By Peter Ryan
In his novel The End of the Affair, Graham Greene wrote, “It's
strange how the human mind swings back and forth, from one extreme to another.”
As with individuals, so with society: the pendulum tends to swing. In the
history of the medical profession, one can observe the same tendency concerning
the respective roles of doctor and patient.
Traditionally, a patient who wanted to enjoy good health was counselled, “Follow the doctor’s orders.” In a society when the masses were poorly educated, and physicians well educated, such counsel made sense. But that approach sometimes led to unhealthy paternalism, with doctors disregarding legitimate concerns and wishes of patients.
Now the pendulum has swung. In a culture where ordinary people are better educated, where adherence to authority has declined and the value of individual autonomy has greatly risen, the doctor-patient relationship is much changed. Physicians are now expected to closely consider patient perspective.
But sometimes that approach goes too far, when a doctor defers too readily to a patient’s unreasonable or unethical wishes, for an abortion or an assisted suicide, for example. When a physician abdicates conscience, we end up with the doctor following the patient’s orders. That is unhealthy for the practice of medicine.
The solution is not to revert to unquestioning paternalism where a patient blindly follows the doctor’s orders. The solution is for doctor and patient to together seek what is medically best, without on the other hand, having the patient impose their values on the doctor.
It comes down to the question of what it means to be medical professional. If society expects physicians to be professionals, we need to think about what that means.
Any profession involves not just a set of knowledge and skills but a commitment to use those in a disinterested way in the service of others, following ethical standards such as honesty, integrity, etc. To be a professional is to be involved in a moral undertaking.
The moral character of medicine was helpfully elucidated in 2002 by a landmark statement jointly authored by the American Board of Internal Medicine (ABIM) Foundation, the American College of Physicians Foundation and the European Federation of Internal Medicine. Medical Professionalism in the New Millennium: A Physician Charter has been endorsed by over 130 medical organizations worldwide including the Royal College of Physicians and Surgeons of Canada and the Medical Council of Canada.
The Charter is built around three ethical principles: (1) The primacy of patient welfare; (2) Patient autonomy; (3) Social justice. Of interest here is how the ABIM Foundation explains patient autonomy:
Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.
What does it mean to be a good doctor in this context? As stated, it is to help the patient make “informed” decisions. But there’s more. A physician is not simply to inform the patient, then do whatever they may decide. Decisions must be “in keeping with ethical practice” and “not lead to demands for inappropriate care”. There is therefore an onus for the doctor to judge what “ethical practice” and “inappropriate care” entail.
It is entirely normal for a physician to judge, for example, whether an abortion or assisted suicide requested by a patient is ethical or appropriate. A discussion based on that judgment needs to be part of the doctor-patient relationship. A good doctor does not just follow the patient’s orders. Seeking what is best for the patient’s health should be a joint ethical pursuit by both doctor and patient.
In Canada, medicine has an added moral dimension that must be factored. For medical treatment to be Medicare-insured, a physician must certify that it is “medically necessary.” The doctor has a contractual obligation with the insurer to honestly make that certification.
A treatment decision cannot simply be about patient wishes. A wish is not ipso facto a medical necessity; it is in fact an elective ineligible for Medicare coverage unless the physician certifies – in good faith, exercising judgment about what is best for the patient – that it is a matter of medical necessity. It would be a manifest dereliction of professional duty for a Canadian doctor to simply follow patient orders.
Autonomy run amok is bad medicine. Physician conscience, on the other hand, is absolutely vital to good medicine. It keeps things in healthy balance. Avoiding those wild pendulum swings.
Peter Ryan is President of LifeCanada and represents New Brunswick.
He holds an advanced degree in