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Ethics: Physician and patient
ETHICS: PHYSICIAN A N D P A T I E N T LUIS A. SANJURJO. M.D. From the Department of Urology, University of Puerto Rico School of Medieine, San Juan, Puerto Rico
}iW~Y is Hippocrates' oath valid and vital today while ~i~ techniques have been entirely forgotten? lilB~cause Hippocrates' oath deals not with the nce, but with the conscience of the physician, {~hd the latter should be directed by principles of ~i:~:rnost lasting durability." Jaime Benitez, Past President, University of Puerto Rico.
~
Ethics, derived from Greek, means, "The ~s~S{ematic study of the ultimate problems of il~{fman conduct"; also called "the philosophy of ~O*als." Fowler said that "ethics is the science ~0f morals and morals the practme of ethms. ~a Roehefaueauld synthesizes ethms as to do !6a~itnessed what you could do in front of the '"{~did. From this it can be said that ethics is ith what human conduct should be ,hat human conduct is. d moral norms are universal, and ) us from religion and society as a trious cultures and civilizations; the physician must also abide by medical ethical principles. The rental principles of medical ethics tte the conduct and behavior of the ~6dieal profession evolved from the Hippocratic ~ath. These principles, we can say, apply with a !certain degree of exclusivity to the medical proi!feSsion because they have no application to i~iher branches of knowledge, and to other profe~gions or trades Medical ethics is known to h{ve existed at the time of Asklepios, the god of {~edicine in Greek mythology. P~eSented at the 71st Annual Meeting of the New York Section, American Urological Association, Inc., Dorado Beach, >U6rto Rico, November 4-7, 1973.
UllbLooy / FEBRUARY 1974 / VOLUME III, NUMBER 2
Although evolution and progress in medicine through the centuries, especially during the last six decades, have b e e n enormous, medical ethics have remained unshattered amid the changing currents resulting from wars, revolutions, and the establishment of n e w governments. Exception must b e made of those countries where God and religion have b e e n arbitrarily denied to their citizens b e c a u s e of the impiety and atheism of their leaders. In the various cultures and civilizations from early history, there has existed and actually do exist different mores which are considered to be ethical moral principles. In some tribes, stealing is punishable by death; in others, polygamy and homosexuality are permitted and are a common practice among men, while w o m e n serve the purposes of childbearing and performing household duties and chores. Although medical ethics should be thoroughly mastered and practiced daily b y every physician, all of us are aware that some physicians at one time or another consciously or unconsciously deviate from the norm. In most instances, this violation of medical ethics is neither flagrant nor serious. There are those who b e l i e v e sincerely that no wrong is being done. This u n d o u b t e d l y is an erroneous interpretation because ethics, like the virtues, must not be subject to changes of interpretation. One must admit with deep sadness that in late years a moderate rate of disintegration has oeeurred in the ethical and moral conduct of some in the medical population. There is ample evidence of this: The sincere, courageous, and energetic compaigns against fee-splitting, ghost surgery, unnecessary surgery, and allied evils launched by The American College of Surgeons, the American Medical Association, and various
243
specialty societies. These campaigns, directed toward removing the stigma resulting from sueh practices have covered extensive territory and have b e e n only partially successful. Physician's Attitude Breaches of ethics are the result of several factors which should be analyzed in the light of available evidence. Personal ambition for greater monetary gains at the expense of ill people, professional envy, jealousy, and thirst for p o w e r and prestige, rank among the first. Others, such as economic pressure and undue hardships on young physicians are responsible for their deviations from ethical and moral conduct• Last, we may incriminate the improper selection of medical students. The n e e d for a growing n u m b e r of physicians to supply adequate medical services to an everincreasing population has forced some medical schools and their admission committees to indulge in varying degrees of laxity in their requirements• The formation of a physician today is on a purely scientific basis• Premedical and medical curricula are prearranged, the humanities and nonscientific courses are of secondary importance, and consequently some students enter medical schools with a unilateral scientific, rather than a well-rounded, education. The evils of this system, the results of which are evident, have b e e n well recognized for many years. To our knowledge, Fouill6 was the first to mention them: "The day medicine passes from an intellectual '61ite,' we shall have left only craftsmen in medicine and surgery• If demoeracy allows the invasion of the liberal professions by opportunists or by individuals who with a superficial training are satisfied with just enough knowledge to pass examinations, and who are not inspired by literary, scientific and philosophieal thought, then this supposed utilitarianism will have as a result the success of the least worthy. The physician loses his authority over families if it is known that he has not reeeived the most careful literary and philosophical education." The selection process of medical school candidates should be a thorough one, and the admissions committees should evaluate not only the academic accomplishment of a candidate b u t should strive to elicit his motivations for choosing m e d i c i n e as a career. This evaluation, which to some may seem to be impractical and difficult, is not impossible. The assistance of psychologists and psychiatrists may be extremely valuable since it may be necessary at an early stage of
9,44
premedical education to divert a candidate's intellectual potentialities to other fields of knowledge. All who have devoted some time to these problems and have some experience in these matters ean hardly refute that the motivations of many students who are attracted to medicine are egotistic, devoid of a profound feeling of saerifiee and devotion, and, last b u t not least, arise from an unconscious or poorly understood: desire and thirst for security, prompt gratification of easy remuneration, and prestige. These advantages, which can be obtained in any profes~ sion, business, or trade, are more difficult to obtain in the medical profession, even by those who have stamina, knowledge, and emotional and mental capacity to do it. But the path i~: indeed more diffeult to follow for those laekin~ in devotion, knowledge, humility, ability, an~ a deep understanding of human nature. TheS~ are the ones who forsake the ethical-moral) principles of the profession. Physician and Patient Discussion of ethics and the patient may b e ~ more diffeult task because no matter how care~!iI the selection of medical students, they are i chosen from among a group that has fulfill6~ at least a minimum of scholastic requirements~ and, undoubtedly, they represent the best i ~ a group. ::'~ However, the patients who seek medical ad~j vice do not constitute either a choice or a seleC~i tlon on the part of the physician. They sprl~i~~ from a large mass of people in whom acute ~ chronic degenerative organic diseases develop~ people with varied emotional patterns, edui~ tion, ethical, moral, religious, and philosophi~ principles. These form a heterogenous sufferih'i population whose prineipal aim is to be rid ~ somatic and emotional complaints which handt cap and threaten their welfare and existence. ::~ The physieian who assumes the r e s p o n s i b i l ~ of treating a patient for a condition resulting frd~ organic or emotional maladjustment is dealiif~ with a human being, who carries not only ag~ vistie patterns but also the result~ :ihdirectly, of his upbringing and a hostile or affable world since ehih ever these and his ethical religio philosophieal principles or beliefs is a person who has to face a hos competition, frustration, and decet the law of diminishing returns af either mathematical equations ant_ . . . .
UROLOGY
/
FEBRUARY 1974
/ V O L U M E III,
NUMDSt!~
emotional pattern, which has sown the for his unhappiness. Patient's Attitude ?~i:iThe behavior of a patient with organic disease Iv~ies according to his emotional, social, eeo?ligious patterns, but there is one i all other considerations converge, [ve of his pattern, he faces up to ;qual fashion. first to provide for his family and hOSt basic and elementary means ,, that is, food, shelter, and clothing. wives to obtain enough m o n e y to material needs which are pleasant td last, he works also to accumulate y for his retirement or for a transii~ry or permanent illness. ~: ~ h e n a person is ill, he not only worries about ~h?sical suffering but he becomes apprehensive, llikes the limitations on his physical activity ~hnfined to bed or to a hospital, and is conaed about the final consequences of his ill~'ss. A patient e n d o w e d with a conscience and i~i'ings similar to those of the physician, not ~pn}y expects a prompt and lasting cure but wishes ~ ; i } e c e i v e sympathy and consideration which ~ a y in some way mitigate his suffering. The ~ f i e n t entrusts his soul and body to the physi~ ) i ~ and expects in some instances impossible ~;~6sults. If the relationship b e t w e e n patient and ~!~hysl ~ : ' '12'lan is warm and sincere, in many instances, ~;a lasting bond of sincere friendship will develop. [ent who does not receive a warm, frank from the person he has chosen to treat mediately becomes aware of this indifHe loses confidence, and he may go to physician or to a charlatan or, he will or later speak evil about the person .
I.,I1OLOcY
.
.
.
/ FEBBUARY 1974 / VOLUME III, NUMBER 2
he thought he could trust. His reaction may be one of cynicism extending to the whole medical profession. How- often has one heard patients accuse the whole medical profession for the wrong committed by one individual! T h e y believe that the whole chain is defective because one link is weak. The patient's ethics toward the physician may become so warped and distorted, frequently seen in the United States but fortunately not in Puerto Rico, that may be conducive to a malpractice suit. The majority of malpractice suits are the result of errors of interpretation on one hand or inadequate frank explanations on the other. Should both parties frankly and sincerely discuss their problems and motives, many of these cases would never reach the courts. In a recent study on malpractice, published in the Bulletin of the American College of Surgeons, it was stated that there are pro-litigation patients as well as physicians, and that this is the result of particular emotional patterns in both. A physician's behavior toward his patient, which is conditioned not only by his intelligence, honesty, and sincerity, is also influenced by his cultural background. The wider his knowledge and understanding, the broader will be his projections toward the problems of life, and these include the patients with whom he has to deal. A mutual understanding is best accomplished by greater tolerance and forbearance on the part of the physician whose education, in most instances, is superior to that of the patient, placing the physician in a position of greater comprehension. 303 De Diego Avenue Santurce, Puerto Rico 00909
245
}iW~Y is Hippocrates' oath valid and vital today while ~i~ techniques have been entirely forgotten? lilB~cause Hippocrates' oath deals not with the nce, but with the conscience of the physician, {~hd the latter should be directed by principles of ~i:~:rnost lasting durability." Jaime Benitez, Past President, University of Puerto Rico.
~
Ethics, derived from Greek, means, "The ~s~S{ematic study of the ultimate problems of il~{fman conduct"; also called "the philosophy of ~O*als." Fowler said that "ethics is the science ~0f morals and morals the practme of ethms. ~a Roehefaueauld synthesizes ethms as to do !6a~itnessed what you could do in front of the '"{~did. From this it can be said that ethics is ith what human conduct should be ,hat human conduct is. d moral norms are universal, and ) us from religion and society as a trious cultures and civilizations; the physician must also abide by medical ethical principles. The rental principles of medical ethics tte the conduct and behavior of the ~6dieal profession evolved from the Hippocratic ~ath. These principles, we can say, apply with a !certain degree of exclusivity to the medical proi!feSsion because they have no application to i~iher branches of knowledge, and to other profe~gions or trades Medical ethics is known to h{ve existed at the time of Asklepios, the god of {~edicine in Greek mythology. P~eSented at the 71st Annual Meeting of the New York Section, American Urological Association, Inc., Dorado Beach, >U6rto Rico, November 4-7, 1973.
UllbLooy / FEBRUARY 1974 / VOLUME III, NUMBER 2
Although evolution and progress in medicine through the centuries, especially during the last six decades, have b e e n enormous, medical ethics have remained unshattered amid the changing currents resulting from wars, revolutions, and the establishment of n e w governments. Exception must b e made of those countries where God and religion have b e e n arbitrarily denied to their citizens b e c a u s e of the impiety and atheism of their leaders. In the various cultures and civilizations from early history, there has existed and actually do exist different mores which are considered to be ethical moral principles. In some tribes, stealing is punishable by death; in others, polygamy and homosexuality are permitted and are a common practice among men, while w o m e n serve the purposes of childbearing and performing household duties and chores. Although medical ethics should be thoroughly mastered and practiced daily b y every physician, all of us are aware that some physicians at one time or another consciously or unconsciously deviate from the norm. In most instances, this violation of medical ethics is neither flagrant nor serious. There are those who b e l i e v e sincerely that no wrong is being done. This u n d o u b t e d l y is an erroneous interpretation because ethics, like the virtues, must not be subject to changes of interpretation. One must admit with deep sadness that in late years a moderate rate of disintegration has oeeurred in the ethical and moral conduct of some in the medical population. There is ample evidence of this: The sincere, courageous, and energetic compaigns against fee-splitting, ghost surgery, unnecessary surgery, and allied evils launched by The American College of Surgeons, the American Medical Association, and various
243
specialty societies. These campaigns, directed toward removing the stigma resulting from sueh practices have covered extensive territory and have b e e n only partially successful. Physician's Attitude Breaches of ethics are the result of several factors which should be analyzed in the light of available evidence. Personal ambition for greater monetary gains at the expense of ill people, professional envy, jealousy, and thirst for p o w e r and prestige, rank among the first. Others, such as economic pressure and undue hardships on young physicians are responsible for their deviations from ethical and moral conduct• Last, we may incriminate the improper selection of medical students. The n e e d for a growing n u m b e r of physicians to supply adequate medical services to an everincreasing population has forced some medical schools and their admission committees to indulge in varying degrees of laxity in their requirements• The formation of a physician today is on a purely scientific basis• Premedical and medical curricula are prearranged, the humanities and nonscientific courses are of secondary importance, and consequently some students enter medical schools with a unilateral scientific, rather than a well-rounded, education. The evils of this system, the results of which are evident, have b e e n well recognized for many years. To our knowledge, Fouill6 was the first to mention them: "The day medicine passes from an intellectual '61ite,' we shall have left only craftsmen in medicine and surgery• If demoeracy allows the invasion of the liberal professions by opportunists or by individuals who with a superficial training are satisfied with just enough knowledge to pass examinations, and who are not inspired by literary, scientific and philosophieal thought, then this supposed utilitarianism will have as a result the success of the least worthy. The physician loses his authority over families if it is known that he has not reeeived the most careful literary and philosophical education." The selection process of medical school candidates should be a thorough one, and the admissions committees should evaluate not only the academic accomplishment of a candidate b u t should strive to elicit his motivations for choosing m e d i c i n e as a career. This evaluation, which to some may seem to be impractical and difficult, is not impossible. The assistance of psychologists and psychiatrists may be extremely valuable since it may be necessary at an early stage of
9,44
premedical education to divert a candidate's intellectual potentialities to other fields of knowledge. All who have devoted some time to these problems and have some experience in these matters ean hardly refute that the motivations of many students who are attracted to medicine are egotistic, devoid of a profound feeling of saerifiee and devotion, and, last b u t not least, arise from an unconscious or poorly understood: desire and thirst for security, prompt gratification of easy remuneration, and prestige. These advantages, which can be obtained in any profes~ sion, business, or trade, are more difficult to obtain in the medical profession, even by those who have stamina, knowledge, and emotional and mental capacity to do it. But the path i~: indeed more diffeult to follow for those laekin~ in devotion, knowledge, humility, ability, an~ a deep understanding of human nature. TheS~ are the ones who forsake the ethical-moral) principles of the profession. Physician and Patient Discussion of ethics and the patient may b e ~ more diffeult task because no matter how care~!iI the selection of medical students, they are i chosen from among a group that has fulfill6~ at least a minimum of scholastic requirements~ and, undoubtedly, they represent the best i ~ a group. ::'~ However, the patients who seek medical ad~j vice do not constitute either a choice or a seleC~i tlon on the part of the physician. They sprl~i~~ from a large mass of people in whom acute ~ chronic degenerative organic diseases develop~ people with varied emotional patterns, edui~ tion, ethical, moral, religious, and philosophi~ principles. These form a heterogenous sufferih'i population whose prineipal aim is to be rid ~ somatic and emotional complaints which handt cap and threaten their welfare and existence. ::~ The physieian who assumes the r e s p o n s i b i l ~ of treating a patient for a condition resulting frd~ organic or emotional maladjustment is dealiif~ with a human being, who carries not only ag~ vistie patterns but also the result~ :ihdirectly, of his upbringing and a hostile or affable world since ehih ever these and his ethical religio philosophieal principles or beliefs is a person who has to face a hos competition, frustration, and decet the law of diminishing returns af either mathematical equations ant_ . . . .
UROLOGY
/
FEBRUARY 1974
/ V O L U M E III,
NUMDSt!~
emotional pattern, which has sown the for his unhappiness. Patient's Attitude ?~i:iThe behavior of a patient with organic disease Iv~ies according to his emotional, social, eeo?ligious patterns, but there is one i all other considerations converge, [ve of his pattern, he faces up to ;qual fashion. first to provide for his family and hOSt basic and elementary means ,, that is, food, shelter, and clothing. wives to obtain enough m o n e y to material needs which are pleasant td last, he works also to accumulate y for his retirement or for a transii~ry or permanent illness. ~: ~ h e n a person is ill, he not only worries about ~h?sical suffering but he becomes apprehensive, llikes the limitations on his physical activity ~hnfined to bed or to a hospital, and is conaed about the final consequences of his ill~'ss. A patient e n d o w e d with a conscience and i~i'ings similar to those of the physician, not ~pn}y expects a prompt and lasting cure but wishes ~ ; i } e c e i v e sympathy and consideration which ~ a y in some way mitigate his suffering. The ~ f i e n t entrusts his soul and body to the physi~ ) i ~ and expects in some instances impossible ~;~6sults. If the relationship b e t w e e n patient and ~!~hysl ~ : ' '12'lan is warm and sincere, in many instances, ~;a lasting bond of sincere friendship will develop. [ent who does not receive a warm, frank from the person he has chosen to treat mediately becomes aware of this indifHe loses confidence, and he may go to physician or to a charlatan or, he will or later speak evil about the person .
I.,I1OLOcY
.
.
.
/ FEBBUARY 1974 / VOLUME III, NUMBER 2
he thought he could trust. His reaction may be one of cynicism extending to the whole medical profession. How- often has one heard patients accuse the whole medical profession for the wrong committed by one individual! T h e y believe that the whole chain is defective because one link is weak. The patient's ethics toward the physician may become so warped and distorted, frequently seen in the United States but fortunately not in Puerto Rico, that may be conducive to a malpractice suit. The majority of malpractice suits are the result of errors of interpretation on one hand or inadequate frank explanations on the other. Should both parties frankly and sincerely discuss their problems and motives, many of these cases would never reach the courts. In a recent study on malpractice, published in the Bulletin of the American College of Surgeons, it was stated that there are pro-litigation patients as well as physicians, and that this is the result of particular emotional patterns in both. A physician's behavior toward his patient, which is conditioned not only by his intelligence, honesty, and sincerity, is also influenced by his cultural background. The wider his knowledge and understanding, the broader will be his projections toward the problems of life, and these include the patients with whom he has to deal. A mutual understanding is best accomplished by greater tolerance and forbearance on the part of the physician whose education, in most instances, is superior to that of the patient, placing the physician in a position of greater comprehension. 303 De Diego Avenue Santurce, Puerto Rico 00909
245