How far should we go for health’s sake?
The modern question is “Whose health should we sacrifice for health’s sake?”
.jpg)
Fernando Borrego
Where We Started.
The Hippocratic oath covers both an ethic, “do no harm,” and
process, “do not ask of medicine what does not pertain to medicine.” Previously,
health was a “declaration of the past, diagnosing the present, and foretelling
the future – to help and not harm” (Jonsen, 2000) . This ancient
idea came to be because of the ill repute ‘physicians’ had in dealing with the
vulnerable and desperate in the first century BC. Some on the Grecian islands
rejected ritualistic medicine and chose a more rational approach. The Oath
includes a principled process: If one demands from an art a power over what
does not pertain to the art, or from nature a power that does not belong to
nature his error is more insanity than ignorance – in other words asking of
medicine what is not in medicine. Medicine
should not expect to master it.
We Bound Ourselves to
Gain Reputation
Medicine, understood by this ethic and process (or art),
required a patient with a disease that the physician’s skill could address, and
the patient was willing and able to cooperate – this was the essence of the art
and ethic of medicine. The physician never did harm, which forbade abortions –
this was true well into the middle ages. Medieval medicine, influenced by
Christianity, began to feel a charitable pull. In fact, Christian charity had
such an impression that it led to many conversions. Guilds organized to
validate individuals and the process of care. Islamic caliphates established
the examinations and licensures near the 10th century. Trust and
credibility was critical for fostering the patient-physician dynamic of
medicine.
We Sought Justice
In 1231, Frederick II King of Sicily decreed a 5-year medical
course in recognition of the “damage and suffering due to the inexperience of
physicians.” The King also instituted something akin to the US Anti-Kick Back
laws: he forbade physicians from making business deals with apothecaries.
Additionally, duties included services to the public and poor. Among the
professional guilds and educational institutions ideas began to emerge
describing the appropriate relationship between the physician and their paying
patient. There was a concern that
opportunistic physicians would harm the reputation of the profession by using
their advantaged position to exploit the vulnerable patient.
We Noticed Our Doom
Cicero wrote a treatise on duty where a shipwreck leaves a
fool with a life-saving plank. The question asked, “should the more valuable
wise-man take it from him?” or “should the owner of the plank, the ship’s
captain, take possession of his property?” -
Cicero compares the utilitarian ethic to the first principle ethics which
he calls a question of Expediency v Humanity.
A similar question of Expediency v Humanity challenged
hearts and minds when the Plague spread across Europe. Should the physician
stay and care for the sick? Was the physician duty bound? What if a city
contract was in place?
The Hippocratic Prescription emerged: Cito, Longe, Tarde.
“Leave fast, Go far, Return slowly. (Jonsen, 2000,p 45)
Though the total abandonment by all city physicians was the
case for many cities, there were some lead by Christian-charity, Patriotic-duty,
or Opportunistic-profit stayed and served their communities. Religious dogma
and political ethics questioned the actions at those critical times. Many
theologians compared physicians to priests and some scholars began to see the
emerging ethic concerning the social good. The virtuous Aristotelian approach
met the Hobbesian calculating approach. Towards the end of the 1700s the idea
of an absolute state and the possibility of its curtailing individual liberties
began to emerge. This was a continuation of the old argument between Expedience
and Humanity but modernized into: ‘Social Welfare’ and ‘Human Sovereignty.’
Should we forgo first principles to aim for an end?
We Sought Mercy
Dr. John Bell, chairman of the National Medical Association
drafting committee, stated in the late 1840s:
Medical ethics must rest on the basis of religion and
morality. They comprise not only the duties but also the rights of a physician.
Every duty or obligation implies for its successful discharge a corresponding
right. Physicians have a duty to endanger their lives for the community and a
reciprocal right to be protected from unnecessary exhaustion of their
benevolent sympathies (Jonsen, 2000, p 70)
In the nineteenth century, the duty to serve at-risk was
common. The political-medical ethic to serve the social good had a greater hold
in Europe than the United Kingdom and the United States. Each seemed to have
their conclusion for seeking care when it is most needed. There was a heavy
influence of moralizing in American Medicine. Immoral behavior caused many illnesses.
The AMA Code even urged the physician to seize the opportunity to promote good
morals especially when a patient is “suffering under the consequences of
vicious conduct.” The idea, therefore, was to give care even when the physician
determined the patient caused the malady.
We Noticed Inequality
The United Nations enshrined health as a human right in the
1948 Declaration of Human Rights. It has become standard knowledge that the
poor have lower health metrics than the rich. The vulnerable of each grouping suffer
but those who are lower in the socioeconomic categories have a clear contrast
in health outcomes. To address these disparities countries began to socialize medicine
and healthcare became a controlled commodity. It is difficult not to see healthcare
as if it were a commodity with some agent choosing outcomes: Share of health,
distribution of health, share of medical need, share of medical care, entitled
life span [‘fair innings’ argument (Williams, 1997) ].
From There to Here: Conclusion
Modern medicine began with a few simple premises: Do no
harm; Do what medicine can do; Participate in your health; All people are vulnerable,
some need more help than others.
From the foundation of our topic individuals were preeminent,
though this premise could cause tension for expediency (or for a rational
calculation.) As governments grew, a politic ethic emerged, the ethic took the
individual from their preeminence and placed society at the head. This value shift
(this ethic shift) philosophers, like Thomas Hobbes, argued to protect the
Commonwealth (Jakonen, 2011) . The new ethic
allows for ideas such as the Fair Innings argument and their conclusion that
living more than 75 years constitutes a “cheating” and living on time unfairly received. There is often a moral-political tone in
academic writings. These lead to suggestions in how to be more persuasive and
creating a spirit to rally the troops, as opposed to seeking to refining and
better understanding academic pursuits: The lack of fairness has strong
intuitive appeal and is likely to be the most influential (Woodward, 2000) ; The fight against health inequalities (Arcaya, 2015).
The approach taken by public health advocates is to seek
problems using ideological foundations of social identity. It becomes “necessary”
to identify differences in groups to solve group disparities. The problem may
not be in the preselected categories of Race, Gender, Region, Religion, but
rather those may be intermediate variables and should therefore not be the
independent variables in the analysis.
Could it be this is why causation is not clear?
Quantifiable statements are taken to be more secure, more
true. Non-empirical, or non-quantifiable, arguments are essentially
contestable, and so the conclusion is that all of them are respectable. This gives
the illusion for the relativity of ethical values. Empirical assertions, on the
other hand, are like mandates from an authority beyond us, something due respect
– the resisting of which would be a kicking against the goads. This represents
a move towards quantification from “what are merely vaguely appealing” (Williams, 1997) .
Modern medicine now does not look a patient in the eyes, but
rather it serves the Commonwealth – believing that doing so patient care will
be more fair.
References
Arcaya, M. A. (2015). Inequalities in health:
defintions, concepts, and theories. Global Health Action, 8.
doi:10.3402/gha.v8.27106
Jakonen, M. (2011). Thomas Hobbes on Revolution. La
Revolution francaise, 5.
Jonsen, A. (2000). A short history of medical
ethics. New York, NY: Oxford University Press.
Williams, A. (1997). Intergenerational equity: an
exploration of the 'fair innings' argument. Health Economics, 6,
117-132. doi:10.1002/(SICI)1099-1050(199703)6:2<117::AID-HEC256>3.0.CO;2-B
Woodward, A. K. (2000). Why reduce health
inequalities? Journal of Epidemiology & Comunity health, 54(12),
923-929. doi:doi:.101136/jech.54.12.923
Comments
Post a Comment