Some thoughts about contemporary ethics in medicine
here is an increased discussion of ethics in our societies which coincides with a growing controversy of ethics in medicine. For a long time any debate of ethics was considered a reactionary topic in which people with progressive views would not engage — and everybody wanted to appear progressive. This has changed.
Recently even the German newsmagazine "Der Spiegel" published a special issue entitled "Volk ohne Moral - People without Morality" branding the Germans as immoral and unethical.
However, the decline of values is not restricted to the German society. The Swiss and the French, the Italians and the British — Europe at large and the rest of world seem to respect less and less basic virtues necessary for people to live together in a peacefully balanced social order. This decline of values has also spread into medicine and radiology. The entertainment and consumption culture are slowly taking over public spirit and sense of responsibility. A life-style of arbitrary and random attitudes towards one’s own and other people’s behavior has developed which euphemistically is described as tolerant and liberal.
The stultification and mental debilitation of the population by television, gutter newspapers, tabloids, combined with poor education, hinder reflection and lead to trivializing tendencies and habit-forming effects which should have been overcome a long time ago according to popular political opinion. In the meantime everybody takes what they want. What seems uncomfortable or what seems not to be interesting is avoided.
The churches as a shrine of moral and ethics — if they ever have been such a shrine — have also lost their importance. When life is good without major problems they always lose their influence. People are sure that, if there are problems, the doctor/lawyer/state will fix them. There is a permanent tenor in some European countries: "The state is responsible."
However, who is the state? A welfare institution we subscribe to? Or an institution we are members of? Hardly anybody seems to remember public moral.
These were its maxims: "Do not do anything to somebody you do not want to happen to you — this is the principle of all virtue and all duties of the human being towards society" (Frederic II of Prussia, describing his ideas of the Prussian state), and “Un prince est le premier serviteur et le premier magistrat de l’Etat” (Frederic II of Prussia: Œuvres. 1, 123; 1751).
The ethics of western medicine have their origin in the Hippocratic oath, a code of conduct which has guided the practice of medicine for more than two millennia (see Appendix). How do these guidelines fit into our medical environment which has more or less become value-neutral? Most of the factors applicable for medicine in general also apply for radiology. In the welfare states some of them differ from countries with a pure capitalist health system.
Honor your teacher ...
Hippocrates begins his oath talking about the bond between mentor and disciple in medicine. This touches human relations between, for instance, radiologists. Who is aware of any account of teachers in radiology complaining about young colleagues not being thankful for what they have learned — that is, if they were good teachers?
... if your teacher respects you.
On the other hand, it is no secret (but a taboo topic) that life in radiological departments can be hell. Bullying is common and, in some countries, believed part of life during the training and education of young radiologists.
Some heads run their departments like small feudal states and spread terror and exploit their employees. Incredible stories about the treatment of young radiologists by their superiors are legion.
There is the recent story of two radiology residents who could not stand the terror of their boss any more. They quit their job. Not only were they told by their boss that their scientific results of the last years were his to keep. He would also see to it that they would never again get a position at a university or at a hospital department in that country. The boss' wife told her children not to play with the children of one of the radiologists in the kindergarten and did not greet or even notice any more the wife of the other one when meeting her in the supermarket.
One can hear such stories over and over again. Usually young radiologists do not dare to quit their job and speak up. Often they are psychologically broken and left with a deformed character. To be at someone's mercy is terrible; fortunately, most leaders of radiological departments are people of rectitude, able to handle their staff without abusing them. Still, there seems to be a minority of morally deviated people among radiologists having fun abusing their power and responsibility.
Determination to defend one's convictions is not a general trademark in our societies. One admires those few who stand up and state: "But not with me!", also, and in particular, among radiologists. However, this in many cases is the end of a career.
One sometimes wonders about the selection of leaders — in radiology and elsewhere. No doubt that many of them are excellent, but some of them reach the top and stay there when they rather should have been removed from their office at an early stage. When they are young you can talk to them and they seem reasonable — but while climbing up the ladder of power and — limited — fame they lose their ability to perceive how they behave to others and what they are doing. They believe that they are demigods and act accordingly. Because they have no integrity — which is known to everybody in their vicinity — they lose their respectability. Their domination is only kept up by intimidation, connections to same-level colleagues, and unscrupulous collaboration with commercial partners and politicians.
Usually narrations about these aberrations stay within the radiological community, but major scandals are blown up in the media: medical scientists fake results; physicians' reports are bought by companies; professors of radiology earn € 10m per year with state-financed equipment and staff.
The faith of people in the integrity of politicians, trade unionists, journalists, lawyers, and, last but not least, physicians has deteriorated during the last decades. Indifference, lack of direction, greed, lust for power in their small world leads to unethical excesses which are not penalized because of the general decay of ethical values.
Payment or compensation
Radiologists, as all physicians, are the stewards of their knowledge. As such, they have the moral obligation to introduce and educate others. They also have a moral obligation to help with their knowledge people who cannot afford their regular fees.
Of course, this holds mainly for countries such as the United States or regions of the world without a functioning public health and welfare system. However, even in western and central European and certain countries in Australasia, providing care to the poor and vulnerable should be part of our moral obligation, because in some cases the social network does not function properly. Certain groups of the population are marginalized, among them the elderly, the mentally ill, the chronically ill, the handicapped, and the uninsured.
It is unethical that, e.g. in the United States, emergency diagnosis and treatment is only provided after money has been put on the table of the emergency room. Yet, in most cases this situation is not to be blamed on the physician but on the health system as such. No doubt that enough income must be created to guarantee the livelihood of the doctor, the medical personnel, and the infrastructure of hospitals. Similar extreme situations you find anywhere between Tirana and Novosibirsk — the lack of basic equipment and accessories makes it extremely difficult to provide basic medical necessities although trained medical doctors are at hand.
The payment of a medical service is always a problem that has been solved by putting up certain fees for certain services. This is the way how a professional should be compensated. Salaried physicians are a development of the last century which advanced hand-in-hand with social progress and health for all. Often salaries are not fair for the effort put in.
In some countries one finds a combination between salaried and private practice radiologists in the same position. One patient is treated by the state-employed radiologist, the next one as a "private" patient by the same radiologist with the same equipment and personnel. This leads to a situation where the head of a department earns a hundred times more than a resident (and often the residents do the work and the tax payer foods the expenses). This is ethical as long as everybody involved gets their adequate share of the profit.
The same holds for private offices: there should be an eventual equality of all radiologists in a group. It is also not ethical to refer a patient to an imaging center in which the referring physician (or even radiologist) has a financial interest. As always in life, there are exceptions, for instance if the examination cannot be performed elsewhere.
In these times of cost containment we have reached some completely opposite evolutions from those considered in earlier discussions: there might be financial advantages for the physician not to diagnose, treat or continue treating the patient. This is worse than diagnosing or treating a patient just to get the fee. No radiologist should be placed in the position of bedside rationing based on the patient's age, financial status, or terminal illness. No patient should be able to acquire organs for transplantation because of his or her financial abilities or connections.
However, decision-making often turns on political and economical not ethical grounds. A typical example is by-passing waiting list. These lists are a sad and immoral by-product of state-run medicine. They are the cause of suffering and deaths of patients. What is worse is the ways people jump the line. With money you can get into most MR, CT, or PET scanners instantaneously without a three-months wait. When you are a politician and you or some member of your family get sick, you make one telephone call and things will be arranged, even if you are the responsible for the misery of the waiting lists. This is were equality and democracy end.
The decay of authority
The British National Health System can be used as a leading example of how medical ethics were corrupted within the last half of the century.
The idea of a welfare system and access to health care for everybody is morally positive. The way of its implementation, however, was against human nature and, as such, prone to fail. In the early years of the NHS, in the 1950s, medicine was considered a profession and most doctors at that time worked with this perception in mind. They had authority based solely upon their professional status and most of them behaved according to this status and its moral standards.
Over the years this changed. Doctors were made into salary receivers and trade union members. Part of their responsibilities was taken from them, step by step; first they lost their administrative, then part of their medical authority. There was hardly any fight against this development. Finally they became wage slaves of the health administration, without their own will and without any power against nurses and administrators (one should not generalize and paint in only black and white without any hues in between — but the general picture looks like this).
A doctor used to be a pillar of society and of medicine. The NHS and other welfare systems undermined this authority. This sounds awkward and old-fashioned. Isn't it good that the ancient high-and-mighty physicians have disappeared and the hierarchy has been replaced by a democratic system? Isn't this a more ethical arrangement?
We have just seen that the little dictators survive and flourish in any system. The majority, however, has lost their high standing. Because their responsibility has been limited their sense of responsibility diminishes. This has a straight and negative impact upon patients. Of course, this kind of responsibility cannot be replaced by a newly created administrative office. One can observe this decline in authority all over: in the relation between parents and children, superiors and employees, radiologists and technicians. No doubt that authority is used and abused, but it also gives protection. There is a reference person, there is an example.
Medicine, in particular equipment-based medicine such as radiology, has to make business sense. Not only in purely capitalistic (U.S.A.) or in social welfare health service systems (Germany, Switzerland) but also in state-run welfare systems (such as Great Britain, Scandinavia, New Zealand) radiologists are increasingly replaced by administrators.
Considering the bureaucratic workload of a physician, this can be advantageous. However, bureaucrats always increase bureaucracy. There are unlimited stories about them aggravating the life of others. But even worse, radiology administrators increasingly are turning to vendors for help in justifying and then providing the worth of technology acquisition. This is part of the perversion of medicine today. Hospitals and the medical system have been put upside down — administrators and bureaucracies govern physicians, nurses and technicians - and patients. The work of physicians has to pay for a multitude of administrators perpetuating office tasks as in any other sphere of contemporary societies.
During the last fifteen years ethical committees sprouted up like mushrooms at universities and medical schools. They were often composed of people with limited knowledge of the tasks and obligations of an ethical committee. Some believe common sense is all one needs to judge ethical questions.
Others are more pragmatic: "We invite only those people to join the committee of whom we know how they will decide ..." which is an attitude as unethical as it comes (this citation has not been invented).
Clinical studies require the approval of these committees which has had a sobering effect upon pharmaceutical companies — but only in some places. Elsewhere the show goes on under the guise of an ethical committee in which everybody has straightforward advantages of their own in their mind. "Conflict of interests? Why should I resign from the committee?"
One argument is that scientific development can and should not be hindered by moral questions or standards which do not fit in our modern times. Iceland has decided to sell the rights to the entire population's genetic code to Roche Holding Ltd., a move that most doctors and scientists in Iceland find quite unethical and unrealistic.
To end: it is very easy to talk about ethics when sitting in an ivory tower. However, one must never forget: "First comes fodder, then the morality" (Berthold Brecht: Die Dreigroschenoper / The three pennies opera, II, finale). It is very difficult to judge the moral aspects of a person. This does not mean that ethical aspects of medicine cannot be put up for discussion. Someone has proposed that together with obligatory continuing education, there should be an obligatory ethical oath — possibly in a modern form that echoes the original's content and intent (see Appendix).
There are numerous other issues in radiological ethics, for instance, is it unethical that the average radiologist does not see or talk to the patient? What about teleradiology? Do we do enough to preserve the patient's dignity in an x-ray department? Or, how ethical is a medicine depending on heavy-equipment? To answer these questions one would have to write a book.
American College of Radiology (ACR). Code of Ethics. www.acr.org
Gunderman RB: Why is ethics needed in the radiology curriculum? Acad Radiol 2001; 8: 82-85
Ohrt HJ: Radiology and Ethics: An Oxymoron? Acad Radiol 1996: 3: 887.
Pellegrino ED. Managed Care at the Bedside; how do we Look in the Moral Mirror. Kennedy Institute of Ethics Journal. 1997; 7: 321-330.
Proval C: Exploring the Ethical Dilemmas in Radiology. Imaging Economics, July/August 1998; 60-67.
Ruff C, O'Connor D: Ethics of Change in a Changing Field: Resident Perspective. Acad Radiol 1998; 5: 119.