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.

Citations:

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

http://www.ama-assn.org/ama/pub/about-ama/our-mission.page?

http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/principles-medical-ethics.page

Two Opposing “Moral” Orders: Who to Respond to?

        In The Medical Profession As A Moral Community, Pellegrino argues that a main dilemma of professional ethics that the physician faces is “an unenviable choice between two opposing moral orders, one based in the primacy of our ethical obligations to the sick, the other in the primacy of self-interest and the marketplace” (Pellegrino 221). To clarify, physicians are forced to choose between focusing on aiding sick individuals versus helping benefit the marketplace, which can be more or less looked at as the debate between beneficence and self-interest. I believe that physicians should focus on the ethical obligations of the sick, both because pursuing an act of self-interest is immoral and is not always noticeable in the grand scheme of things.

        What would a moral order be comprised of? In my opinion, a moral order would have to originate from a moral community, whose “members are bound to each other by a set of commonly held ethical commitments and whose purpose is something other than mere self-interest” (Pellegrino 225). If conforming to the character of the market “legitimates self-interest over beneficence and makes vices out of most of our traditional virtues” then how could it be moral? (Pellegrino 221). We could further argue the statement that, “medicine is at the heart a moral enterprise and those who practice it are de facto members of a moral community” (Pellegrino 222). Yes, medicine is intended to be moral but the focus can vary from self-interest to beneficence; hence, this does not ensure that a moral community exists or that moral enterprise is taking place. Similarly, when physicians speak about medical procedures, we cannot to prove they are acting in any way besides their self-interests, also showing that medicine does not guarantee morality.

Another good reason to stand firm on the belief that being a physician imposes certain necessities that impede turning ourselves primarily to entrepreneurs or businessmen is that individual aid is seen on an individual level; whereas acts reflecting the economic policy may go unnoticed.  If an individual was aided economically in disease-treatment, beneficence is much more prevalent than if an economic policy arose that attempted to increase health for all, but truly did not make an impact. Since, beneficence is defined as, “an act of charity, mercy, and kindness with a strong connotation of doing good to others including moral obligation,” responding to those in need is clearly moral. (Kisinger 44).

In conclusion, the ethical obligations to the sick should take precedence in the “who to respond to” debate, because of one: the morality associated with helping those in need and two: the concept of making a difference in an individual’s life. Business-like, fiscal behavior can be understandable for economic reasons during times of deficits; however, when we look at the larger picture, beneficence and morality represent what medicine should consist of.

Works Cited:

1.) Kisinger, Frank Stuart. “Beneficence and the Professional’s Moral Imperative.” NCBI. N.p., Dec. 2009. Web. 19 Apr. 2014. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342811/>

2.) Pellegrino, Edmund D. “The Medical Profession As A Moral Community.” N.p., May 1990. Web. 19 Apr.2014.

The following article supplements my post. I encourage you to read it.

http://www.thedailybeast.com/articles/2014/04/14/how-being-a-doctor-became-the-most-miserable-profession.html

 After reading “How Being a Doctor Became the Most Miserable Profession”, I could not shake the reality that I, and many of you, will face when entering the medical profession. The thought has always been tucked in the back of my mind but recently is has become more prevalent as I step closer towards becoming a doctor. As this nation’s future physicians, how do we change the corrupt healthcare system and medical practice?  How do we give patients what they deserve? Is it through policy and large corporate changes that take years to implement? No. To me the answer is simple: we must change from the inside out.

As Edmund Pellegrino writes in The Medical Profession as a Moral Community, “Today, our profession faces an unenviable choice between two opposing moral orders, one based in the primacy of our ethical obligations to the sick, the other in the primacy of self-interest and the marketplace.” Physicians cannot serve multiple cohorts of society. They either serve the patient or they serve the economy, policy or the law. We cannot blame the state of medical care on the outside factors of society. While it is understandable, the blame compromises our moral integrity. We can overcome this crisis “by acting not on the basis of what external forces do to us, but on what they do to those we serve” (Pellegrino).

I cannot think of a better time to apply and practice Pellegrino’s opinion about moral communities than in today’s society. “A moral community is one whose members are bound to each other by a set of commonly held ethical commitments and whose purpose is something other than mere self-interest” (Pellegrino). He continues his definition of a moral community and states that the group must posses the following: “the inequality of the medical relationship, the nature of medical decisions, the nature of medical knowledge, and the ineradicable moral complicity of the physician in whatever happens to his patient” (Pellegrino).

Pellegrino says it perfectly, “only if we have the will to use our collective moral force will the integrity of the profession be preserved.” As future doctors, we must unite on this moral mater and further its foundation in the medical community.

Citations:

Pellegrino, Edmund. “The Medical Profession as a Moral Community” Bulletin of the New York Academy of Medicine 66 (3): 221-232.

Drake, Daniela. “How Being a Doctor Became the Most Miserable Profession.” The Daily Beast. Newsweek/Daily Beast, 14 Apr. 2014. Web. 20 Apr. 2014.

In The Medical Profession as a Moral Community, Edmund Pellegrino defines a moral community as “one whose members are bound to each other by a set of commonly held ethical commitments and whose purpose is something other than mere self-interest” (Pellegrino 225). It was extremely interesting to me how he referenced Nazi Germany a couple of times throughout his article in order to establish an understanding of how medicine is a moral community. He mentions how, in Nazi Germany, the vast amount of murders would not have been possible without the cooperation of the physicians (228). The Nazis performed thousands of medical experiments on their concentration camp prisoners that were extremely painful and often deadly. Again, without the cooperation of the physicians, these experiments would not have been “successful” (killing them) and many more people would have survived.

In his article, Pellegrino argues that medicine is basically a moral community because of the numerous aspects of medicine that give it a moral status. According to Pellegrino, there are four aspects of medicine that give it a moral status: the inequality of a medical relationship, the nature of medical decisions, the nature of medical knowledge, and the moral complicity that the physician has over his or her patient. The inequality of a medical relationship refers to when the physician takes care of the patient and does everything in the patient’s best interest. The physician does not think of himself or, for example, the patient’s family members. All of the decisions made are made with the patient’s best interest in mind.  The nature of the medical decisions involves proper diagnosis and recommendations that are also done for the patient’s well-being. Moreover, the nature of medical knowledge involves practical knowledge and knowledge that people get through medical education. Pellegrino gave the example of how students in medical school encounter many moral decisions and break moral barriers. Medical school requires students to practice and impose on the privacy of people’s bodies through medical procedures like autopsies. Finally, the moral complicity of the physician refers to the overall responsibility that the physician has for his or her patient. The physician is (or, at least, should be) the one who makes the recommendations for the patient with the patient’s best interest in mind.

Though medicine does have many moral aspects, I would not define it as a moral community like Pellegrino does. He argues that a moral community is independent of what its leaders or members might be at a particular time (225). I think that the Nazi Germany example specifically contradicts this statement because the physicians running the Nazi medical experiments were following orders at a specific point in time. A “moral community” would not perform these kinds of experiments on people if it was truly a moral community. Unless he argues with this example because the Nazis sincerely believed that they were doing something morally correct and had a greater purpose beyond self-interest. So then I pose the question: though a community may be tied together by a set of ethical commitments and does things that have a greater purpose than self-interest, are they really considered a “moral community” if their community involves immoral behaviors like murder?

Works Cited

Pellegrino, Edmund D. “The Medical Profession as a Moral Community” Bulletin of the New York Academy of Medicine 66 (3): 221-232.

In his article, Health Care and Equality of Opportunity, Gopal Sreenivasan argues that universal healthcare isn’t really the answer to our call for equality of opportunity. Yes, a loss of health can take away one’s fair share of opportunity, but health is not the same as healthcare. There are social determinants  to health that  make a much bigger impact on health than any healthcare system. These social determinants boil down to income levels. Poorer people suffer from more chronic conditions and have on average, lower life expectancies. That’s not surprising. But Sreenivasan wants to make it clear that having access to a doctor and a clinic won’t change that. It’s poverty that influences key factors to health like diet, living conditions, health literacy, and education. Without addressing this poverty – and since equal opportunity is based on relative shares, reducing the income disparity as a whole, we will be doing little in the long run.

It seems that Sreenivasan has overlooked the fact that providing universal access to healthcare is a crucial step to centering the social gradient in the same way that a system like public education is. Imagine living in a country where access to public education was as limited to lower-income families as healthcare is today in the US. Sreenivasan could plausibly make the same logical argument. There are other social determinants that determine educational and career success. Addressing income inequality is the real solution, one might argue. The false assumption being made here is that these systems do little or nothing to change the social gradient itself.

Healthcare can be extremely expensive, and it pushes people into poverty. Poverty rates rise considerably when healthcare costs are taken into account. In fact, covering healthcare costs for the poor has the potential to make the biggest difference according to census data. The current measure of how many people are officially living in poverty does not take medical costs into account. If out-of-pocket healthcare costs were included, 10 million more people (a 3.3 point increase in the poverty rate) would be added to our count.

Sources:

S. R. Collins, New Census Poverty Measure Shows Medical Expenses Push 10 Million More Americans into Poverty, The Commonwealth Fund Blog, November 2011.

Sreenivasan, Gopal. “Health care and equality of opportunity.” Hastings Center Report 37.2 (2007): 21-31.

Public Health is an emerging field that has goals to improve the the access of  healthcare to all individuals. Some believe that equal health care is not attainable for all. Some believe that there should be a bare minimum for all people and they are entitled to this right. However, is it really possible to create a bare minimum of health care for all? There are those that realize this concept, and strive to work against the negative effects of social determinants in our societies. Sreenivasan states that, “Social determinants of health, roughly speaking, are those social factor outside the traditional health care system that have an effect either positive or negative, on the health status of individuals in a given population”. There is obviously a relationship between access and quality of health care to the wealth of an individual. However, it is important to note that health care is not the sole control social factor that significantly impacts one’s health. The article makes very realistic points about how we should view the social gradient. If we were to achieve this idea of “equal opportunity”, every one would “more or less” have the same access and quality health care.This article does not stress that there is a right to health care for all. However, there are organizations that strive for this goal, and have had great successes in reaching this goal. For example, PIH and BRAC have both made great strides toward better health care regardless of the amount of wealth a person accumulates. Sreenivasan more or less states that there is always going to be someone that doesn’t have health care, and doesn’t believe that everyone has a right to health care. However, Buchanan’s article is a very good contrast to the points made in Sreenivasans article.

Buchanan’s article seems to hold a perspective that may be better applied to the outlook of how health should be viewed. Buchanan states, “The main difficulty is that assuring any significant level of health for all is simply not within the domain of social control.” The article discusses how the idea of equal opportunity, but is it truly realistic. Also, it is noted that there is a strong difference between a decent minimum of healthcare and access to health care. Which one should be implemented? There may or may not be a better choice depending on finances and other factors, but which one seems to be more realistic in our world today? Can we provide a decent minimum for all? An important point to note is that people require different levels of health care. People have different cases and diseases that all require differing levels of money to treat. There will always be someone that doesn’t quite receive the adequate amount of healthcare that they should receive, and the reality of it is harsh. However, as a society we can try our best to treat the ones that are affected negatively by these social determinants. There may be wiggle room for the bar to be set as to where to begin treating everyone, but how do we establish a set bar? Each case can have a different level of severity and urgency, so can we really make a bare minimum in the field of public health.

References

Sreenivasan, Gopal. “Health Care and Equality of Opportunity”. The Hastings Center Report (2007). p. 21-31.

A. Buchanan, “The Right to a Decent Minimum of Health Care”. Philosophy and Public Affairs (1984). p.55-78

A month ago, I had the opportunity to visit one of the CDC’s exhibitions entitled, “Health is a Human Right: Race and Place in America” The exhibition examined challenges which made it difficult for certain minority groups and socially disadvantaged peoples to receive equal access to healthcare throughout history. The exhibit attempted to show that, whether due to socioeconomic and/or political factors, many groups of people in the United States are being forced to live without the basic resources that ensure health, including clean water, sanitation, housing, food, and health care. The purpose of this exhibit was to explain that health should be accessible to everyone, and that universal health should be provided to people regardless of their status, class, race, or gender. The exhibition emphasized that the aim of universal health should be to ensure that all people have equal and rights and access to health services without suffering from financial difficulty. However, this raises the ethical dilemma of whether or not providing universal healthcare alone, guarantees health and well-being. Do we have any social or moral responsibilities and obligations in other’s overall health? According to Gopal Sreenivasan, in his article, Health Care and Equality of Opportunity “one widely accepted way of justifying universal access to health care is to argue that access to health care is necessary to ensure health, which is necessary to provide equality of opportunity, but the evidence on the social determinants of health undermines this argument.” Sreenivasan further argues that “universal access to healthcare” and “actual health and well-being” are two different phenomena. His suggestion is that “instead of introducing a national health insurance scheme, [if] we had spent the same amount of money on equalizing the distribution of social status – then our society’s gradient in health would have been significantly reduced.”

What Sreenivasan points out is that well-being in terms of an individual’s health status, first requires a commitment of social investment for public goods because the socio-economic class is a deterrent in providing fair share of health to people. Sreenivasan explains that a “social determinant of health is a socially controllable factor outside the traditional health care system that is an independent partial cause of an individual’s health status.” For example, poverty alone is the cause of many unpleasant health problems; for the poor even small costs to visit a medical clinic can be devastating for the family’s financial situation; merely providing an equal amount of care to them would not be enough.  Sreenivasan’s argument implies that we should invest less on health and more on limiting the negative consequences of social determinants of health; the objective should be to tackle socioeconomic factors that create major discrepancies in health inequalities.

As was witnessed in the CDC exhibit, there are many political complexities preventing us from promoting and offering universal healthcare, we should still strive to achieve this goal. However, this should not be the only goal we strive for. As Sreenivasan states, offering healthcare alone will not create drastic improvements in the health of the general population. While we must offer healthcare, we must simultaneously battle the socioeconomic forces that worsen the health of the economically marginalized. If we can strive towards accomplishing these two goals, we can reverse the course of the history of healthcare and overall health of the general population.

Work Cited

Sreenivasan, Gopal. “Health Care and Equality of Opportunity”. The Hastings Center Report (2007). Pg 21-31.

http://www.un.org/millenniumgoals/poverty.shtml

In his report entitled “Health Care and Equality of Opportunity”, Sreenivasan argues that equality of opportunity may not be a sufficient rationale for universal healthcare. First, this idea implies that a fair share of opportunity leads to a fair share of health. Second, the equality of opportunity argument assumes that a fair share of health leads to a fair share of health care. Sreenivasan primarily focuses on the second argument, by analyzing the extent to which health care contributes to health. In his analysis, Sreenivasan points out other social determinants that may have an equal or even larger impact on health than health insurance. He states, “suppose that instead of introducing a national health insurance scheme, we had spent the same amount of money on equalizing the distribution of social status – then our society’s gradient in health would have been significantly reduced.”

This idea was very intriguing to me, as equalizing the distribution of social status would not only benefit individuals in terms of their physical health, but also help their mental and social wellbeing. However, one idea that Sreenivasan doesn’t really touch upon is what the idea of universal healthcare means to the individual and to a democratic society. From an economical standpoint, it is easy to understand why many would be against pumping a ton of money into a system that may not have substantial effects on overall human health. However, from a more sociological perspective, the idea of universal health insurance is an integral piece missing from the puzzle that is democracy.

The term itself has developed great meaning far beyond the policy implications that are fervently debated. Upon typing “what health cares means to me” into youtube, thousands of results pop up. Among the results, I watched several accounts of American citizens who recorded videos of their responses. For some, universal health care means being able to take their sick child a doctor without spending a week’s salary. For others, it is a security blanket – a back up plan to rely on if life takes a turn for the worst. And for others, it is a right that they deserve for living in a country as esteemed and developed as the United States. Many of the individuals in these videos don’t have the luxury of thinking about health care in political terms. In one of the youtube videos, a woman talked about her epilepsy that is fortunately controlled by a medication. However, this medication is extremely expensive and without it she would be unable to breathe. Without health insurance, this woman would not have access to the medication and would likely lose her life. It is of utmost importance that policymakers consider these voices that are often muted by political debate and contemplate not just what health care means to them, but to you and to me.

Sources

Sreenivasan, Gopal. “Health Care and Equality of Opportunity”. The Hastings Center Report (2007). Pg 21-31.

https://www.youtube.com/watch?v=UsV48GKrEBk

https://www.youtube.com/watch?v=0-36kdS7FqY#aid=P-9Ym54MmvM

https://www.youtube.com/watch?v=DH0LFrSfl0k