Society's values, fears support health care's noble cause. (Big Business/Noble Profession).

A PROFESSION THAT deals effectively with something of great value to a society that encompasses people's greatest fears is likely to receive high status in any culture.

In a branch of philosophy known as axiology (the theory of values), there is a distinction that may help explain the reasons behind the public's interest in health care and medicine -- and the relationship to people's values and fears.

It centers on the difference between intrinsic values and instrumental values.

Intrinsic values are "things" valued for their own sake. They are their own justification. They are sometimes called final values or terminal values because you can't reasonably challenge that they are good or question what makes them good.

For many people, intrinsic values include:

* Security and autonomy

* Acceptance and approval

* Positive relationships

* Recognition

* Praise

* Gratitude

* Appreciation

* Success and achievement

* Respect

* Status and esteem in the eyes of others

* Happiness

* Satisfaction

* Fun

* Feeling good about yourself

* And, of course, life itself

Instrumental values are valued only because they are perceived to be the key to protecting or fulfilling intrinsic values.

Money is often cited as the most instrumental value.

Whether something is an intrinsic or instrumental value depends on the perception of the person doing the valuing. For example, the miser may think of money as intrinsically valuable and die of malnutrition with $750,000 dollars stuffed in his mattress.

Health care value

What does this have to do with medicine and health care?

Most people in our culture, as well as in many other cultures, regard health to be both an intrinsic and an instrumental value.

Health is considered good for its own sake, "When you have your health you have everything." And, it is likewise considered essential, or at least highly desirable, in the pursuit (and protection) of many other intrinsic values. Good health helps ensure autonomy, achievement and fun.

When we enjoy good health, multiple possibilities for enhancing the quality of life are more easily facilitated than when we do not. And at the most basic level, the preservation and quality of your own life are deeply and intrinsically valued.

One way to gauge the importance of a value is to note how many words in our language are associated with that value. Since our fears concerning loss of value or threat to a value seem to occupy much of our attention, the words that express threats to that value are equally significant.

The number of English words associated with illness, pain and suffering is huge.

* We can be ill, ailing, diseased, weak, feeble, impaired, incapacitated, paralyzed, disabled, infirm, sick or dying.

* This can be due to an affliction, malady, disorder, wound, injury, condition or other medical problem.

* We can suffer aches, pains, soreness, hurts, discomfort, irritations, spasms and cramps.

* Our pains can be stabbing, burning, throbbing, shooting, stinging, piercing, chafing and gnawing.

* They can be described as wrenching, unbearable, insufferable, excruciating, debilitating, agonizing or merely annoying.

* We can be wracked with pain, writhe in pain and be tormented by pain, both physical and emotional.

* And we can be wasting away.

Little wonder a profession that claims to be able to prevent, alleviate, ease, heal, remedy or cure these undesirable or life-threatening conditions is considered "noble."

When this is done with specialized training, knowledge, skill and instrumentation, it seems even nobler. With pills and powders, potions and poultices, the medicine man, the witch doctor, the shaman and the physician provide relief.

In part, it is the elixirs, the tonics, the antidotes, the anesthetics and the surgical procedure that the physician brings to the patient that accounts for nobility because it is regarded as noble to relieve suffering and preserve life.

Higher standards

But there is a second, more important aspect to the nobility of the profession.

All the drugs, prophylactics, therapies and palliatives in the world are of little value (and even less nobility) unless those administering them do so with a moral sense of obligation and prohibition, professionalism, justice and honesty, compassion and concern.

The nobility is in the profession as a calling to a higher standard of conduct than may be demanded in other professions. It is precisely the critical importance of the phenomena dealt with: life and death, functionality, relief of suffering, the essentials of the quality of life, that call for nobility on the part of the practitioners.

* This means giving the best you have to give even when it is inconvenient and problematic, costly and risky for the physician.

* This means doing so even when you are not recognized or rewarded, appreciated or praised.

* This means doing so in the service of patients who are difficult, demanding, and even abusive and insulting.

* This means doing so for your enemies as well as your friends.

* This means doing so to the best of your abilities despite the irritation and annoyance, the interference and theft of autonomy that may come from non-medical oversight and the intrusion of government.

* This means doing so even in the midst of an erosion of status, the distractions of technology and the forces pulling against the "art of medicine."

In short, nobility is in the practice of the profession of medicine and in the daily behavior of the practitioners of medicine, more so than in the profession itself.

When many of your own intrinsic values as a physician are most deeply threatened, nobility requires the above responses.

We may prefer to think of nobility as something we get from association with a profession. But the irony is we can get it only if those in the profession continuously give it to the profession, often under the most trying circumstances.

The critical importance of good health drives people to look to alternative medicine and other sources of remedy and well-being.

That same critical importance drives many to challenge and criticize the medical profession. Their frustration often focuses on physicians, who also are oppressed by the system, but are the most convenient, available and visible target.

Despite this turbulent environment, physicians must be willing to make a personal sacrifice, to put aside their prudential concerns in the service of the welfare of others. This is the only way to preserve medicine as a noble profession.

ACPE Resources

Bring Charles Dwyer to your organization for an OnSite Educational program. Call Lou Ellen Horwitz at 800/562-8088 or visit www.acpe.org/onsite for more information.

Dwyer's book, Shifting Sources of Power and Influence is also available from ACPE. Visit the online ACPE Bookstore at www.acpe.org/Publications/index.htm or call 800/562-8088.

Charles E. Dwyer, PhD, has been on the faculty of the University of Pennsylvania since 1966. He has held positions as chairman of the hoard of the Wharton Center for applied Research, director of Wharton Management and Behavioral Science Center and faculty coordinator for Wharton's Effective Executive Development Programs. He has more than 30 years of experience in corporate and organizational consulting and executive development and is a member of ACPE's faculty. He can he reached by phone at 215/898-5674 or by e-mail at [e-mail].