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?
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.
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.'
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.
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.
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 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, 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