Medical professionalism involves not just the relationship between a physician and a patient. It also involves a relationship with society. This relationship can be characterized as a ‘social contract’ whereby society grants the profession privileges, including exclusive or primary responsibility for the provision of certain services and a high degree of self-regulation, and in return, the profession agrees to use these privileges primarily for the benefit of others and only secondarily for its own benefit.
Medicine is today, more than ever before, a social rather than a strictly individual activity. It takes place in a context of government and corporate organization and funding. It relies on public and corporate medical research and product development for its knowledge base and treatments. It requires complex healthcare institutions for many of its procedures. It treats diseases and illnesses that are as much social as biological in origin. The Hippocratic tradition of medical ethics has little guidance to offer with regard to relationships with society. To supplement this tradition, present-day medical ethics addresses the issues that arise beyond the individual patient-physician relationship and provides criteria and processes for dealing with these issues. To speak of the ‘social’ character of medicine immediately raises the question – what is society?
The term refers to a community or nation. It is not synonymous with government; governments should, but often do not, represent the interests of society, but even when they do, they are acting for society, not as society. Physicians have various relationships with society. Because society, and its physical environment, are important factors in the health of patients, both the medical profession in general and individual physicians have significant roles to play in public health, health education, environmental protection, laws affecting the health or well-being of the community, and testimony at judicial proceedings. As the WMA Declaration on the Rights of the Patient puts it: “Whenever legislation, government action or any other administration or institution denies patients [their] rights, physicians should pursue appropriate means to assure or to restore them.” Physicians are also called upon to play a major role in the allocation of society’s scarce healthcare resources, and sometimes they have a duty to prevent patients from accessing services to which they are not entitled. Implementing these responsibilities can raise ethical conflicts, especially when the interests of society seem to conflict with those of individual patients.
When physicians have responsibilities and are accountable both to their patients and to a third party and when these responsibilities and accountabilities are incompatible, they find themselves in a situation of ‘dual loyalty’. Third parties that demand physician loyalty include governments, employers (e.g., hospitals and managed healthcare organizations), insurers, military officers, police, prison officials and family members. Although the WMA International Code of Medical Ethics states that “A physician shall owe his/her patients’ complete loyalty,” it is generally accepted that physicians may in exceptional situations have to place the interests of others above those of the patient. The ethical challenge is to decide when and how to protect the patient in the face of pressures from third parties. Dual loyalty situations comprise a spectrum ranging from those where society’s interests should take precedence to those where the patient’s interests are clearly paramount. In between is a large grey area where the right course of action requires considerable discernment.
Closer to the middle of the spectrum are the practices of some managed healthcare programs that limit the clinical autonomy of physicians to determine how their patients should be treated. A particular form of a dual loyalty issue faced by physicians is the potential or actual conflict of interest between a commercial organization on the one hand and patients and/or society on the other. Pharmaceutical companies, medical device manufacturers and other commercial organizations frequently offer physicians gifts and other benefits that range from free samples to travel and accommodation at educational events to excessive remuneration for research activities. A common underlying motive for such company largesse is to convince the physician to prescribe or use the company’s products, which may not be the best ones for the physician’s patients and/or may add unnecessarily to a society’s health costs. The WMA’s 2009 Statement Concerning the Relationship between Physicians and Commercial Enterprises provides guidelines for physicians in such situations and many national medical associations have their own guidelines. The primary ethical principle underlying these guidelines is that physicians should resolve any conflict between their own interests and those of their patients in their patients’ favor.
In every country in the world, including the richest ones, there is an already wide and steadily increasing gap between the needs and desires for healthcare services and the availability of resources to provide these services. This gap requires that the existing resources be rationed in some manner. Healthcare rationing, or ‘resource allocation’ as it is more commonly referred to, takes place at three levels:
• At the highest (‘macro’) level, governments decide how much of the overall budget should be allocated to health; which healthcare expenses will be provided at no charge and which will require payment either directly from patients or from their medical insurance plans; within the health budget, how much will go to remuneration for physicians, nurses and other heath care workers, to capital and operating expenses for hospitals and other institutions, to research, to education of health professionals, to treatment of specific conditions such as tuberculosis or AIDS, and so on.
• At the institutional (‘meso’) level, which includes hospitals, clinics, healthcare agencies, etc., authorities decide which services to provide; how much to spend on staff, equipment, security, other operating expenses, renovations, expansion, etc.
• At the individual patient (‘micro’) level, healthcare providers, especially physicians, decide what tests should be ordered, whether a referral to another physician is needed, whether the patient should be hospitalized, whether a brand-name drug is required rather than a generic one, etc. It has been estimated that physicians are responsible for initiating 80% of healthcare expenditures, and despite the growing encroachment of managed care, they still have considerable discretion as to which resources their patients will have access. The choices that are made at each level have a major ethical component, since they are based on values and have significant consequences for the health and well-being of individuals and communities. Although individual physicians are affected by decisions at all levels, they have the greatest involvement at the micro-level.
Clinical practice guidelines are available for many medical conditions; they help to distinguish between effective and ineffective treatments. Physicians should familiarize themselves with these guidelines, both to conserve resources and to provide optimal treatment to their patients. A type of allocation decision that many physicians must make is the choice between two or more patients who are in need of a scarce resource such as emergency staff attention, the one remaining intensive care bed, organs for transplantation, high-tech radiological tests, and certain very expensive drugs. Physicians who exercise control over these resources must decide which patients will have access to them and which will not, knowing full well that those who are denied may suffer, and even die, as a result. Some physicians face an additional conflict in allocating resources, in that they play a role in formulating general policies that affect their own patients, among others. This conflict occurs in hospitals and other institutions where physicians hold administrative positions or serve on committees where policies are recommended or determined. Although many physicians attempt to detach themselves from their preoccupation with their own patients, others may try to use their position to advance the cause of their patients over others with greater needs. In dealing with these allocation issues, physicians must not only balance the principles of compassion and justice but, in doing so, must decide which approach to justice is preferable. There are several such approaches, including the following:
• LIBERTARIAN – resources should be distributed according to market principles (individual choice conditioned by ability and willingness to pay, with limited charity care for the destitute); • UTILITARIAN – resources should be distributed according to the principle of maximum benefit for all;
• EGALITARIAN – resources should be distributed strictly according to need;
• RESTORATIVE – resources should be distributed so as to favor the historically disadvantaged. As noted above, physicians have been gradually moving away from the traditional individualism of medical ethics, which would favor the libertarian approach, towards a more social conception of their role. Society has an obligation to provide a reasonable subsidy for care of the needy, and physicians have an obligation to participate to a reasonable degree in such subsidized care.” Even if the libertarian approach is generally rejected, however, medical ethicists have reached no consensus on which of the other three approaches is superior. The utilitarian approach is probably the most difficult for individual physicians to practice, since it requires a great deal of data on the probable outcomes of different interventions, not just for the physician’s own patients but for all others. The choice between the other two (or three, if the libertarian is included) will depend on the physician’s own personal morality as well as the socio-political environment in which he or she practices. Some countries, such as the U.S.A., favor the libertarian approach; others, e.g., Sweden, are known for their egalitarianism; while still others, such as South Africa, are attempting a restorative approach. Many health planners promote utilitarianism. Despite their differences, two or more of these concepts of justice often coexist in national health systems, and in these countries, physicians may be able to choose a practice setting (e.g., public or private) that accords with their own approach
The relationship that exists between physicians and the society is crucial, hence attention seeking. As physicians do their part, so must the society do theirs and vice versa to enable healthcare achieve its purported effect.
ARTICLE WRITTEN BY,
THEOPHILUS YANKEY JUNIOR
2NDYEAR PHYSICIAN ASSISTANT STUDENT
UNIVERSITY OF CAPE COAST
DR. KINGSLEY PEREKO
DR. A.T DERRICK
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