Sunday, October 20, 2013

The politicalization of medical ethics

The politicization of medicine is a topic raised and discussed cogently by Dr. Thomas Huddle. See here for an abstract of his article.

First, with the publication of the Charter, Professionalism in the New Millennium in 2002 the notion of social justice was injected into the listing of attributes and behaviors that physicians should exhibit to act professionally.

Subsequently a commitment to social justice was declared to be an ethical imperative in the American College of Physicians'  (ACP) ethics manual. Other professional organizations followed suit pledging at least rhetorical support of the inclusion of social justice into their ethical propositions.

 Dr Huddle, who teaches at University of Alabama Medical School at Birmingham, says in part:

"Advocacy on behalf of societal goals... is inevitably political".

" civil virtues are outside of the professional realm" and " the profession of medicine ought not to require any political stance".

Requiring a commitment to social justice is clearly  political and requires physicians to take a particular political stance .Advocacy for social justice is one feature of the modern liberal or progressive political stance.Such advocacy is not typically part of the conservative political viewpoint or the libertarian ( aka classical liberal) position.

The notion of justice upon which which the country was founded  was that of the justice embodied in the rule of law,i.e. treating everyone equally under the law. The foundational notion of the social justice line of thinking is essentially that treating folks who are unequal equally is unfair and unjust and therefor there must be societal  effort to mitigate inequality by redistributional efforts of the state.

The physicians who authored the Charter and the ACP's new ethics would appear to be of the progressive persuasion while there are many physicians in the country who are not. A small group of what I have labeled as the medical progressive elite have seemingly captured the conversation and are attempting to  profoundly alter traditional medical ethics.To the extent that they and similar minded individuals set the agenda of major medical professional organizations and medical students education they may have succeed. but I wonder how many practicing physicians are even aware of the views that they pretend to be a settled issue.

Wednesday, October 16, 2013

ABIM Foundation reveals how physicians can further social justice

Older physicians,inculcated as they were with outmoded,no longer applicable in the new millennium, ethical principles might have wondered how they should put into practice the newest addition to the ethical pillars of medical practice.The new addition, of course is social justice.

Social justice is part  of the new professionalism and also of the new latest version of Medical Ethics as conceived  by the America College of Physicians.

Fortunately-for those puzzled doctors-there is an organization whose professed reason for existence is to "advance medical professionalism and physician leadership in quality assessment and improvement". We will be instructed about professionalism and also how to strive for social justice.When social justice was proclaimed as the third pillar of professionalism we were given a broad charge, ambiguous and lacking in operational details. Put simply- how do practicing doctor "do" social justice.

In the July 19,2013 edition of the Medical Professionalism blog we get the answer. We physicians are to bring about social justice through "just distribution of resources and stewardship of resources".

 As enlightening as this may be ,some of the older physicians wonder what is their definition of "just".  My intuition is that later we well be told ( we may well have been told that already) that just distribution is  the distribution that results from a cost effectiveness driven set of guidelines which just happens to be the same way that operationally the rank and file docs can be said  to act as stewards of resources.

Here is another quote from the ABIMF's blog that attempts to elucidate the notion of just distribution
  ( my bolding):

" While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost effective care. The physician’s professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one’s patients to avoidable harm and expense but also diminishes the resources available for others."

Physician are admonished to strive for a fair and cost effectiveness allocation of medical resources.Presumably the allocation must be both. While the methods of cost effectiveness analysis are well known and explicit- though not without serious criticism- the term "fair" is as ambiguous,vague and without obvious operational details as is the term social justice and is as subject to varying meanings.

 Philosophers have thought much and written a great deal on justice and on fairness.There is much that two of the 20th century most  noted philosophers disagree about but John Rawls and Robert Nozick seem in general agreement that utilitarianism did not conform with their notions of justice and fairness.  The utilitarian approach does not respect the separateness of individuals and it may treat individuals as pawns in some social scheme allegedly bringing about some hypothetical aggregate good or utility.Utilitarian theory is basic to cost effectiveness analysis as benefits and costs are aggregated over a group of people and it is the group analysis that trump a given individual's benefit or loss.

The philosophical mavens at the ABIM Foundation presume to instruct physicians on proper professionalism by advocating cost effectiveness analysis and the "appropriate guidelines " that follow. So, in the formulation declared to the ethical law of the medical land physicians are to strive for social justice by being committed to develop guidelines for cost effective  medical care.

 Then the question is raised:is cost effectiveness allocation of medical resources socially just?Is recently crowned new ethical precept,social justice, actually  achieved by allocating medical resources by guidelines derived from cost effectiveness studies? The third party payers would be joyous if that link were accepted. That is a topic for later comments.I am still trying to get my thinking around the notion that cost effectiveness furthers social justice.