Oaths for Physicians -- Necessary Protection or Elaborate Hoax?

Erich H. Loewy, MD

In This Article

To Keep From Harm

A conversation with a neighbor (who certainly does not live in an impoverished area) at a pharmacy, as quoted by Dr. Miles, should send shivers down our spine:


Dr. Miles, I would like to ask you a question. My husband and I are on blood thinners. We share those pills -- each of us gets half a dose because we cannot afford two prescriptions. But, what I really want to ask you is this: I have both congestive heart failure and breast cancer, for which I am taking two costly medicines. I cannot afford them both and am planning to stop one of them. So, I'd like your opinion on which one to stop. Is it less painful to die of breast cancer or congestive heart failure?[20]

It is obvious that this is a system error. My wife, picking up my medications from the drug store, was preceded by a gentleman who takes only what medications he considered to be "essential" and regretfully gave back those he simply could not afford. We do not live in an impoverished area, and that this even happens to residents here leaves one imagining what happens in poverty-stricken areas. My wife inquired the clerk at the pharmacy counter what was going on, and she shrugged and said this happens several times a day. When asked how she felt about this, she shrugged her shoulders and said, "That's the way it is; it isn't my problem." This is a beautiful example not only of what the "system error" has done to our character but a sad reflection on the way we feel about the plight of our neighbor. Simply accepting the "way it is" without trying as a citizen to make at least others aware of these repetitive tragedies but simply "shrugging our shoulders" is unbecoming to a society, which appears to have lost its sense of outrage.

The average pay in the United States is $8.50/hour, which is a little under $16,000.00 per year -- or well below the poverty range of a small family. Usually such jobs carry no health insurance and other benefits, and even if they do, patients often cannot meet the copayment. When they do carry health insurance, which permits them hospitalization, laboratory examinations, x-rays, etc, they appear as "fully insured" in our statistics. Yet this is a lie if the copayment for each visit, each test, and each procedure is so formidable as to make it impossible for them to do many of the things the physician ordered. It is quite likely that such patients become labeled as "noncompliant." Very often they are too proud (whether that is reasonable or not, it is so, since an emotional response cannot be dictated) to tell their physician that they are too poor to buy the medication. This is a humiliating shame and one which we as physicians -- since it affects health, disease, and the ability to buy medications -- cannot ignore if we are to act ethically. There are many ways in which we as single physicians and as an organized body of physicians can work to alter this state of affairs.

When confronted with a "system error" it is not enough to call it that, shrug, and comply. If we are to follow the oath we take or if we pay any attention to the AMA code of ethics, we are obliged to do something about such recurring system errors. In this case we have an obligation both as citizens and as healthcare professionals. What we can do varies with the position we occupy: we can lecture, write, persuade our professional association to lobby, speak to our patients and to civic groups - physicians, like other people, have different talents. But to simply shrug off something you feel is necessary for your patient that your patient agrees to but the HMO/MCO will not approve is akin to abandoning your patient and violating the fiduciary relationship you have. Above all, we should stop seeing ourselves merely as individual selves and realize that if we unite to bring about a change in our inequitable, inefficient, costly, and basically inhumane approach to healthcare or other social systems, we can truly act as a "we," forcing the legislature and the politicians to come up with a system of uniform access -- not the details of a solution but a recognition of the fact that we have egregious social problems of which healthcare is one, and that it cannot be properly dealt with if we see it as unconnected to the others.

If we take our oath and our commitment to our profession seriously instead of feeling that we are merely employees who are ethically committed to do a good job within the limits set by our employer, we are violating our oath - or, even worse -- believe that we are discharging our obligations to the best of our ability. The oath we take (tacitly or explicitly) not only enjoins us to "serve the highest interests of our patients through the practice of our science and our art" but likewise expects us to be "advocates for our patients in need and to strive for justice in the care of the sick." Shrugging our shoulders when our patients cannot afford to pursue what we and our colleagues feel are necessary tests, procedures, or medications because we are confronted with a system error, or resorting to habitual lying in dealing with a recalcitrant system, is treason to our patients, to our art and not least to ourselves.


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