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Volume 4, Number 2

THE CORE VALUES OF THE PHYSICIAN*

FREDERICK H. LOWY, MD, FRCP(C)

This is an exhilarating era in which to be a physician, but in many ways it is not an easy time in which to fulfill society's mandate to be a healer. It is exhilarating because, to a greater extent than at any time in history, biomedical knowledge and technology have reached the point where it is possible, in unprecedented fashion, to diagnose, alleviate, and cure many of humanity's ills. The rapid pace of scientific progress promises to continue, the transfer time from laboratory bench to bedside is continually shrinking, and - at least in our major cities - we have a rich concentration of hospital and community resources; in short, we have the skills and resources to practice medicine with a high degree of craftmanship.

Yet, while necessary, skilled craftmanship is not enough; it is not all there is to good medicine, any more than it is to good art, music, literature, or science. The difficulty begins because there is much controversy and even doubt about the other necessary ingredients of good medicine. Our profession is grappling painfully with basic questions that, though latent for a long time, are now coming into clearer focus. These touch on the changing roles of physicians in their various relationships - with patients, administrators, governments, the broader society, and each other. These questions involve political, economic, social, and ethical considerations and the practical dilemmas embedded therein.

Does a physician have a duty to treat an AIDS patient or is this a matter of choice? What is a physician's responsibility when a patient refuses a life-saving treatment - say, an operation or a blood transfusion? How does a physician balance the obligation of confidentiality with claims for information, whether from managers of health insurance plans, who want an accurate diagnosis (however stigmatizing); parents of a teenager, who want to know whether their child is on drugs; or sexual partners of HIV-positive patients, who wish to protect their lives? Can the physician remain the agent and advocate of the individual patient when a third party - the government, the hospital, or a health maintenance organization - is the paymaster and insists that the physician be a "gatekeeper" to finite resources? Do physicians have a right, granted to most groups in society, to negotiate in their own interests with all legal resources, including the withdrawal of services? If not, how can they safeguard their legitimate interests and their professional autonomy? Is collegial solidarity the overriding intraprofessional value - and, if so, how do we address and resolve profound (and inevitable) differences with respect to these and many other similar questions? Clearly it requires much time and thought to deal with any one of these questions in depth. Our major medical journals and the burgeoning literature in biomedical ethics now address these issues regularly.

However, these and similar questions are joined by one thread - the identity of the physician. When you are awarded the MD degree and swear the Hippocratic Oath and when you have qualified for licensing as a member of the medical profession, what have you professed? What, if anything, distinguishes a physician from other professionals and other purveyors of specialized services in society? Apart from specific role-related skills, does a common set of professional values define the ideal physician? Do physicians in different cultures throughout the world share common criteria of professional conduct?

Establishing a core definition for the physician is beyond the scope of this paper. However, I can cite some things about the core values of our profession that, so to speak, "come with the territory." I would like to believe that they are widely accepted by physicians, even when we disagree about specific moral issues.

First, I take for granted the need to acquire the knowledge, methods, and skills that all physicians must master to be competent and must maintain current (as appropriate to their practices) through lifelong continuing education. Historically, the physician has been the paradigm for all the healing professions. Other members of the health-care team - nurses, social workers, psychologists, dentists, etc. - share with us many of the core values; therefore, when speaking of these in relation to physicians, we should recognize the large commonality we share.

What, then, are our core values? These are often traced to the 5th century BC and Hippocrates: "I swear by Appollo the physician ... [that] I will follow that method of treatment which, according to my ability and judgment, I consider for the benefit of my patients" (1). "For the benefit of my patients," patient-centered beneficence, is the first and most important shared value of physicians. It is the expectation of every patient - and one we have encouraged by our public pronouncements and our "bedside" manners - that when a patient's medical needs are in conflict with the convenience and self-interest of the physician or others, the patient's needs have priority. Where the physician is not free to honor this priority, he or she must say so promptly: this may occur because the physician is the agent of a third party (e.g., an insurance company or regulatory agency to which a medical report will go) or because of personal reasons (e.g., health or conflicting commitments). Unless patients have been informed that the physician cannot put their interests first, they have every right to expect this as the physician's duty.

To summarize, we declare openly that in the doctor/patient relationship the patient's needs come first; if necessary (and often it is), these needs must be served beyond the physician's self-interest.

The expectation that this will be so permits a person in the state of anxiety, pain, and dependency that characterizes patienthood to place confidence and trust even in a stranger. This trusting relationship is vital in promoting frank disclosure of highly personal information, access to the patient's body for diagnosis and treatment, compliance with recommendations, and - through psychoimmunological and neurohormonal mechanisms - the healing process itself.

Corollaries to this trusting relationship are respect for the patient's personhood and privacy and a commitment to maintaining confidentiality. To return to Hippocrates: "Whatever I may see or hear in the course of my profession ... which ought not to be spoken abroad I will not divulge, holding these to be holy secrets" (1).

A further corollary is that, in the ideal, the doctor/patient relationship is one between consenting, informed, autonomous adults who, as fellow human beings, are equal in worth. However, there is clearly no equality with respect to the power they wield: one is ill or fears becoming ill, with all the vulnerability this implies, and the other, usually on the home ground of hospital or office, professes the competence and preparedness to help. This is the context in which the debate over paternalism versus autonomy rages. In our society at the close of the 1980s, the ideal patient is one who, having been fully informed about the medical facts, the prognosis, and the therapeutic options, is able, in conjunction with the physician, to make a wise decision, even when the choices are agonizing or tragic. Often, in the real world, this ideal is not attained and the physician's benign paternalism is called for; here physicians must act not as they would wish for themselves, but as the patients in their particular situations would wish if they were fully capable of exercising autonomous decision-making. Pellegrino (2) and others have discussed these issues with clarity and sensitivity.

Any discussion of the physician's core values must consider the old concept - some say an anachronism - of the physician's "calling." Just as judges were "called" to the bench and clergymen were "called" to the pulpit, physicians were once said to have a "calling" to medicine. This concept has least two implications: first, that the individual has a strong wish for and is deemed worthy of the honor (not everyone is called); second, that there is an obligation of service to a higher cause. Indeed, Moline (3), a philosopher examining the concept of a profession, contrasts people of various occupations who do this or that for a living ("I work in a bookstore" or "I run a business") and the professional, who is a doctor, priest, or lawyer. This implies that the professional "has an entire way of life, not simply a time-consuming job" (3). This tradition is incorporated into the individual's identity as a person to a far greater extent than in most other occupations. Embarking on a medical career is a decision of what to be, and one is a member of a profession like medicine 24 hours a day; one may be off duty or on vacation, yet one remains a physician, with certain prerogatives and obligations. Furthermore, the "calling" is to service; in our case, service to those who are ill - primarily our own patients, who have contracted for this, but also others. In war after a battle, physicians and clergymen, each in their own way, minister to the injured of both sides because of this "calling."

This example illustrates an important principle that constitutes another core value. Medical knowledge and skill are not proprietary. They do not belong exclusively to the individual physician who has mastered them; he or she has acquired them, as a result of heavy public investment in medical education and research, upon a knowledge base created by previous generations of physicians and patients. Therefore, the physician's expertise must be widely available and not hoarded and sold, like a commodity, to the highest bidder.

Over time, this and other core values have been accepted as modal standards by physicians who work in different medical systems and who are remunerated in various ways. Of course, everywhere there are physicians who do not live up to these values, but they do not enjoy high status among their colleagues, even when they have had commercial success. Furthermore, they are usually apologetic and defensive about these activities, thereby confirming that they accept the principles even while they violate them. However, in the United States, the deliberate commercialization of medicine in an attempt to control health-care costs poses a severe challenge to this last principle (that a physician's knowledge and skill must not be regarded as proprietary).

Another distinguishing feature of physicians, along with some other professionals, is our preparedness to undertake - indeed, our insistence on - self-policing to ensure quality control and adherence to standards of behavior. This is one of the major obligations of the Colleges of Physicians and Surgeons in the Canadian provinces and of similar authorities in other juridictions. It is also, unquestionably, the most difficult. Just as a civilian police force in a democratic country (in contrast to the security forces of a police state) depends for its effectiveness upon a co-operative citizenry, medical regulating authorities can be effective only to the extent that the members of the medical profession co-operate with them and accept their disciplinary role.

This mandate will be eroded whenever the public and its elected representatives lose confidence in medicine's self-governing institutions and their ability to protect the public and support its social policies. This danger is real and present. Physicians must not only obey the law and observe professional regulations, but also support their self-governing institutions in disciplining the few who do not observe these laws.

It follows that physicians, as well as other health-care professionals, hold to a set of core values that go well beyond laws and regulations. The latter are the minimally accepted standards of behavior; the former, our core values, point to a code of conduct that expresses the best in a profession that, justifiably, is still the most honored in virtually all societies.

I believe firmly that the continuing effort to clarify our values and to protect our ethical heritage is not an abstract, pious counsel of perfection. It is the key to the survival of our profession with anything like our present status, freedoms, and incomes.

Frederick H. Lowy, MD, FRCP(C)
The Institute of Medical Science and
The Department of Psychiatry
University of Toronto
and Toronto General Hospital


REFERENCES

  • Hippocrates. The Oath. In: Jones WHS, ed. Hippocrates. London: Heinemann, 1923.
  • Pellegrino ED. Toward a reconstruction of medical morality: The primacy of the act of profession and the fact of illness. I Med and Philosophy 1979;4:32-56.
  • Moline JN. Professionals and professions: A philosophical examination of an ideal. Social Sci and Med 1986;22:501-8.
* Based upon the convocation address, Admissions-to-Membership Ceremony, College of Physicians and Surgeons of Ontario, Toronto, Oct 30 1987.