Hull Royal Infirmary, United Kingdom (Spring 2015)
But society has now fairly got the better of individuality; and the danger which threatens human nature, is not the excess, but the deficiency, of personal impulses and preferences.
John Stuart Mill (1806 – 1873), On Liberty, chapter 3, 1859
| John Snow memorial and pub
Licensed under CC BY-SA 2.0 via Wikimedia Commons
John Snow’s classical publication, On the Mode of Communication of Cholera, 1849, exemplified the undoubted benefits of traditional public health by the application of medical knowledge to the public. However, in Europe and America medical advice tailored to the individual has become insidiously more intrusive, bearing wider social and ethical implications.1 Intractable conflicts may arise between duty to their patients and their duty to society.2 A crisis of confidence, from which the medical profession is suffering in part relates to these issues.3 Despite sharing the desire for improving understanding and treatment, there is evidence of problems, contradictions, and unintended consequences—of a divergence between one patient’s welfare and that of society at large. Examples of such conflicts abound.
Although there are undoubtedly instances of rival benefits to the patient and society that can be irreconcilable, physicians sometimes seem unaware of the differences between their clinical interventions and the effects of propagating their views to society at large. They were most evident in the once popular interest in eugenics and selective breeding, a concept of the polymath, Francis Galton FRS. (1822-1911), anthropologist and cousin of Charles Darwin, who made important contributions to statistics and to the hereditary nature of ability and intelligence. Galton’s word ‘eugenics’ denoted scientific endeavors to increase the proportion of persons with better than average genetic endowment, physical and mental, through selective breeding.4 Doubtless well intentioned, he crossed the divide between science and its general application to society. He proposed selective breeding and a system of arranged marriages between men of distinction and women of wealth that would eventually produce an improved race.
His ideas, exploited by Hitler and other racist dictators, were highly influential.5 As recently as 1999, Robert Edwards, Nobel prizewinner, advocated in London’s Sunday Times, “Soon it will be a sin [sic] of parents to have a child that carries the heavy burden of genetic disease.” Sir Macfarlane Burnet (1899–1985) FRS in 1978 advised* the abortion of defective fetuses, infanticide of children with severe genetic disorders, euthanasia for patients with incurable diseases, and the death penalty for those who were a danger to society.6 These may seem extreme views but they were initiated by some of the most accomplished, respected scientists in medicine. Few would doubt that intervention is desirable in certain instances: but how severe is defective? What is incurable? How do we define dangerous? Where are the boundaries?
Whereas it would be indefensible if doctors failed to use their knowledge, experience and practices to individual patients, unforeseen consequences can arise when incautiously applied to the population. The resulting organizational edicts sometimes appear ineffectual; this reduces confidence in the profession and may justify the accusations of physicians being patronizing and unduly authoritarian.
Medical advice publicized through the establishment is often confusing or contradictory. Warnings, based on medical advice and reports, sometimes contradict scientific evidence (e.g. GM foods). The indiscriminate ban on smoking in pubs and restaurants resulted in hundreds of them closing; many lost their jobs. Several edicts have contradicted other warnings offered by physicians (e.g. recommended blood pressure levels and safe alcohol, cholesterol, and salt intakes). When recommendations to the public vary in place or time, peoples’ trust in medical wisdom may be shaken.
How does this conflict affect a doctor’s practice and, his or her professional duties in the wider social setting? The extension of scientific knowledge to governments and social agencies is both necessary and unexceptionable. As Kathleen Norris, novelist and columnist (1880-1966) remarked: “In any free society, the conflict between social conformity and individual liberty is permanent, unresolvable, and necessary.” But dangers arise when scientists and physicians become agents in the public implementation of societal objectives.
In medical research, drug trials, and education, relationships with industry are widespread among practicing physicians. One might assume that when interests conflict, physicians subordinate any personal benefits to the best interests of their patients. But the gaping divide between the rights and choices of the individual and that of society at large is plain,7 and at times is irreconcilable. As physicians we have learned to examine, advise, and prescribe to the patient in front of us. We would rightly be alarmed if the cough medicine we advised for dear Aunt Sally were to be mandated by an edict of some bureaucratic agency.
We are urged to take on a major role in leadership of the health services. “To date too few physicians are installed in leadership and management positions beyond those of clinical director,” says Baroness Cumberlege CBE DL chairman of the Royal College of Physicians report.8 Yet too close an association with the medical establishment has been viewed as “a major threat to health.” Health, argued Ivan Illich, is the person’s capacity to cope with the human reality of death, pain, and sickness. But Illich’s thought attempts to eradicate these universal issues in modern medicine had gone too far.9 In doing so, it turns people into objects; social iatrogenesis results from the medicalization of life, he observed. It is encouraged or positively exhorted by the organizational propagation of inchoate medical dictates, and by commercial or political interests.
That the patient’s interests always came first was once axiomatic. But the respected expert in medical ethics, Dr Raanan Gillon giving the contrary view tells us that this is certainly not true in practice and is undesirable as a moral imperative. He believes the medical profession must also accept a number of diverse social obligations as a part of a social network that may override the interests of individual patients.10 This carries moral and ethical implications.
In the instance of confidentiality various medical institutions state the patient’s interest can legitimately be subordinated to the interests of society.11 Rationing of resources may be necessary, but if for example, physicians are instrumental in rationing of expensive drugs they place their patient’s interests secondary to those of society. Such decisions are primarily the responsibility of politicians.
There are circumstances when physicians reasonably take on independent roles, which affect the public. For example when requested to provide impartial reports on fitness to work or drive, or to assess responsibility for alleged criminal acts, or to examine police suspects, they are not acting in a conventional clinical role where “the patient’s interests always come first.” They act as independent expert witnesses: ethically a separate role, which they are at liberty to decline. In such circumstances, the physician is subject to expectations from a third party. At the same time, he has ethical obligations towards the “patient” and is thus faced with the problem of dual loyalty. In these situations of potential conflict, prime responsibility lies plainly with the non-medical authority asking for impartial medical appraisal. It is these organisations, not the doctor, who make the final decisions of the competing claims in the interests of justice.10
Dissatisfaction and unhappiness amongst physicians are also partly caused by the nonmedical roles for which they were never trained, which they have accepted with pensive resignation. Conventional training to apply medical science to peoples’ illness has changed so that physicians are now expected to be managers and bureaucrats.12 The modern perspective is that physicians should shape the goals of the organization and participate in allocating resources, a job better suited to administrators. Regulatory duties for medical managers and government agencies threaten the once-inviolable doctor–patient relationship.13 Not surprisingly, a majority of physicians and laymen believe that trust in the medical profession is declining, with “new contracts” damaging professionalism.14
At times managerial dictates and proposals appear to come from minds detached from clinical evidence. Many are recognizable by their Orwellian Newspeak, described by the philosopher Roger Scruton as a language whose purpose is to avoid encounters with realities. Have we fallen into the trap where managers and administrators suborn the profession, often pushing responsibility onto an oligarchy of “medical experts” (whose advice they too often ignore) in order to excuse their own misguided policies? The consequences for doctors, as we witness daily, are diminished clinical time, skills and responsibility owing to increased accountability to officialdom rather than to patients.
There are indeed serious concerns about clinical decisions being inappropriately influenced by managers, and pressures on clinicians to meet targets regardless of clinical priorities 15, 16 Managerial decisions, often ill-informed, expressed in box-ticking, target setting, and strategic planning reflect a “naïve hyperrationalism,” which adversely affects patient care.But ambiguously the report also recommended “the centrality of managerial and leadership skills as key competencies of professional practice.”15Crucial to an ethical balance to maintain optimal standards is the exercise of medical professionalism, currently hampered by the political and cultural environment of health, which many physicians consider disabling. A commitment to medical ethics invites a role in the distribution of medical resources to individual patients and to the sick and deprived worldwide. But should it be based on hard medical facts or on politicised, managerial involvement?
There is also a philosophical argument which rests between Bertrand Russell’s utopian scientific society (in which individual liberty in a variety of forms was curtailed in favour of the collective good … and human beings had to become tamer than they had ever been), and Russell’s comment that: “Science as the pursuit of power must not obtrude upon the sphere of values, and scientific technique, if it is to enrich human life, it must not outweigh the ends which it should serve.” 17
An example is the suggested breakdown in the implicit compact between the profession and society, where medical needs of the patient do not always fit the demands of current healthcare systems. Weinstein noted18 that the physician cannot be expected to compromise the wellbeing of the patient in the office in favour of anonymous patients elsewhere. Hence, as in other domains of public policy where individual and collective interests clash,11 a collective solution is required.
These conflicts threaten the integrity of scientific investigations, the objectivity of professional education, the quality of patient care, and the public’s trust in medicine.11 But highly complex deliberations between justice, religious and ethical bodies have produced changing systems, which ought to work for the betterment of both individuals and society. Should we not eschew an accountability to officialdom rather than to patients? To this end physicians should freely make available their knowledge and experience, but confine their activities to scientific, compassionate medical advice, not to organizational propaganda.
*Endurance of Life: The Implications of Genetics for Human Life (1978)
- Russell, Bertrand. The Impact of Science on Society. London: Allen & Unwin, 1952
- Emanuel E, Thompson DF. The concept of conflicts of interest. In: Emanuel E, Grady C, Crouch R, Lie R, Miller F, Wendler D, editors. The Oxford Textbook of Clinical Research Ethics. New York: Oxford University Press; 2008.
- Tallis RC. Physicians in society: medical professionalism in a changing world. Clinical Medicine 2006;6(1):7-10.
- Galton F. Inquiries into Human Faculty and its development. London, Macmillan 1883.
- Huxley JS. Eugenics and Society (The Galton Lecture given to the Eugenics Society), by The Eugenics Review 1936; 28:1-21.)
- Mazumdar Pauline M. H., ‘Burnet, Sir Frank Macfarlane (1899–1985)’, Oxford Dictionary of National Biography, Oxford University Press, 2004; online edn, Oct 2005 [http://www.oxforddnb.com/view/article/55271, accessed 6 March 2014]
- Kevles DJ. In the name of Eugenics: Genetics and the Uses of Human Heredity. Berkeley, University of California Press 1985.p. 300.
- Report of Royal College of Physicians. Future physician: changing physicians in changing times. 2010.
- Ivan Illich,: Limits to medicine. Medical nemesis: the expropriation of health. London, Marion Boyars, 1974, pp. 294.
- Gillon R. Philosophical Medical-Ethics “The patient’s interests always come first”? Physicians and society. British Medical Journal 1986; 292:398-400.
- Lo B, Field MJ. Conflict of Interest in Medical Research, Education, and Practice. Edited Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education, and Practice. Washington (DC): National Academies Press (US); 2009.
- Smith R. Why are physicians so unhappy? BMJ 2001;322:1073-4.
- Gilmore IT. The future of the medical profession. BMJ 2007;335:53;
- Working Party of the Royal College of Physicians. Physicians in society. Medical professionalism in a changing world. Clin Med. 2005;5(6 Suppl 1):S5-40.
- Chard D, Elsharkawy A, Newbery N. Medical professionalism: the trainees’ views. Clinical Medicine Vol 6 No 1 January/February 2006
- Russell B. The Scientific Outlook, London. Unwin 1934. pp. 265-267
- Weinstein MC. Should physicians be gatekeepers of medical resources? J Med Ethics 2001;27:268-274
J.M.S. PEARCE, MD, FRCP (London) is emeritus consultant neurologist in the Department of Neurology at the Hull Royal Infirmary, England. All correspondence to: 304 Beverley Road, Anlaby, East Yorkshire, HU10 7BG, England, or to my email address [jms.pearce[at]me[dot]com].