Mennonite Health JournalArticles on the intersection of faith and health
Reclaiming Moral Probity:
An Essential and Foundational Part of Being a Physician
Peter Carney, M.D., F.A.A.NS
from Mennonite Health Journal, Vol. 15, No. 4 – November 2013
“Medicine is a sensitive societal moral weathervane.
When its beneficence is blurred it is time
for society to examine its own claim to moral probity.”
Health Care Impacts the Viability of the U.S.
Health care costs are rising faster than the gross domestic product (GDP). This has caused many to project that by 2020 health care will consume 20% of the nation’s GDP. This has led Dr. Robert Brook to conclude that the federal “deficit cannot be reduced unless medical spending can be controlled.” Elisabeth Rosenthal has noted “Americans pay more for almost every interaction with the medical system. …. A list of drug, scan, and procedure prices compiled by the International Federation of Health Plans, a global network of health insurers, found that the United States came out the most costly in all 21 categories – and often by a huge margin.” Yet a recent review matching the state of health in the U.S. as compared to 34 other countries in the OECD (Organisation [sic] for Economic Co-operation and Development) showed that in the U.S. age-standardized death rate changed from being ranked 18th in 1990 to being ranked 27th in 2010 while for the Healthy Life Expectancy (HALE) the U.S. moved from being ranked 14th in 1990 to 26th in 2010. Clearly, spending more money for health care in America than the rest of the world has not resulted in outcomes that are better than other developed countries have.
Dr. Robert Brook describes three scenarios open to physicians in controlling rising health care costs. First, do nothing. Costs continue to rise unabated and sooner or later the solutions will be applied that neither “physicians nor their patients want.” In the second scenario, health care is rationed, a solution that causes “all rational discussion to cease.” The third scenario requires physicians to “take the lead in identifying and eliminating waste in U.S. health care.” After defining wasteful medical procedures, devices, or drugs as ones whose potential harms are greater than their potential benefits, Dr. Brooks states that “Before draconian measures are enacted, the waste question needs a scientific answer that physicians agree is valid and reliable.” Among his solutions, Dr. Brook includes “teaching physicians to recognize and reduce clinical waste. Board certification examinations and tests in medical school could require physicians to separate waste from necessary care and demonstrate that they use such knowledge in day-to-day practice.” To accomplish such a scientific solution, Dr. Bradley Weiner recommends the use of evidence-based medicine, improved education for surgeons and their patients, regulations to restrain wasteful surgical practices, and a strong ethical foundation for surgical care. Where can such a foundation be discovered?
A Christian Perspective
At the 27th Annual Notre Dame Medical Ethics Conference an example of wasteful medical care was presented wherein a Worker’s Compensation patient underwent a procedure that cost $369,244 and had very little chance of being helped by the operation. Some renowned medical ethicists used this case to emphasize the need for a Christian Medical Ethic as opposed to a more secular medical ethic. In response to this assertion, the original case has been changed slightly to emphasize its relevance for those who wish to practice medicine in accordance with the teaching of Jesus Christ.
Case #4: A 33 year old teacher who works part time in the summer at his father’s carpentry shop injured his back at work. His MRI showed mild to moderate degenerative changes. After three months of conservative management including medication, physical therapy and spinal injections failed to relieve his pain he was referred to a surgeon. The surgeon reviewed the patient’s case, told him that he could be paralyzed within the next five years without surgery and recommended that the patient undergo a two level 360o fusion operation.
The teacher, who had already examined the medical evidence concerning his case, knew that:
- The chance of his becoming “paralyzed’ following an injury such as he underwent is “rare.”
- 80-91% of Worker’s Compensation patients with low back pain who underwent a fusion operation have significant functional impairment following their operation.
- 74% of Worker’s Compensation cases with low back pain who underwent lumbar fusion operation had not returned to work two years after their surgery.
- This operation would generate $369,244 in costs.
Fortified with this information, the teacher stood up, turned to his left and said to the surgeon:“Get you from my presence you cursed into everlasting fire reserved for the devil and his angels.”
This patient’s response may cause Christian physicians and surgeons to consider this question: “Why should we be surprised that this patient accurately described how Christ has responded to those who harm people?” Christ states very clearly that “As you have done unto these the least of my subjects so you have done unto me.”
Thus, doesn’t any physician who recommends that a patient without cancer or a life threatening illness undergo a very expensive operation that has an extremely low chance of benefiting the patient violate the basic Hippocratic principle: “as to disease make a habit of two things; to help or at least do no harm”? And don’t those who consider themselves Christian physicians have an obligation to support and promote the concepts taught by Christ and Hippocrates?
Forgiveness and Truth in Medical Practice
Yet even Christ himself does not immediately apply the judgment he describes in Matthew 25:41. Within twenty-four hours of pronouncing what Christian retributive justice entails, Christ discovered what the real world would do to him. One of his disciples betrayed him. The “rock” upon which he would build his church denied him three times. The authorities arrested him and prosecuted him unjustly. They marched him through the streets of Jerusalem with a crown of thorns on his head while the people mocked him and then had him nailed to a cross to be crucified and die while hanging between two criminals. Having endured all these tribulations, Christ did not return to what he taught in Matt. 25:41, but rather with his last words said: “Father, forgive them for they know not what they do.” These last words represent the most profound, fundamental, and radical concept taught by Christ. Thus, as we look at how physicians sometimes do not embody the noblest aspects of their profession should “forgiveness” rather than retribution be a more effective way to ensure the integrity of the practice of medicine, since it would give offending physicians an opportunity to acknowledge and remedy their errors?
Ingmar Bergman, in his famous movie, Wild Strawberries, teaches that the first act of any physician who deals with a patient is “to ask forgiveness.” I first heard this concept in my first year of medical school. In the last fifty-four years since then I have dealt with over 15,000 patients many of whom have had some of the most challenging and difficult neurosurgical problems one could imagine. Over 90-95% of these patients have, in one way or another, benefited from what I have done. But some have not, in part because of the complexity of their problem and in part because I did not help them as well as I should have. Thus today, each time I encounter another patient I continue to marvel at the wisdom contained in Bergman’s concept.
But of course many will dismiss the need for and the very act of forgiveness as weak and destructive. As Auden states, “Every crook will argue ‘I like committing crimes. God likes forgiving them. Truly the world is admirably arranged.’” That analysis misses the basic point of forgiveness. Having been forgiven, one can either accept or reject the gift. Those who accept the gift must acknowledge the harm their actions have created and take steps to rectify that harm. On the other hand, those who reject the gift must be willing to accept the judgment that awaits them. For Christians who reject the gift of forgiveness, it means realizing that they may hear Matthew 25:41 read to them on their final day of judgment. For Buddhists it means creating more bad Karma which will follow them into their future lifetimes. For those who deny the existence of either heaven or hell or Karma and claim that “we live, we die and that is all there is to that” the words of Gandhi still apply; “the future depends on what we do in the present.”
What type of future do we create when our children grow up believing that “it doesn’t matter what the truth is?”
Goodness and Virtue in Health Care
Since I first reviewed the first case I have subsequently seen three additional Worker’s Compensation patients treated by three other spine surgeons, all of whom recommended that his or her patient undergo a similar spinal operation, even though all three of these patients had the same chance of doing as poorly as the first patient. The four surgeons involved in the care of these patients are well trained to perform an exceedingly difficult and demanding operation. All have helped hundreds of patients, all are well regarded by their peers, all generate millions of dollars for the institutions at which they work, and all also make a few million dollars a year for themselves.
Accordingly, a more profitable analysis of these cases comes from understanding how the goodness inherent in all physicians can help to correct the harm these good and decent surgeons wish to inflict on some of their patients. These four surgeons represent approximately 20% of spine surgeons in the two areas where they work and receive widespread support from both their surgical colleagues and their medical communities. The fact that they function as they do demonstrates the ease with which the current culture of medical practice allows physicians to accept wasteful and harmful medical practices which undermine the very foundation of the art of medicine and the economic viability of this country.
Looking at how Iraqi physicians functioned under the Saddam Hussein regime, Dr. Edmund Pellegrino suggested the environment within which these physicians functioned acted “like perverse retroviruses .…[that transformed] moral DNA. Pellegrino discussed the dangers inherent in actions that subvert the “moral center of medicine.” He goes on to state that
“More than education is needed. Character formation is in the end the surest way to inculcate the virtues. This cannot occur unless the profession is itself ethically rigorous. Even the most virtuous physicians need a supportive culture to remain virtuous. Heroes can stand alone, but they are few and often castigated.”
In June of 2013 the Indiana Department of Insurance announced that $63 million dollars will be paid out of its Patient’s Compensation Fund (PCF) to cover settlements reached in nearly 350 malpractice cases brought against a single defendant. Gordon Hughes, M.D. and ISMA (Indiana State Medical Association) President has said: “These settlements are an important reminder to all of us that it is our legal and moral duty to police our profession. When we don’t, we hurt our patients, ourselves and our profession.” The effectiveness of his statement depends on the vigor with which he and ISMA will implement his words. Those physicians who believe that they have a legal and moral duty to speak out against their friends, partners, colleagues and competitors may face great difficulty and potential harm. Yet as Martin Luther King Jr. taught “Like a boil that can never be cured so long as it is covered up but must be opened with all its ugliness to the natural medicine of air and light, injustice must be exposed, with all its tensions its exposure creates, to the light of human conscience and the air of national opinion before it can be cured.”
The opportunity to treat patients less than ethically creates a major challenge to physicians who wish to maintain “the art of medicine” as the greatest endeavor ever created by the mind of human beings. Webster defines “moral” as a standard of right behavior and “probity” as adherence to the highest principles and ideals, or as uprightness. To restore “moral probity” to its place as one of the most important foundation stones of the art of medicine requires patience and courage to develop a definition of moral probity that all can understand and to which all can adhere. That definition has four parts, each of which depends on the others and cannot be used separately. These parts are (1) Integrity, (2) Compassion, (3) Honesty, and (4) Wisdom.
- Integrity means being able to speak up for what is correct and beneficial behavior when many disregard such behavior. It also means speaking out against behavior that harms patients.
- Compassion means not only giving compassionate care to our patients but also being compassionate to our colleagues and ourselves. Because, as we trod “the narrow and stony path” between trying to help and avoiding harm we sometimes become blind to our fundamental obligation to our patients.
- Honesty means being able to understand how good and decent people like ourselves and our colleagues can let harmful actions occur.
- Wisdom requires physicians to use the goodness that lies within ourselves and our colleagues to combat the dangers that the perverse retroviruses of greed, anger, and ignorance pose to our moral DNA.
By making moral probity a central part of serving the art of medicine, physicians will continue to uphold the highest values of our profession. Institutions such as medical schools, teaching hospitals, specialty boards, and medical societies must take the lead in establishing the concept of moral probity as the essential foundation of the art of medicine.
 Edmund D. Pellegrino, “Medical Ethics Suborned by Tyranny and War.” JAMA 2004: 291, pp. 1505-6.
 S. P. Keehan, et al., “National Health Spending Projections through 2020,” Health AFF (Millword) 2011:30(8): 1594-1605; Shatto, JD, and Clemens, MK, Projected Medicare Expenditure under an Illustrative Scenario with Alternative Payment Updates to Medicare Services. Washington DC: Centers for Medicare Medicaid Services, Office of Actuary, 2011. https:www.cms.gov/ReportsTrustFund/Downloads/2011TRAlternative Scenario.pdf.
 Robert H. Brook, MD, ScD, “The Role of Physicians in Controlling Medical Costs and Reducing Waste.” JAMA 2011:306, pp. 650-51.
 Elisabeth Rosenthal, “Paying Till it Hurts: The 2.7 Trillion Medical Bills,” The New York Times (Health Section), June 2, 2013.
 U.S. Burden of Disease Collaborators, “The State of U.S. Health, 1990-2010. Burden of Diseases, Injuries, and Risk Factors.” JAMA 2013: 310, pp. 591-608.
 Brook, “Role of Physicians,” pp. 650-1.
 B. K. Weiner, “Necessary and Potentially Evil.” The Spine Journal 2011:11, pp. 715-717.
 Case #4. “Greed and Medicine,” 27th Annual Notre Dame Annual Medical Ethics Conference. March 2-4, 2012, pp. 15-19.
 Eugene Carragee, et al., “Does Minor Trauma Cause Serious Low Back Illness?” Spine 2006:31, pp. 2942-49.
 Leah E., Carreon et al., “Clinical Outcomes after Posterolateral Lumbar Fusion in Worker’s Compensation Patients,” Spine 2010:35, pp. 1812-17.
 Trang H. Nguyen, et al., “Long-term Outcomes of Lumbar Fusion among Worker’s Compensation Subjects.” Spine 2011: 36, pp. 320-331.
 Matt. 25:41.
 Matt. 25:40. The word “subjects” is author’s word choice.
 Hippocrates, Vol.1 (Cambridge, MA: Harvard University Press, 1962), p.165
 Luke 23:34
 Ingmar Bergman, Wild Strawberries, 1957.
 W.H. Auden. For the Time Being: A Christmas Oratorio, 1942: Herod’s speech.
 Memorable quote from M. Gandhi.
 On Sept. 11, 2003 the Chairman of the Department of Anesthesiology at a hospital said under oath. “It does not matter what the Assistant Professor of Anesthesiology from our State University School of Medicine says. It will not change my mind.” That very same day the Chairman’s hometown newspaper had a front page story describing how his schizophrenic son had been sentenced to life in prison for brutally murdering and decapitating a young woman. For rational and thoughtful people these two facts validate Bateson’s Double Bind Theory of Schizophrenia. Bateson described the “double bind” as “a situation in which no matter what a person does, he ‘can’t win.’ It is hypothesized that a person caught in the double bind may develop schizophrenic symptoms.” (Bateson, Gregory, et al. “Toward a Theory of Schizophrenia” Behavioral Science [1956} 1 [4}: 251-4.)
 There are 21 spine surgeons in the two metropolitan areas where these four spine surgeons work.
 Edmund D Pellegrino, “Medical Ethics Suborned by Tyranny and War” JAMA, 2004: 291, pp.1505-6.
 PCF settles all Weinberger cases, significantly dropping fund balance; surcharges increases likely. ISMA Reports, July 8, 2013.
 Martin Luther King Jr. “Letter from Birmingham Jail” (http://www.africa.upenn.edu/Articles_Gen/Letter_Birmingham.html)
 Richard Selzer, M.D. “The Soul of a Surgeon” U.S. News & World Report, July, 12, 2004, pp. 80-81.
About the author
Peter Carney, M.D., F.A.A.NS., is from Elkhart, Indiana. After graduating from Western Reserve Medical School in 1962, he completed his training in neurosurgery and then taught and practiced in New England and in Saudi Arabia. Since 1985, Dr. Carney has practiced neurosurgery in Elkhart, Indiana while developing a special interest in medical ethics and treating patients in pain. After 51 years of medical practice, he still sees 50-60 patients a week, teaching them how to effectively deal with the ravages of chronic pain.
Mennonite Health Journal also wishes to acknowledge and thank Willard Swartley, author and Professor Emeritus of New Testament at AMBS, for his gracious assistance in editing this article.