Book Review

Ethical gray zones put the Hippocratic ideal in jeopardy

By Dennis Rosen
March 16, 2011

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Are doctors routinely betraying the trust of their patients and violating the Hippocratic Oath, one of the central tenets of medicine? According to M. Gregg Bloche, physician and professor of law at Georgetown University, the answer is yes.

Bloche sees this happening for many reasons, including advances in technology, which have outpaced society’s willingness to grapple with their consequences; greed; and attempts by individual physicians to do the best they can for their patients under circumstances that force them to operate in ethical gray zones.

Bloche provides many examples, some very persuasive, others less so. The strongest sections of the book are those that discuss the participation of military physicians in “ ‘enhanced’ interrogation methods’’ of prisoners (or as he less euphemistically puts it, “complicity in torture [and] other conduct that violated the laws of war,’’ and the complicity of professional societies, which sanctioned such actions. Actively aiding or abetting the purposeful infliction of pain or bodily harm by someone who has sworn to “do no bodily harm or injustice’’ can only occur if the physician-patient relationship is considered to be superseded by one between the physician and the government. This is antithetical to the conventional doctor-patient relationship, which places care of the patient and the safeguarding of his interests at its core. Redefining this relationship so that the physician’s first loyalty is to the government or one of its agencies jeopardizes the very trust without which doctors cannot provide good care.

Some of the other areas in which Bloche sees an assault on “the Hippocratic promise of uncompromising loyalty to patients’’ are less clear cut. Much has been made recently of the evils of medical rationing, with its images of death panels pulling the plug on grandmothers conjured up by demagogues wishing to reap short-term advantage from efforts to control rising health care costs. And certainly, when insurers make it financially advantageous for physicians to restrict diagnostic tests or treatments, patients’ interests can be directly pitted against those of doctors, with foreseeable results.

But is always doing everything humanly possible for every patient under any circumstance the best policy? Many, this reader included, would argue that it is not, and that there are many instances when blindly pursuing treatments that guarantee pain and suffering but offer very little chance of cure is simply the wrong decision.

Seen this way, not recommending triple bypass surgery for a 92-year-old woman with advanced Alzheimer’s disease and metastatic colon cancer appears less a violation of the physician’s sworn duty and more an expression of humility and concern for the dignity and well being of the patient. Characterizing decisions such as this as “quietly and gently hypocritical’’ and even as a matter of breaking faith seem too strong a condemnation of what are in most cases thoughtful attempts by dedicated and compassionate physicians to navigate their patient to the best possible outcomes, balancing survival and quality of life with a maximum of dignity against a minimum of suffering.

It is true that conflicts of interest and personal biases can affect a doctor’s decisions about what courses of action to recommend. Bloche cites a 2003 Institute of Medicine report on disparities in health care, which found that among people with health insurance, African-Americans received worse care than white Americans for heart disease, cancer, and diabetes. This disparity underscores why the conversation about health care resource allocation and prioritization needs to be held by society at large, and not just by physicians or politicians.

While not quite succeeding in connecting the different themes of the book, Bloche is nonetheless to be commended for thoughtfully presenting the issues in a way that will hopefully spur such a conversation, sorely needed and long overdue.

Dennis Rosen, a pediatric pulmonologist, can be reached at dennis.rosen@childrens.harvard .edu.

THE HIPPOCRATIC MYTH: Why Doctors Are Under Pressure to Ration Care, Practice Politics, and Compromise Their Promise to Heal By M. Gregg Bloche

Palgrave Macmillan, 264 pp., $27