International Journal for Quality in Health Care 14:349-351 (2002)
© 2002 International Society for Quality in Health Care
Editorial |
Old values, new challenges: what is a professional to do?
Northwestern University, Chicago, IL, USA
McGill University, Montreal, QC, Canada
McGill University, Montreal, QC, Canada
Northwestern University, Chicago, IL, USA
Medical professionals are engaged in a particular set of roles and relationships in society. The obligations and boundaries of these relationships are set out in ancient and modern codes of ethics. To a degree, they speak with one voice, thereby affirming their authenticity [1]. After all, being derived from a deeply human response to existential realities of illness and death, there are only so many degrees of freedom in medical ethics. Medical professionals must preserve health, heal, care, and be trustworthy on an individual and collective level. Simple in its ethical declarations, achieving professionalism in our actions can test the limits of cognitive and moral strength. Today the challenges of change are tectonic in magnitude, electronic in speed, and arriving on several fronts simultaneously. To help draw out our collective strength, major medical groups have put out new versions of professional declarations such as the American Board of Internal Medicine’s international Charter on Medical Professionalism, and the American Medical Association’s Declaration of Professional Responsibility [2,3]. But, what exactly are the challenges? Translating the commitments into action also requires a deep understanding of and engagement with the challenges. In order to invite more intense consideration of what professionals should be doing today, this editorial attempts a description of two challenges that must engage moral attention. These two challenges are in an all-important, overarching domain: medicine’s relationship with the commercial sector on one side and with the political sector on the other. Situated at one side of a triangle of sectors in society, professionals must engage with the other two sides: society’s commercial and political sectors. Each is distinct in nature from and reliant on the other two. The nature of these relationships is all-important for a well functioning society [4].
Medicine’s relationship with commerce is marked by periodic failures, such as the abortive alliance between the Sunbeam Corporation and the American Medical Association, but also by continuing uncelebrated successes such as clearer conflict of interest policies for individuals and more recently for organizations help to keep the range of healthy relationships [5–8]. One key reality that has bound medicine and commerce in the US is that the service sector does not and should not have the capacity of industry to finance biomedical research and development. This necessarily tense relationship can only grow in the era of genetic and nano-technology, with the potential impact and the resources needed being many fold larger. Global epidemics such as AIDS and its related illnesses also demand a response that far outstretches medicine’s research capacity [9]. The same dilemma is magnified in the case of preparedness for a bioterror or other rapidly spread epidemic that demands massive, rapid-response capacity. So, for instance, when an anthrax scare occurred, controversy emerged over breaking the Bayer Company’s patent on its antibacterial medication Ciprofloxacin[10], pharmacies experienced a ‘run on the bank’ as many people lined up to get a supply of the drug, and health delivery sites were temporarily helpless without vaccination policies or emergency supplies. Strategies to stem the AIDS epidemic, to harness the genetic and nano-technology revolution to good use, and to respond to bioterror require new modulations of medicine’s relationship with the private sector.
The second challenge is in medicine’s relationship with the political sector, and this too has been marked by periodic failure as well as suitable regulation. A few examples illustrate the depth and complexity of the relationship. The medical lobby has, in its time, been among the most powerful interest groups in Washington; professionals populate the federal government’s Food and Drug Administration, an agency originally spawned by the profession’s American Medical Association [11]; the professions’ service delivery operates in close relationship to Medicare and Medicaid policy; much of medical research conducted by academic medical centers and much of its infrastructure is funded through the US government’s National Institutes of Health. The tensions of this deep relationship reach higher orders of magnitude in times of political crisis, when it may appear legitimate to subjugate professional to political purposes and professionals may bow to the pressure. Indeed, repression of professionals or misuse by professionals of their skills has historically been a harbinger of war or other social crises. Examples come readily from the USSR, apartheid South Africa, Nazi Germany, and more recently from Al-Qaeda [12–15]. Current concerns over bioterror present the prospect that medicine’s technical skills might be misappropriated for destructive purposes. Professionals (including scientists) may be as intimately involved in preparing to defend against bioterror as in any historical war efforts [16]. We may be included in strategic planning; bioterror defense research inevitably involves professionals [17]. How will these professionals be held to requirements that protect against misuse of their ideas or findings? These and related challenges will require a sustained professionalism that is not only technically expert but also has the moral integrity that can help ensure medicine’s use for human health.
As the medical profession takes on these new challenges of added dimensions to its relationships with commercial and political entities, it is essential to know, not only our own but also the values and pertinent regulatory mechanisms of the groups of the commercial and political sectors with whom we interact. Some of the most promising approaches to the AIDS epidemic are alliances between professional, commercial, and political groups. One example may be the alliance that started with support from the Bill and Melinda Gates Foundation, a foundation started using Microsoft earnings. The alliance involves medical groups including the Harvard AIDS Institute, companies including Merck, Boehringer-Ingelheim, and Unilever PLC, and political groups including the Botswanan government and the United Nations [18]. On the other hand, powerful orchestrations that use all three sectors of society also underlie controversial efforts, such as Monsanto’s, to overpower the environmentalist lobby against genetically modified food products. Egregious periods in history, such as Nazi rule, also combined alliances from all three sectors of society. It therefore behooves all three sectors to articulate their own essential values and pertinent regulatory codes in ways that can be understood and used by all parties to avoid compromising the legitimate values of any party.
The values of the commercial sector are undergoing a paradigm shift. This sector’s wealth and impact has brought a new focus on corporations’ obligations to society, including to health and health care. Many activists and some corporations are promoting social accounting and even annual reporting of such [19]. Some are taking action. For instance, the Coca Cola Company appears to have reflected on its capacity to achieve beverage sales in remote areas of Africa and other regions where people live in poverty. The MTV Company appears to have reflected on the capacity of its television program ‘Staying Alive 2’ to bring safe sexual practice messages to 326 million homes in 139 countries. Observing that public health efforts to bring about widely disseminated, helpful AIDS policies have had far too little success, it appears that these companies have acted on a felt obligation to help [20,21]. But how should corporations engage in such expensive activities when their fiduciary obligation is to the stockholder? The shifting paradigm in the commercial sector’s values recognizes an obligation to the stakeholder (any group impacted by the company) as well as the stockholder, and that this may involve regular reporting of what good has been done for the stakeholder or any citizen group [22,23]. But additional questions remain. How far does the obligation to the stakeholder or any citizen group extend? Does it vary depending on the core skills or resources that the corporation has? Should the activities be done as part of the corporation or should foundations be set up for the purpose? To make effective alliances, the medical profession as well as the corporate leadership must understand these issues more fully.
Similarly, the values of the political sector need to be understood. They vary by country and type of governance. Some political mandates may clash with professional mandates, and when this occurs, professionals must engage the political sector in a healthy debate. If, for instance, a government is pursuing activities with professionals under conditions of secrecy that defense or privacy regulations afford but those activities go against the health profession’s mandate, or if a political leader fosters or fails to act to stem an epidemic because of a political perception that poverty is the root cause, the public must be able to rely on the profession to address the issue with the government [4]. In doing so, the profession must also be able to understand and respect the legitimate political values of the government or leader to represent various constituencies and balance conflicting social needs. Only with mutual respect for each sectors’ differing, legitimate purposes can the balanced relationship that makes for synergistic partnerships be achieved.
Medicine cannot fulfill its obligations without having relationships with the commercial and political sectors. Today, fulfilling these obligations is both difficult and pressing and new relationships are springing up as a result. But the risk to the integrity of professional purpose is significant. Moral reiterations of professionalism and related analyses of accountability are essential [24–26]. But they are not enough. We need to: engage in discerning types of desirable and undesirable relationships under conditions of today’s new challenges; engage in discussion with the two sectors on matters of ethics so that each party can maximize the chance of preserving the integrity of all and keep the balance society needs; and engage in active, practical partnerships that allow the power and speed that is needed to meet the challenges of the AIDS era, the genetic and nano-technical medicine era, the electronic era, and the era of protection against bioterror—all at once.
We wish to thank Martha Jacobs for her assistance. We wish to acknowledge the extensive work of Greg Hughes and Sonali Rammahon that inspired and substantiated many of the points in this article.
REFERENCES
- Orr RD, Pang N, Pellegrino ED, Siegler M. Use of the Hippocratic Oath: a review of twentieth century practice and a content analysis of oaths administered in medical schools in the U.S. and Canada in 1993. J Clin Ethics 1997; 8: 377–388.[ISI][Medline]
- Declaration of Professional Responsibility: medicine’s social contract with humanity. Adopted by the House of Delegates of the American Medical Association, December 4th 2001. www.ama-assn.org or AMA, Chicago, IL.
- Brennan T, Medical Professionalism Project. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002; 136: 243–246.
[Free Full Text] - Wynia MK, Latham SR, Kao AC, Berg JW, Emanuel LL. Medical professionalism in society. N Engl J Med 1999; 341: 1612–1616.
[Free Full Text] - ‘Leasing logo hurts consumers’. USA Today, August 6, 1998. p. 12A.
- Thompson DF. Understanding financial conflict of interest. N Engl J Med 1993; 329: 573–576.
[Free Full Text] - Emanuel E, Steiner D. Institutional Conflict of Interest. N Engl J Med 1995; 332: 262–267.
[Free Full Text] - American Medical Association. Report on Association–Corporate Relationships. Chicago, IL, 1995.
- UNAIDS Report on the global AIDS epidemic. June 2000. www.unaids.org/epidemicupdate/report/ Accessed July 13 2002.
- Harmon A, Pear R. Canada overrides patent for Cipro to treat anthrax. The New York Times, Business Section. October 19 2001.
- Baker R, Emanuel LL. The efficacy of professional ethics: the AMA code of ethics in historical and current perspective. Hastings Center Report 2000; 30: S13–S17.
- Alexander L. Medical science under the dictatorship. N Engl J Med 1949; 241: 39–47.[Medline]
- Grodin M, Annas G. Legacies of Nuremberg. Medical ethics and human rights. J Am Med Assoc 1996; 276: 1682–1683.[ISI][Medline]
- Sidley P. Doctors contributed to poor health of black South Africans. Br Med J 1998; 317: 1269.
[Free Full Text] - http://abcnews.go.com/sections/wnt/WorldNewsTonight/WTCzawahiri0101002.html Accessed September 29 2001.
- Perutz MF. The Threat of Biological Weapons. Review of Biohazard: The Chilling Story of the Largest Covert Biological Weapons Program in the World. Told from the Inside by the man who ran it, by Ken Alibek and Stephen Handelman, NY Review of Books, April 13 2000.
- Pollack A. Scientists create a live polio virus. The New York Times. July 12 2002.
- Hughs G, Rammohan S. The Botswana Comprehensive HIV/AIDS Partnership: a case study. Available on request from The Ford Center on Corporate Citizenship.
- Corporate citizens in a changing world. May 29 2002. http://www2.exxonmobil.com/Corporate/Newsroom/Publications/ccc02/index.html Accessed July 13 2002.
- http://www.unaids.org/whatsnew/press/eng/pressarc01/CocaCola200601.html Accessed July 11 2002.
- MTV Press Release ‘MTV Unveils Global Multimedia Commitment to HIV & AIDS Awareness on World AIDS Day, 1st December 2001.’ November 26 2001.
- Spencer EM, Mills AE, Rorty MV, Werhane PH. Organization Ethics in Health Care. Oxford, 2000.
- Commission of the European Communities. Concerning corporate social responsibility: a business contribution to sustainable development. COM (2002) 347 final. Brussels, July 2 2002.
- Emanuel LL. A professional response to demands for accountability: practical recommendations regarding ethical aspects of patient care. Ann Intern Med 1996; 124: 240–249.
[Abstract/Free Full Text] - Cruess RL, Cruess SR, Johnston SE. Professionalism—an ideal to be pursued. Lancet 2000; 365: 156–159.
- Freidson E. Professionalism: the third logic. Chicago, IL: University of Chicago Press, 2001.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||