Assault on the professional ethic: will professionalism survive?

On June 30, 2007, two religious zealots drove a Jeep Wagoneer loaded with explosives into the Glasgow airport. Investigations so far suggest that the responsible terrorists are medical doctors.

The incident provoked a warning that the extremely effective Al Queda brain trust has found a new way to frighten us. An Al Queda leader in Baghdad was quoted as saying, "Those who cure you will kill you." (1) Is this the final mortal blow to an already wounded and staggering professional medical ethic?

The professional ethic

The professional ethic is a code of behavior that takes different forms in different professions. However, some ethical themes are common to all professions. Chief among these is trustworthiness.

In the learned professions such as medicine, trust includes trust in advanced knowledge and understanding of the professional's field of work. In addition, trust in one's physician includes confidence in the doctor's commitment to truth telling, respect for confidentiality of personal information, caring about the interests of another as well as about one's own interests, and a refusal to exploit others' problems to achieve personal gain.

Individuals who exhibit the professional ethic are a stabilizing influence, if not an indispensable component of civilized society. Until recent years it was safe to take for granted the trustworthiness of most lawyers, bankers, preachers, doctors, journalists and professors. I hasten to add that it was certainly necessary to beware of sleazy exceptions.

What if unprofessional behavior became the norm? Think about it. If we could not confidently entrust our money, our health, our education and our view of religious and ethical values to professionals, what would society be like?

Imagining health care without the professional ethic is no longer an abstract academic exercise. In the United States especially, the once presumed promise that a patient's interests come above all other considerations has been under attack for several decades.

Challenges to the medical professional ethic

To find The Greatest Generation, (2) Tom Brokaw had to go back 50 years. The same is true when one asks, "When did the professional ethic last trump political and economic considerations in health care?"

The 1950's were the golden age in medicine. Researchers were free of commitments to special interest funding. Researchers added one amazing new medical technique after another to the practicing physician's clinical armamentarium. Physicians applied those techniques in hospitals characterized by commitment, caring and concern rather than by compliance, confidentiality and campaigning.

Then came Medicare and Medicaid. In 1965 this patchwork, piecemeal, inconsistent, incomplete compromise was the closest Congress would come to following the lead of other countries by making health care a right of citizenship, which by the way is not at all the same as enacting "universal" health care. (3)

In the 1990s, while seeking to re-form U.S. health care policy, politicians and their friends stumbled on an excellent way to fully exploit health care's deep pockets. Today, people's health care dollars are converted into personal profits, legally if not ethically, by an efficient machine known as managed care.

Profit is paramount. Patient care is a back seat passenger. Indeed, maximizing profit for a time included such measures as forcing physicians to sign "gag orders." A gag order was a stipulation that a health care organization's physicians not tell patients of the need for expensive diagnostic and treatment modalities. Professionalism's foundations trembled.

Without political and corporate maneuvering, would professionalism be flourishing today? Not likely. Just on our own, we seem to find a lot of ways to self-destruct. A glaring example is physician credentialing.

In 1914, in response to the famous Flexner report that revealed the presence of many poorly trained physicians in U.S. hospitals, the American College of Surgeons invented hospital-specific physician credentialing as a patient protective measure. (4)

Even before managed care, hospitals and doctors had begun exploiting this patient-focused initiative. Throughout the 1980s and 1990s, physician credentialing was sometimes primarily a power tool in the now highly competitive hospital/physician workplace. Indeed, hospitals actually flaunted the term, "economic credentialing."

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The clear implication was that concern for patient safety and good patient results was secondary to building a medical staff that would achieve for the hospital a commanding edge in market share.

Meanwhile, some physician leaders also exploited credentialing, seeing a good opportunity (they thought) to exclude competitors by denying hospital privileges. Aggrieved physician applicants sued. As a result, physicians lost their learned professionals designation under anti-trust law because the law viewed examples of credentialing seen in the courts as business maneuvering rather than as professionalism in action.

In the new millennium, new concerns about the professional ethic have appeared. Some question the impact on professional image if not on professionalism itself of requiring physicians to attend and supervise executions of convicted criminals. (5) Impact on professionalism is also one concern of some who oppose legalization of assisted suicide.

Now professionalism faces its biggest threat ever, religious extremism. How brilliant it is to terrorize people by making them wonder if they can truly trust a "foreign doctor."

However, we are not just talking terrorism here, believe it or not. If intensely religious physicians whether Christian, Jewish, Islamic, Hindu, or Buddhist, ignore a patient's personal beliefs, religious or secular, and impose their own, can that physician truly be trusted to act in the patient's best interests?

Studies indicating that physicians have a surprisingly high level of deep religious conviction create the need to know more about how a doctor's personal beliefs affect his or her professionalism. (6)

The potential problem is not limited to physicians. Already, devout pharmacists have refused to honor prescriptions for birth control measures. (7) A nurse in one of my medical ethics classes said, in a case discussion, that she could see the facts as well as anyone but her God just did not want her to make some of the decisions it is necessary to make in this new biotechnical world.

Will professionalism survive?

Those who are dismayed by the idea that professionalism might join courtesy, respect, duty and genuine justice on the endangered species list, take heart. The ethical and moral notions that keep society civilized have faced intense challenges before, and they have always found a way to survive.

Something in human DNA simply will not allow the eventual crumbling of society that some consider inevitable. The most oft-cited instance is the Nazi Holocaust. Continuing outrage at such inhumane behavior is viewed by some as clear evidence that there is indeed a human nature and that in most times, the prevailing human nature is good.

True, there are undeniable threats to the very existence of life on this planet such as antibiotic resistant organisms and global warming. True, Mother Nature might eventually reject us altogether.

Furthermore, ironically, religious extremism might eventually kill a religion because backlash directed at the extremists gets misdirected to the religion itself. But extremism will never kill professionalism. Professionalism might cease to exist. But if it does, the cause will be our own tendencies to self-destruct.

Richard E. Thompson, MD, is former vice president of the Illinois Hospital Association, taught ethics at St. Petersburg College and Missouri State University, and is author of Think Before You Believe, Xlibris, 2005. He can be reached at [e-mail].

References

1. ABC News online. http://abcnews.go.com/International/wireStory?id=3344989 Last accessed 8/2/2007.

2. Brokaw, T. The Greatest Generation. New York: Random House, 2004.

3. Thompson RE. Employer Provided Health Care: Where's the Justice? The Physician Executive 32(6):66-9. Nov.-Dec., 2006.

4. One Page Standard for Hospitals. The American College of Surgeons. 1914.

5. The Christian Science Monitor online http://www.csmonitor.com/2006/0224/p01s01-ussc.html Last accessed 8/2/2007.

6. University of Chicago Medical Center. http://www.uchospitals.edu/news/2005/20050622-religious.html Last accessed 8/2/2007.

7. The Washington Post online http://www.washingtonpost.com/wp-dyn/articles/A5490-2005Mar27.html Last accessed 8/2/2007.

By Richard E. Thompson, MD

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