The Medical Role
We assume in everyday life that it is individuals who are to be held morally responsible for their actions, on the grounds that it is only individuals who can have the freedom of choice and prior knowledge that are considered to be the necessary conditions of moral responsibility.
I shall not discuss the many challenges to this assumption. But my argument does require that I stress that the conception of the individual in the common assumption tends to be a thin one. The self which emerges from Cartesian, Kantian, or existentialist assumptions is one defined simply by an ability to choose, to have a rational will; it carries no social baggage. By contrast, I shall argue for a self which is social in nature (Macmurray 1970). Our identities are influenced or indeed constituted by values from many sources. From our arrival in this world, we assimilate values from family, high school education, professional education, newspapers, and influences of all kinds. In short, we take on the values of assorted groups and collectives. This means that the self which chooses is expressing collective values through individual choices. These collective values and attitudes are especially focused when we examine professional choices, especially those involved in the long tradition of health care. To enable me to conceptualize this point, I shall use the concept of a social role. I shall not argue for the thesis sometimes found in sociological literature that all actions and choices take place in a social role (Hindin 2007). My argument is less extreme: I shall assume only that the actions of doctors and other professionals in health care are carried out in a social role, a role which is constituted by a long history and contemporary expectations.Over the years, the medical role has grown and developed. It is constituted by three main elements. The first is the Hippocratic element.
Hippocrates was a Greek physician who was born around 460 BC. He and his School were dedicated to investigating the rational, scientific basis of medicine (Lloyd 1983: 29). This scientific approach ignores the individuality of patients and concentrates on what diseases have in common: it is assumed that diseases follow a pattern, the causal laws of which can be discovered. This belief is the foundation of Western, scientific medicine, expressed nowadays in the slogan or a pattern, the causal. It is the dominant value in the medical role at the moment and is the inspiration behind the algorithmic approach to patient care, which I shall discuss later. Many doctors in fact see medicine as an applied science, and they strongly value a scientific approach to disease.The second element shaping the role is also Greek in origin: it is the tradition of Asclepius, a shadowy figure in Greek thought who was claimed to be the son of Apollo (the god of healing and the arts) by a mortal woman. Patients sought relief from their sufferings in the temples of Asclepius, where harmless serpents (Coluber Iongissima) lived. Their hypnotic gaze was thought to encourage healing to come from within the patient: as contrasted with the external interventions favored by the Hippocratic tradition, the Asclepian tradition stresses quiet waiting and listening (Hart 2000). Dr. Marie Therese Southgate, former Deputy Editor of the Journal of the American Medical Association, brings out the nature of the Asclepian tradition by means of a comparison with the approach of the artist. She argues that both have a common goal, to complete what nature cannot bring to a close: this is done, she suggests, by paying attention: “If we are attentive in looking, in listening, and in waiting, then sooner or later something in the depths of ourselves will respond” (Southgate 1997: xii). This approach draws attention to the mystique of a medical consultation and ascribes to the doctor an almost shamanic quality, corresponding to the hypnotic gaze of the healing serpents.
In more contemporary, down-to-earth terms, doctors retain a high status in Western society and remain similarly respected and deferred to. Doctors are aware of this status and see it as part of the medical inheritance. The awareness of status contributes to the make-up of the role, although, as I shall suggest, the shamanic quality is under threat, or at least modification, from patient consumerism.The third element consists of a combination of Greek and Christian influences. The Greek influence derives again from Hippocrates and his School. Hippocrates is usually given the credit for introducing the idea of ethics into medical practice. Even if medical students no longer take the Hippocratic Oath the idea of the values expressed in that Oath continues in forms modified by cultural changes. Medical ethics has of course greatly developed in the period since 1945 and doctors see ethics as central to their role. Medical law has also developed. But the regulations of medical law and ethics cannot cover what might be termed the adverbial side to ethics — the manner and extent of medical interventions. This is where the Christian influence has been powerful. The parable of the Good Samaritan (Luke 10: 30—37) tells of the good physician who has compassion and cares for a victim regardless of race, religion, or danger. There is a tradition that St Luke was a physician and certainly the New Testament Greek contains references to remedies from Greek medicine. This element is wider than the rights and duties of medical ethics — it stresses the centrality of dedication and vocation in professional practice.
These three elements — the Hippocratic/scientific, the Asclepian/shamanic, and the eth- ical/Samaritan — have created a sense of solidarity and shared values within the profession and have given rise to a mystique surrounding the medical consultation, not unlike the deference formally accorded to priests. Indeed, the views of doctors are sought on many matters wider than medical ones.
It is convenient to encapsulate the three elements in the idea of a medical “ethos.” The ethos pervades medical education and becomes part of the identity of the doctor qua doctor. When medical students graduate from medical school they accept a role constituted by this ethos. This is what it means to act as a doctor. The ethos has molded the role and therefore strongly influenced the actions and decisions emerging from it. Consider the following quotations, which are typical of contemporary attitudes:Medicine is one of the few spheres of human activity in which the purposes are unambiguously altruistic.
(New England Journal of Medicine 2000: 42)
or:
Altruism is the essence of professionalism. The best interest of patients, not self-interest, is the rule.
(American Board of Internal Medicine 1998: 5)
These shared values and attitudes — the ethos — are cultivated through medical education. From the start of medical education, students are taught together and share a curriculum, which is largely similar for all students, and even extra-curricular activities reinforce the ethos through informal student societies, such as “year clubs.” Such factors play a role in inculcating a sense of loyalty even in the earliest years of professionalization. This loyalty is directed partly towards the institution and its members, but also towards medicine itself. In later years, ways of relating to patients and other health workers, even in other institutions, become part of medical professionalism. The professional ethic of medicine is steeped in collective attitudes and values. Those values and attitudes constitute the role of the doctor and are expressed in the continuity of the ethos. The ethos, or the collective values of medicine, will causally affect medical policies and decisions, but moral responsibility enters the scene only if the individual is willing to go along with the ethos.
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