The president wants to transform healthcare with new laws and new technology, but once upon a time, a moral bond ruled between patient and physician.
Recently, I experienced something so rare in American medicine that it often catches people up short when I relate the story. A doctor actually apologized to me. Not only that, but he admitted that he caused harm, hurt feelings and inconvenience. Not only that: he agreed to refund all charges for office visits leading to up to his poor performance.
Sir William Osler treating a patient in the almshouse. Painting by John Howard Sanden
Why is this experience so rare? Ambulance-chasing lawyers and greedy HMOs immediately come to mind as forces that hinder candor, but they are not the only culprits. Perhaps not even the primary ones. For that we must look to something else: the absence today of any moral and social bond between patient and physician.
That bond has been torn for so many years that it is hard to recall when—or if—it ever existed. Yet for at least two millennia western medicine was shaped by all kinds of formal and informal institutions of medical redress.All recognized the mutual responsibilities of both the treated and the person performing the treatment. Even Visigothian law mandated that “should the patient die, the physician should not request the fee…Thereafter, neither party shall bring suit against the other.”
Roman law implicitly recognized this pact as well. In 368 AD, the Theodosian Code promulgated that “a town physician [archiater] should be hired for each of the city quarters (except for the area of portus Systi and that of the Vestal Virgins). The town physicians should be aware that their salaries [annonaria commoda] come from the public, and in consequence they should honestly treat the poor rather than shamelessly serve the rich. They will be allowed to accept what their patients offer them once they have been cured, but not what those who are dangerously sick promise in exchange for health.”
The Medieval era placed the onus on both parties to define the cure and its cost. In 1224, when Rogerio of Bergamo promised to treat Bosso the wool carder for a disease affecting the man’s mouth, hands and legs, Rogerio promised to cure his patient “in such a way that you will be able to feed yourself by hand and cut bread and wear shoes and speak much better than you do now….and you shall not eat any fruit, beef, pasta—whether boiled or dry—or cabbage. If I do not keep my promises to you, you will not have to give me anything.” What about the patient? “And I, the aforementioned Bosso, promise to you, Rogerio, to pay you seven Genoese lire within three days after my recovery and improvement.”
In the late Renaissance this moral bond was institutionalized via an institution called the Protomedicato. The medicato was set up as a forum where patients could grieve against bad doctors or bad treatment and have their contrattos vetted. The medicato even asked patients if advertising a cure was a good idea, to which the answer was, unlike the AMA’s, a resounding no.
All of this mutuality ended in the 19th century, when empirical science overtook traditional medicine. By and large, this was for the good; there are, after all, few outright cures for many diseases. But there was an unintended consequence as well. In the rush to make doctoring modern, physicians and jurists decided that payment by results was incompatible with professionalization. The contract for a cure was lost, as was the ability to apologize for ill treatment and a whole range of human interchange we so crave today.
With its clanking machinery of technocrats, lobbyists and policy wonks, the AMA seems to have little interest in renewing these bonds, fixating instead on killing the president’s reasonable health care plan. HMOs and insurance companies don’t even know the problem exists, so tied are they to today’s profitable system of alienating, fragmented care.
But one growing new constituency could take up the cause: medical students. Recent years have witnessed resurgence in med school activism not seen since the 1960s. It was med students, not their instructors, who championed the now-widely-accepted restrictions on pharmaceutical company gifts to doctors. It was the med students who first challenged the onslaught of TV ads for Prozac, among others. Med students are now behind the push to restrict patient data mining ( and its sale) by big pharmacy chains. And the trend for narrative medicine—viewing a patient’s condition as part of a complex, interrelated life story—has struck home with many of these young healers as well.
That same group could also lead the way back to a new social and moral compact between patient and doctor.
Then the words “I’m sorry” won’t be so hard to utter.
Greg Critser is the author of the forthcoming Eternity Soup: Inside the Quest to End Aging.
It's hard to fathom how an institution such as the Protomedicato would work today. Part of me thinks that if moral behavior in an arena absolutely depends on setting up such an artificial institution, then there's something wrong with the larger system.
Another large factor relates to the shortage of doctors. A steep shortage of - not MD's - but general practitioners is bound to give them a bit more license to act against the customers interests. In a word, if a average is upset w/their doctor&tells them they're going to find a new one, the doctor wouldn't be worried about replacing the patient. The blame for this shortage I think falls largely on the AMA for creating such artificially high barriers to medical education & med school entry. Of the few students accepted for medical education, the costs to entry are greater than they can recoop, unless many of them specialize rather than practice general/internal medicine.