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. 


  1. Can you develop the second part of your post a bit more, the part about how doctors engage in systems of domination? On the one hand, you acknowledge how Rabinow and others have pointed to the ethical and beneficial impacts of some types of biopower. On the other hand, you problematize by situating it within an unequal and subordinating relationship between patient and doctor. What would be a better system?

  2. Hi Veena,
    Thanks for your thoughts. I think this is a fundamental dilemma for most 'humanitarian' interventions, which are often simultaneously acts of love and violence. My own perhaps ambitious response is to be able to educate myself enough to a Kantian sense of 'maturity', becoming my own guide in matters of medicine, spirituality, and other forms of expertise. As for my patients, it is a struggle I'm looking forward to tackling and addressing, perhaps through a novel approach to health that works to equalize the power dynamic between patient and practitioner.
    Best, Sam

  3. Hi Sam,
    Great to hear you are engaging in these questions. I am totally on board with the first issue you raised, and the second, but some points:

    I for one am happy to live in a society where we share the burden of understanding the human condition. It is not my calling to learn the mechanics of musical electrical engineering (or maybe it is, but life is too short to make the world in its entirety for myself, but that would be great) but I am really happy that someone is doing it so I can blast music in my apartment while I pretend to study. In a way, expertise is a way in which we collectively make society together, so as not to put the entire burden of existence on every individual--it knits us together into a society of interdependence. So, expertise is good, although condescension/arrogance is bad. Clearly, believing that having medical knowledge makes you more able to understand human disease is not giving enough value to the fact that a patient-doctor relationship is a process of two-way learning. Biomedicine is a cultural viewpoint, with its own system of beliefs and values, even if it would like to posit itself as "objective." People experience disease themselves, and that knowledge is as important as the molecular mechanism of the disease in terms of understanding how to help them find relief from suffering.

    Secondly--isn't it a bit condescending to assume that people don't think about/make active choices about their bodies because they see a doctor who can make those decisions for them? I think that in a sense assumes that humans are unable to make choices about their own health and life. While I do believe that people are constrained by various circumstances of personal context which affect their health, I don't think that people are not autonomous such that they will sit on their haunches and do whatever their doctor told them (if that were the case, the health of our nation would improve for sure).

    Glad to hear your reflections!


  4. Hi Kate,
    Thanks so much for taking the time to write with your important questions and thoughts. You make some really great points.

    There’s no doubt that a society of interdependence can bring about advancements like music, and I can appreciate the benefits of a division of labor (although this too has its problems – as sociologist Emile Durkheim has studied, and the French philosopher Rousseau has pointed out in his Discourse on Inequality, where he radically argued that society itself is the source of inequality). I certainly agree that the patient-doctor relationship is (or at least, should be) a two-way street, and that people experience disease culturally. This is what physician-anthropologist Arthur Kleinman meant when he posited a distinction between disease (the biomedical mechanisms of sickness) and illness (the personal and social experience of disease and suffering). For me, this is all tremendously important for physicians to remember.

    What I am really concerned with here is not that I or other physicians treat patients in a condescending way; it is that we operate within a structure or institution that inflicts what sociologist Pierre Bourdieu would call ‘symbolic violence’ on patients. Bourdieu’s idea is almost like a psychoanalysis of society. Here is what he has to say about symbolic violence:
    Symbolic violence is instituted through the adherence that the dominated [in our case, patients] cannot fail to grant to the dominant [doctors] (and therefore to the domination)…she has only cognitive instruments that she shares with him and which, being no more than the embodied form of the relation of domination, cause that relation to appear as natural.

    Symbolic violence isn’t the physical violence of a stabbing or the political violence of an assassination. It is the ‘gentle and often invisible violence’ that usually goes unrecognized. It is a violence that, below the level of our consciousness, causes us to act in certain ways that allows for us to be dominated. If this doesn’t sound so convincing to you, let me assure you I’m not entirely on board with the idea of symbolic violence. It does seem arrogant in that it assumes that something (like medicine) that a person readily seeks out and accepts is harmful to them. It is the argument, for example, that one could take with the burqa – that it is a type of symbolic violence against women. One could say, “What are these women doing? They have been brainwashed to wear this oppressive piece of clothing that covers up their entire body because they live in such a sexist society.” I’m not sure this line of thinking is correct or productive; I would at least ask for some type of ethnographic inquiry with women who choose to wear the burqa in order to understand why they wear it. One might find something surprising, as with women newly wearing hijabs after 9/11 as a symbol of political resistance rather than any submission to male dominance. So whether or not medical expertise constitutes a form of symbolic violence, I think, is certainly a question for debate. Are people making active choices about their bodies? Or are they, within a particular habitus (another one of Bourdieu’s terms, used to describe the unconscious structures that shape the way we think and act), given a limited set of choices and culturally predisposed in particular ways (medical advertisements, hospitals, etc.) such that they are almost programmed to make a particular choice? (continued below)

  5. (continuing from above)
    I agree with your point that people are active to an extent – no one follows exactly what their doctors tell them, intentionally or not. People don’t fill prescriptions because they can’t read or the labels are in a language they don’t speak; people give or sell pills to others; and so forth. They even sometimes resist what their doctor says. But I’m not sure that unleashes them from their doctor’s more subtle domination. Let me stretch an analogy: a stubborn dog can pull its owner this way and that, but ultimately the owner decides where they finally end up. What does a patient’s resistance to taking a certain medication mean when the patient still decides to visit the doctor of his/her own volition? I would argue – certainly contentiously – that we have to think more deeply about the ways in which our choices are always pre-constructed. When we choose to go to the doctor, it is an active choice, but only to the extent that we have been culturally conditioned in an endless series of normative reactions: that we must act on our experience of suffering; that we must seek out another rather than solve our own pain; that we should visit experts we don’t know rather than, for example, kin we do; that we should be prepared to swallow pills or undergo surgery to fix our problems. It is this subtle domination of biomedicine that I refer to when I speak of ‘immaturity’ (a Kantian word that doesn’t translate well – perhaps we should stick to ‘domination’) or violence. It is, more broadly, to question the very meaning and limits of autonomy. What does it mean to be free? This is a question that has troubled philosophers and social scientists for a very long time!

    Thanks again for writing in, Kate! You really helped me think through some of these issues. I hope my explanations speak precisely to your comments.