Archive for the 'HealthCare' Category

WHO AM I TO JUDGE: PROFESSIONAL SOLIDARITY, AMENABLE MORTALITY AND PREVENTABLE HARM IN MEDICINE?

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Italian journalist Andrea Tornielli, when interviewing Pope Francis, asked the pope how he might act as a confessor to a gay person in light of his now famous remarks in a press conference in 2013 when he asked: “Who am I to judge?” The pope answered. “I was paraphrasing by heart the Catechism of the Catholic Church where it says that these people should be treated with delicacy and not be marginalized.

In the healthcare system, we define or imagine as patient centered the patients should also be treated with professional respect, delicacy and not marginalized. If not, the cost of disrespect and the lack of proper care is very high and could be measured in high avoidable mortality rates and burden of disease. In the health care systems with less developed quality control and assurance protocols, there is an intrinsic conflict between the professions efforts to maintain the solidarity of its members and its fiduciary relationship with patients, populations at risk and society as a whole.  The concept that professional work has a moral value compels the physician to behave ethically in his or her personal and professional life.  The greatest number of physicians adhere to high ethical and moral standards and principles of beneficence and non-maleficence. Physicians have a duty to do right and to avoid doing wrong. However, our greatest concerns are related to the method of sustaining the solidarity of the profession at the high expense of patients and lay people.

As Freidson argues, even if the physician does shoddy work or malpractice in the most cases there is a reluctance to judge the work of a colleague physician or specialist.  Physicians respond to societal needs, and their behaviors reflect a social contract with the communities served.  The question is how the profession of medicine understands the fulfillment of social contract?

 

From the very beginning of its professional and social activities the American Medical Association (AMA) in 1847, primary intentions were to improve medical education. At this time, medicine had not yet become a science-based profession.  It was somewhere in between the social organization, movement and layer organization inclining to support a scientific principle. That inclination helped the AMA to drive the medical reform at the beginning of XX century. The Abraham Flexner’s report, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, was published with the intention of transforming medical education. It was that breaking point after which AMA accomplished the goal of establishing the monopoly over medical education. From that moment in history, medicine has been going through the profound changes. Which had to adhere strictly to the protocols of mainstream science in their teaching and research and was expected to be thoroughly grounded in human physiology and biochemistry. The movement toward an emphasis on basic sciences demonstrated that medicine was embracing science as its foundation instead of the earlier dogma of bleeding and purging. The disciplines of “pathology, bacteriology, and clinical microscopy” were considered the basis for the scientific method, and therefore were emphasized in the new medical curricula. The drive for scientific instead of dogmatic methods was a primary theme running through the Flexner report.  Medical research adheres fully to the protocols of scientific research. The most important recommendation for the establishment of monopoly over the professional education was the recommendation that each state branch of the American Medical Association has oversight over the conventional medical schools located within the state. One of the immediate consequences was that medicine in the US and Canada had become a highly paid and well-respected profession. No medical school can be created without the permission of the state government. Variations in policies and organizations of health care around the world are influencing the power and practice of such professions as medicine and law.

 

What was the turning point in the historical development of the notion of professionalism in medicine and health care?

 

Eliot Freidson argues that professionalism is sustained If there are two essential elements and four distinctive conditions of professionalism. The two essential elements are the commitment to practicing the body of knowledge and skills of special value and to maintain a fiduciary relationship with clients/patients.  And what about the four distinctive conditions? How are they related to the essential elements of the medical profession?

 

According to  Freidson, the first and most distinctive condition is the ownership of the specialized knowledge not easily understood by the citizens with an average education. The medical profession holds the monopoly, argues Freidson, over the use of the medical knowledge and responsibility for its teaching. In the United States, medical profession developed institutions designed to “control the selection, training, and credentials of their members and to gain privileges providing a marked advantage in the marketplace.”  What are the grounds on which the institutions implement the monopoly over the health care services and the strict professional rules? When the idea of professional approach appeared?

 

Second, argues Freidson, this knowledge should be used in services of individual patient and society in an altruistic manner if we understand altruism as the performance of cooperative unselfish acts beneficial to others.  However, physicians altruism towards their patients and others has not been a broad subject of studies, and there is fragile empirical evidence on what does it mean in everyday behavior of physician although it is often mentioned in statements about medical professional values and attitudes. It has been studied in contexts of the donation of organs and genetic material and patients’ participation in potentially hazardous experiments and trials. 

 

Freidson’s third distinctive condition of the medical profession is inaccessible nature of the knowledge and commitment to altruism. They are the justification for the profession’s autonomy to establish and maintain standards and practice of self-regulation. It is not only a technical knowledge and skills that assure quality. The core tasks of medical professionals are taught to require discretionary judgment “so that ordinary mechanization or bureaucratic rationalization is not possible” and believed to be “beyond the capacity of untrained lay people to evaluate.” Peer-review is understood more the collegial rather than the hierarchical method of evaluating of the professional knowledge base and research. They accept only professional cognitive superiors.

 

Freidson considers responsibility for the integrity of their knowledge base and expansion through research as the way to ensuring the highest standards of the medical profession. Physicians  do not “merely exercise complex skills but identify themselves with it.”

 

Licensing bodies and professional associations like American Medical Association have the responsibility based on the above mentioned four distinctions, to establish common professional goals and encourage commitment to them. AMA also has organizational power and obligation to discipline unprofessional behavior.

 

To what extent we experience threats to the maintenance of this four condition?

 

Studies dealing with quality assurance in health care and clinical risk management suggested that rates of adverse events in patients in the hospitals in the developed world were much higher than previously thought.  Multiple sources and studies are showing rates of at least 8% of total amenable mortality rates. Of these adverse events, more than 50% were judged to be preventable. These reports suggest that the deaths of between 0.5% and 2% of patients in the hospital are associated with an adverse event, which was often, but not always, preventable. Reducing the number of deaths and injuries attributable to medical error is also related to favoring of a fiduciary relationship with professional colleagues instead to patients. The consequence is measurable in a report from the Institute of Medicine in Washington which estimated that as many as 98 000 deaths a year were caused by the medical error (BMJ 1999;319:1519).

Picture 1. Major Causes of Death in the USA

These studies would rank harm from health care high on the list of all causes of death for the countries being considered. All published studies to date, however, have been from developed countries, with no reports from developing or transitional economies. In the whole region of South East Europe in last twenty, five years not a single case of hospital deaths was registered and attributed to medical error. The simple calculation, if the lowest US standard of o,5% would be applied, we would be speaking about thousand of death associated with the adverse event. This estimation shows extremely worrisome situation with negligence of medical profession and non-fiduciary relationship with patients.

Preventable harm to patients resulting from their healthcare is unacceptable at any time. Patient safety is first and foremost a clinical problem, but it is also an important cause of wasted resources.

 

Picture 2. Health Care System Waste in the USA

Norm Levinsky in his paper “The doctor master”  argues that the physician is required to do everything that may benefit each patient “without regard to costs or other societal considerations” and physician is permitted and even obliged to all that they can for their patients “without regard to any costs to society.”  Physicians cannot discharge “their responsibility to their individual patients if they try to conserve societal resources by discounting treatment on statistical grounds.” His radical position which explains and defends doctor-patient relationship as socially, ethically and economically isolated. His key argument is that doctors cannot serve two masters, society, and the patient. Other considerations related to cost-containment or the greater good of the alleged population of patients being served by a given community or organization must never interfere in the doctor-patient relationship. Doctor’s master must be the patient he concludes his vigorous and straightforward argumentation. He draws a superficial and flat analogy with the role of a lawyer defending a client against criminal charges.

Morreim, on the other hand, claims that contemporary notions of professionalism must expand to include responsibility for both patient and population-based concerns. Morreim’s argumentation and logic are more complex and systemic. She argues that every medical decision has its economic costs as well as its medical wisdom.  Not only clinical or diagnostics decisions are subject to economic rational but “every laboratory test, every roentgenogram”  is an allocation issue. She understands that modern medicine, evidence-based medicine, and evidence based practice,  cannot ground itself into  the logic of “do anything that might help.” An intervention which is based on marginal benefits to the patients belongs to the 19th century professional logic of bleeding and purging. Morreim understands the basic health care law that “our finite resources cannot possibly meet the limitless health care needs.” Modern medicine has developed instruments, tools, models, concepts, and theories capable of establishing a relationship between efficiency, quality, safety and equality in health care delivery. The World Health Organization has carried out analysis of the world’s health systems using five performance indicators to measure health systems in 191 member states. It finds that France provides the best overall health care followed among major countries by Italy, Spain, Oman, Austria, and Japan. The model taken from the OECD database shows how the health system in France, considered best healthcare system in the World, manages to establish a simultaneous relationship between different clinical procedures and clinical, economic and indicators and between structures, processes, and outcomes of health care.

Picture 3 Health Care Indicators and Quality of Care in France

Considering doctor-patient relationship like the one in which physician is permitted and even obliged to do all that they can for their patients “without regard to any costs go society” sounds like more cynical than emphatic one.

We cannot escape from the proper ethical, professional, clinical and economic obligation to make decisions about fair, and efficient resources allocation. We are obliged to understand and implement the best practice of medical care not only to a single patient but as many as possible members of body social. And yes, we are obliged to make hard professional decisions and ethical judgments in the professionally and morally challenging situations.

 

Reference:

 

Pellegrino, E,  and Thomasma, D. For the Patient’s Good. Chapter 9. “The good physician.” In: New York: Oxford University Press, 1988.

Freidson, E. Professionalism Reborn: Theory, Prophecy, and Policy. Chapter 12. “Nourishing Professionalism.” Chicago: University of Chicago Press, 1994.

Jones, R. Declining altruism in medicine. Understanding medical altruism is important in workforce planning. BMJ. 2002. Mar 16:324 (7338): 624-624.

R. M. Wilson et all. Patient safety in developing countries: retrospective estimation of scale and nature of the harm to patients in the hospital. BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e832

A Makary, M, Daniel Medical error—the third leading cause of death in the US. BMJ2016;353 doi: http://dx.doi.org/10.1136/bmj.i2139

Coulehan, J. and Williams, P. “Conflicting professional values in medical education.” Cambridge Quarterly of Healthcare Ethics Vol. 12, No. 1 (2003): 7-20.

Brook RH. “The role of physicians in controlling medical care costs and reducing waste.” JAMA Vol. 306, No.6 (August 30, 2011): 650-651

Morreim, EH. “Fiscal scarcity and the inevitability of bedside budget balancing.” Arch Intern Med 149 (1989): 1012-1015.

Levinsky, NG. “The doctor’s master.” NEJM December 13, 1984; 311(24): 1573-1575.

Angell, M. “The doctor as a double agent.” Institute of Ethics Journal 1993; 3(3): 279-286