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Wednesday, September 05, 2018

Does the notion that people have a duty to be healthy shatter traditional medical ethics

First lets define what we mean by traditional medical ethics.This would include the medical ethical precepts that constituted medical ethics before the announcement of the "New Professionalism" by the ACP and others. Basically and stating it informally it is that the physician has a fiduciary duty to the patients, and he should place the patients interests before his and of course first do no harm.

Keeping those precepts in mind, consider the following statement which is typical of a growing trend in medical commentaries .

People ( patients) have a duty to be healthy ( practice "healthy behaviors" and eschew "unhealthy behaviors") and comply with medical advice for the good of healthy population.

Drs. JF Wharam and D. Salmasy, writing in the Jan. 14,2009 issue of JAMA. In their discussion of P4P arrangements they state:

...policy makers, health care executives,disease advocates, and scientists with clinical or epidemiological expertise effectively choose population-level goals and thus impose obligations in a manner that
might ( my italics) infringe on patient and physician autonomy. Without fair deliberation,such goals, however wise, cannot claim legitimacy

I suggest that the word "might" be deleted from the above quote. It will infringe. Further, it is not clear what would constitute "fair" deliberation.When someone begins to talk about being fair,watch out.So with "fair deliberation " such claims ( if wise) are , according to the authors therefore  legitimate.



When physicians get some of their income by meeting certain population based goals( e.g. have x% of patients with a hemoglobin A1c under some number) patients who might seem to eat too much or not always take their medicine or whatever else might  be perceived  by the physicians as getting in the way of the population based goals and keeping  the doc from her bonus.Again it is issue of serving two masters,the real life patient in the exam room  versus some insurance based collective construct.

2 comments:

Nicolas Martin said...

Duty to whom? To ourselves? Health is a value not an object, and for nobody is it always the primary value. We risk our health by eating, driving, having sex, playing sports, being lethargic, and almost any other activity or non-activity. We all value health sometimes, while subordinating it other times. So, the duty to be healthy is meaningless. We can’t take the word of physicians (and other health experts) about what is salubrious because they are so often wrong, and they so often make our health worse.

Szasz made an excellent point about “do no harm.” It is absurd. In his book “Cruel Compassion” he says, “Primum non nocere (First, do no harm) sounds better than it is. In fact, it fails to tell us precisely what we need to know: what is harm and what is help.” A few sentences later he notes that “harming people in the name of helping them is one of mankind’s favorite pastimes.” Perhaps only socialists have outdone physicians in that regard.

All that said, we have nobody to blame but ourselves if we reap what we have sewn. If we get diabetes from too much food or HIV from too much risky sex, it’s on us. Physicians can and should ply their trade as best they can, but we bear the responsibility, physical, mental, and financial, for our deeds.

Anonymous said...

From a patient standpoint- I pay my Dr for advice. That is it. Not some binding contract that if I seek medical advice I am now contractually required to follow their "latest" wellness guidelines(Eggs in the 80's??) . I go to the Attorney and pay him/her for advice. Whether I follow it or not is completely up to me. I think half of Drs. are weary of now being held responsible for making their patients follow trends in order to get a paycheck or to avoid litigation and the other half embrace it as it either gives them an out for having to restrain themselves from passing judgement or allows them to power trip. I think based on the current trends and liabilities heaped on Drs. they need to have more control over who they opt to see or not(you can tell when a Dr. doesn't like you but they always book that follow up appt!). It would be better for the patient and Dr and perhaps a wakeup call for all that there is a line between advice and demands. (From both parties). I often wonder that for as hard as it is for an overweight, drinking, big mac loving 40 year old man to get an earful at the Dr.s office, how hard is it when that overweight, out of shape guy is the Dr ??