Thursday, September 29, 2011

Reflections on the Ethics of Practicing Medicine

Like many aspiring doctors, I imagined myself working to serve the underprivileged, to ‘help humanity’ by dedicating my life towards health for all.  I wanted to use the privilege of my position to help those less fortunate, those struggling with poverty, inequality, and injustice. 

But after two years at Harvard Medical School, I became quite disillusioned with the possibility of putting this vision into practice.  In this post, I want to share with you some of my frustration with medicine – both the American system and the discipline itself – that brings to light some fundamental ethical problems that haunt me and others.  It was this frustration that led me to enter a program in medical anthropology in which I have been exploring these issues and trying to find fresh ways of doing medicine that are ethical and just.

Many of you are no doubt aware of the ways in which American healthcare perpetuates inequality.  Without a single payer national healthcare plan, many of our nation’s poor (and middle class) do not have adequate access to healthcare.  We spend far more money on expensive treatments of preventable disease than on cheap, effective public health measures.  Despite far outspending many countries on healthcare, our health outcomes are no better, if not worse.  While our technological advancements in genomics are leading us into age of ‘personalized’ medicine, we still don’t have the ‘impersonalized’ structures in place to guarantee even basic healthcare for all.  As a medical student, I saw these problems daily: observing costly procedures to insert cardiac stents in people living in a culture of over-eating and under-exercising, or watching homeless patients getting pushed back out onto the streets once their acute medical problems had resolved.  It can be difficult to remember you are performing a ‘humanitarian’ job when you sometimes create or perpetuate more problems than you solve.

At their core, these are structural problems that could be solved with a shift in budgetary priorities to reflect a commitment to prevention and equality.  This is an important problem that policy makers, physicians, and activists across the country have rightly dedicated their lives to.  But what I find more disconcerting in everyday practice as a physician is not necessarily the structures in which we practice medicine, but the underlying ideologies and assumptions that accompany our practice. 

Let me paint a picture of what I’m referring to.  In many adult primary care clinics, but especially ones that serve low-income patients, depression and mental illness is a common diagnosis.  Depression certainly has biomedical causes and can be traced to chemical imbalances in the brain.  But, more than medicine would like to admit, depression (as physician-anthropologist Arthur Kleinman and others have shown) can be a product of social and cultural problems.  It is no surprise that a single, immigrant mother who has just lost her job should be prone to depression; like the way we think of PTSD, depression can be a normal reaction to an abnormal situation.  As doctors, we are torn between the structural problems of the world and the suffering patient before us.  In prescribing an SSRI, we may relieve the tremendous pain of our patient; yet are we merely papering over the cracks of socioeconomic injustice and inequality, providing (almost literally) the ‘opium’ to the masses once described by Karl Marx?  In acting bioethically to our patient (that is, following the Hippocratic Oath and standard medical practice), are we acting unethically with respect to the broader suffering and problems of the world?  In providing loving care to our patient, are we underwriting the very violence that wrought so much suffering onto our patient? 

This is one dilemma of practicing medicine that I would refer to as the problem of ‘superstructure’.  Marx wrote about superstructure as encompassing all those institutions and practices that perpetuated a fundamentally unequal capitalist mode of production.  For Marx, superstructures in society were meant to placate the masses and prevent them from organizing revolution to take over the means of production.  His classic example was the church – the place where workers were taught to endure misery in this life for reward in Heaven.  Today, I fear that the hospital is taking the place of the church, keeping workers in good condition while allowing what are essentially social problems to be seen as medical problems. 

A second, and arguably more fundamental dilemma, is what I would call the problem of ‘biopolitics’.  ‘Biopolitics’ is a term popularized by French philosopher Michel Foucault and, put simply, refers to the ways in which populations are managed or controlled.  This may sound menacing, but biopolitics can sometimes be quite beneficial to society and its individuals: the practice of having a yearly health exam, of not being allowed to smoke in buildings, of understanding the importance of eating right and exercising regularly – these are all effects of biopolitics.  They save money and lives, improving the quality of life of all.  Yet they are not entirely non-violent practices.  Being a doctor who encourages people not to smoke, who urges them to have yearly physical exams, and who suggests ways to get more exercise is to have an unquestioned sway in influencing others, to be guides for others on how to live.  If not social coercion, it is a persuasion, a way to tell others ‘this is right, this is wrong, and you should believe me because I wear a white coat.’  It uses expertise and authority to dictate ethics to others. 

Allow me to quote from a 1784 essay by philosopher Immanuel Kant, in which he attempts to answer the question of ‘What is Enlightenment?’:
It is so easy to be immature. If I have a book to serve as my understanding, a pastor to serve as my conscience, a physician to determine my diet for me, and so on, I need not exert myself at all. I need not think, if only I can pay: others will readily undertake the irksome work for me. The guardians who have so benevolently taken over the supervision of men have carefully seen to it that the far greatest part of them (including the entire fair sex) regard taking the step to maturity as very dangerous, not to mention difficult.
In my reading, Kant implies that having others like physicians determine your sense of ethics is a sign of immaturity, a symptom of imprisonment within the chains of ignorance, awaiting to be Enlightened.  We are far too happy to allow doctors to supervise us, rather than to declare ourselves mature enough to supervise ourselves.  I do not mean to suggest that doctors are involved in brainwashing or controlling patients via bioethics; Foucauldian anthropologists like Paul Rabinow have been careful to show the consensual and beneficial ways in which biopolitics are practiced.  What worries me is that the very practice of guiding patients creates social difference between the patient and physician.  In daily practice, I draw on a specialized body of knowledge to solve problems that others cannot solve for themselves.  In this process, I re-iterate my medical maturity over their medical immaturity.  Even as I am on leave from medical practice while in graduate school, I am sometimes asked by my colleagues for medical advice, and in the very practice of guiding them I exert a type of domination over them.  Even if it is benevolent, it produces inequality and creates an ethical problem for me.  I would term this the dilemma of ‘Enlightenment’ – the product of dividing (quite rationally) an enormous body of knowledge into various systems of interconnected labor, making patients dependent on physicians to help decide what is right and wrong for their bodies and health. 

If you’ve gotten this far with me, I thank you for reading.  If you’ve (quite reasonably) skipped to this last paragraph for a little summary of what I have to say, here it is: bioethics go beyond problems of deciding who gets care when there are limited resources, or whether physician-assisted suicide is a legitimate medical practice.  It transcends too the material problems of our healthcare system and its inability to provide healthcare for all.  What I’ve suggested are two ethical dilemmas that we often ignore – the ways in which doctors brush social problems under the carpet of medicine (the dilemma of ‘superstructure’) and the ways in which relations of social domination are established by the practical confinement of medical knowledge to an elite few (the dilemma of ‘enlightenment’).  I happily welcome comments on these problems, both from practicing medical students and physicians on how they negotiate and attempt to transcend these troubling dilemmas to remain ‘ethical’ doctors, as well as patients who rely on physicians to solve the problems of their bodies and lives. 


Welcome to my blog! 

I am an MD/PhD student in medical anthropology at Harvard Medical School and UC-Berkeley.  My area of study is ethics, particularly the ethics of humanitarianism and violence in northern Uganda.  I am interested not only in moral philosophy, but also in the everyday ways that people develop a sense of what is 'right' and 'wrong' and how this changes over time and in different parts of the world.  Deeply critical of the state of our world today, I seek to become a physician-anthropologist-philosopher to be able to contribute to the relief of suffering both practically and theoretically. 

I'm looking forward to sharing my thoughts with you here and engaging in the gritty details of what it means to be ethical in an unethical world - not only with respect to humanitarianism, but also politics, medicine, culture, food, and so many other aspects of life.  In our modern society, ethics can no longer be confined to sermons or constitutions.  Morality is an ever-present and all-encompassing set of guidelines that influences everything from the way we speak and act to the way we eat and love. 

I welcome your comments and hope that our exchange will promote a better understanding of how we - the privileged of the earth - can best inhabit this world of poverty, inequality, injustice, and suffering.