Do No Harm

THE OPEN MIND
Host: Richard D. Heffner
Guest: Dr. Robert Michels
Title: “Do No Harm”
VTR: 10/9/88

I’m Richard Heffner, your host on The Open Mind. Once, when I was talking with today’s guest about medical ethics, at the very end of our program we got around to the sensitive and quite difficult matter of how to teach medical students about the ethical dilemmas they will face in their profession, and how to live up to the Hippocratic Oath to “Do No Harm”…ethically, morally, as well as physically. Well, I asked about the formal courses in professional ethics that more and more medical schools – like more and more law schools, too – are giving these days, and got a fascinating answer.

So, let’s pick up the matter again with Dr. Robert Michels, Chairman of the Department of Psychiatry at Cornell University Medical College and Psychiatrist-in-Chief at New York Hospital. Dr. Michels, thank you for joining me again. You know your very-end-of our program comment son medical school ethics courses were: “They are worth having but I wouldn’t overestimate their impact on what doctors actually do. I think two things are far more important than formal courses in ethics. One is the selection, who comes to medical school, and who’s allowed to go through medical education. If I wanted to influence the ethics of the medical profession, I’d much rather have impact on the selection committee than the curriculum committee in a medical school. And the other issue is models. The kinds of doctors that students are exposed to and given a chance to use as objects of identification in their medical education. And that falls back on the medical profession itself. An item of concern is whether the increasing transformation of medicine into what looks, from the outside like a traditional business organization, isn’t going to impair the kinds of models we provide medical students and change the ethics of the medical profession in an undesirable way. One of the things”, you concluded, “we must make sure of is that the models that students are exposed to are the models selected for being the kinds of ethical professionals we want, rather than because of their businesses success in the business of medicine”. Well, that’s what you wanted. What have we got?

Michels: I’d like to say first that I agree totally with whoever said that, Dick…

Heffner: (laughter)

Michels: …that’s very good comments. We have big problems and we’re groping for solutions. Medicine has been undergoing dramatic changes in the last few years and it looks like it’s in the middle of a period of transformation after some decades of stability that ended within the last ten years. that has most to do with the social organization of the medical profession and the economics of the medical profession. And I think the importance of preserving values that go back to the beginnings of Western civilization in this profession are very great and there are some threats. The question you’re asking really is one of the first ones. What is virtue and how can it be taught? And what is medical virtue and how can it be taught? I’m skeptical about formal curricular teaching. I don’t think you make an ethical physician by giving him eight hours of lecture on medical ethics. I think it’s worth having the seminars on ethics. I think it’s worth encouraging people to think about the problems, sharing with them the ideas of others, but I don’t think that would provide me much security about the standards of the profession. I’m very concerned about selection, partly because the pool of applicants to medical schools has diminished in the last decade relative to the class size. Because of economic changes in our society, medicine is not as attractive a career compared to some of its obvious competitors. Twenty or thirty years ago somebody finishing college, entering medicine probably had more promising economic potential than entering law. Today people graduating law school make two or three times as much money within the next few years as people graduating medical school. Medicine is not as comfortable to practice. Our concern with regulating medical practice, with the control of it by government organizations, with the organization of health care in large corporate entities rather than as solo practitioners has all made it less appealing for many people. The results of this is that a smaller pool of people and a pool of people who, perhaps some, might be more comfortable thinking themselves in the role of the employee of an organization rather than a professional with an obligation to a set of professional ethics. To the extent those changes in the setting of the profession have occurred, there are dangers we must attend to preserve some of the enduring ethical principles of the profession.

Heffner: It’s so interesting that you used the word “comfortable”, you said that the medical…the practice of medicine isn’t as “comfortable” or thinking through one’s future in medicine isn’t as comfortable. Was it really as comfortable, years ago? Was it really so comfortable years ago that that was an attraction?

Michels: I think it was more comfortable and was perceived that way by people entering the field, and there are complicated reasons for this. There’s a legitimate public concern with the quality of medical practice, but that’s not a simple or single issue. The public is very concerned that there not be egregious disasters by physicians…appropriately. And in order to prevent those we have codes of ethics, we have laws or cases concerning malpractice. Those are designed to keep the worst thing from happening. But they create an administrative apparatus which influenced the best physicians as well as the worst. So to prevent bad things from happening, good doctors have to fill out all kinds of forms and submit to all kinds of scrutiny and have their work include large components of surveillance by government agencies that weren’t true twenty or thirty years ago. Another way to make medicine better is to make sure that it involves support for research. In the e last few years our society has been much more involved in making the worst things less likely than in making the best things more likely. And to a practicing physician, that’s less fun.

Heffner: The question of business practices. Is it true that given the problems that you have, that doctors have with insurance, malpractice insurance, and a whole range of other things, that the accounting principles that must go into the everyday practice of medicine loom larger and larger and larger?

Michels: My impression is most doctors themselves don’t know much about those things. But, they certainly experience themselves spending a much higher percentage of their time attending to the details of the business, than they had planned to when they entered medical school; the forms that have to be filled out, the scrutiny of their patterns of care that they have to participate in are much more onerous and times-taking than once seemed would be the case.

Heffner: Of course I didn’t mean to stay on this issue. I have been fascinated by it. But, you know, I knew that when I made up my list of question to ask Bob Michels about medical ethics, one of them – I used a phrase that I use quite frequently when I do programs with my lawyer friends – original intent. And I can’t help but refer to original intent because I’ve had the opportunity again to read the Oath of Hippocrates, and to wonder whether one could possibly, in this day and age, repair to that Oath and assume that it is a meaningful document? And I wonder what you – whether it is a decent guide to medical ethics today? I mean, we’ve talked about privacy, we’ve talked about confidentiality, and that part of the Hippocratic Oath that relates to that might be considered to be set aside more frequently today than at other times. “I will give no deadly medicine to anyone if asked”. That bring sup the question of euthanasia. “Nor suggest any such counsel and like matter I will not give to a woman an abortive remedy”. It seems to me, shockingly, that the Hippocratic Oath has very little to do with what you doctors do today.

Michels: I don’t think that’s true. I kind of like the Oath. Its origins are sort of interesting. The Hippocratic physicians were only one group of physicians at the time. And they wandered from town to town sort of setting up practice for a few days when they go there, and then moving on. So, like some aspects of modern medicine, they didn’t always know their patients very well. And if you read the Hippocratic Oath, the primary thing that you pledge allegiance to is not the patient’s welfare, but your colleagues, the other members of the group. The primary allegiance is to the profession. Now, there’s a very good, practical reason for this. If a doctor comes in who is a Hippocratic physician and comes to the agora, the marketplace and sets up his practice for a few days, and you don’t know him and have never seen him before, it’s certainly important that you know that Hippocratic physicians can be trusted. But the only way you think they could be trusted is if all the other Hippocratic physicians you’d ever come across kept their promises and were good doctors. So they recognized – in effect they were the proto-profession, and they all had to adhere to the Code because otherwise the public wouldn’t trust any one of them.

Heffner: Yeah, Bob, you scare me. Does “do no harm” mean, do no harm to your fellow practitioner then?

Michels: In some ways I think it does, and that’s not so bad. I’m reassured when there’s a self-serving motive for someone to do good, because I think he’s pretty likely to do good under those circumstances. I think the Hippocratic physicians recognized that in the long run their own practice required public trust. And therefore being trustworthy was in their self-interest. I’d kind of think I’d trust someone more if I thought being trustworthy was not only something he thought was virtuous, but was in his personal self-interest.

Heffner: But is this the reason then why it is so infrequent that one finds doctors testifying to the limitations of other doctors? I mean, after all, you know that for the rest of the world, we lay people are very much concerned with the notion that doctors won’t blow the whistle on their fellow takers of the Hippocratic Oath. And you give me more reason now for being worried.

Michels: Well,. It’s interesting. I think that tradition had, as one of its undesirable consequences, that that used to be the case. However, as that tradition is being weakened, it’s no longer any problem at all to find doctors to testify against their colleagues. That’s a desirable consequence of weakening the collegiality of the profession. But we have to recognize their dangers as well. If physicians are simply employees who work nine to five and belong to unions and go on strike and want to maximize their income and don’t’ feel any further obligation to do their work than they do because of the contract they have with their employer, I think the public will be poorly served.

Heffner: Well that’s a little like trying to figure out what that elephant really is, it depends upon what your perspective is. But, let me ask a question that came up in thinking and talking about this. Medical ethics, are we talking about medicine or are we talking about ethics? Where should we focus? On the medical person’s responsibilities? Is this a medical matter? Or is it a matter for the philosopher? For the person interested, professionally, in ethics?

Michels: Well, medical ethics – ethics is, to me, a branch of philosophy, it’s the rules of the dialogue in discussing issues of good and bad, of virtue and vice, of responsibility and obligation, duty. And it’s important to make those discussions coherent and rational and an ethicist is a philosopher who is an expert on how to do that. But there are many areas of life in which those issues come up. Medicine has certain unique characteristics because we ask doctors to do unique things. We ask them to cut into our bodies. We ask them to share our most intimate secrets with us. We ask them to take responsibility for matters of life and death, and quite literally hold those matters in their hands while weighing and making judgments about what to do about them. And therefore there are unique questions of good and bad that come up in that area.

Heffner: But that in a sense is just what I mean – though you’re more articulate in expressing them. How does a doctor who is not trained in philosophic matters, but who spends so much time and must spend so much time – and you and I want him to spend so much time…becoming as expert as he can be, as a surgeon, as a general practitioner, as whatever…how is he equipped to deal with the ethical matters?

Michels: Let me start by saying that if I had to have my appendix removed, I would much rather have it removed by someone who got an “A” in surgery and a “C” in medical ethics, than by somebody who got a “C” in surgery and an “A” in medical ethics.

Heffner: Yes, but now suppose we get to the point where it’s not a matter of taking out your appendix, but being concerned with whether you’re going to live or you’re going to die, with whether we resuscitate or do not resuscitate.

Michels: I would say I have several…there’s several issues that I would speak to about that. One is medicine’s a profession, and by a profession we mean that certain issues of ethics are decided upon by the group, rather than by individuals. So I would frown upon a doctor who formulates his own decisions about what are the standards of right and wrong in medical practice and what are the limits of confidentiality, for example, or of his weighing is responsibility to family or to patient, or his responsibility to preserve life or to maximize health. Those are not matters for an individual decision about what the guidelines are, those are matters in which the doctor should know the profession’s view, have participated in the profession enough to understand where the profession stands and to represent that view to the public. I would say that a corollary of that is that there are two kinds of ethical obligations that a physician has. One is to his patient…”to do no harm”, to be competent, to keep secrets when appropriate, and that’s almost all the time. But there are another set of ethical obligations which are to be a member of the profession: to participate in this professional dialogue, to help train new physicians, to listen to senior members of the profession as they worry about these problems, and an ethical physician has to do both of those things.

Heffner: But it’s interesting, nowhere in these past moments have you mentioned anyone other than a medically trained person, although you point out at the beginning that ethics is a branch of philosophy. On a hospital’s “God Committee”, that decides who lives and who doesn’t, is it sufficient to have people who are trained in one way, with one essential point of view, they differ, they have different experiences, but essentially they’re the same personal, the same professional. Wouldn’t you want, and don’t we often have on these “God Committees”, those who are trained professionally to think in terms of ethics rather than medicine?

Michels: Absolutely and, in fact, most of those committees mandate that there be representatives of the larger community. One of the changes in medicine as a profession, as in many other professions, as in law, in other areas of our society is the recognition that the setting of professional goals and standards has to be…has to occur in a dialogue between the profession and the public, not in the profession alone. So that, for example, the licensure boards for the specialization in medicine, from the boards in the various medical specialties, include delegates of the general public who are not physicians. That’s relatively new in the last few decades, and is part of the growing recognition that part of the legitimization of the profession’s privilege in our society is that they share the setting of standards and the implementing of them with the public at large.

Heffner: It’s interesting you use the word “the profession’s privilege” in our society, and that is very real, isn’t it? It is a privilege to be a medical person and to have such responsibility. I would say it’s an immense privilege. It’s one of the major things that attracts people into the profession, the possibility of sharing in the privilege. Your name changes when you become a doctor, and it’s never the same again. There are trivial aspects of the privilege: you can park your car in a different spot on the street…sometimes, and you can get up and leave a dinner party when your beeper beeps without anyone thinking you’re rude. But, those are symbols of something more, which is that society says, “we trust you with certain things, and they’re so important to us that if you’ll promise to attend to them, we’ll help you in every way we can”.

Heffner: Now what will be the impact upon that position of the physician in our society of the fact, as you stated, that there are fewer and fewer young people applying to medical schools?

Michels: That’s an important concern. There’s still more than enough superior applicants for the places that we have in medical schools for education.

Heffner: You mean that?

Michels: Yes. But barely more than enough. It used to be that we had a large oversupply. We no longer do, and we have an interesting question to ask ourselves as a society, “Do we want the brightest and the best of our young people to become Wall Street financial experts, criminal lawyers, venture capitalists, surgeons, pediatricians? Where do we want them to go? And how do we want to arrange our reward system to distribute them there?” We’ve changed that reward system in the last few decades so that we have a lot of people who want to go to business school and hope to enter the world of finance. Does that reflect our nation’s goals?

Heffner: Well, Bob, talking about ethics. You’re obviously talking about dollars, too. And answering the question that you just raised, thinking about the financial burden that a person studying medicine has to bear today…comes out of medical school or comes out of medical training with a huge burden of debt, can there be the practice of medicine as you want to see medicine practiced with the present financial arrangements in place?

Michels: That’s a serious problem. At one time the economic potential of a physician was very great, and the cost of medical education was less than now and so it was possible to amortize that cost over your future career. What’s happened recently is the cost of the education has gone up, while the probable rewards have diminished. One corollary of that is that people graduating medical school with large debts are likely to select those sub-specialties of medicine that generate enough income to pay off those debts. Those aren’t necessarily the sub-specialties where we need physicians the most. They’re for example, not primary care medicine, they’re more likely to be surgical specialties. That’s not good from the point of view of public health. Another corollary is that it’s very difficult for someone who’s poor to see medical education as a promising career track with the huge debt that will be added to the poverty from which they start. And, therefore, we’ve not done a very good job at attracting people from the lowest social economic groups into our medical training.

Heffner: But there must be another element of attraction. Talk about the rank ion society, all those privileges that you have…when the beeper goes off you can leave the dinner party. The way in which people look to doctors for help, for the sustenance of life. I wondered whether you would…and we don’t’ have very much time left…help me think through what must be the psychological impact upon the physician of his increasingly god-like qualities, abilities. The degree to which he has command…I mean the old notion that we’ve given up the idea that doctors are gods, seems to me to have been, to have been reversed as doctors can, with our new scientific knowledge control so much of present and future.

Michels: That’s interesting because I guess I see it a different way, and it must come from different experiences. I think the public may once have thought that doctors were gods because of the belief that doctors had immense impact over the outcome of someone suffering from a disease. Doctors don’t have immense impact over the outcome of someone suffering from a disease. They used to have almost none, and now they have a very small amount. Where public attitudes and patient attitudes may invite one to feel grandiose, the reality of one’s own experience, and the subjective experience of working to save a life, or to help someone get better and failing are immensely humbling. Further, doctors now practice more in groups and more under the scrutiny of their colleagues than they once did. Very few physicians are alone in working with the public, and it’s quite correcting an experience to the adulation of your patients to face the reviews of your colleagues who tell you what you did wrong and what you might have done better.

Heffner: Yes, but in the future, increasingly now, you and your fellow scientific colleagues have the capacity of genetic manipulation, have the capacity to replace our hearts, our kidneys, have the capacity to create of us bionic men and women. I wondered what that does to one’s sense of one’s self?

Michels: I believe that it would be centuries before anyone would question the notion that it’s far more important to pick your parents than your physician, if you’re concerned about your health. And the more we learn about the determinants of health and illness, the more modest we become about what difference the medical interventions of the physician can make. In fact, a quick summary of what we’ve learned this century is that the preventive medical measures of public health and of modifying lifestyle and behavior have far more to do with the health of the population than the treatments of medicine for diseases after they’ve occurred.

Heffner: Yes, okay. Suppose we say that now…the old story about the Dean of the medical school who greets the students the first day and says that fifty percent of everything that we’re going to teach you will be untrue by the time you’re four or five years. The only question is we don’t know which fifty percent.

Michels: (Laughter)

Heffner: But certainly it’s not centuries from now where our capacity to manipulate the genetic content of mankind will enable us to do things we’ve never even dreamed of in the past.

Michels: The usual estimate is that it was only until the turn of this century before the average contact between a physician and a patient was, did more good than harm for the patient. Probably the average contact does more good than harm now. But still we’re dealing with a secondary, repair mechanism in modern medicine. We help patients, we make a difference. But the variance we control, compared to the variance that they control themselves is very small. We’ve become very impressed by the power of health education and habit control and changing people’s lifestyles before they become sick is immensely more potent than treating their diseases. That’s going to be true for a long time. Medicine has learned how impotent medicine is.

Heffner: It’s interesting that you say that and I dare say, at the end of the program here, that you’re really reflecting the good doctor’s desire to see society more and more concerned with preventative medicine, rather than guessing accurately about what you fellows are going to be able to do with manipulating our content.

Michels: And one of our professional, ethical obligations is to make sure that people’s delusions about the potency of medicine doesn’t leave them to give us too many resources, taking them away from more effective methods of prevention.

Heffner: No Frankenstein here. Dr. Robert Michels, thank you so much for joining me again today. I hope you come back many times to discuss all of the remaining problems in medical ethics.

Michels: Thank you, Dick.

Heffner: Thanks. And thanks too, to you in the audience. I hope that you’ll join us again next time. And if you care to share your thoughts about today’s program, today’s guest, today’s themes, please write to The Open Mind, PO Box 7977, FDR Station, New York, NY 10150. For transcripts send $2.00 in check or money order. Meanwhile, as an old friend used to say, “Good night and good luck.”

Continuing production of this series has generously been made possible by grants from: the Rosalind P. Walter Foundation; the M. Weiner Foundation of New Jersey; the Mediators and Richard and Gloria Manney; the Richard Lounsbery Foundation; Mr. Lawrence A. Wein; and the New York Times Company Foundation.