ONLY IN THE LAST few decades has the previously sacrosanct relationship between the doctor and his patient become frayed. Many have speculated on a network of sources for the new conflict. Certainly recent technical developments in diagnosis and treatment have prevented the human contact that had been the trademark of the pre-twentieth century doctor-patient relationship. Increased emphasis upon the contractual aspect of the alliance between the professional and his lay client, and the consequent reduction of time spent between the two parties have enervated that once sacred affinity. Some have additionally, if not alternately, suggested that media advertising has provided a profitable--yet relatively inexpensive--spawning ground for diagnostic and remedial advice that contradicts a doctor's personalized treatment.
We have apprehensively begun to question the basis for the distribution of medical authority and its concurrent responsibilities. Centuries ago the delegation of that responsibility to an individual whom we would be quick to condemn as a primitive medicine man stemmed from his possession of some sort of divine right. Today the physician's privilege to practice results from years of expensive classroom education and extensive clinical training. And yet, the modern physician's privilege--one that we would say is based upon more objective criteria than that of the early medicine man--must now be reexamined. For we must delineate where his legal prerogatives end and where his moral responsibilities begin.
THE CONTEMPORARY physician is not a divinely-endowed medicine man, and yet society has dictated that he have God-like attributes. Although he is actually a craftsman, many would deny him the human right to be fallible. He is not supra-human, but rather he is subject to the same fallibility as his human peers. The contemporary American physician enjoys an inflated aura of ultra-professionalism, one not so readily attainable by any other occupational group in our society. Indubitably this in itself has become a source of contention between the doctor and his patient, paternalism being the most definable of the malignant outgrowths. The modern American doctor commands salaries way beyond those of virtually all of his countrymen, and he consequently maintains an otherwise inaccessible elevation in social status. But these are only the symptoms of our veneration for our medicine men. It is the very nature of the physician's work, that of healing and life-saving, that has made him the subject of the reverence of his patients and potential clientele. We hold in awe his abilities to preserve life at what appears to be virtual whim. He is the subject of our respect and our fear. For that which we fear most--death--we regard as in his capacity to control.
Because the relationship between the doctor and his patient represents a human dialogue, it inherently possesses an ethical aspect that is analogous to the current religious and moral codes of the society. Some have noted that even if a "natural medical ethics" were definable, the variability of certain purely medical facets of the relationship would preclude real stability.
The dichotomies and contradictions implicit in the practice of medicine are numerous. The nature of medicine is two-fold: the science and the art coexist. The doctor's relationship with his patient is of a dual character. As Plato suggests, the physician is a friend to his patient as both a technophile (friend of medicine) and an anthropophile (friend of man). We seek an answer to the contradicitions in the physician's oath: Is the doctor foresworn primarily to prolong life or to curtail suffering? Is he bound primarily to a legal code or his own conscience? Furthermore, the sacred age-old injunctions to confidentiality and non-criticism inside the medical profession are not always the most pragmatic or desirable self-regulations. Is not the exorbitant cost of medical care a contradiction of the physician's supposed heart-felt concern for the ailing? Is good health merely an expensive commodity or a priceless inalienable right? Are medical resources simply a luxurious prerogative of the affluent? The physician must study the laws of medicine and probability, and yet disease is not specific. The consequences of medical acts cannot always be predicted; individual cases must be examined for their own nuances and patients for their own biological idiosyncracies. Finally, where is the line that distinguishes between the act that will merit the Nobel Prize and the one that will be awarded a malpractice suit?
Three general questions emerge. Where do we draw the lines? Who is to play what role in the very complex decision-making process? Do we instill in our physicians unrestrained trust, or must we retain some of the apprehension that ordinarily accompanies that which we revere?
FOR A WHILE Americans placed utmost trust in modern medicine and its servants. However, the more advanced technology of recent decades has forced us to become wary of that medical modernity. The issues--instead of completely resolving themselves--have become far more complex than we had ever believed they could.
We have revised our attitudes toward life and death. With the discovery and widespread availability of antibiotics, we can no longer expect to die of an acute infectious disease before we reach 50 years of age. In 1973 our life expectancy is over 70 years. We can anticipate death following a long and debilitating chronic illness like heart disease, cancer or any of a series of neurological disorders including stroke. We can expect to suffer months of anguish on the road to death. Where the very nature of death itself has changed, so have our attitudes and perspectives on life and its termination. Euthenasia is not a new term, but in recent years it has become a more frequent subject of discussion.
Clearly the physician cannot have the upper-hand in decision making. We must view him as a craftsman with indispensible technical expertise, but we cannot allow him to assume the position of a God.
These are only some of the infinite issues of medical ethics. Some others are as blatantly obvious as still others are oblique. While revised state laws and a Supreme Court ruling have legitimized the distribution of most contraceptive devices to most women and cleared the way for safe and legal abortion, infanticide remains a simple and sometimes not so illegal method of selective birth control.
ALTHOUGH MEDICARE and Medicaid legislation represent a step in the right direction to alleviate inaccessibility to medical resources, recent Congressional legislation that will provide kidney dialysis to all who require the expensive treatment raises additional questions regarding the most positive ways to spend tax dollars to benefit the greatest numbers.
And what of experimentation with human subjects? The issue has become a heated one in light of the recently disclosed Tuskegee syphillitic study. This and the aforementioned economic questions illuminate issues of more general social consequences than those in the strictly medical arena. Amidst legitimate charges of the abuse of the lower income brackets and minority groups, the medical profession, guided by the society in which it thrives, must come to terms with its discrimination.
I have only presented in capsulated from some of the issue of contemporary medical ethics. Although our biases in the following pages will inevitably be transparent, we attempt only to enlighten our readers to the issues. For clearly all of society must now contend with these problems. We cannot give tacit consent to physicians to behave in manners subject only to the judgment of their own consciences. For their profession is not a private affair: they must be subject to the evaluation of their individual clientele and responsible to the society at large. Historically, sanction by silence has inveitably led to exploitation. Trust becomes a license for abuse. Abuse of individuals by those whom we regard as our healers, constitutes abuse of the whole of humanity.
It is not clear whether the issues of medical ethics can be resolved in themselves. It would appear that society must not only examine ethical behavior in the medical sphere, although no doubt it ought to study each of the issues in depth. Rather than isolating it as a substratum of the larger ethical system, medical ethics should be viewed as an integral part of the comprehensive system of morality in the society at large.