Dr. Robert Michels discusses 20th century ethical issues in American medicine.
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GUEST: Dr. Robert Michels
I’m Richard Heffner, your host on The Open Mind. Five years ago, when the traditional so-called medical model seemed to me somewhat to be twisting and turning – crumbling, perhaps, under the impact of modern technology…a greater and greater capacity (mo matter what the cost or the consequences) to nurture life at the beginning, extend it at the end, and continually to manipulate it in between…I thought it wise to focus here on The Open Mind on the singular issue of informed consent: Each patient’s right, indeed, even his or her responsibility to be fully informed about what the doctor believes is wrong, what the doctor intends to do about it, and what risks are involved in the medical treatment suggested. In short, “What is to b done?” is to be done only with the patient’s full and informed consent. “Whose life is it anyway?” is the way most of us put it these days.
Well, I thought (and from your response, you clearly agreed) that one of the best minds to focus on this ever more prominent patient-doctor issue was Dr. Robert Michels, Chairman of the Department of Psychiatry at Cornell University Medical College and Psychiatrist-in-Chief at the New York Hospital. Then, not so long ago, on some of Fred W. Friendly’s always provocative media events, I watched Dr. Michels and a whole roomful of eminences from medicine man’s ever-more commanding role in our lives. Dr. Michels to examine some of these issues. So thank you for joining me for this half-hour, Dr. Michels. And I wonder whether you would agree that well, that my perception is correct, that there are more and more of these ethical concerns that may be stemming from a different kind of medicine that you and your colleagues practice today?
Michels: I think there is certainly more and more awareness of them. And that’s good, it seems to me. I suspect that the issues have been there, but have been ignored, or set aside. Patients expect to know more and to be more involved in making choices. And doctors may have more to tell them that’s relevant to choices. And at the same time, the guiding values that were myths that structure medical care, such as “Everyone should always get the best possible care” and “there should be no differences in the quality of care delivered to people because of their ability to pay for it”, those wonderful myths are now widely known to be transparently untrue. All those things mean that ethical issues in medicine are silent and compelling and cant’ be ignored.
Heffner: But, of course, there is always the notion that I’ve heard expressed so many times, that it is the poor people who go to the city institutions where they get the best possible care or the most modern possible treatment. And the very well-to-do, too. And it is just those of us who are in the middle who don’t always get that same high-quality care. Is that true or is that one of those myths today?
Michels: I think there’s some truth to it, but it depends on what you mean by “the best care”. Certainly some of the great medical centers that have high percentages of relatively impoverished patients give very good technical and scientific care. Although they don’t always pay maximal attention to the human needs of patients while receiving that care. And that’s part of good care, too. The economic problems of care are so great that not only are the people who pay for it themselves and have limited resources, the middle people, having trouble but governments are balking at paying for reasonably good care for lots of poor people, too.
Heffner: That’s the major crisis facing American medicine. It’s clear that we don’t have the resources to give everyone the best possible care without making serious compromises with other social values. Yet we continue to announce that that’s our explicit social value that we want to follow. And that dilemma hasn’t’ been solved.
Michels: Well, to some extent, I guess both. As a country we spend a relatively high percentage, not the highest, but a relatively high percentage of our total resources on health care.
Heffner: Where is it higher by the way?
Michels: Well there are Scandinavian countries that spend more than we do. And there’s certainly wide disparity among segments of our own country. So that depending on where you live and in what community, those numbers would vary significantly. But still there are pockets of care, both in terms of the kind of medical problem and the region of the country, where care is very sub-standard. There are people who, for example, an area I’m interested in, people with mental illness, who are cared for in public institutions often receive woefully inadequate care. And even worse than that, people who aren’t cared for by any institutions. A walk around the streets of a major city, such as New York reveals them very quickly.
Heffner: Yes, but wasn’t it your profession that took the lead in “turning them out” in a sense of institutions so that they end up walking the streets?
Michels: Proudly and sadly, both…yes.
Heffner: You’ve got to explain that one.
Michels: Okay. Many in my profession felt that institutions were bad places for many chronically psychiatrically ill people who were housed in them without receiving treatment.
Heffner: You mean the snake pits.
Michels: The snake pits. And they thought that it would be both more humane and clinically preferable for those patients to live in the community rather than in those institutions and receive care. Political forces and governments recognized that the opportunity to rationalize discharging patients from those institutions would save a huge amount of resources. And so they did that. But at the same time they failed to provide the care. So we didn’t do what my profession wanted, which is move from institutionalized care to community care, we moved from institutionalized non-care to community non-care. And if you’re seriously impaired, being un-cared for in a community can be worse than being poorly cared for in an institution.
Heffner: Well let’s go back for a moment to this other question of resources. And the increasing costs of medical care, psychiatric care, etc. what’s your own fix, your own position, on the morality of it all. The notion of taking from other social needs and giving to the extension of life, to the saving of life at the beginning and extension of life at the end. If you were king, emperor, what would you do, seriously?
Michels: Well, if I were a benevolent king or emperor…
Heffner: I assume that you would be.
Michels: I guess I’d want to abdicate first of all. And make sure that decision was shared by a wider group than some benevolent despot. It seems to me that’s an important social decision. And one of the important things about it is that the public make it, not only that they experience the results of it.
Michels: Well, I think they have to be fully educated about what the choices are and what the options are. They have to know what incremental resources would buy and what some of the current resources are failing to buy. For example, we frequently spend a lot more money in treating illnesses than we do in preventing them. The costs of prevention are often lower than the costs of treatment, but the benefits take a long time to appear. Because of the way our health care system is structured, it’s easier to get people to pay for treatment once they’re sick then to get the public to pay for preventive programs that will keep them from getting sick. Now we have to go through an educational process that will lead the public to want to support preventive medicine programs that in the long run will reduce health costs.
Heffner: Now I couldn’t find a better guest than you, as a psychiatrist to ask the follow up question. Do you think that it is possible…strike that, not possible, that it is likely, given the way we think as people that we can accomplish that educational task?
Michels: I think it’s likely that we can make some serious inroads into accomplishing it and make a difference.
Michels: Let me give you a timely and vital example. We have a wonderful compared, controlled study between two health crises in the same area of human life in two different historic epics. Syphilis and venereal disease five or six decades ago, AIDS today. I think we’re seeing, very impressively, how with all kinds of problems, with conflicts slowly with different segments of society fighting over it, but nonetheless, very impressively how we’ve moved toward a widespread discussion of preventive health measures in this AIDS epidemic that would have been unthinkable fifty or sixty years ago when we were faced with other venereal disease epidemics.
Heffner: You know, it’s interesting you say that because Mathilde Krim has been on the program a couple times talking about AIDS and the first time was a couple of years ago when public consciousness had not yet been raised. Anybody in the media tends to look at the downside, tends to say “Woe is us” and to look at the dark side of things, but I thought the other day, too, just what you’re saying, what an amazing amount of progress has been made in the area of public information and public education. Yet, do you feel, the media person again asking the question that supposed to elicit a negative answer. Do you feel that we can, do you think that we’re equipped psychologically to deal with the kind of fundamental questions you want to have answered by everyone, rather than the medical profession itself?
Michels: I think the dialogue must be and is being widened. So I think that there was a time when we talked about government expenditures for some form of health care, that they generally weren’t seen as a choice, but simply the need, a value. I think we’re moving toward a period when we’re beginning to recognize that if we decide to spend resources for treating this chronic illness or prolonging the life of this group of individuals, somewhere there’s another option that we’re not going to pursue because of that decision. That beginning awareness, it seems to me, is a big step toward more rational health planning. And that’s desirable.
Heffner: So you would accept the notion that we can’t, as a nation, afford to have everything, medically speaking.
Michels: Of course not. You can never afford everything. And, if you could, there’d be no interesting problem, ethically. If everything is available, there’s no ethical dilemma.
Heffner: Well, there was one interesting ethical question that you raised five years ago here. You made the point that though we as a people say that we’re very child oriented and we’re very much concerned with our young children, that it is in the area of the care of the young that we did most poorly in terms of governmental resources. Is that still the case, has anything changed there?
Michels: I think that is the case and it’s a sad and complicated case with some important political overtones. If you look at the demography of our country, there are differences between the young and the old in terms of the ethnic groups, social class, political orientation and the natural supportive constituencies that are connected with them. Young people are more likely to come from minority groups in this country because of comparative birth rates. And so we have an unfortunate interaction between health planning and political decision making based on which constituency supports which group of elected officials. I think, at times I fear, it looks as though the young get short shrift because they’re members of communities which don’t have good connections to the important power bases that support our government.
Heffner: What are the ethical considerations when it comes to the obligations of the medical profession to help change this? Any? Or none? I mean in a sense the medicine man serves the public and this seems to be a public decision.
Michels: Certainly. And in the micro situation medicine’s very good at that. Doctors don’t turn away from young patients in need, or at least they shouldn’t, but micro solutions don’t go very far because if doctors don’t turn away it doesn’t do any good if the people live in communities where there are no doctors to see them in the first place. So the question is, for example, do we have rational systems of educating health professionals and rewarding them so that they practice in areas where they’re needed and practice the kinds of medicine that are most needed in those areas? The answer to that question today is largely, no. medicine works in distributing its resources in what’s largely a market economy and we not infrequently train too many doctors of the type we don’t need and not enough doctors of the type we do need.
Heffner: Let me go back for a moment to this question that was raised in the Fred Friendly programs, patient-doctor confidentiality. I had the feeling as I watched that quite fascinating program there was a game being played and it was being played, to some extent, for the sake of the game. Is that as crucial an issue today as it seemed or was made to seem?
Michels: I would say, no, it’s not a crucial issue in the vast majority of doctor-patient interactions. Confidentiality is never a concern. It’s probably more prominent in psychiatry than more other areas of medical care. And even there, it’s rarely a central issue. It’s a symbolic issue.
Heffner: What do you mean?
Michels: It embodies certain core aspects of3the essence of being a doctor and of the doctor-patient relationship and of the role of the professional. I would say that the broader issue is, “Who is the doctor working for?” is he working for the patient or is he working for society or the community the patient’s a member of?
Heffner: What’s the answer to the question?
Michels: The answer is both. I guess I tend to give answers like that. Doctors generally like to think of themselves as working for their patients. But there are always limits on that contract with the patient. The patient has a contagious disease that endangers others, that’s a public health limit. If the patient is threatening the lives of others, that’s a limit imposed by the courts on doctors, about the needs of the community for protection. More important today, if the doctor’s interested in pursuing his own interests in terms of income or the pleasures of life or the preferences for styles of medical practice that can come into conflict with the needs of groups of patients.. We don’t have a system that mediates well between the rewards we want to use to get doctors to do what the society’s medical needs call for, and the rewards we actually offer doctors.
Heffner: I’ve heard so often recently, doctor-friends say, “I’m glad that I’ve reached this stage of life now. Were I to begin the practice of medicine today I would find myself the servant of society and I don’t want that” A, and B, “I don’t believe that I could do as good medical work as the servant of society”. What’s your response to that?
Michels: That’s a very pressing problem in the medical profession and, therefore, for the public, for the patients of the medical profession. We’ve just passed the point where the average doctor in this country is not self-employed in the private practice of medicine. The stereotype doctor of the television programs of the family practitioner are of historic interest at this point. Most doctors today and many more in the future, work for organizations, hospitals, medical schools, HMOs, organized health care delivery systems and more and more between themselves and their patients, there are third parties involved, insurance companies , employers, institutions. The doctor is in danger of feeling that this primary relationship is not to a patient, and the only thing that bonds the doctor to the patient now is that mysterious, amorphous professional ethic, rather than the primary contract the doctor’s working under. Many doctors fear that that will lead to a deterioration in the quality of the relationship with the patient and the quality of care.
Heffner: What do you think about that, because that’s probably the most interesting question. Is that necessarily so?
Michels: I don’t think it’s necessarily so, but I think it’s quite possibly so and I think there are areas where it’s already happened. It seems to me there’s possible ways of safeguarding against it. One is to make sure that the organized delivery of health care is structure in a way where the primary motive is the quality of care. I, and many others, for example, are extremely concerned about the fact that a large part of our health care delivery system is now a “For-profit” industry, with the doctor working for somebody who’s primary interest is the bottom line, the profit or loss that will occur from the business of medicine. And that’s sort of scary to somebody who thought medicine was a profession dedicated to something other than profit or loss.
Heffner: Is it less true in psychiatry, your own field? I would assume so, but I don’t know.
Michels: Well, in some ways it is. Psychiatry in one sense is ahead of this historically, because psychiatrists have long been primarily working for institutions, hospitals or governments, caring for the mentally ill. However, psychiatry in general has not been a very lucrative branch of medicine and, therefore although it’s been institutionalized and there’s been a bureaucracy, there hasn’t been a profit motive. In fact the problem has been the non-profit aspect of psychiatry. So we have elements of the problem in psychiatry, but perhaps not the newest and most severely malignant element, the element of non-medical profiteers running health care delivery systems. Though that, too, has emerged recently in psychiatry.
Heffner: I understand that there are those in the field and out who protest, in medicine and out, who protest that the old model of authority, of the relationship between the good doctor and the young doctor that that is a block in the way of the best possible kind of practice of medicine. And that the authoritarian model, not just between doctor and patient, between doctor and doctor, teacher and student, is hard put to be set aside. True? I mean are medical schools moving away from that? Can it be moved away from…that model?
Michels: I think it is to some extent being moved away from and probably well so. And I think it reflects something that’s going on in society at large. Medicine in general is more knowledge-based and less tradition-based than it was only a few decades ago. And when you move toward decisions that are based on knowledge and can be communicated rationally rather than based on experience and tradition and require copying mentors. When you move in that direction, you weaken the authority of people simply because of age. I remember a favorite teacher of mine once told me that a doctor who tells you he’s doing something because of his clinical experience is probably someone who’s made the same mistake for twenty years and used it to justify itself.
Heffner: There was a fascinating program on Sixty Minutes recently concerning the authoritarian model and the ways in which the older, better-established members of the medical community impose burdens upon the younger student, that is the intern, the resident, burdens that are not bearable and that impact upon the treatment of patients in major teaching hospitals. Do you have any view on that?
Michels: Young house staff work very, very hard. Not as hard as they used to, so doctors my age still have a chance to say sentences that begin with “In my day…”. However, they probably work so hard that at times their lives are burdened by their work and perhaps even at times their judgments are burdened by their work. There’s been a growing recognition of this. Actual studies of the kind of decisions the doctors in emergency rooms make when they’ve been up for twenty-four hours or that interns might make when they’ve been on every other night for the last two weeks. And there’s been a tendency toward some loosening of those kinds of initiation rite aspects of medicine. I think things are going to get much better for a special reason. We’ve long lived in a society with a relative shortage of physicians and we’re at a point of transition now. We’re rapidly moving toward a society with a surplus of physicians. And when you have a surplus, it’s much less likely that anyone’s going to be asked to work that hard.
Heffner: Well as good economic determinists perhaps, or quantitative determinists, do you think that the rationale for imposing that kind of burden upon young doctors in training will change? As I understand it, the rationale is, “It teaches you to meet emergencies. It teaches you to meet the kinds of pressures you’re going to find later in life”. Do you think that has been simply a rationalization of the numbers question…not enough doctors, and that that will change?
Michels: I think it’s been both a rationale and a rationalization. I hope it is preserved as a rationale. I, myself, wouldn’t want to have a doctor who thought of himself as being a doctor from to 5, Monday through Friday. And I would assume that for somebody to experience himself as always a member of a profession, always on call, always having to attend to the needs of the people, whose needs he’s charged with attending to, in order to think of yourself that way, you have to go through some kind of initiation experience that socializes you into the profession. What you learn in medical school, far more than the science of biology, is to be socialized into the role of being a care-taker. And that requires a sort of total immersion for a period of time. However, it may be that we’ve used that as an excuse for getting a lot of cheap labor from young professionals. And that may go away.
Heffner: Well, that’s why I wondered if the excuse is no longer needed if numbers pressure is not there, whether we’ll find a change in the rationale as, I think, seems to be happening, or at least the spotlight on the work that young doctors have done may bring about that change. We only have a few minutes left and, gosh, there were so many questions that I wanted to ask you, so many things to discuss. This question of ethics and the ethical considerations that doctors face, I’ve asked this question of others before. What preparation is there of people going into medicine for the ethical dilemmas that they will face? To what degree are the medical schools doing, what I gather the law schools are increasingly doing, saying, “You’re going to face these ethical problems and let’s sit down and try and deal with them now.”
Michels: There’s been a major move toward that in the last decade. So that most medical schools in the United States now have formal courses that discuss something about the ethical dilemmas of the practice of medicine. And something about the attitudes or ideas about ethics that are relevant to the problems of the physician.
Heffner: Do you think that slops over into the practice?
Michels: I think that’s largely theoretical talk. I think it’s worth having, but I wouldn’t overestimate the impact it has 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. I guess an item of concern with the modern changes 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.
Heffner: From the look on your face, it looks as though the answer to that is “yes”, you’re afraid that is happening.
Michels: I’m afraid that is happening and I think one of the things 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 business success in the business of medicine.
Heffner: And if you had to make a bet, will it happen or won’t it?
Michels: I’m an optimist. I think we’ll win, but it’s going to be a rocky decade ahead.
Heffner: Dr. Robert Michels, thanks so much for joining me today on The Open Mind.
Michels: Thank you, Dick.
Heffner: And thanks too, to you in the audience. I hope that you’ll join us again next time on The Open Mind. And if you care to share your thoughts about today’s program, today’s subject, please write 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.”
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