Friday, August 31, 2012

ACP celebrates 10th anniversary of A Physician Charter -but all physicians may not agree

In the August 21,2012 issue of the Annals of Internal Medicine Drs.Christine K. Cassel,Virginia Hood and Werner Bauer have offered the readers a largely celebratory , somewhat self congratulatory and slightly cautious piece recognizing the 10th year anniversary of the Charter. They are referring to A Physician Charter.


In 2002, a group of internists from the American College of Physicians and the European Federation of Internal Medicine jointly authored a commentary that was designed to "supply a concise foundation that would shape how physicians viewed the practice of medicine."In this they not only emphasized how physicians would behave in regard to their patients but " toward society". It was this relationship to society which the authors said distinguished their work from previous professional codes. and there is no doubt about that.

The Charter spoke of a professionalism that consisted of three fundamental principles:patient welfare,patient autonomy and social justice. It was the term social justice that the charter authors used to designate this new emphasis on the relationship of physicians to society.

The term social justice has a long history but in general use in western democratic societies refers to a trend of thought that favors a greater degree of equality in regard to income and wealth and access to various institutional opportunities and equality of outcome in instances in which equality of opportunity does not achieve some notion of appropriate outcome. Redistribution to correct or mitigate various inequalities is considered part of its conceptual package.Social justice also emphasizes equality in general and human rights and human dignity.
The term social justice has a long history in religious thought, both Christian and Jewish and aspects of it play a prominent role in parties of the political left and is prominent in the expressed political philosophy of the the European social democracies.

Unfortunately for purposes of clarity of meaning the term social justice is often controverted and assumes variable meanings. Of course, from a tactical point of view those characteristics may have an advantage in a debate as opponents may find a elusive target.

The authors of the recent Annals article note that 130 organizations have endorsed the Charter and medical schools have embraced the professionalism that the charter defines.

However,as much progress as they claim has been made to make the idea of the medical profession as depicted in the Charter a reality, more needs to be done.There are gaps,according to the authors.

In regard to one such gap,I was surprised but pleased that the authors actually recognized that there remains some controversy.They admit that some object to the notion that physicians bear an obligation to serve the needs of society and to work to ensure a just distribution of health care resources. Of course that is where the controversy lies, there is no serious opposition of the ides of patient welfare and patient autonomy.

There was no scarcity of audacity in the charter when it a relatively small group of internists declared that to be ethical professionals one had to necessarily accept and work towards a political philosophy whose acceptance in United States was far from universal.

It is another chapter in the ancient tension between the individual and the collective. Physicians' ethics has traditionally been that of a fiduciary duty to the patient with a co-duty to some collective only being gratuitously added to discussion of medical ethics in the last twenty or so years,most famously in the Physicians Charter .

There are several-not necessarily mutually exclusive-lines of argument that disagree with the inclusion of a quest for social justice as a key element of medical ethics and which may well resonate with some physicians.

Here is a small sampling of some of those arguments:

1)Some may accept that social justice is a valid concept and one worth pursuing but see no reason to have social justice as one of the three fundamental precepts of medical ethics having heard no convincing argument for its inclusion. From my reading, a convincing argument for its inclusion was not found in the text of the Charter but seemed to be a gratuitous assertion.

2)Others believe that the concept of social justice itself is bogus,bereft of useful,meaningful intellectual content and operational details.Advocates of this position find support from the writings of Nobel laureate FA Hayek and economists Thomas Sowell and Anthony de Jasay and others.

Quoting Jasay.

...one of the pathetic infirmities of social justice, namely that it has no rules by which a socially just state of affairs could ever be identified.

What rules do they advocate that would bring about an equitable distribution of health care resources.? Who decides what is equitable?

De Jasay speaks of justice as a property of an act and that an unjust state of affairs results from unjust acts. Who has committed the acts that lead to the unjust conditions that the social justice advocate yearn to rectify? (from The Collected Papers of Anthony de Jasay.Political Economy Concisely.)

Are the better-off obligated to help the worse-off even if their condition is no fault of theirs. What perversion of justice is it that places the " obligation of redressing an injustice on those who have not committed it."?

Social justice is when you blame someone for an inequality that they did not bring about and then make them pay to correct it.

By this line of argument social justice is not justice at all but a rhetorical tool to justify any and all plans for redistribution to rectify inequality in regard to any number of characteristics.

What is the argument for the claim that this egalitarian view with corrective redistribution must be a part of a physician's ethical package ? Would not one's choice in this regard be a matter for political philosophy and not professional ethics?

DeSay's arguments echo Hayek's ideas. To speak of notions of justice regarding the relative holding across an entire society is confused thinking in Hayek's view. Quoting Hayek:

Social justice does not belong to the category of error but to that of nonsense,like the term 'a moral stone'.

3) Others believe that the insertion of social justice into the medical ethical framework may or may not be unjustified intellectually and may or may not have meaningful operational content but more importantly it is harmful and has the potential to destroy medical ethics as it has been known and practiced for hundreds of years.

Dr Richard Fogoros on his blog The Covert Rationing Blog explains how the Charter and the New Ethics of the ACP differs from and conflicts with the old time medical ethics and warns of its harms.

The New Ethics takes classical medical ethics (which obligates doctors to always place the welfare of their individual patients first) and adds on to it a new ethical obligation, called Social Justice, which obligates doctors to work toward “the fair distribution of healthcare resources.” This new obligation (which is to society) will inherently conflict, at least some of the time, with the physician’s traditional obligation to the individual patient. So, under the New Ethics, the doctor’s loyalty is now officially divided. DrRich asserts that this divided loyalty (which is now declared to be entirely ethical) leaves the patient in a dangerous position, and breaks the profession of medicine
.

You will not find "fiduciary duty" discussed in the new ethics.New ethics advocates hope that if the word is not used that the obligation will go down the memory hole.Plaintiff attorneys may think otherwise.

Maybe the Mafia Rule (Cui Bono) does not always lead one to a useful insight but it often does. Who might benefit from this transformation of medical ethics ? The third party payers benefit because physician's ethics now include the precept to act for the good of the collective (third party payers and the ACOs will play the role of the collective) and if cost benefit analysis concludes that a given treatment is not cost effective then the ethical doc (by the Charter definition) will do what it right for the good of the collective. The medical elite might gain because they will be the ones who play a major role in writing the rules (guidelines) that will direct the ethical physician to act in the cost effective manner than will in the end benefit the group if not the individual patient and conserve society's resources. Are we looking at the old story of the baptist and bootleggers here?

Minor editorial changes made on 9/4/2012












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