Morals and Medicine

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Suddenly,
I have awoken to find change all around me. This essay will address
the morals surrounding the practice of medicine. I have worked in
this field for a third of a century, and have been preoccupied with
study and treatment of patients. Formalities and legalities have
been there, but I have signed the forms to get along, not wanting
to divert time and attention to these peripheral things. Presumably,
my medical society and the lawyers have taken care of it. Or have
they? I have woken up, suddenly, to a horrible realization that
they have led me astray. The whole issue revolves around informed
consent.

DOING
THINGS TO THE PATIENTS

In
the old days, surgery took a second place to medicine. The most
important services were diagnosis and selection of treatment, and
so it should still be today. The performance of procedures, though
very important, is a technical matter. Skill is required, and, of
course, appropriate technological accouterments. The u2018who,' the
u2018why,' and the u2018when,' are the important decisions to be made by
the physician, let alone the u2018if.' The u2018how' is the business of
the surgeon or the appropriate alternative technician, depending
on the specific circumstances.

THE
SEMANTIC CLUE

Merely
35 years ago, patients would sign forms asking for treatment when
entering an establishment or institution; nothing more was required.
Sometime later, the word request appeared on these forms.
This was changed along to consent, and it is about 15 years
ago that, with a fanfare of apparent support for patients' rights,
the contradictory term informed consent arrived. Well, from
my point of view, the word informed is contained in the word
consent. How can you possibly agree to something if you do
not know what it is? So, I let the qualifier u201Cinformedu201D get itself
attached to forms in my practice and around me without making much
of a fuss, although it did seem redundant, at best. Just now, however,
I have come to realize why these words have changed and the redundancy
added. Let us look at the issue in a little more detail.

TRADE
AND COMMERCE

A
week ago I bought a pair of shoes. On paying for them and leaving
the store, I was quite pleased with my new footwear. I had tried
the shoes on in the store, and they were comfortable. The appearance
pleased me, and I could afford the price. The storekeeper who served
me was also pleased; he had another customer and had made a small
profit, presumably a 30-50% markup on his wholesale price to help
defray his overheads, and bring something home to his wife and children.
I was grateful that he maintained the store in my town. I did not
have to travel far to purchase shoes from him. The interaction was
beneficial to both of us — a fair trade. I proceeded from the shoe
store to my office to engage in the practice of medicine. During
the course of the day, I saw a number of patients to whom I gave
advice, at times lists of nutrients to purchase for their health,
at times prescriptions for items to obtain from a pharmacy, and
performed a number of minor procedures in the course of this day.
In all these interactions the patients attended for the services,
they paid and departed. As far as I can judge, in the same frame
of mind — of satisfaction from the exchange — that I experienced
in the shoe store. What is the difference?

PROFESSIONAL
STATUS

In
the case of the patients who accepted specific technical advice
from me, the difference between the interaction in my office and
that in the shoe store is, that the patient needed to trust me
that the advice was correct, because although they might have seen
the merchandise such as pills or capsules in a bottle, they had
no way of judging the potential benefit other than my word. In other
words, it was for my opinion, wisdom, knowledge, advice, and above
all, trustworthiness, that they paid the fee. It is true that they
would be unlikely to come back if I had deceived them, but they
came to see me out of trust. This trust was built in part on the
knowledge that patients have of my qualifications, but mostly on
the basis of my reputation, either with themselves, their relatives,
friends, or neighbors. So, in what way is the interaction in the
shoe store different from the interaction in my office? The difference
is trust. Trust because of my professionalism. The
services provided by me are different and too complex for the patient
to judge, unlike the simple act of trying a pair of shoes on. It
will take several months, and, in the cases of dangerous or rare
illnesses, perhaps a lifetime, to decide whether the advice was
worthy. After all, I can throw the shoes away after a while if they
are no good, but, if I took a dangerous medicine wrongly prescribed
for my ailment, I might have permanent harm. Therein lies the difference.
Trust and knowledge, and we summarize these qualities with the word
professionalism, which comes from the word profess;
in other words, the commitment of the professional to the oath of
his profession. In medicine this oath has traditionally been the
oath of Hippocrates.

THE
INFORMED CONSENT FORM

In
many medical practices the patient is asked to sign a piece of paper
in which he states that he has received, whatever this is — informed
consent — before accepting the advice, taking the remedy, accepting
the operation, or whatever it is. An explanation is offered to the
patient verbally, in writing, or both. It goes without saying that,
had the patient the ability to acquire all the requisite knowledge
to make a decision for himself, he would not need to come to the
doctor's office. The very fact that he seeks assistance from the
doctor, informing the physician about his needs indicates that he
is dependent on the doctor's cumulative knowledge, advice, and professionalism.
Does signing one's name at the bottom of a form which has the words
u201Cinformed consentu201D at the top change this relationship? Yes and
no. It does not change the relationship substantially, but it pretends
to. This pretense is a source of potential argument, particularly
if the outcome of treatment is less than favorable.

WHAT
OF SURGERY?

In
the Hippocratic oath, there is a distinct separation between the
professionalism of the physician who prepares the plan and gives
advice on the one hand, and the wielder of the knife, the surgeon,
on the other. In the Hippocratic oath, the example of removal of
a kidney stone is emblematic of all surgery. In modern times, many
practitioners combine diagnostic and surgical skills in some branch
or other of medicine. Why does this matter? The skill in performing
a procedure is a technological one, enhanced, probably, by implements
and skill acquired predominantly through training and repetition,
which is probably best begun with an apprenticeship.

FEES

It
goes without saying that, as in all trades, there is an exchange
for the benefit of each. Customarily, we exchange services and procedures
on the one hand for money on the other. The best surety that the
advice (the physician's job) and procedures (the surgeon's job)
are each chosen and paid for most ethically, is when the user, or
customer, pays each professional. The professionals, in turn, share
only information and experience (no kickbacks). Is there any way
that the patient can know all about an operation? Of course not;
if he did, he would be the surgeon. He should reasonably know what
the expectation of success and the risks of failure are, and, if
failure occurs, what might go wrong, and what the odds are. But
even this statement should be qualified. Suppose one had a dangerous
disease in which case the choice for an operation was not a choice
at all, though there is a risk. Absent the operation disaster looms;
what is the point of belaboring all the details of potential dangers
in a situation like this? They only create unnecessary fear and
anxiety. Circumstances have cast the die. Who should be the guide
as to the choice? The physician, of course. If every jot and tittle
of every complication and hazard were belabored endlessly in order
to satisfy the legalistic concept of informed consent, whose
interest is served? This cruel ritual merely serves an attempt to
placate a potential adversarial litigating attorney in speculative
and uncertain future court battles. This is not a service to the
ill person. It is certainly not professionalism. There are, of course,
other circumstances where the medical intervention is one for comfort,
cosmetic, or convenience. In this situation the customer would be
wise — before the equivalent of trying on the new shoes — to weigh
the pros and cons. This is the usual scenario in the marketplace
where cosmetic surgery is performed privately, i.e., not through
u2018health insurance.'

PATERNALISM

It
is fashionable in this age of the rights of the child, feminism,
racial equality, and other examples of what I will call pseudo fairness,
based on Marxist dialectical ideology, to buttress the apparent
rights of various small groups, of course, always in the name of
fairness. What is not said is that it is always at the expense of
the bourgeois ideal of mutual benefit in a fair trade. The accused
class, in the argument about paternalism in medical care,
are the doctors (there is always an accused class in the phenomenon
of dialectic materialism). High-handedly it is claimed, and with
authoritarianism and disregard for the ignorant, the doctor simply
tells the poor patient what to do; that is paternalism. The
politically correct term medically-educationally-deprived
has not yet reached the joke-circuit, but you will get the idea
with an analogy to the prohibition of exclusion of the vertically
challenged from playing basketball.

INFORMED
CONSENT

I
make the claim, therefore, that informed consent is a nonsense
phrase, or u201Cnewspeak,u201D as George Orwell would call it. What term
should we use? I propose trust. If the patient has selected
a physician and the trust is maintained after the interaction of
evaluation and advice. The relationship is consummated. Second and
third opinions are very reasonable, but each such interaction is,
in itself, a relationship with a physician and stands in its own
right.

MIDDLE
CLASS ETHICS

What
are the essentials of this interaction? The essentials are those
of middle class ethics; those of the trade.

Is
the relationship entered into voluntarily?

Is
it advantageous to each party?

Is
the relationship honest (in other words, no deceit)?

Is
the relationship such that it will enhance the reputation and well-being
of each?

These
are the only questions which are relevant. Individuals acting in
more or less closed societies, whose future interactions depend
on their reputation, are compelled by this environment to abide
by these good practices. This is the essence of the conscience of
the middle class. These are the traditions which have come down
to us from the citizens of Athens, from the Ten Commandments Moses
brought down from Mt. Sinai. These are the ethics of the Arab traders
during the height of the Berber Empire, and the principles of the
merchants of the Hansa cities. This is the essence of bourgeois,
middle class society in Europe during and after the Renaissance.
This is the commercial tradition of Western civilization. In what
way is it different when dealing with a profession? In that the
members of the profession have professed; i.e., taken an
oath, to provide their knowledge for a fee, and that the advice
they provide is honest to the best of their ability and judgment.

CHANGES
IN MODERN TIMES

There
have appeared in what goes by the term u2018medical literature,' dozens
of exhortations for change and reconsideration of the Hippocratic
oath. These parallel, I claim, the transition in terminology from
request, to consent, and finally to informed-consent.
They represent a change in responsibility. In a normal bourgeoisie
environment, responsibility lies with each private individual or
entity. In a Platonic republic, or what we would now call a socialist,
or fascist regime such as we live in, in virtually all the countries
of the 21st Century, responsibility has been usurped
by groups. The province, the state, the HMO, the licensing board,
the insurance commissioner, or a strange mishmash of all of these,
but, above all, we need to ask why is the word consent used?
After all, it is the patient who should be requiring, requesting,
begging-for, nay supplicating-for the service in order to heal his
disease. Well, paradoxically, that is exactly what is happening.
Patients in the socialist system have long waiting periods for surgical
procedures, but the pretense is maintained that the favor is done
to the surgeon. Hence, consent, for a surgeon, is
the license to make a living through performing procedures, surgeries.

THE
PROBLEM OF SPECIALIZATION

In
the Hippocratic models, and presumably during Hippocrates' time,
the role of the physician was quite separate from the role of the
surgeon. After the reorganization of medicine, at the behest of
the Rockefellers, and under the nominal directorship of the Flexner
report, the branches of medicine were divided according to systems
and parts of the body. At first we followed the Hippocratic model;
the internist diagnoses; the general surgeon disposes…. But when
one attempts to extrapolate this model we find that it does not
match the modern reality. The ENT physician is also a surgeon; the
dentist is mostly a surgeon, and, even the internist has become
a procedural internist. Does the gastroenterologist not make his
living by endoscopy? And the cardiologist through procedures? In
fact, the insurance business, and later regulatory business controlling
the insurance business, have so arranged our affairs that it is
the doing which yields the income, not the thinking
and diagnosing. I will not use the term cognitive services,
because thinking cannot be a service; but that is a separate issue.

SO
WHAT HAS GONE WRONG?

I
am not sure that u201Cgone wrongu201D is exactly the right term. There have
been two intersecting trends affecting medicine in the last century:

Modernization,
the introduction of technology, and scientific advances.

STATE
INTERVENTION

Between
them, they have distorted the marketplace, elevating fees for doing
things and reducing fees for good advice, coercing doctors, thereby,
gradually over about three generations, to being what is called
procedure oriented. The process of down-coding of cognitive services,
as it is called; in other words, refusing to allow doctors time
with their patients for pay for medical care has been a boom business
for the pharmaceutical companies. The doctor is unable to take time
and select the right herbs, nutrients, remedies, homeopathics, etc.,
for the patient, even if he has the knowledge of how to do so; can
only dispense with the patient's presence — in order to get on with
his next short-term responsibility — by issuing a prescription.
These prescriptions have many disadvantages. At best, they are harmless,
but often they lead to complications such as the destruction of
the normal flora of the large intestine (antibiotics); the destruction
of the healing process of the lining of the intestines and the fascioligamentous
system (NSAIDs). The temporary improvement in some temperamental
problem and failure of addressing underlying problems (antineurotics
and antipsychotics), and the general failure of diagnosis of illnesses
(pain medication).

THE
COMMON DENOMINATOR

What
then, is the common denominator for this unfortunate scenario? The
answer is easy, dear reader. It is socialism. Many socialist
intervenors are well motivated, but they are unable to predict every
need of every patient at every time. Only the physician on the spot
can do that. If his motivation is perverted by standards-of-care,
evidence-based-medicine, work quotas, financial credentialing, fear
of the quackery label, and the other impediments imposed
by the socialist system often under the title of organized medicine,
the individual professional responsibility is degraded. This is
what has happened in our century. This is the destructive process
of socialism. Expensive, complicated technological care; ever-increasing
drug bills; losing the war on cancer; a multitude of invisible diseases;
illnesses with untold suffering such as chronic fatigue and whiplash
injuries. Doctors can diagnose and treat these illnesses individually,
but they do not lend themselves to measurement by the insurance
business. Therefore, the victims of these illnesses become the pariahs,
the untouchables of Western civilization.

CREEPING
CORRUPTION

Creeping
corruption is the outcome of regulation. In America, we started
regulating medicine with the McCurran Ferguson amendment in 1934,
when insurance premiums for large businesses were made tax deductible.
The next step was the introduction of Medicare, (1964) and, since
then, the cascade of increasing regulation is riding an exponential
curve. In all cases, the side effects of the regulations are very
much worse than the problem they ostensibly set out to solve. Arguments
about problems in health-care seldom discuss the proximal cause,
the phenomenon of socialism and regulation. They usually discuss
some side effect of a previous regulation and attempt to patch up
the problem. We are collectively on a great gallop to disaster,
disease, despondency, degeneration, and worst of all, dictatorship.
Whether this mess is here by design for the pleasure of some future
dictator or whether it is a curse peculiar to human society, I do
not know. I can say that it is a result of socialism; a result of
the destruction of the private interaction between individuals for
mutual benefit.

IN
CONCLUSION

In
conclusion, the semantic change from request to informed consent,
is emblematic of the change from freedom of choice in plenty, to
control and deprivation. The engine of this disaster is socialism.

March
13, 2002

Thomas
Dorman, MD, [send him mail]
edits Fact,
Fiction, & Fraud in Modern Medicine
.

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