Social Justice and Physicians

I have been reading again the Charter on Medical Professionalism put forth in the Annals of Internal Medicine, Feb 5, 2002 by Harold C. Cox, a project of ABIM Foundation, ACP-ASIM and European Federation of Internal Medicine.  In it there are three principles, Principle of Primacy of Patient Welfare and Principle of Patient Autonomy and finally Principle of Social Justice. It's the last one that catches in the craw.

It says the medical profession must promote justice in the health care system, including fair distribution of health care resources.  Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion or "any other social category".

It "sounds" sweet and nice and sugar and spice but really is it 'reasonable' or 'emotionally sound'.  Collectively it's a good thing for the profession to promote those things that make any 'brand' look good.  However this all round 'anti discrimination' clause seems horribly reactionary and communist rather than socialist even but especially anti capitalist.

And really "any other social category".  I immediately think should a serial murder in prison have same access to cataract surgery as the neonatal brain surgeon.  What is most concerning is this 'any other social category'.  What concerns me here is the 'entitlement' in society today where people who do not contribute to 'insurance' plans expect equal benefits from those insurance plans.

Further we specifically as physicians have 'rationed' health care resources on the basis of 'compliance' with treatment. I was early involved in the decision to give 'pig skin heart halves' to chronic alcoholics over mechanical heart valves because of the issue of 'blood thinners'. The chronic alcoholics would be at risk of not doing the appropriate after care and with the lesser beneficial 'natural' valve there was less after care.  Given this clause I would think this reasonable medical decision making would be considered discriminatory towards an individual who is choosing excessive alcohol as a 'cultural imperative'.

I have spent alot of my career doing 'missionary' type work, choosing to work always in the areas of 'greatest needs' and not choosing the areas of greatest comfort, prestige or monetary reward in the profession. I could well have become a plastic surgeon but instead became a country northern physician and later a psychiatrist and addiction medicine specialist. I certainly would like more resources compared to my rich and richer brethren but somehow I don't want them if my plastic surgeon buddy with his multi millions is penalized for his attention to breasts and noses.  I think this 'clause' is destructive of what was always thought of as key component of medical professionalism, that is 'physician autonomy'.

I read this charter and it reads like a government employment brochure. It's a great salaried position yet it overlooks the word 'freedom'.  Professions have attracted the very best because of the potential for 'autonomy' and 'freedom'.

This charter by it's failure to address such central issues while focussing on matters such as "committment to just distribution of finite resources' and committment to professional responsibilities, seems highly weighted to governmental imperatives.

I personally was attracted to the profession of medicine because I was enterring a covenanted relationship with a patient in which I was to serve as a 'healer'. Clearly I would put the patient's interests first but how it was decided who would be my patient, the patient selection process itself, was never something I thought it was the responsibility of the 'profession'. In this way I'm arguing against myself in fact but that itself is 'professional'.

My first position was to go to a country hospital whereas the city positions carried more glamor, luxury, resources, pay and priviledge. I was a leading doctor and have always have tremendous choice something that perhaps those at the 'bottom of the class' didn't or didn't perceive.  Many of my colleagues today choose the 'easy street' of 'administrative medicine' which carries power, priviledge, and 9-5 jobs and no patient contact with considerable capacity to be extraordinarily parental.  Others choose 'forensic' medicine where there's a 'capitive' population.  There is limitted considerations of 'social justice' in either of these spheres.

I was the only provincial doctor willing to work in Northern Manitoba on the Island Lake reserves the years I was there. The Northern Medical Unit had to bring in doctors from England to take positions which for 2 years could not be filled because of the low pay, high risk and general unattractiveness of the position. I got TB. I was in a plane crash. I was attacked. I was injured. I went through the ice in a snow mobile on a mercy run. I was without resources on many occasions. I had little back up. The greatest priviledge of the position was working with Dr. Jack Hildes.

After country medicine and northern medicine I did a community medicine, public health and psychiatry residency. There was no support in the psychiatry residency for 'social medicine' at the time.  I wrote a paper on 'social responsibility' and it was belittled.  The psychoanalytic model at the time favoured 'labour intensive' service for a few whereas despite my psychoanalytic training I went to work in the provincial asylum where no Canadian Psychiatrist was willing to work.  The conditions for physicians were horrendous.  Patients had it almost as bad. The administration was living the life of bliss.

As a psychiatrist I worked in the country and the north again and then moved to work in addiction psychiatry.  My life has been threatened repeatedly. I have lost hundreds of thousands of dollars because my patients can't pay and the system penalizes doctors working with those who lack resources.  I have found in general the stigma against psychiatric patients and those who care for them suffocating.  I am now working in the Vancouver downtown east side with homeless drug addicts and street prostitutes part of my week. The hospitals and their services literally abuse my patients and myself because of the frustration within the 'system'.

I was a member of the International Society of Physicians against Nuclear War which got a Nobel Prize one day. I was never in favour of 'unilateral disarmament' during the cold war.  I think it's a good thing to consider 'social justice' but given the present administrations in Canada, those managing health resources and their desire to increase their positions and their pay without having a similiar committment to 'patient's first' I'm concerned that we as physicians giving up 'autonomy' will play into the nefarious self interest of these groups who have to date not demonstrated their ability to have high ethical standards.

I see that my colleagues are willing to do 'service'. It's extremely common for missionary doctors to go to work in equally difficult place. The Evangelical Medical Association is forever having doctors volunteer to work in difficult situations yet most would not have worked in the situations that I have because of the government interference in health care, the over riding tendency of administration to use whips rather than rewards and all manner of concerns with health care in secular societies.

The greatest risk to patients is the 'company' doctor. The 'company' doctor or 'government doctor' was a doctor who to protect his own position of priviledge did as he was 'told' and 'told' the patients what the 'company' or 'government' propaganda or corporate stategy of the day was.  He was a 'cog in the wheel' and his 'cowardice' in the medical community is legenday.  He was described in detail by Dr. Jay Lifton in "Nazi Doctors".  I personally don't want to be a 'nazi' doctor. I want my freedom and the patient's freedom enshrined.  I want choice and I want the patient to have choice.  Together we choose and together we stand.  That's the nature of covenant. That's historically the nature of professionalism.  This instead is something else and so watered down as to serve neither patients or doctor but likely to serve special interest groups and destroy the very trust that patients have historically had knowing their physicians are 'autonomous'.  This emphasis on freedom and autonomy is not dealt with in the 'committment to conflict of interest'.  I fear that the writers of this charter don't grasp or agree with what I and professionals before me meant by 'freedom" and 'autonomy".  Alternatively they may have deliberately excluded this in preference for this 'brand' they are definitely promoting as a universal when truly I believe it falls far short of encompassing the purest conception of medical professionalism that has allowed it to spread world wide and served so many of us even as we are ostracized by those who have so many resources.

This charter of medical professionalism fails extremely because it in no way protects the autonomy of the physician. It doesn't address the need for a physician to ethically and morally refuse to participate in situations where it is obvious that 'systemic' abuse is taking place.  It indeed appears to serve not the 'patient' but the very agencies that have so often ensured resources do not get to the patient or the physician providing direct care.

Professionalism requires 'autonomy' and 'freedom' for 'physician' and 'patient'.

Medical Professionalism Charter 2002

Lancet and the Archives of Internal Medicine in 2002 published the Medical Professionalism Charter 2002 renewing committment to patient care as primary, committment to patient autonomy and a committment to social justice.  Harold Sox, Annals of Internal Medicine, Feb 5, 2002.
I studied community medicine and public health and served in the areas of greatest need. I wrote a paper on Social Responsibility for the Canadian Journal of Psychiatry. I served in the north where doctors simply would not go and in asylums where psychiatrists couldn't be recruited. I worked pro bono for years in many areas and with the dangerously insane and the infected and questionable.  I got on well with doctors who had done missionary service. My colleagues who were most successful and most lauded in awards and promotion were highly particular about concern for the richest of patients.  Indeed, the doctor to the king, has always gone a lot further than the doctor to the poor. I've been an outsider stigmatized with the same stigma that my patients experienced.
Now I see that 'social justice' is part of the 'new world of order' in the 'profession'.  Irks me, considering how much heat I have taken personally for championing lost causes and fighting for the disenfranchised and going where doctors wouldn't go.  I was told by one of the head doctors in the Canadian Medical Protective Association that I was the most persecuted doctor they knew while at the same time I was told by a former head of the Canadian Medical Association that I was possibly the only  psychiatrist with integrity in the province.
I muddle along.  I love medicine and the practice of medicine.  I daily though seem to be fighting government for services for my patients, patients who as ignorantly as I assume those services are available to them as part of the social contract and the taxes we pay.  There have been no elective hospital beds and no nurses and demands for everything political but health care.  I feel like a cop who goes from fighting crime to guarding parking meters.
The charter makes a committment to patients, a committment to honesty with patients, committment to patient confidentiality, committment to appropriate relationships, with patients, committment to improving quality of care, committment to improving access to care, committment to just distribution of finite resources, committment to scientific knowledge, committment to maintaining trust by managing conflict of interest, committment to professional responsibilities.
It has been my experience the authorities pay lip service to the 'committment to honesty with patients."  It's a crock. My own experience and the experiences of my patients testify to the hierarchal dishonesty in the system. Twice I have had doctors lie in their care for me to cover up their errors and save their asses. It's a routine failing in the system.  I have witnessed it routinely.  It's as if there were two ledgers in the health care system, one for the patient to read, and one for the authorities. The same system applies in the baurocracy with secrecy and close doors and clandestine discussions.  Until there is a 'culture of honesty' there will only be the appearances in this regard. The reason I am following the Julian Assange case and Wikileaks is that it speaks to our very own governments real position on honesty to those who are served.  There is too much power in secret societies to expect this to go away with flowery words.
Committment to just distribution of finite resources - I can be committed to anything but in the end the rich and powerful get the kidneys or whatever. No one I know is standing in their way and all of the beaurocratic authorities have been there to assist in this.  Committment to scientific knowledge seems to be mostly whatever scientific knowledge is fashionable.
I am hopeful regarding conflict of interest.  I was forever getting into trouble objecting to the conflicts of interests in patient care. People were doing all manner of dirties locally and I was getting into all manner of trouble bringing it to the attention of the authorities. It was al most like 'no publicity is bad publicity'. Caught red handed the perpetrators of heinous wrongs went right on doing them at increased profit.
Now I don't see this so much.  Partly because I've taken to looking the other way like most of my colleagues always did.  Partly because pharmacists are calling themselves 'professionals' and people are expecting them to act in a less cavalierly tyrranical manner than they have to date so the heats off the doctors and moved to the pharmacists and perhaps others in the system rich on conflict of interest.
Committment to professional responsibilities is a vague thing. The more I 've been committed to my profession the more I've been criticized.  As a specialist and subspecialist I've devoted another 6 or more years of loss of income and study to being trained at best for my patients while my colleagues who didn't do further training remained with position authority and gained more money and power. Today it's common to see the highest ranking professional being ordered about by the lowest common denominator in the health care system. The patient and the doctor are least welcome too often.
I think the charter is a good thing. I wonder about the language. It seems a lot of work and yet it doesn't appear to add much to the code of ethics for physicians . I am not sure I agree with words like 'justice' being used in medicine given such short thrift the word got in legal circles. Blind judges are one thing but blind surgeons are another.
Since 2002 things don't seem to have got much better in the patient care area despite this fine manifesto and I fear mostly there are fewer and fewer hands to do the work while more and more people seem to be getting paid vast sums to talk about the problems of the patients.
That said the charter overall seems fine unless it is used as too many such papers have been used, to beat doctors and deny patients. The devil is in the details.