By Mozafer Rajabali
Perhaps one of the most important bedrocks of current-day ethics in medicine is the Hippocratic Oath, a series of ethical standards that clinicians have to swear by before they enter the workforce. Medicine by its very nature requires an ability by the clinician to enter into some of the most private realms of another individual on a regular basis. For myself, while I may have initially almost stumbled into medicine, what now appeals to me the most is the ability to care for another individual in a way that requires their ultimate trust. This is not to say that I seek to adopt paternalist attitudes towards those I interact with, but that I wish to be able to work with them in achieving the best possible goals. Here, I wish to point out some of the reasons why & how my motivations for medicine have evolved, and try to contextualise them in a more globally relevant setting.
After unwittingly ending up in medicine, I began to grow attached to the role of the physician as the individual responsible – to some extent – regarding the health of another individual. Attending ward rounds and clinics made me salivate over the idea of sitting in the physician’s chair, but at the same time left me ambivalent regarding my ability to be of practical use to someone else.
In the modern world for the most part, the patient-clinician relationship was determined with the modus operandi of medical paternalism – an attitude on the patients’ behalf to perhaps blindly trust in the attending physician (Medical Protection, 2017). With the increased proliferation of antibiotic resistance, physicians are taking a much slower approach in prescribing immediate antibiotic medications, and this may play a role in how the relationship has evolved over time. In some economically-less developed countries, it is still commonplace for antibiotics to be easily and often prescribed, as well as in some local clinical environments (Ross J, 2017).
In observing consultants and registrars on different wards across a few hospitals, I can easily say that there is no one way in striking the right balance. My favourites have included gentle but firm clinicians, intelligent and decisive but also witty clinicians, and more than anything, empathic clinicians. Granted as well, in hospitals there are times of drug overuse and genuine mistakes on the part of some clinicians, but for the most part the use of medications is done with a certain degree of purpose. I have genuinely tried to interrogate my interests in medicine as a result of this, because empathy burnout is a thing. What I learnt about myself is that I enjoyed coming to hospital, even if it meant I did not complete a tangible, measurable task. Perhaps, this means that my altruism – or so I believe – is rooted in being able to serve another individual (Xu, 2014, p.217).
Unbeknownst to myself at the beginning of my clinical years however, was this idea of what the current postmodern world order has resulted in. Postmodernism – aside from being a largely dishevelled philosophical framework – is perhaps a good way to capture current global ideas and thoughts. In our preclinical years we are taught that from an ethical perspective, we are moving away from a paternalistic approach towards a more patient-centred approach – and this is only logical. But what I only came to understand after entering the hospital environment, is that patients come to a clinician with all these randomly-assorted ideas about their illness and its supposed treatment. Cancer, for one, is a culturally appropriate expectation at the end of the list of possible diagnoses on a google-search for flu-like symptoms. For the overly-informed citizen, prescribing a drug can be a remarkable task because of the plethora of information available out there (Hodgkin, 1996). Directing them to the correct resources is the task of the clinician, but what is accessible to the patient at their fingertips is definitely much wider than that. In essence, from a postmodernist perspective, there is an increased scepticism of anything scientifically objective (Cadario, 2011). Of course, this is not to say that every patient is like that, but rather that these are overarching ideas and perhaps more prevalent in young-to-middle age groups, which will go on to become the largest burden on healthcare in the near future.
These sorts of changes left me puzzled for a while, it made me question why I was pursuing medicine. And what hit me, perhaps one morning as I dragged myself out of bed, was that I really appreciated science. I really appreciated evidence-based medicine, and everything it stood for. Granted, new research can amend certain clinical guidelines and can profoundly change diagnoses and prognoses, but there was a rigorous, evidence-based approach play to it all. And that was something I avidly want to stand by. I recall the first time I heard the phrase evidence-based medicine and thinking to myself – I will have to forever remain a studious pupil of the medical sciences, and cringing at it. I still do – but with less aversion and more appreciation.
Upon arriving at this seemingly benign conclusion, I ventured into clinical settings with a different sort of purview – sometimes leaving me at the mercy of supposedly innocuous questions from my seniors. What I noticed was that the more proficient clinicians were the ones who found a good balance. They were neither paternalistic, nor were they completely surrendering their clinical reasoning to the patient. What I mean by this is that, the clinician would present options to a patient, but also then take up the responsibility of presenting the best option – under whatever circumstance (Salwitz, 2014). And to me, that was gold.
What this all inevitably means is that the clinician can work towards achieving results, and is at liberty of trying to improve the healthcare of their patients, in order to make a financial gain. Now some may proprietarily argue that this is a ludicrous way of looking at the world and that emotional and altruistic needs should be at the forefront. But I think the reverse argument can be made as readily. If a clinician seeks to make financial gain, and as a result provides quality healthcare for their patient, then so be it. Of course, if that results in sacrificing a patient-centred approach, then that would contribute to a lack of quality healthcare. Further, if the research study by Xu (2014) is anything to go by, medical students do tend to move away from purely altruistic attitudes as they progress through medical school and into the workplace (p.216). Although I may have not reached this point myself, I do not see it as problematic, but perhaps simply as a way for me to improve my medical aptitude.
Cadario, Barbara (2011). Drug Safety and Postmodernism: The Rise of the Patient? British Columbia Drug and Poison Information Centre. Retrieved from: http://www.dpic.org/article/professional/drug-safety-and-postmodernism-rise-patient
Hodgkin, P. (1996). Medicine, postmodernism, and the end of certainty. BMJ: British Medical Journal, 313(7072), 1568.
Medical Protection. (2017). The end of paternalism. Medical Protection. Retrieved from: https://www.medicalprotection.org/uk/advice-booklets/mps-guide-to-ethics—a-map-for-the-moral-maze/chapter-1—ethics-values-and-the-law/the-end-of-paternalism
Ross, John (2017, February 17). Patients often bully doctors into prescribing useless antibiotics. The Australian. Retrieved from: http://www.theaustralian.com.au/news/health-science/patients-often-bully-doctors-into-prescribing-useless-antibiotics/news-story/3db60f6ff3a4e36646ec1df664ffdbae
Salwitz, James C. (2014, June 19). Has abolishing medical paternalism gone too far? Medpage Today. Retrieved from: http://www.kevinmd.com/blog/2014/06/abolishing-medical-paternalism-gone-far.html
Xu, M. (2014). Medical students’ motivations for studying medicine: changes and relationship with altruistic attitudes, expectations, and experiences of learning at university (Doctoral dissertation).
Feature image by user Nephron at Wikimedia Commons.