Thursday, December 05, 2013

The dangerous shift from the medical ethics of the individual to the ethics of the collective

The long running,thoughtful  blog "DrWes" discusses an important issue .See here.

The author is Dr.Westby G. Fisher,a cardiac electrophysiologist from Illinois.
Quoting Dr. Fisher:

"Doctors are currently witnessing the profession of medicine moving from the ethic of the individual to the ethic of the collective. The passage of the Affordable Care Act has solidified this treatment ethic and, as a consequence, often creates conflicts between the treating physician and their individual patients.

Nowhere is this shift to the ethic of the collective clearer than our expanding attempt to determine treatment "appropriateness" using a look-up chart of euphemistically-scored clinical scenarios owned and trademarked as "Appropriateness Criteria®" or "AUC®" by our own medical professional organizations."

A important-perhaps critical-step in this shift was the effort to change medical ethics. At least nominally this has occurred. I believe this conceptual sea change  was largely brought about -at least in the United States- about by a relatively small number of physicians who I describe as the progressive medical elite. Influential folks in the American College of Physicians and the American Board of Internal Medicine and its foundation , the ABIM Foundation, are among those who have lead the charge.I have written about this development more than once. See here  details on this sea change in ethics.

These new ethics and a movement labelled medical professionalism  push the fiduciary duty of the physician to the patient past the back burner and attempts to shove that notion into the memory hole. This duty has ( had?) been the fundamental core of the physician patient relationship. Try and find the word "fiduciary" in the most recent rendition of medical ethics from ACP or in the white paper on Medical Professionalism.

The first encounter I had with this notion of treat the collective not the patient was in a series of articles in JAMA in 1995 written by  Dr. David Eddy in which he promised to show the medical world how to increase quality while conserving costs. The answer was simply to allocate resources in a medical collective ( such as an HMO) using some version of cost benefit analysis so as there would be achieved the greatest benefit to the greatest number, i.e. utilitarianism.Letters to the editor raised the issue of the upending of traditional  medical ethics, the tort system which did not and does  not recognize a utilitarian defense of harming the individual patient  to benefit some statistical aggregate  and the basic human tendency to act in one own perceived best interest and those of their family and not that of some possibly hypothetical collective.The dogs barked and the caravan moved on and currently we see that this duty to the collective notion has hijacked traditional medical ethics and I fear is doing the same to medical education.





1 comment:

Walter Bond said...

Thanks for the link. I left a comment there, as well, about the singular illogic of the central planners setting prices and then making recommendations not to do tests/procedures due to costs!

In the world of the USPTF now making recommendations not to check vital signs (in pediatrics) we are moving past tests/procedures to the land of unintentional self-parody; only few seem to notice nor laugh.