I found an interesting article on the recent measles cases in the U.S. and how whether you get vaccinated or not actually affects people. What do you think?
Pellegrino (1990) argues that the idea of medicine as a moral community can be linked back to Hippocrates. What intrigues me about this is that, given that the Hippocratic Oath was written c.a. 500 BCE, this document is clearly one of the most momentous and long-lasting codes of ethics. In this blog post, I will give some background information on the Hippocratic Oath and argue that the oath should presents a model code of professional ethics.
Hippocrates engraving by Peter Paul Rubens, 1638. (Wikimedia)
Hippocrates’ time (c.a. 460-370 BCE) was one when many untrained charlatans tried to present themselves off as physicians (Boylan “Hippocrates”). These charlatans swindled their patients, convincing them that health problems were the product of supernatural forces not understandable by the patient (Couch 1934). The term ‘fleecing’ shows up in descriptions of these quacks—etymologically, ‘fleecing’ is a metaphor for stripping a person “of money, property, etc., as a sheep is stripped of its fleece” (Oxford English Dictionary). They were self-serving individualists trying to make a quick buck. In this way, honest professional physicians were confronted with a dilemma, similar to what Pellegrino (1990) sees in contemporary professional medical ethics debates.
While it is uncertain if the oath itself was written by Hippocrates (Boylan “Hippocrates”), genuine physicians sought to protect patients from the dangers of these charlatans by setting up a code of ethics. The Oath was a way of “establishing medicine as a profession that ordinary people could trust” and a way to distinguish trained physicians from medical con men.
The contents of The Oath may strike the contemporary reader as outdated, or perhaps misguided. It contains specific bans of practices, such as “I will never induce an abortion” and “I will not engage in surgery”, which seem to run against contemporary medical ethics. But if we put these proscriptions in historical context, they make sense. In Hippocrates’ time, abortion and (most) surgeries would surely endanger the lives of the patient. The aim in forbidding these practices was to set up The Oath as a guide against physicians putting their patients through undue harm.
The Hippocratic Oath is a model code of professional ethics. Unlike many modern professional codes, its intent was to describe the “moral vision” for members of the medical community rather than to protect members of the community from incurring on the law (Boylan “Hippocrates”). In this way, it is a positive code of ethics—it describes what physicians ought to do, not only what they ought not do. On may object that the two bans mentioned above (i.e. ban on abortion, and ban on surgery) seem to work against this aim. But the reason for these bans is that physicians are supposed to help their patients, not harm them. As Pellegrino (1990) argues, it is not enough to provide “mere commitment to common beliefs” to provide the ethics of a professional moral community. Otherwise, morally repugnant groups like White supremacists and Nazi physicians would have claim to being members of a moral community (Pellegrino 1990).
Another important aspect of the Hippocratic Oath, which strengthens its position as a model code of professional ethics, is the inclusion of guidance for entering the profession. Medical practitioners have an obligation to “teach his/her family the art of medicine, if they want to learn it, without tuition or any other conditions of service” (Boylan “Hippocrates”). In this way, it shapes the medical community of inclusive. Those whom the guiding moral theory appeals to (heal, don’t harm) appeal to have a right to join the profession. At the same time, The Oath sets up medical knowledge not as a knowledge which is good in itself, but a knowledge that “generates obligations in those who possess it” (Pellegrino 1990).
Balance, Sir Charles. 1921. “The History of Brain Surgery”, The British Medical Journal 2.3181 (1041-1042).
Boylan. Michael. “Hippocrates”, The Stanford Encyclopedia of Philosophy (Winter 2012 Edition), Edward N. Zalta (ed.).
Courch, Herbert N. 1934. “The Hippocratic Patient and His Physician”, Transactions and Proceedings of the American Philological Association 65 (138-162).
Pellegrino, Edmund D. 1990. “The Medical Profession as a Moral Community”, Bulletin of the New York Academy of Medicine 66:2 (221-232).
 As an interesting aside, trepination, a surgical procedure of drilling a hole in the skull to relieve conditions such as brain swelling, has been practiced since pre-history (Balance 1921).
Two different factors brought me to this post: firstly my potentially obsessive fascination with the ethical issues surrounding vaccination, and secondly my unhealthy and frequent tendency to avoid my problems by binge-watching TV shows on Netflix.
I was enjoying one of my aforementioned Netflix binges, pretending that graduation wasn’t looming and that my life was totally on track, when I stumbled upon an interesting representation of the vaccine issue. I was watching a Grey’s Anatomy spinoff entitled Private Practice (try graduating with no life plan before you judge my TV habits). In the episode, a pediatrician named Dr. Freedman is treating a child presenting with symptoms of the common cold. In a stereotypically melodramatic fashion, Dr. Freedman eventually discovers that the kid has the measles. The child has two younger brothers, the older of whom has severe autism that his mother blames on immunization. As such, she is forcefully opposed to vaccination, to the point where she refuses to vaccinate her youngest son for fear of losing him to the same fate as his middle brother.
The oldest brother must be quarantined in a hospital, and his health rapidly deteriorates. Dr. Freedman continues urging the mother to vaccinate her youngest son, who stands to catch the measles from his oldest brother. Dr. Freedman’s genuine and intense concern for the youngest son goes unappreciated as the mother continues to refuse, getting more and more adamant as the episode continues.
Finally, moments after the oldest child has passed away in the quarantine ICU, Dr. Freedman gives the mother a look, turns away, and, in what I like to call “The True Shonda Rhimes Drama Strut”, marches over to the youngest child, vaccine in hand. The mother, initially confused and eventually horrified, runs screaming after Dr. Freedman, begging him to stop. In the pinnacle of dramatic tension, Dr. Freedman pokes the youngest child with the needle, and the camera pans to the mother, whose face falls tragically before she runs to kneel before her child and check him for any potential signs of autism (take a moment to appreciate how ridiculous that looks).
In a very clear lesson in the morality of vaccination administration, this episode shows Dr. Freedman’s overflowing concern for his patients, and his willingness to break CLEARLY DEFINED laws for the sake of his patients’ health.
I found this episode especially interesting because, unlike much of our focus on vaccination in class, Dr. Freedman is not concerned with the pubic health repercussions of leaving the potentially infected child unvaccinated (sidenote: if the child may be infected, administering a vaccine is the BEST way to take care of it. (Sarcasm.)). He is, instead, solely focused on the well-being of the child. This different perspective marks other vaccination motivations for doctors: preventative medicine on a case-by-case basis and the right of the child to safety from infectious disease.
There also exists here an angle on paternalism. Dr. Freedman overrides the mother’s right to make health decisions on behalf of her child, having clearly stated that there exists no medical connection between vaccination and autism. This overstepping of boundaries, while hugely illegal, is an interesting decision on behalf of the doctor. Dr. Freedman, ignoring all opinions and decisions made by the mother, barges through and vaccinates the child because he knows it is the right thing to do, parental consent be damned.
Overall, I felt this episode raised some very important and difficult questions about vaccination and parental control over a child’s medical decisions. The focus on individuals rather than public health in the debate about vaccination was also a nice shift. The show may be hyper-dramatized to the point of ridiculousness, but they definitely got their point across, loud and clear.
Childress, James F, Faden, R.R., Gaare, R.D., Gostin, L.O., Kahn, J., Bonnie, R.J., Kass, N.E., Mastroianni, A.C., Moreno, J.D. and Nieburg, P. “Public Health Ethics: Mapping the Terrain.” Arguing About Bioethics. By Stephen Holland. London: Routledge, 2012. 10075-0461. Kindle.
“Contamination.” Private Practice. American Broadcasting Company. Netflix. Web. 8 Jan. 2009.
Isaacs, D., H. A. Kilham, and H. Marshall. “Should Routine Childhood Immunizations Be Compulsory?” Arguing About Bioethics. Ed. Stephen Holland. New York: Routledge, 2012. 398-406. Kindle.
In his essay “The Medical Profession as a Moral Community,” Pellegrino addresses the characteristics of a moral community:
- Members of the group share a covenantal relationship both with each other and with society.
- The community has certain standards that remain constant regardless of contemporary leaders or members.
- The community is more than the sum of all its members.
By this definition, the field of medicine can be considered a moral community. The medical profession is more than each physician treating his or her respective patients. The moral nature of the medical profession can actually be seen as completely necessary for the continued ethical function of the profession, given the vulnerability of patients.
Pellegrino describes the vulnerability of patients, and how this imposes even more of a need for doctors to remain moral as individuals and as a community. In the not infrequent event of illness or disease, Pellegrino argues that the patient, no matter how self-sufficient they may be in other situations, becomes vulnerable in the medical setting. This inescapable vulnerability then creates a moral obligation for the physician.
This balance between beneficence and patient autonomy in a complex medical situation brings us back to what we discussed at the beginning of this semester. While the physician has the obligation to “First, do no harm,” they must also, Pellegrino says, protect their patients against exploitation, which may include protection from the patient themselves or the physicians themselves. One aspect of protecting the patient from themselves may be in the case of routine vaccination.
If physicians belong to a moral community that share a covenantal relationship with both each other and with society at large, then it would follow that they should support public health policies that protect the population majority. One of these policies is mandatory vaccination.
While vaccinations are considered mandatory for children to attend public school, the majority of the states in the US allow both religious and philosophical exemptions, which allow parents to refuse vaccination on any terms. If the medical profession is a moral community, then they have the obligation to protect their patients from the exploitation of the media with regards to anti-vaccination campaigns.
If physicians were to truly take a stand as moral agents in the medical profession, vaccination rates could possibly increase, which would decrease the number of outbreaks in communities, like the measles outbreaks which have gained attention recently. If physicians were to make their case for vaccination instead of deferring to the opinions of uninformed parents, they might be able to make a difference.
Pellegrino, Edmund (1990). The Medical Profession as a Moral Community. Bulletin of the New York Academy of Medicine. 66/3 221-232.
I had written my first paper on the ethics of 3-D printing and the future implications if this technology was developed. I recently saw these two articles and thought they were really interesting on how scientific advancements might affect our humanity and morality.
Pellegrino makes a strong argument for our need for a moral community for doctors. In doing so he highlights the fine line faced in this profession between the ethical obligations to the sick vs. self-interest and the marketplace. As he continues his argument, he makes a clear argument for the former stating the moral and ethical obligations of a doctor to care for the sick over all else. While I morally agree with this statement, in the context of the United States I do not know that I buy this premise.
Pellegrino makes states a variety of examples of situations in which doctors would refuse patients saying, “we must feel demeaned by them and act to repudiate them” pushing for the Hippocratic oath as the ethical guide for doctors. While I completely agree that refusing to see a Medicare patient or patient with HIV is morally and ethically wrong – I want to also understand the other side of the story before agreeing to such absolute statements.
It is no shock that doctors are now making less money than they were before. Medical school costs having increased while pay has decreased leading to a significant number of doctors struggling to pay off student loans. In Escape Fire, the struggles of doctors to pay off current bills in order to stay in business are highlighted as a fault of the system. If doctors are paid by patients seen per day, it cannot be completely faulted on the doctor that slightly unethical practices (referring to the Hippocratic Oath regarding empathy) occur. Many practices are forced to fit in an increasing number of patients simply to stay in business – creating a culture of apathetic treatment as we have discussed many times in class. But is that really the fault of the doctor?
Speaking on patient rejecting, prior to Obama care a study in the Health Policy Journal Health Affairs found that 33% of primary care physicians were not accepting new Medicaid patients. Why? Low government reimbursement rates. Certain practices simply could not afford to stay in business while continually taking on new Medicaid patients while reimbursement rates were so low.
***Increasingly more ironic, an economist with the CDC found that reimbursement rates were highest in states with high rates of physicians accepting Medicare.
Under Obama Care certain physical salaries will take a decrease depending on the federal decision to expand Medicaid. However, the doctor shortage will also be heightened leading to an increasing number of ethical concerns within Pellegrino’s quest for a moral community.
I do not condone much of the behavior that is being discussed. My position is rather that it is (in many cases) the fault of a system over the fault of a doctor. It is completely rational for a doctor to worry about paying his own bills vs. seeing one patient at times. Beyond Pellegrino’s moral community, I think we should be calling for greater government funding to offset the costs of medical school which will also allow for federal agencies to dictate specialties, etc that doctor’s choose to pursue. The change has to be more than just a call for morality, but true structural change.
Kliff, S. (2012, August 6). Study: One-third of doctors wouldn’t take new Medicaid patients last year. Washington Post. Retrieved , from http://www.washingtonpost.com
Matthews, M. (2013, November 25). When Will The Government Start Forcing Doctors To See Obamacare Patients?. Forbes. Retrieved , from http://www.forbes.com
Pellegrino, E. The medical profession as a moral community. PubMed, 66, 221-230.
Tyson, P. (2001, March 27). The Hippocratic Oath Today. PBS. Retrieved April 23, 2014, from http://www.pbs.org
Throughout the course of this semester, one of the major questions that often came up was about the role of physicians in patient care. What kind of obligations do they have? How does the role of being a doctor factor into the ethical dilemmas that often come up in medicine. Pellegrino gives us a pretty straightforward answer to that question. The role of a physician is a communal one; that is to say that the individual choices a physician makes should be for the greater good of the community. This goal is problematic in modern society however, because of the conflicting ethos of the marketplace. The ethos of the market is one that is concerned with profit as the primary goal, which unfortunately puts people on the backburner.
This toleration of treating people as a means to an end is directly opposed to morality. Philosopher Immanuel Kant explicates why we should not treat people as a means to an end in his Groundwork for the Metaphysics of Morals; each individual has moral autonomy– that is, their will can be guided by the question “what ought I do?” (107). This question should be answered by following what Kant refers to as the categorical imperative. The categorical imperative states that one should “act only in accordance with that maxim through which you can at the same time will that it become a universal law” (56). The ethos of the marketplace directly contradicts this because its goal is meant to benefit a small subset of people at the expense of others. Additionally, everyone has a duty to act in accordance with the moral law (Kant, 13). Thus, ideally physicians should always oppose the ethos of the market since it is not in the best interest of the greater community.
Pellegrino also gives us a good reasoning as to why we should believe that the moral duty of a physician is always to protect each individual patient. He mentions that gaining a medical education is a privilege in that it gives access to knowledge that is not readily available to those outside of the medical field (Pellegrino, 227). Thus, patients are vulnerable in that they are relying on the knowledge and skill of someone else because they do not possess the knowledge themselves. SInce the patient’s autonomy is at stake when they are sick, it then becomes the responsibility of the doctor to return them to a state of well-being. Pellegrino suggests that the way to go about de-profitizing medicine is to convince legal professionals that the medical field is being harmed by this profitization (230). While I agree with his reasoning here, I think we can take it even one step further. Since treating people as a means to an end is never moral in any case, we need to change the ethos of the marketplace altogether. As long as the ethos of the market remains as it is, no industry can ever be safe from becoming or remaining privatized; so perhaps the solution is to make profit a secondary goal to protecting the right of people not being treated as means. The question then is, how exactly do we go about changing a value that seems so ingrained in our society.
Kant, Immanuel, and Allen W. Wood. Groundwork for the metaphysics of morals. New Haven: Yale University Press, 2002. Print.
Pellegrino, Edmund. “The Medical Profession as a Moral Community.” Bulletin of the New York Academy of Medicine 66 (3): 37-74. Print.
Brennan’s article, written during the Clinton administration—over a decade ago—is just as relevant now as it was then. Brennan puts forward several statements, including his assessment that medical care has, at its base, ethical roots. Because of this, “ethical roots ought to inform the institutions to which they give rise and their attendant financing arrangements”. He states, in his introduction, that ethics is generally left out of debates about finance reform, and that these debates are predominantly governed by economics and politics. This is logical; it’s hard to argue with real numbers and data, which is what economics can provide.
After presenting three solutions: health care insurance reform, health care financing reform, and health care cost reform, he concludes that financing and cost reforms are necessary to remedy the situation, and that an insurance reform is simply not enough. Whether or not Brennan’s assertion about ethics being at the root of health care is true, is not as important. Ethics is inherently linked to any social industry; working for the good of people. Ethics should be considered in any debate when an outcome will affect the well being of people.
However, the problem is figuring out how to get ethics involved. Right now, Congress, a room of politicians, decides on reforms. Brennan mentions, “The plan is only now taking shape…what will eventually emerge from Congress is impossible to predict.” He is referring to the issues of health care costs and restricted access that were addressed during the Clinton administration. However, as we all are very much aware of, the health care system is still dysfunctional. “The plan”, or any plan for that matter, has not yet seemed to work.
Right now we are in the beginning stages of Obamacare, a plan significantly based on reforming insurance. However, it seems unlikely that any big “plan” is likely to work, unless the way in which plans are created and approved is reformed. It will take more then just allowing ethics to enter the “debate”, ethics must take a main role, instead of the backseat position it has been holding for a long time. If the medical system is to indeed become the social institution that it logically should be, integrating ethics—an entity to speak on behalf of people’s health—is imperative.
In The Medical Profession as a Moral Community, Pellegrino discusses the two opposing moral orders that the medical profession faces: their ethical obligations to the sick and their obligation to self-interest and the marketplace. There is no resolution to the two conflicting orders, and those in the medical profession are usually forced to choose one or the other. Today, that is exactly what we see happen in the medical community today. Physicians are often conflicted with their moral obligation to treat, care, and give patients the best possible options and their obligation to their own personal interests. Pellegrino already provides us a couple examples in his essay of how physicians protect their own interests, such as taking part in physician sponsored corporations, unions or strikes or refusing to see poor, Medicare, Medicaid, or AIDS patients (pg. 224).
The American Medical Association (AMA) is one of the largest associations of physicians in the United States. According to the AMA website, its mission is “to promote the art and science of medicine and the betterment of public health.” The AMA website also provides a list of past and current physician ethics that it uses to set standards for medical education. Some examples from the AMA’s 2001 version of Principals of Medical Ethics include:
- “A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.
- A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.
- A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interest of the patient.
- A physician shall support access to medical care for all people.”
As you can see, many of the AMA medical ethics serve to protect the physician as well as the patients. However, I find this set of AMA medical ethics rather ironic. Historically, the AMA has been known to oppose any legislation that does not benefit the physician even though it benefits other people, such as universal healthcare. Many times throughout our history, some form of universal healthcare has been proposed but it has been opposed by the AMA, physicians, and insurance companies. Rather than acting in the interest of patients, physicians and leaders of the AMA have acted in self-interest. This very concerning since the AMA has a lot of influence over physicians and the government. No longer is medicine a moral community, but it is a community that acts in the self-interest.
Pellegrino proposes that American health care system needs moral leadership and medical statesmanship, and I completely agree. Associations, like the AMA, insurance companies, and the government currently have a lot of power over our health care. However, their interests are power and money, which is not what medicine and health care should be about. I have heard stories about physicians go into medical school with a moral obligation to help the sick. However, once they finish, their priorities change. They get trapped into this system created by the AMA, insurance companies, and the government. While they are not morally “bad,” sometimes physicians are forced to refuse patients on Medicare or Medicaid because they need to pay off their medical debts or have an obligation to the hospital. I think if our generation of future physicians is able to stand together as a moral community, change is possible. If everyone is going into the profession with a moral obligation to help the sick, we might have very different leaders serving at these powerful organizations and perhaps medicine can truly be a moral community.
Pellegrino, E. D. “The Medical Profession as a Moral Community.” Bulletin of the New York Academy of Medicine 66.3 (1990): 221-32. NCBI. Web. 20 Apr. 2014