MacKenzie - What Would a Good Doctor Do? Reflections on the Ethics of Medicine

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  ETHICS What Would a Good Doctor Do? Re 󿬂 ections on the Ethicsof Medicine C. Ronald MacKenzie, MD Published online: 21 July 2009 *  Hospital for Special Surgery 2009 Abstract  Ethical challenges are prevalent in modern-daymedicine. Whether arising in the daily practice of medicine,in the conduct of research, or in our educational practices, physicians need to understand the relevance ethics plays inour professional lives. This paper examines the ethicalfoundations of medical ethics, suggests qualities that de 󿬁 neoptimal professionalism, and frames the discussion employ-ing two hypothetic case presentations. Keywords  medicalprofessionalism.ethics.altruism.obligation Introduction Challenges of an ethical nature abound in modern-daymedicine. Patients, their families, those who provide medicalcare, and the institutions where this care is conducted facedif  󿬁 cult choices almost as a matter of routine. In addition tothose arising in clinical practice, important and controversialethical concerns also arise in the arena of clinical research andinoureducationalpractices.Nodomainofmodernmedicineisuntouched.Inparticular, the problem ofcon 󿬂 ict ofinterest has become an issue especially relevant in our time.Amongst the classical disciplines, ethics provides us amethod for identifying, confronting, and resolving the moraland professional questions arising in clinical medicine.Whether the problem arises at the beginning as in the neonatalintensive care unit, at the end of life as in caring for patientswith terminal cancer or Alzheimer  ’ s disease, or somewhere in between, grounding in the principles of ethics should be of considerable interest and value to all who provide patient care.In order to better understand the relevance of and role played by ethics in our daily activity, we can learn by going back to the srcinal meaning of the word. The ancient Greek words ethos anditsroot  ethica areimportantforunderstandingthemeaningofrightandwrong.Originallyareferencetoone ’ s place of dwelling or abode, during the time of Aristotle,  ethos came tomean a person ’ s interiordwelling place, a reference towhat a person carries within themselves: their attitudes,orientations, and disposition to those with whom they interact,indeed with the world around them [1]. As such,  ethos , in thesense of a person ’ s inner being, is essentially the core of all of one ’ s acts. While contemporary medicine, particularly theexamination of the ethics of medicine, has been moreconcerned with acts or decisions, it is this deeper, historicalderivationofwhatethicsmeansthatliesclosertowhatitmeansto be a  professional   in the context of medical practice [2]. Foundational theories The discipline of philosophy has played a vital role in thedevelopment of modern ethical discourse and certainfoundational elements continue to provide a framework upon which ethical concepts are formulated and discussed.Broadly speaking, contemporary ethics is seen from twocontrasting viewpoints:  consequentialism  with its focus onconsequences and the  nonconsequentialist   beliefs whichderive guidance from rule-based (deontological) approaches[3, 4]. The consequentialist believes that human beings ought to behave (and make decisions) in ways that result inthe greatest good. Their most dominant philosophicaltradition is that of   utilitarianism . Based on the writings of Bentham and Mill, utilitarianism derives its name from HSSJ (2009) 5: 196  –  199DOI 10.1007/s11420-009-9126-7This paper was prepared for presentation at the Hospital for SpecialSurgery Alumni Meeting, November 15, 2008. C. R. MacKenzie ( * )Hospital for Special Surgery,535 East 70th Street, New York, NY 10021, USAe-mail: mackenzier@hss.eduC. R. MacKenzieWeill Medical College of Cornell University, New York, NY, USA The author certi 󿬁 es that he has no commercial associations (e.g.,consultancies, stock ownership, equity interest, patent/licensingarrangements, etc.) that might pose a con 󿬂 ict of interest in connectionwith the submitted article.  utility, a reference to  “ usefulness. ”  Therefore, a utilitarian believes that   “ everyone should perform that act or followthat moral rule that will bring about the greatest good (or happiness) for everyone concerned ”  [5].In contrast, the  nonconsequetialists  claim that conse-quences do not, in fact should not, enter into judging theactions of others. Relying on  “ higher  ”  standards of morality(for instance, God), actions (and people) are to be judgedsolely on whether they are right. Nonconsequentialism is premised on a belief that rules of a moral nature exist andthat such rules can be employed to guide appropriatedecision-making. Kant and his categorical imperative arederived from this philosophical school.However, there is a third approach, more ancient in itsorigins, which seems a better   󿬁 t in terms of helping usunderstand our ethical responsibilities. That is the school of  virtue  ethics [6]. Perhaps because of its attention to a realrole model performing the action who actually embodiesvirtue (i.e., the doctor), as opposed to just following abstract  principles which make certain actions right or wrong, virtueethics has an intuitive appeal in the discourse pertaining tomedical ethics and particularly to physicians concernedabout how they can become good medical professionals.Virtue ethics considers the kind of person the physicianshould be, and as such, is a good  󿬁 t when matters related to professional obligation and standards are at the core of consideration. For contemporary medical professionals,questions arise when we as a profession ask, what are thevirtues that help us de 󿬁 ne the good physician. Let meclarify this point a bit further. Modern medical ethics Historically, the tenant of Western medical ethics may betraced to beliefs relating to the duty of physicians such asthe Hippocratic Oath and other early rabbinic and Christianteachings. In modern times, particularly the 1960  –  1970s, acore set of values or principles have come to dominate thelandscape of ethical discourse. In the collective, theyconstitute a kind of   “ repository of wisdom ”  that serves tohelp us answer a  —   perhaps  the  —  question that sums up what lies at the core of our professional ethics  … What would a good person (doctor) do in this situation? In attempting to answer this question, I offer twoqualities central to the notion of good doctoring and professionalism that I believe, if routinely employed, wouldsolve many of our dif  󿬁 culties. These are the notions of  altruism  and  obligation . Altruism speaks to the idea of the physician working primarily for the best interest of others,speci 󿬁 cally their patients. As a behavior, it connotes anattitude or disposition of the physician to act for the bene 󿬁 t of others; as a principle, it becomes morally compulsory.When a patient entrusts him/herself to the care of a physician, certain ethical  obligations  are immediatelyimplied. Of these, perhaps the most important is the   󿬁 duciary  duty; that is, the relationship of con 󿬁 dence or trust that develops between the patient and their doctor. Theword comes from the Latin  󿬁 des  (faith) and  󿬁 ducia  (trust).A  󿬁 duciary is someone who has undertaken to act for andon behalf of another in a particular matter in circumstanceswhich give rise to a relationship of trust and con 󿬁 dence.Such duties require the highest standard of care andmaintenance as well as extreme loyalty. The  󿬁 duciaryresponsibility that accompanies the role of a professionalis the principal difference between working in an occupa-tion and practicing a profession.So how does a practicing physician develop an under-standing and a practical approach to these responsibilities?Let meemphasize, thechallengebeforeus is,Aristotlewouldsay, practical in nature, not theoretical. That is, our challengeis not just a matter of understanding professional virtues but rather becoming a certain kind of physician and in so doingexemplifying those virtues in our everyday practice. Twocase examples that raise professional challenges will help toillustrate this point. The  󿬁 rst is a somewhat ordinary casethough common dilemma, and a second that is more a product of our times and technology. Case 1  You are referred an 85-year-old woman withincapacitating low back pain due to severe spinal stenosis.Her medical history is signi 󿬁 cant for chronic congestiveheart failure, currently well managed though she has beenhospitalized twice in the last year for episodes of decom- pensation. She is frail and has been physically limited for several years. She lives independently though her daughter,the only living family member, has wanted her to move intoa nursing home for many years, mainly for her mother  ’ ssafety. The patient has refused. Her mental capacity is intact though she has experienced a few, transient episodes of confusion in the setting of urinary tract infections in therecent past. She goes out only on Sundays to the home of her daughter. The patient is very desirous of undergoingsurgery, mainly because she believes it will allow her tomaintain her independent living status.Should you operate on this patient? Case 2  It has been known for some time (some would saysince  time immemorial  ) that the female knee has unique physical characteristics. Narrower, thinner, and with a morenatural tracking mechanism than the male counterpart, these physical characteristics have been incorporated into thedesign of a new  “ gender-speci 󿬁 c ”  knee replacement that  better approximates these unique anatomic features of thefemale knee. Because it is similar in design to existing knee prostheses currently approved and on the market, the Foodand Drug Administration has approved this new designunder a 510K exemption. As such, the new prosthesis hasnot undergone clinical trials.As a respected and in 󿬂 uential arthroplasty surgeon, youhave been approached by the company about your potentialinterest in using their new prosthesis in your female patients. The company is new; indeed, this is their   󿬁 rst  HSSJ (2009) 5: 196  –  199 197   product. The research and development that have resulted inthis exciting product is viewed as justifying its costs, twicethat of the current standard prosthesis of the company ’ scompetitors (who too are working on their own versions). Inthe companies overture to you, you are offered a week-longtraining course in an animal laboratory at their expense inCalifornia. In addition, you are being presented with anopportunity to purchase a 1% equity interest in the companyand, once you are using the device, you will be paid a $1,000 per patient fee in order to facilitate the gathering of informationonthepostmarketing experiencewiththedevice. Should you accept this offer? How does one approach these situations? What is agood physician in these two cases? Here are four guiding principles of contemporary medical ethics:  bene   󿬁 cence , nonmale   󿬁 cence ,  autonomy , and  justice  that can beemployed to help guide our deliberations.The oldest of these tenants are those of   bene   󿬁 cence , that is, a practitioner should always act in the best interest of the patient, and  nonmale   󿬁 cence , the dictum of   “ do no harm ” (  primum non noncere ). Their ancient origins underscoretheir enduring relevance to the practice of medicine.  Bene   󿬁 cence  not only connotes acts of mercy, kindness, andcharity,itgoesbeyond,subsuming allforms ofactiondoneto bene 󿬁 t others (patient). Conceptually, it differs from benev-olence, a term that references the character trait of beingdisposed to act for the bene 󿬁 t of others. As a term, bene 󿬁 cence covers bene 󿬁 cent actions in general; as a principle, it refers to one ’ s moral obligation to act for the bene 󿬁 t of others. In contrast, the principle of   nonmale   󿬁 cence imposes an obligation not to in 󿬂 ict injury on others and, assuch, introduces the notion of harm [7]. These principleshave particular relevance to the  󿬁 rst case where balancingthese competing motives may be particularly at odds. As patients get older and less robust and as they acquirecomorbidities, it becomes more dif  󿬁 cult to know when youare doing good (by performing surgery) versus whenconditions should be pushing you the other way. How riskyis this surgery in this 85-year-old woman? Indeed, should her age be a consideration at all? Even if successful, how muchand for how long will she bene 󿬁 t from it? Could a surgical procedure of lesser magnitude (and lesser risk) accomplishmost of the goals (i.e., Going for a home run when a 󿬁 rst basehit wins the game?) What are her motives, pain relief or theavoidance of institutionalization? Are the surgeon ’ s goalscongruent with the patients? While you may not think of them in this way, these are everyday ethical and practicalchallenges for the practicing surgeon.In the case of the female knee replacement, issues pertaining to bene 󿬁 cence also arise. Does the experience withthis device suggest at least equivalency of outcome to thetraditionalprosthesisorcouldthepatientsdoworse  —  recallingthe  “ do no harm ”  dictum. There is also the  󿬁 duciaryresponsibility. Does a recommendation to use the new deviceadhere to this principle? What would the good surgeon do?The concepts of   autonomy  and  justice  have emergedmuch more recently [8]. Indeed, the notion of the respect for autonomy of the patient has come to lie at the heart of Western medical practice and its ethics, replacing the legacyof medical paternalism of the physician. This principle, onceunfamiliar to physicians, has lead to a major reformulation of the practice of medicine allowing patients the right to choseand refuse treatment, altering medical research, and changing practice with respect to such matters as truth-telling. Thelatter had important implications both in clinical medicine,especially in the setting of terminal malignancy where the paternalistic physician of a now bygone era might withholddif  󿬁 cult but vital diagnostic and prognostic information. Theresultant notions of autonomy and justice were subsequentlyinstrumental in the development of the concept of   informed consent  . In the context of ethics and professionalism, thenotion of   informed consent   has broader implications than theroutine consent procedure prior to surgery.In both clinical scenarios, it is the physician ’ s respon-sibility to inform patients of what they should expect, bothin terms of nature of the perioperative experience and withrespect to the anticipated outcomes. In the elderly womanwith spinal stenosis, not only should she be informed about her outcome with respect to pain, her likelihood of independent living after recovery from surgery needs to bediscussed. One does not necessarily follow the other. In theuse of the gender knee, its rationale, the application of that rationale to the patient contemplating surgery, the relativelysmall accrued experience with the device, and the surgeon ’ s 󿬁 nancial interest in the company [9] are just some of theissues relevant to ethically informed consent. The goodsurgeon would demonstrate a critical understanding of theseconcerns.Lastly, the work of Wennberg [10] during the past twodecades concerning unexplained geographic variation inmedical practice and the even more disturbing observationsconcerning racial disparities in health care have further  promoted the ascendance of   just allocation of expensiveresources  as a central principle of medical ethics [11].Indeed, given the dramatic and uncontrolled problem of health care costs, autonomy, as a central ethical principle,may loose ground to notions of justice in an ever   󿬁 nanciallyconstrained medical system. Health care costs and how to provide ef  󿬁 cient and equitable care to all patients willincreasingly in 󿬂 uence our professional sense of justice. If the new  “ female ”  knee is truly an advance in total joint arthroplasty, who will or should have access to thistechnology? Are the long-term functional outcomes suf  󿬁 -ciently superior with this device when compared to thestandard, nongender models? If not, why are we spendingtime and resources developing and marketing them?Wouldn ’ t justice considerations suggest we should go theother way, that is, cheaper, more generic models that give patients almost everything most will ever need? Again howwould the good physician and surgeon understand his/her responsibilities in this setting? Speci 󿬁 cally, what would the just physician be inclined to do?In closing, ethics is important simply because it is anessential dimension of our work as physicians. We rely, oftenwithout knowing it, on its principles to formulate judgmentsand to make decisions on behalf of our patients. Given the 198 HSSJ (2009) 5: 196  –  199  complexity of modern medicine, physicians, indeed anyoneworking in the current medical environment, needs a frame-work upon which approaches to these challenges can beformulated. Ethics and its philosophical foundations, alongwith our ongoing critical input as a profession, provide us thetools. But ultimately, our challenge is for our profession andfor each of us individually to critically explore the age oldquestion: what does it mean to be a good doctor? References 1. Drane JF (1988) Becoming a Good Doctor: The Place of Virtueand Character in Medical Ethics. Sheed & Wood, Kansas City2. MacKenzie CR (2007) Professionalism and medicine. HSS J3:222  –  2273. Veatch RM (2003) The Basics of Bioethics, 2nd edn. PrenticeHall, Upper Saddle River 4. Tong R (1997) Feminist Approaches to Bioethics: TheoreticalRe 󿬂 ections and Practical Applications. Westview, Boulder 5. Thiroux JP, Krasemann KW (2007) Ethics: Theory and Practice,9th edn. Prentice Hall, Upper Saddle River 6. Pellegrino ED (2002) Professionalism, profession and the virtuesof the good physician. Mt. Sinai J. Med 69:378  –  3847. Beauchamp TL, Childress JL (2009) Principles of BiomedicalEthics, 6th edn. Oxford University Press, New York 8. Jonsen AR (2000) A Short History of Medical Ethics. OxfordUniversity Press, New York 9. MacKenzie CR, Cronstein B (2006) Con 󿬂 ict of Interest. HSS J2:198  –  20110. Wennberg DE (1998) Variation in the delivery of health care: thestakes are high. Ann. Intern. Med 128:866  –  86811. Rom M, Fins JJ, MacKenzie CR (2007) Articulating a justiceethic for rheumatology: a critical analysis of disparities inrheumatic diseases. Arthritis Rheum 8:1343  –  1345HSSJ (2009) 5: 196  –  199 199
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