Doctors' Loss of Moral Agency
Medicine is a moral profession and physicians are agents of the commitment to place another's concern above their own. The practice of medicine provides a singular opportunity for moral clarity. The proposals for healthcare reform presuppose that the underlying economic model sustains unsatisfactory outcomes and social inequities. We believe, however, that a root cause resides in ethical failings now systemic in the day-to-day practice of medicine.
These failings, hidden from the public but corrosive to the physician, have taken a great toll. Physician surveys document disillusionment, depression, and a sense of powerlessness. Blame is sought in "bureaucracy," a litigious society, or from diminished patient "loyalty." Doctors flee practices or choose specialties distant from patient contact. Palpable resentments surface when doctors talk privately.
In two generations, medicine has fallen from a near-religious height to descend steeply down the slope of social worth. Though patients are reluctant to say it, we suspect that there is more than a little Michael Moore in many. No one likes what has happened to the profession. But doctors in practice, not doctors as "policy wonks," are the only group that can really change it.
Doctors know what they do not know. They know that a 10-minute visit skims the surface of most illnesses. Case presentations to other doctors are filled with too many tests and often too many complications. Society imagines that better healthcare will come from finding just the right payment formula. Yet the truth is that, even in a reformed system, doctors must again choose to practice within boundaries set by moral standards.
Medical school and residency training remains as much about building character as about developing skills. Curricula are replete with medical ethics, the nature and value of empathy, and increasing discussions about the spiritual aspects of the beginning and the end of life. After graduation, new practitioners are meant to adhere to Plato's reminder that, "A physician studies only the patient's interest and not his own."
It is towards the end of training, however, that moral thinking becomes a luxury and debt and young families refocus long-range plans. For too many, choosing a practice is no more than choosing a job with contracts, covenants, and revenue triggers for bonuses or eventually a partnership. It is not that physicians explicitly seek to do badly for their patients. It is more that the "real world" resets how good, diligent, selfless, and honest they can afford to be. Time does become money. So, for reasons that seem "mature," the moral strictures are subtly loosened.
This loss of moral agency remains well-hidden behind the Oz curtain of technology. Technology is wondrous but seductive for both the patient and doctor. Tests are employed defensively or entrepreneurially. However, the most pernicious effect is to further dilute the intimacy of the historic doctor-patient relationship. Testing often becomes the physician's shortcut. Ordering tests and having results conveyed by office staff is smart "retail" but at the edge of indifference. Good care may not be a function of time alone but extended interactions permit patients to actually hear and feel a doctor's concern.
Such intimacy is essential. All that passes between a doctor and patients is tinged with fear which can be ameliorated when there is trust. Every patient feels vulnerable when visiting a doctor. It is the quintessential "power" relationship that should never be abused, but too often is. When they or their families become ill, doctors hardly seek the level of care they provide for others. They know how fragile a patient feels and what it takes to decrease any form of suffering.
The modern practice, however, is often less about service than productivity and self-protection. A masterful diagnosis does not generate any more "revenue" than a pedestrian one. Better to be "provider" without true responsibility than to assiduously measure if all of your actions are moral. At this safer distance, a doctor can still sympathize with the limits of a patient's insurance or impenetrable administrative rules but not deem them intolerable or a call to action. After all, "What can one doctor or practice do?" Frankly, if physicians were actively reengaged with their "better angels," much could be done.
A doctor could easily say that it is not right to hurriedly see patients or pack twenty into an afternoon. A practice could readily devise methods for accommodating those without insurance. Prevention could become integral to patient care even if few insurers are currently willing to pay for it. Seeing physicians being adaptive and creative, patients would likely trust more and demand less. A solid and honest bond between patient and doctor pits both against disease and less against each other.
Certainly there will be tradeoffs. There would be a loss of personal income. Hospitals might have to reshape a bit, regionalize more. Amidst these contractions, physician would restock their self-worth and sense of purpose and, by an exercise of the will, reclaim their moral standing. By so doing they would more likely champion behaviors that could solve many seemingly intractable problems. Most social movements did not succeed because "stakeholders" met in Washington to trade self-interests. If practicing physicians were to take stock of each day's motives and incentives, improving national health care can start one physician at a time. Moral leadership will not be easily denied.
Dr. Levine is a Professor of Medicine at the University of Connecticut Health Center. Mr. Wallach is a consultant at the Yale Interdisciplinary Center for Bio-ethics Research.