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The Hippocratic Myth
Why Doctors Are Under Pressure to Ration Care, Practice Politics, and Compromise Their Promise To Heal
By M. Gregg Bloche
Palgrave MacmillanCopyright © 2011 M. Gregg Bloche
All rights reserved.
Dr. Mara gave my mother her last laugh. Every week or so, Dr. Mara, wearing black, would approach me near the nurses' station to tell me Mom had said, "It's time." At stake were the high-priced bags of bloodclotting cells Dr. Mara reluctantly hung over Mom's bed every few days. The donated cells kept her alive. Leukemia had wiped out her bone marrow, and she couldn't make blood cells. Unless the little straw-colored bags kept appearing atop her intravenous line, she would bleed into her brain, kidneys, and bowels.
Mom's cancer was untreatable. Johns Hopkins had discharged her, and money was a problem. But her dismal prognosis made her eligible for Medicare's hospice benefit. She was a winning financial proposition for any hospice program that would have her—unless the clotting cells were part of the deal. Mom, though, insisted on them. So did I. She was at least as mentally active as I—and determined to astonish her doctors by surviving long past the time they'd given her.
All but one hospice refused to take her unless she agreed to forgo the clotting cells. Transfusions delayed death unnaturally, we were told. They went against hospice thinking about the need to accept the end of life. The program that took her counted on the promise of death within a few weeks. Weeks, though, stretched into months, and Mom didn't die. Instead, she kept consuming clotting cells and incurring costs that Medicare didn't cover.
Mom stayed alert, without pain, as end-stage leukemia patients often do until their last hours. The first time Dr. Mara told me Mom was "ready" for the treatments to stop, I went into her room girded for the final farewell. But she insisted she'd said no such thing. She begged me to keep the cells coming, which I did. A week later, Dr. Mara, Mom, and I repeated this cycle.
It became a ritual. Mom wouldn't behave like a "good" hospice patient. She wouldn't go without a fight, and Dr. Mara gave her one. Dr. Mara told me the cells were a gift, wasted on my mother since she couldn't be saved. Mom joked about Dr. Mara's black dress and unrelenting efforts to close the Final Sale, until, eventually, leukemia had the Final Say.
Dr. Mara, I suspect, was sincere in her belief that my mother would've been better off without that final fight. She would've taken offense, I'm sure, at the suggestion that money affected either her clinical judgment or her understanding of Mom's wishes. But she also felt that the clotting cells were a precious thing, to be preserved for those who might most benefit from them. I would have seen things her way too, were my mother's final hopes not at stake.
I teach and write about health policy. I've cared for patients and advised public officials on what to do about soaring medical costs. During the 2008 presidential campaign, I helped to formulate President Obama's health reform plan. So I'm painfully aware that our medical spending habits are unsustainable. The numbers are scary—the fiscal equivalent of global warming. Within twenty-five years, if we keep on the current track, we'll be spending nearly a third of our income on medical care, unless we learn to say no to pricey treatments that produce tiny benefits.
But don't tell that to me when it's my mother's life that's at stake. And if you're a political office-holder, tell it to the public at your peril. Alarm over "rationing," real or imagined, may well end your career.
As citizens and shoppers, we demand limits on health spending—by voting for politicians who promise to cut taxes and by surfing the web or heading to Wal-Mart to find the lowest prices for products and services. Our pursuit of the best price—for everything from cars, to computers, to lawn care—forces American firms into the breach against medical costs, since more than half of all Americans get their health care coverage through the workplace. But we don't want our doctors to step into the breach alongside the cost-cutters. We expect them to stand with us when we're ill and afraid. We expect them to stand by their Hippocratic commitment to their patients, whatever the consequences.
In most medical schools, students make this commitment by reciting the Hippocratic Oath in formal assembly. Some of what they recite hasn't worn well with time. The Oath forbids abortion, rejects surgery, and promises free medical training to its swearers' sons. But the Oath's core premise has stood for more than 2,000 years. "In every house where I come," the Oath proclaims, "I will enter only for the good of my patients." This precept— the doctor's promise to stand for his or her patients without compromise— became a global ideal. It was slow to catch on. The Oath wasn't widely sworn to until centuries after Hippocrates' time. Yet eventually it spread throughout the world, beyond the boundaries of any nation or religion. It was carried west by Roman conquerors, then east by Muslim caliphates. It survived Europe's Dark Ages and the fall and rise of faiths and empires. It became fundamental to the medical profession's conception of itself and to patients' expectations of their doctors. And its core premise—uncompromising commitment to patients—has been embraced by clinical psychologists and others who care for the ill.
Yet this commitment is under unprecedented threat. Medicine's escalating costs and capabilities have transformed it from a politically unnoticed endeavor into a high-profile industry. We can't sustain health care spending that soars to a third or more of our gross domestic product. We'll eventually insist that doctors say no to beneficial or even lifesaving treatments because society can't afford them. As I show in this book, physicians are already doing so, covertly. And we'll demand that doctors put their skills and science to use for myriad nontherapeutic purposes—indeed, they already are. Advances in medicine's capabilities are spawning new public applications. Drugs and medical devices are being used to interrogate terror suspects, kill condemned inmates, and enhance performance at school and work, in sports, and in battle. Doctors opine in court and the press on who should be blamed for overeating, smoking, acting on sexual desire, and committing crimes of violence. Medicine, moreover, has become a weapon in our national battles over abortion, same-sex desire, and other social and cultural matters.
How to square this expanding range of social purposes with medicine's 2,000-year-old promise to stand by the sick is the central focus of this book. It won't do, I argue, to reject all uses of medical skill, science, and judgment for nontherapeutic purposes. Medicine's soaring costs have made clinical judgment a public matter, and doctors will need to become wise stewards of limited resources. Leaps in our scientific understanding of mind and body can't be cordoned within the clinical realm; innovators beyond the bedside will inevitably seize on the possibilities. Some of these, I contend, pose grave threats to the profession's trustworthiness in the eyes of patients. Others are putting personal liberty and privacy at growing risk. And medicine's rising power as an arbiter of public morals is usurping the authority of our institutions of self-government.
Medicine's furtherance of social purposes is oftentimes veiled. Doctors ration care covertly, and clinical judgment conceals myriad moral and cultural norms. Beliefs about the proper scope of personal responsibility and the balance between freedom and security shape diagnostic categories and therapeutic recommendations. This book probes for medicine's hidden moral content with an eye toward better understanding of the profession's public and intimate roles.
Conflict among medicine's aims, I argue, animates the health sphere's most bitter moral controversies. Curing and caring are sometimes at odds with each other and often at odds with medicine's public purposes. Stewardship of scarce resources, criminal justice and national security, and support for shared moral beliefs are among these purposes. Struggles over who should receive pricey therapies, whether one or another psychiatric diagnosis should excuse a vicious crime, or whether behaviors scorned by many constitute mental illness reflect tensions among medicine's purposes. Debates over whether doctors should ration care or coach CIA interrogators reflect conflict between public purposes and Hippocratic commitment to patients.
Doctors encounter this conflict within work settings that put pressure on them to go along. Too often, they've gone too far. They've prescribed dubious therapies in response to dubious financial rewards, abetted torture, and covered up clandestine killings. We've countenanced these things, in America and abroad, by tolerating business and political arrangements that invite them. And doctors have rationalized these bad behaviors to themselves as somehow beneficial to patients, required to defeat foreign enemies, or otherwise necessary for the public good. The risk of such rationalization underscores the need to draw lines: to set clear limits on what doctors can do on society's and the state's behalf.
Power and Myth: Medicine's Public Roles
Before Hippocrates, ill health was a sign of divine dismay. The gods had expectations, not always knowable but best not crossed. Diagnosis and treatment demanded an appreciation of their whims and wants. Greek healers who came before Hippocrates were devoted to the supernatural. Asclepius, the Greek god of healing, started out as the mortal son of Apollo. In Homer's Iliad, he's both a warrior and a healer. By one account, Asclepius's powers grew to the point that he enraged Hades by reviving the dead, threatening to shrink Hades' domain. Hades conveyed his anger to Zeus, who killed the uppity mortal with a thunderbolt. This, in turn, aroused the wrath of Apollo. Apollo's retribution was quick: he slew the Cyclops, makers of thunderbolts. A chastened Zeus then tried to set things right with Apollo by bringing Asclepius back as a god. Priests of Asclepius were public officials. Ancient sources record their astonishing feats—impregnation of infertile women, restoration of sight to a man with empty eye sockets, removal of spear points from soldiers' lungs, and enabling the lame to walk simply by instructing them to do so. Medicine's therapeutic and social roles were, at the time, without distinction. Cure required pleasing God. It was thus a public matter, no less so than pleas for divine intervention to avert military or natural disaster. Cities sponsored temples and prescribed rituals. Patients pursued cure by doing their social and religious duty, and priests saw their supplicants' welfare as a by-product of devotion to the gods.
Hippocrates and his followers broke sharply with this way of thinking. They made the radical claim that illness arises from the natural world and that cures thus should be based on the workings of the body. To this end, they put the patient at the center of their endeavors. They collected detailed case histories, rejected religious explanations, and crafted remedies—mainly diet, exercise, and mixed minerals and herbs—based on their physical understandings of sickness.
Hippocrates himself was an unlikely rebel. His family claimed descent from Asclepius himself. The Oath for which he is famed—although he almost certainly didn't write it—opens by invoking Asclepius, Apollo, and other gods as witnesses. But the gods are decorations. Hippocrates focused on illness's mundane, material causes and on the craft of clinical observation. Diet and drugs, not incantations, he claimed, accounted for the priests' treatment successes. In a clever bit of triangulation (it was risky, then as now, to seem dismissive of faith), he said that those who blamed the gods for disease were guilty of blasphemy. The intellectual leaders of classical Athens, including Plato, also gave lip service to the gods, but they embraced Hippocrates's unmagical analytics of clinical classification and cause.
This inward turn, from the demands of the divine to the needs of the body, had momentous implications for the ethics of medicine. It shrank medicine's moral domain, from the social realm to the life of the individual. Hippocrates's followers proclaimed their devotion to the patient as a person, and they set out to win their patients' trust. To this end, they foreswore sex with patients, emphasized accurate prognosis, and avoided curative promises they couldn't keep. They also introduced privacy to the doctor-patient relationship. Since the gods neither caused nor cured illness, the personal lives of the sick weren't their business. More to the point, what went on between doctors and patients wasn't the business of priests, politicians, or others who wielded power by claiming to know the gods' will.
The Hippocratic Oath affirms these commitments to the patient. It challenges doctors to resist market pressures, social expectations, and the state's demands. Its promise of loyalty to patients is central to its pledgetaker's professional identity. It has endured for 2,000 years because it appeals powerfully to people's yearnings for someone to stand by them when sickness stirs anxiety and fear. The Hippocratic vow of fidelity, moreover, is therapeutic in itself. A growing body of research shows that patients' belief in their doctors' commitment and competence makes treatment more effective.
But part of what sustained the Hippocratic promise of uncompromising commitment to patients for twenty-some centuries was medical technology's inability to accomplish much. Soldiers, police, and public officials were disinclined to turn to doctors for help in protecting (or oppressing) citizens, since their methods had so little to offer. Medicine could predict the course of illnesses but could do almost nothing to treat them. Its failed remedies were often ghoulish—bloodletting, cutting without anesthesia, and toxic mineral brews. And medicine was cheap to the point of economic irrelevance from a policy perspective. All but the poorest could afford its mostly pointless ministrations; thus those in power had little reason to fret about its cost.
Not until the nineteenth century did this start to change. It can fairly be said that the change began on October 16, 1846, in an operating arena overseen by a dentist, John Warren, at the Massachusetts General Hospital. Warren's guest that day, William Morton, asked a patient to inhale ether before a surgical procedure that would otherwise have been pure agony— slicing into the patient's neck to take out a tumor. The operation was painless and a triumph. Within a few months, pioneering surgeons around the world were using ether to put their patients to sleep—and to open a new universe of therapeutic possibility. Six years later, a British doctor gave chloroform to Queen Victoria for the birth of Prince Leopold. Religious fundamentalists were outraged—scripture enjoined women to bring forth in pain—but popular interest was enormous. Anesthesia quickly became commonplace in operating theaters around the world.
The problem of infection remained. Surgeons operated with dirty instruments, in filthy surroundings, wearing unwashed, blood-splattered frocks. But over the next few decades, the profession grudgingly came to grips with this problem, belatedly acknowledging proof of the germ theory of disease. Surgeons began sterilizing their instruments, first with acid, then with heat. They abandoned their filthy frocks in favor of sterile gowns, and they donned gloves and masks and bathed wounds in antiseptics. The results were astonishing. Deaths from such common procedures as amputation and repair of compound fractures dropped from 50 percent or more to low double digits or less. More than that, the revolutions in anesthesia and antisepsis opened the body to the surgeon's blade. Agonizing pain and deadly putrefaction had kept the chest, abdomen, and brain off-limits; now medicine could invade these biological sancta as a matter of routine.
By the beginning of the twentieth century, X-rays, the electrocardiogram, and a host of other innovations had added to medicine's capabilities and costs. No longer could a doctor deliver state- of-the-art care out of a saddlebag, riding from house to house or town to town. Medicine had begun its march from a nineteenth-century cottage endeavor to an industrial-scale enterprise. Locating anesthesia, antisepsis, and other emerging capabilities in a central setting, typically the hospital, made economic sense. The needed rooms, equipment, and other gadgetry required large numbers of patients to cover their costs. But with rising capabilities came rising public expectations—and rising pressure on governments to make medicine's promise available to all. Germany was the first to do so, offering national health insurance to its citizens in 1883, as a salve for the battlefield sacrifices its leaders demanded in wars against most of its neighbors. Other European nations followed, making medicine a public matter as never before. At the turn of the last century, medical care was a percentage point or less of their economic activity, but the stage was set for state involvement in the setting of priorities and the imposition of limits.
Excerpted from The Hippocratic Myth by M. Gregg Bloche. Copyright © 2011 M. Gregg Bloche. Excerpted by permission of Palgrave Macmillan.
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