Oaths for Physicians -- Necessary Protection or Elaborate Hoax?

Erich H. Loewy, MD

In This Article

The Physician as Advocate of the Poor in Today's Managed Care Environment

The function of medical colleges (as it is of all schools) is to foster good habits in their students: habits of proper history taking and physical examination, habits of critical thinking, habits of proper behavior while engaged in their professional duties, habits of "keeping up with the literature", etc. I reiterate that I strongly doubt that subjecting a physician to a course in healthcare ethics will change their habits -- when they believe themselves observed, their behavior for purely prudential reasons may change; that what we call their "character" is, in my view, unlikely to change. In some respects, we who are their teachers or preceptors are at fault.

In the managed care environment, physicians are no longer free to order medications or clinical tests or procedures, are no longer free to send patients for a consultation (which today, after all, constitutes an admission by physicians that they may be in over their heads) or free to do procedures they deem necessary. In order to have certain tests done, for example, the patient must fulfill certain predetermined criteria. And, after a while, physicians get used to acting in a way they know to be wrong and shrug it off as a "system error." By "system," I mean something that has internal coherence and controlling elements -- the CV system or governments are examples. A brief paragraph from the holocaust literature points out the danger of the "system":


...a political, economic, or cultural system insinuates itself between myself and the other. If the other is excluded, it is the system that is doing the excluding, a system in which I participate because I must survive and against which I do not rebel because it cannot be changed. . . . I start to view horror, and my implication in it, as normalcy.[19]

A system is not a "natural occurrence" such as a tsunami or a hurricane. It is something that -- especially in a democracy -- we construct and then are expected to continue to monitor. Imagine a patient whom you suspect of possible cancer of colon or stomach and you, the primary care physician, feel that he or she needs a colonoscopy or gastroscopy. The patient, however, denies ever seeing blood with defecation. Unfortunately, that happens to be one of the criteria. There are 3 roads open to you: (1) you can spend countless hours arguing with the clerk who denied the request and finally battle yourself through to a physician who may or may not permit the procedure (It is not something that a physician in a busy practice can do often); (2) you can refrain from doing what you think necessary and violate your oath, which quite clearly states that you will do what you consider best for every patient; or (3) you can lie and put down bleeding or coerce the patient into lying and admit to seeing blood. The first option is time-consuming and in many practices simply not possible; the second option clearly violates your oath; and the third either causes the physician to lie or encourages the patient do so. Lying, or suggesting to another that he or she lie, is hardly a habit that one should encourage in anyone -- especially not in physicians!

You can, of course, choose a fourth road and tell the patient why you think a particular investigation, medication, or procedure is indicated but that the insurance company will not allow it because it does not meet all of its criteria. This may result in causing undue anxiety to patients; encourage them to lie in your stead, deluding yourself into believing that you have kept your hands clean, and send the message that lying to your physician so that he can lie for you to the insurance company is perfectly all right. The message that lying is not so bad after all is loud and clear. For a physician to knowingly distort the patient's history is, furthermore, destructive to the whole enterprise of patient care. Honesty is a keystone of mutual trust and confidence.


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