May 1980 I/9
THE ETHICAL PHYSICIAN
Self-understanding is the beginning of wisdom. But in order for one to understand oneself well, one must have the benefit of honest reactions from other people. Otherwise, there is not an opportunity for objective evaluation and testing of one's subjective thoughts, attitudes, and ideals.
What is true of individuals is true of a profession as well. Unless the members of a profession receive honest and objective information from people outside the profession, there is little hope for healthy and effective self-understanding. Over the past few years, the profession of medicine has received candid and worthwhile evaluations in regard to its ethical perspectives and standards from scholars outside the profession.(1) Some of these evaluations may be summarized as follows:
1. Most physicians have a "strong sense of vocation" rooted in the original priestly character of medicine and reinforced in American culture by the religious stress on vocation. Yet this religious motivation has been covered over: "The vast growth of science and technology in the four hundred years since Luther has obscured the specifically religious conception of most vocations. The physician seldom speaks of God anymore when discussing his concern for the patient. Yet he still finds satisfaction in measuring up to personal standards" (Ford; p.140).
2. To be effective, physicians maintain they must be motivated and competent, and must show concern for the patient. An important component of motivation is the physicians' sense of specific competence, that is, they have an important and well-defined service to offer. Much of physicians' personal satisfaction in their work depends upon this sense of competence. Most physicians believe they must "care for the whole patient," but only a minority of physicians have a well-developed social conscience.
3. Physicians tend to think pragmatically, so their basic attitude can be characterized thus: "The physician sees himself as a professionally competent person who is in a social position to apply scientific knowledge and to exercise impartial control over the situation in order to achieve the rational goal of curing or helping a sick patient. The patient's part of the job is to trust the doctor and cooperate with him" (ibid. p.144).
4. Furthermore, physicians on the whole do not regard themselves as research scientists, but rather as applied scientists, and they do not clearly experience a dichotomy between the scientific and the humanistic or affective aspects of medicine. Their satisfactions are not theoretical but pragmatic.
5. Physicians take much satisfaction in their professional position as a mark of achievement. This sense of achievement is more important for physicians than monetary rewards, which they do not like to think of as a primary motivation. Moreover, while physicians gain some satisfaction from scientific interest in their work, they gain more from the therapeutic results. An important element of satisfaction or dissatisfaction is found in the sense of consistency between personal and professional ethics. Thus, physicians do seem to have a common sense of ethical purpose.
Some possible ethical biases which medical professionals need to be aware of and which medical education should strive to balance if the medical profession is to make good ethical judgments are:
1. On the whole, physicians continue to exhibit the dualistic balance between the scientific and the humanistic. But the balance is constantly imperiled by the fact that their scientific training is explicit, detailed, and specialized, while their humanistic and moral training is left largely to example and symbols transmitted to them without explicit reflection or criticism. Physicians thus assume that, while science is exact, ethical discourse is vague, subjective, a matter of opinion. On the one hand, this assumption leads to a kind of moral skepticism and on the other to a dogmatic rigidity, since no method of dialogue or research for critical consensus is available.
2. Physicians tend "to take a pragmatic view whereby what is most valued is an immediate, practical solution" (Freidson, p.147). In ethical matters, this pragmatism may lead physicians to act so that (1) they will not be made to feel guilty if an action is taken against their professional or personal standards, and (2) they will not seem inhuman toward the patient, and (3) they will not go beyond the limits of the patient to wider social problems.
3. Because the motivation of physicians is so bound up with their sense of vocation, autonomy, and competence, they resent interference in their own decisions. They believe that only the physicians are in the position to make medico-ethical judgments and they can be relied upon to be decent and humane in these decisions. This attitude may lead to deeply felt but simplistic attitudes toward ethical questions (Carlton, p.173).
4. Physicians are often resentful that so much responsibility is laid on their shoulders. They cannot understand why a wider sociological, religious, psychological, or interrelational view should be their responsibility. Physicians believe such concerns are someone else's business.
None of these attitudes is wrong. Undoubtedly they are the result of the medical professional's need to live by a clear motivation, with manageable responsibilities, and to have sufficient freedom for action and personal judgement. However, if they result in a closed attitude which renders the physician incapable of learning from others or sharing in a team effort to improve ethical treatment of health problems on a social scale, they are harmful biases that may lead to gravely mistaken ethical judgment.
Kevin O'Rourke, OP
The following works are the main source of these observations:
Ford, Amasa, et al, The Doctor's Perspective: Physicians View Their Practice (Cleveland: Case Western Res. Univ., 1967).
Freidson, Eliot, Profession of Medicine, A Study of the Sociology of Applied Knowledge (New York: Dodd Mead, 1971).
Carlton, Wendy, In Our Professional Opinion (Univ. of Notre Dame Press, 1979).
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