription that could create a conflict of interest between doctor and patient. Ditto, granting a right to patients to force doctors’ complicity in procedures that the physician finds morally objectionable. Thus, creating proper ethical guidelines for doctors is not as simple as it might have once been.
As discussed in an earlier post, the American College of Physicians has published a new Ethics Manual that—all things considered—seems pretty good, at least from my perspective. Still, there are some reasons for concern. From the discussion, “Patients First and Stewardship of Resources” (No link):
- The physician’s first and primary duty is to the patient.
- Physicians must base their counsel on the interests of the individual patient, regardless of the insurance or medical care delivery setting.
- The physician’s professional role is to make recommendations on the basis of the best available medical evidence and to pursue options that comport with the patient’s unique health needs, values, and preferences.
- Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.
This language needs clarifying. I like the parts I emphasized in italics, but not the clauses that I underlined.
First, a doctor should certainly respect a patients “values and preferences” in the context of carrying out medical treatment. If a patient doesn’t want chemotherapy for cancer, for example, the patient should be able to say no even if it will shorten life. But what if the patient wants a doctor to kill a fetus in an abortion or participate in life ending acts such as euthanasia or assisted suicide? Should doctors be forced to be complicit in actively terminating life? I say no. Thus, I would add a specific clause protecting medical conscience rights of doctors, subject to certain terms and conditions, (as I have written), such as notice to patients ahead of time. (The Manual does briefly discusses medical conscience in the context of reproductive issues. We’ll look at that in more detail in a subsequent post.)
As to the issue of husbanding resources: “Equitable availability” should be irrelevant in the context of an individual patient’s treatment and could become a wedge for creating the conflict of interest that I worry is coming with Obamacare and other policy shifts. In other words, Doctor A treating Patient A has no ethical obligation to hypothetical Patient C, D, and E, much less to society overall.
Thus, I would rewrite the last point to read, “In the context of physicians primary responsibility to the patient, the physician should practice effective and efficient health care, use health care resources responsibly, and do so in such a way that the individual medical needs of the patient are not compromised.” End of sentence. I think that would prevent cooperation with health care rationing or the imposition of Futile Care Theory based on financial considerations, while also informing doctors that they should not be profligate in the way they practice their art.