The Fundamental Goal of Medicine

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The fundamental goal of medicine is the patient‘s good. Edmund Pellegrino and David Thomasma both focus on that point in their 1981 book, A Philosophical Basis of Medical Practice, the book that has most influenced my approach to medical ethics. All other goals–having an up-to-date facility, having the best equipment at a clinic or hospital, turning a profit, and efficiency in finances, must be subsumed under that primary goal. The good of the patient may involve curative care, or it may involve palliative care in the case of a dying patient. The human person is a whole, body and soul, so medical practice must focus on the good of the whole person and not just on body parts and diseases. The good of the patient may include physical good, but it may also include psychological and spiritual good. Recognizing the complex dimensions of personhood and treating a patient as a person, not as a thing, will do more for the good of the patient than merely diagnosing and treating a physical disease. Even a “physical disease” contains a psychological component, since the patient’s mood can influence the course of the disease for good or ill. Sometimes a physical disease can be triggered by psychological stress. Extreme emotional stress can activate the HIV virus so that a person gets full-blown AIDS. Other diseases may be activated by stress: cardiovascular disease, cancer, rheumatoid arthritis, lupus, infectious diseases. Part of a medical practitioner’s job is to recognize when a patient is having a great deal of emotional stress and encourage the patient to deal with that stress.

Treating the patient as a person implies that assembly line medicine is not ideal. Despite massive debt that young physicians often try to pay off with a high volume of appointments, at some point a provider is spending too little time with patients and comes across an uncaring. Constantly looking at one’s watch does not help. Talking to a patient in a real conversation does. Of course any doctor, PA, or nurse practitioner must have some limitations on patient appointments in order to receive all those in need. Finding the correct balance is not subject to exact rules and is a matter of prudence. Prudence is the ability to make a good decision in both routine and in more troublesome and complex situations. It is an essential virtue, necessary for both everyday medical, as well as for moral, decision making. A list of absolute rules to follow will not help in ethical dilemmas in which rules conflict and are only prima facie, which higher-level rules may supercede.

The fundamental end of medicine implies the principles of benevolence, nonmaleficence, and justice. Autonomy is trickier, since it is an enlightenment concept that may be conditioned by contemporary Western Culture. Kant himself thought we would autonomously give ourselves the moral law, but the term is used today for “the right of every adult to make choices based on their own value systems.” In practice, there is limited autonomy in medicine; not everyone can practice medicine, and drugs must pass FDA approval before being placed on the market. These limitations are so patients will not be misled by quacks or those pushing an untested, ineffective, and perhaps dangerous, drug. Autonomy in patient decision making recognizes that it is the patient’s body who is being affected by medical treatment, and that the patient’s values are not necessarily the physician’s values. I think of respecting autonomy in terms of respecting the free will of patients to make their own decisions regarding health care.¬† This helps preserve the dignity of the patient in a setting in which the sick patient, feeling powerless, tends to lose a sense of dignity.

There are a number of controversial issues in medical ethics that focus on the nature of the patient’s good, or even if there is a patient present to whom the health care provider does good or harm. The abortion issue is one of these–if the fetus is a patient, then abortion amounts to murdering a living human person. If the fetus is not a patient because he is not a person, then the opposite conclusion seems stronger. My own view is that personhood begins at conception, so that any doctor or health care worker helping with an abortion is violating the fundamental end of medicine. The same would follow for euthanasia and for physician-assisted suicide. Many people will disagree with these positions, and I welcome rational argument on any position I set forth in this blog.

Most issues regarding the fundamental good of medicine are more mundane that the large scale bioethical issues often discussed in undergraduate medical ethics courses. Usually the practical everyday issues involve the amount of time spent with patients, dealing with difficult patients, keeping information confidential, keeping medical records accurate instead of falsifying “the little stuff,” and so forth. All these issues involve remembering that the patient is a human person with feelings, with a life, with loved ones, just like the health care provider–and that providers can help a person leave better than when he arrived.

For Profit Medicine: An Oxymoron

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As a traditional conservative I oppose for profit medicine. The classical liberal who calls himself a “conservative,” would probably label the previous sentence as an oxymoron. However, conservatives are not all of one stripe. The ethics of medicine must stem from the nature of medicine itself as an inherently moral enterprise. A patient, sick or injured, in need of help, comes to a health care practitioner. The practitioner, whether he be a physician, a D.O., a physician assistant, or a nurse practitioner, has the moral responsibility to use his skills and knowledge for the good of the patient. The profit motive should not enter into the patient-practitioner relationship–if it does, it becomes inherently corrupting.

For-profit hospitals are a monstrosity. When part of the responsibility of the physician is to the shareholders, business decisions often end up trumping medical decisions. This can lead to suboptimal patient care in order to bring more profit to the corporation, especially in a capitation system in which the practice keeps money left over that is not spent on patient care. . Even in “non profit hospitals,” business decisions affect medical care, and business people “run the show.” Hospital administrators are paid enormous salaries (500,000+ per annum in some cases) along with expensive benefits. I know of a case in which a CEO received a huge bonus even though the hospital had been in the red the previous year. Does this sound familiar? Remember the Wall Street bankers.

The American system of medicine, then, is run as a business rather than as a practice. It is no longer a true profession. Physicians are distrusted. Lawsuits are common and sometimes result in big judgments against a physician.

In reading UK newspaper articles about accidents or shootings, I have found (informally) that paramedics and physicians in the UK are more aggressive in starting trauma codes than their American counterparts. This is, of course, anecdotal–it would be interesting if a large-scale study could be done to compare the numbers in both systems. American physicians used to work up to two hours on a patient in a medical code (that did happen with my mother, who lived with no neurological sequelae). Now, three shocks interrupted by CPR, and often that’s it. Twenty minutes, perhaps thirty, and in rare cases, over an hour–but shorter periods are becoming more and more the norm. Doctors will say this is due to the low success rate–still, twenty minutes even in witnessed arrest in which the patient has no DNR is a short time to say, “He’s dead Jim,” given the utter finality of death. Money may play a bigger role in these decisions than medicine. The UK lacks the profit motive in medicine outside the private health facilities there, so the incentive is to keep trying in a code rather than stop in order to save money (I am indebted to my friend Megan for this insight).

Is it possible for a traditional conservative to endorse a non-for profit single payer system of health care for the United States? It has already happened: Paul Craig Roberts, whose conservative credentials are stronger than most self-styled “conservatives,” has endorsed that system. Affordability in the age of massive deficits is the problem, but if the system is run correctly more money might be saved in the long run due to decreasing health care costs–and if tort law is revised so as to protect physicians from frivolous suits, this could help even more. I am not quite ready to endorse such a system, but the more greed I encounter in the present privatized system the more I am tempted to endorse a nationalized system of health care.¬† It would at least take out the profit motive that is corrupting current medicine and taking it away from its proper ends.

“Evidence-Based Medicine”: Dangers and Opportunities

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“Evidence-based medicine” (EBM) is a mantra mouthed by many physicians and health care policy makers today. The idea sounds good on the surface: that medical treatment be based on sound studies showing a significant statistical benefit (vs. harms due to side-effects) of a particular drug or treatment. When wasteful and ineffective treatments are rooted out of the system, patients will benefit, and treatments will be more cost-efficient. This is, advocates of EBM affirm, a continuation of the tradition of medicine since the scientific revolution of the seventeenth century: good medicine is based on the best science of the day. What could be the problem with that?

Set the clock back to the 1970s. Medicare and Medicaid, even then, were costing taxpayers dearly. Medical costs were rising rapidly, and policy makers sought some means of controlling such costs. Government officials began to collect data from doctors and from hospitals on the drugs and medical procedures used to treat particular diseases and injuries. This included data on the average number of days spent in the hospital, for example, after surgery for acute appendicitis. In this way Diagnosis Related Groups (DRGs) were born.

DRGs were originally meant to be useful data so Medicare and Medicaid could better know how their money was being spent. But in the early 1980s, Medicare¬† and Medicaid used DRGs to limit care to what had been customary. These federal programs would only pay for customary care; if a patient had to stay in the hospital an extra day after surgery, tough. Later, private insurance firms established similar policies, policies that ignored the needs of individual patients. Not everyone is “customary” in the care needed. Someone with a fever after appendicitis surgery might need to stay in the hospital an extra day or two, but insurance companies make it difficult for the patient to be compensated.

Now “evidence-based medicine,” if used the wrong way, can function like DRGs. It can be used to place all treatments and patients undergoing those treatment into a single category that ignores individual differences between patients. This can lead to undertreatment, in the case of a patient that needs more drugs or a treatment that “evidence-based medicine” does not support. Or it could lead to overtreatment if a patient has a condition that would normally be considered risky, but that patient is an exception. Take the rule of thumb that more than six PVCs (“skipped heartbeats” that originate in the ventricles, the lower chambers of the heart) a minute are a danger sign. Often I get far more than six a minute–sometimes fifteen a minute, sometimes ten, sometimes with runs of bigemeny (one normal beat, one PVC, and so on), sometimes trigemeny (two normal beats, PVC, two normal beats, PVC, etc.) But after I was given a stress test it was determined that I was one of the exceptions and that these PVCs are not dangerous for me. But suppose a physician followed the general rule and treated me with beta blockers. These carry their own side effects and risks. The point is that even the best evidence-based conclusions may not fit every individual patient. So prudence remains necessary in applying evidence based medicine to particular patients–medicine is based on science, but medicine itself is a practical art. Hopefully, evidence-based medicine will be used wisely to benefit patients and prevent needless or harmful treatments. Applied solely as a cost-cutting measure or applied legalistically without prudence, it can do patients more harm than good.

Physician Assisted Suicide and the Ends of Medicine

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When I ask my medical ethics students whether they support physician assisted suicide (in the sense of the physician prescribing a deadly dose of a drug, usually barbituates, for the patient to take when he wishes), the vast majority raise their hands. Even most students in my classes who oppose abortion support physician assisted suicide (PAS). To me this is disturbing, especially since the strongest support for PAS has been in my class of future physician assistants.

What is so wrong, you may ask, about physician assisted suicide? After all, even with ideal pain control, some terminally ill patients either remain in a great deal of pain or have to be totally sedated. Why not allow such patients to “control the time and manner of their own deaths?” Surely PAS will encourage more dignified deaths among patients in intractable pain. And in referendums, Oregon and Washington have passed laws permitting PAS. Shouldn’t this practice spread to other states?

Although PAS sounds attractive, its practice would be a fundamental distortion of the proper goals of medical practice. The internal goods of medicine include restoring a patient to health, and when a patient cannot be restored to health, to make that patient as comfortable as possible. But supporting a patient’s suicide indirectly involves the physician in killing a patient. Physicians have a great deal of power over patients, power which, if misused, can lead to pain, suffering, and death–as the Nazi medical experiments and the Tuskegee Syphillis Experiment revealed. Now a physician can withhold or withdraw medical care that is only prolonging the dying process. The goal is not to hasten death per se, but to relieve the patient’s suffering. But prescribing a deadly dosage of a drug is designed to let the patient hasten his death. One may say that the motive is to relieve suffering, but there is a difference between allowing the disease process to take its course and giving a drug so a patient can actively commit suicide. This abuse of medical power has already spread in the Netherlands, where PAS is legal, to doctors actively killing patients without the patient’s permission or the patient’s family’s permission. Once the line forbidding a physician from assisting in a patient’s death is crossed, it will be difficult to turn back. Doctors participating in PAS will not be practicing medicine, but doing something else entirely–being accessories to suicide.

There is an assumption in the modern world that pain is the worst thing that a person can experience. That was not the view of the premodern world. Socrates was willing to suffer pain and death to keep his integrity. The early Christians suffered excruciating torture via persecution–they believed that they were sharing in the sufferings of Christ. And without modern pain control methods, people suffered far more from diseases than they do today, yet the drive for PAS is a modern movement (David Hume was among the first to defend suicide as an option in a person in great pain). This does not mean that we should not try to stop pain as much as possible short of actively killing the patient or giving the patients the means to suicide. Relieving suffering is a moral obligation of physicians as long as medical power does not cross over the line into aiding a patient in his active demise. Even in this post-Christian world, would secularists really want doctors to cross the line into PAS? Could PAS be controlled once the genie is out of the bottle? I do not believe so–but even if PAS is the only line that is crossed, it remains inimical to the ends of medicine and is wrong.