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Ann Thorac Surg 1997;63:7-8
© 1997 The Society of Thoracic Surgeons
President, The Society of Thoracic Surgeons
In my opinion, we are witnessing the shattering of a code of behavior that has served society well, a code of behavior spelled out by the Oath of Hippocrates, taken by nearly every medical graduate in this country. Today the self-imposed principles promulgated in the Oath are being derided as self-serving and elitist, used by the medical profession for leverage to achieve its own selfish interests. Those principles are being replaced by employment contracts and practice legislation; thus the enforcement of behavior is being regulated by external sources rather than by the self-imposed standards of the individual.
Is there a parallel between the apparent decline in appreciation of the principles enunciated by the Oath of Hippocrates and the decline in the attitudes of society toward values that were traditional when I took it? Is society no longer concerned with integrity; have we reached the point where honor is no longer a necessary virtue; is virtue no longer a virtue? If this is so, the cataclysmic effects, not only for our professional world, but for society, have been described as "looking into the abyss."
End of the world scenarios have long been a favorite topic for Freshman Composition courses and TV evangelists. However, I believe we may have reached such new levels of violence, mendacity, dishonesty, and deceit in the past 2 or 3 decades, with little in the way of public outrage, that we may have achieved social immunosuppression by massive antigen challenge.
The impetus for this sermonizing comes from the recent debate in the political process, where the majority of the media authorities seem to feel that character does not matter. I shall define character. It is not the cigar chomping, suspender pulling, gravelly voiced boozer, á la W. C. Fields. It is descriptive of someone possessing integrity, honor, and a sense of responsibility, professionally and personally.
What are the consequences for society if these values are no longer important or even necessary? I cannot speak for the political consequences, because there are certain checks and balances in government, flimsy as they are. I can speak to the consequences for people who need medical care. John Benfield wrote an editorial last year on "The Tyranny of Managed Care," identifying the potential for abuse that exists in our rush to cost control. If physicians do not take the responsibility for the protection of their patients ("I will use my power to help the sick to the best of my ability and judgment; I will abstain from harming or wrongdoing any man by it"-Hippocrates), then who will? How does a patient know that she or he is receiving a physician's best effort? How do we know that the physician is resisting the temptation to cut corners just a bit, to reduce costs, when he or she may be sharing in the revenue generated by cost reduction? It is not completely different from athletes shaving points on a sporting event. They do not mean to lose the game, just cut the point spread. The physician does not mean to harm the patient, perhaps inconvenience her or him a bit, but not really to cause injury or increase risk.
I shall illustrate with a case report. I operated on a 65-year-old man last week. The procedure was straightforward three-vessel coronary artery bypass grafting. He was 1.8 m tall, weighed 108 kg, and had been a cigarette smoker for many years; he stopped some time ago. The procedure was uneventful; however, his blood gases were not really good for several hours after the operation; oxygen tension was in the 60 to 70 mm Hg range. I kept him intubated until early the morning after the operation; then a pneumothorax developed on the side contralateral to the mammary artery take-down. We put a tube in, the lung expanded, and he was transferred out of the unit on the second day. On the third day his managed care quality assurance manager came along and said he had to go home: the Millenson-Robertson optimal recovery time was 3 days after coronary artery bypass grafting and he was 3 days postoperative.
Now here is a problem that we all know too well. If you do not send him home, you will look less competitive and the managed care organizations will doubtless look to your colleague down the street for the new contract, and may even refuse payment to the hospital for the inpatient time beyond 3 days. His blood gases are still not great; on the other hand, he will probably be alright at home (note the qualifier "probably"). What do you do? Whatever is decided, I submit that I want the decision to be made by someone with character, as I define it. You cannot make enough rules, or regulations, or guidelines to sort out every contingency, and we all know the tort system is a joke, doing little or nothing to regulate the quality of medical practice. We need people with responsibility, honor, and integrity. Now, I know I am preaching to the choir; I believe you all agree with what I have said. Why is it that ABC, NBC, or the New York Times do not appear to agree, and are they sufficiently influential that the country is being convinced that character does not matter?
We can debate ethics, there is room for disagreement on public health policy, and there can be legitimate arguments of ways for accomplishing the goals of providing the best medical care for the most people. However, none of this will ever work out, in my opinion, unless the participants recognize in each other the virtues we have been discussing. Without character, there is no basis for mutual agreement on where we stand, no way to arrive at negotiation, and no way to begin the debate. We have to hold fast on this one.
Footnotes
Address reprint requests to Dr Replogle, Ingalls Memorial Hospital, One Ingalls Dr, Suite W536, Harvey, IL 60426 (e-mail: rreplogl{at}midway.uchicago.edu).
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