This paper examines whether physicians have a special responsibility to not only treat their patients, but also to seek to alter the conditions that are creating ill-health among the populations they serve. Despite positive support for a widened and idealistic view of physician accountability, it is tractable to critique, poorly defined, and comes with unique bioethical implications. Upon closer look, “greater physician accountability” might not be feasible in practice if we negotiate idealism with pragmatism. It is ineffectual if it perpetuates a mere cognitive understanding rather than substantive action, and leads to unintended, sometimes dangerous, consequences that violate the ethical principle of non-maleficence. This paper argues why it is not yet justifiable to expect physicians to act upon this call for increased accountability, particularly by examining the current medical education system that trains physicians and the complex structural and social levels onto which this accountability plays out. Re-conceptualization toward a more collaborative approach among disciplines, health professionals, and institutions might prove to be more effective and sustainable in improving health care equity and outcomes.

With a push for “greater physician accountability” comes the expectation for physicians to not only treat their patients, but also to seek to alter the conditions that are creating ill-health among the population they are treating. In this view, physicians hold a special and unique responsibility within the social justice system to address local and global health issues, especially as they pertain to the underserved and destitute sick. Although seemingly beneficent in its intent and outcomes, this broadened view of physician accountability is susceptible to critique. I argue that the current medical education system does not adequately train physicians to take on this accountability, and the many complex and interlacing levels at which this accountability comes into play makes its attribution more complicated than it may first appear. The idealism of what a doctor should do ought to be contrasted against the pragmatism of what a doctor can feasibly do.  As it stands, it is not justifiable to expect physicians to act upon this call for greater physician responsibility, which has both limitations and bioethical implications seriously challenging its validity. In fact, an entirely re-strategized, collaborative approach might be the more compelling and feasible course of action toward promoting health care equity.

As an anthropologist and physician widely known for his humanitarian work providing health care to under-resourced areas in developing countries, Paul Farmer firmly believes that physicians, given their privilege, should be judged by a “special calculus of responsibility” (Farmer, 2005, p. 210). He is an advocate for targeting health care wherever the pathology lies heaviest– where “the patients are sicker and poorer, but what you do makes more of a difference” (Hopkins, Living in Emergency). This standpoint does indeed have merit – much can be accomplished by treating systemic roots of health problems rather than simply treating effects and leaving the causes untouched. As social justice becomes inserted into medical ethics discussions, I agree that improving health outcomes should account not only for cutting-edge biomedical technology, but also the social, political, and environmental determinants of health disparities (Turner, 2005, p. 377). In the context of Egypt, where water pollution contributes to the country’s growing burden of renal disease, this would mean advocating for cleaner water systems rather just pushing for more dialysis machines when the kidney failure manifests (Hamdy, 2008, p. 563). Nevertheless, it remains unclear whether “greater physician accountability” means targeting care for the suffering poor, attempting to address the underlying structural causes that contribute to their ill health, or both. As a term it remains abstract in that it has not been institutionally defined nor does it have set limits. This makes it less of a clear framework to act upon and more of a mere rhetorical understanding or discussion point.

Secondly, it is difficult to reconcile the various levels at which this responsibility comes into play. There is the structural level, where health inequities manifest as a result of built and social environments, and the individual level, where those forces become embodied as individual experiences of illness. It is not necessarily valid to require physicians, who typically treat patients at the individual level, to address illness-contributing forces that exist on an expansive, social level. Not to mention that to do so can be a paralyzing challenge for a single physician. Social workers, lawyers, policy makers in government and legislation, and public health leaders would add key interprofessional perspective. We need to recognize the value in a collaborative approach that holds multiple professions and health care institutions accountable, not just physicians.

Furthermore, physicians cannot be called out for lack of accountability without addressing the role, or lack thereof, their medical education plays in preparing them to tackle such issues of structural inequity. Frederic Hafferty and Ronald Franks, pioneering voices of professionalism in medicine who have extensively studied the structure of medical education, have found that traditional physician training models do not place emphasis on cultural competence or basic public health principles. In fact, they are historically structured to de-emphasize macro communities by using case studies and framing learning within the context of the doctor-patient relationship (Hafferty and Franks, 2004, p. 867). This can lead to a “blindness to the social”, where physicians and health institutions look purely at biological, clinical factors when presented with sick patients. Patients, however, are not merely bodies to be fixed when they are ailing, but unique human stories heavy with sociocultural meaning. Thus, a potential for cultural myopia or blindness in medical school graduates does not project well onto greater physician accountability to treat diverse and underserved populations. This begs the question – if physicians are schooled and disciplined to prioritize clinical case facts and high-tech interventions over broader public health measures and lower-tech medicine that might be more effective in treating underserved patients, is it justifiable to expect them to do otherwise? Unless the structure of medical education is changed to de-emphasize individualism and examine more interdependent sociological issues that contribute to health, physicians cannot be expected to act upon this call for greater accountability.

The idealism of what a doctor should do ought to be contrasted against the pragmatism of what a doctor can feasibly do. As it stands, it is not justifiable to expect physicians to act upon this call for greater physician responsibility, which has both limitations and bioethical implications seriously challenging its validity.

We must also be wary of unintended consequences. By broadening the responsibility we attribute to physicians, it can become easier for medicine to serve the dangerous purposes of political expediency, as in the apartheid state. In South Africa, physician accountability for marginalized black women at one point became distorted and used as an excuse to manipulate reproduction for state eugenic policy (De Gruchy & Baldwin-Ragaven, 2000, p. 312). This suggests the difficulty of drawing a line between “helping” an underserved patient and compromising that patient care for the purpose of a larger sociopolitical cause. We also cannot assume that physicians who account for sociopolitical factors in their provision of medical care will not exploit that responsibility. “The presumption that doctors and scientists would behave ethically reflects the hegemony of scientific positivism, and of rationalism more generally” (p. 324). In places like South Africa, where black female bodies have been historically disrespected, it has been difficult for health professionals to take on women-centered practice styles and redress power imbalances.

Similarly, the case of the Israeli Open Clinic is an example of how a humanitarian aid organization involving physicians can become a placeholder for a state lacking in a comprehensive or functioning health care system (Gottlieb, 2012, p. 840). The physicians working in an “Open Clinic” run by an Israeli human rights organization, in the process of trying to give voice to marginalized population needs, obstructed medical treatment by becoming politically involved. By operating the clinic, physicians entered a relationship with patient communities that could not be easily withdrawn. Relieving the state of its responsibilities to address the healthcare needs of its underserved populations led physicians to become involved in roles that go beyond healing, such as humanitarian and legitimizing political advocate. Discrepancies in the health care delivered by the physicians to asylum seekers versus immigrants also raises critical issues of “deservingness” in discourse about accountability (p. 844). Yes, physicians should ideally target their care to those most in need, but what counts as need? Despite the good intentions of their humanitarian work, physicians found that they took on too much to handle with the frustrations of low-grade medicine and lack of governmental support, and in turn the quality of the medical care suffered. Acting on this principle of “greater physician accountability” becomes unethical if it compromises the medical treatment of individual patients.

Ironically, it is highly educated experts and health professionals who are having these discussions, rather than the actual populations that would be impacted most by broadened physician accountability. Without placing rhetoric of “greater physician responsibility” in the context of power imbalance, the phrase alienates the target populations by not giving them a voice in this matter. This somewhat narrow frame of an ideal physician with both privilege and increased responsibility hides other important questions. Is it currently feasible for physicians to be advocates both inside of health institutions (offices, clinics, hospitals, etc.) and outside of them (local and global community networks)? What does the physician sacrifice personally and professionally if their practice shifts to target the “neediest” patients? Should physicians who practice in high-need areas be receiving higher monetary reimbursement, and should other physicians be incentivized to do the same? These are the kinds of questions that need to be asked when considering the validity and feasibility of “greater physician accountability”.

This is not to say that there is not a rightful calling for a socializing of medical ethics and a time for physicians to prioritize care for destitute sick and underserved populations. Even though there is no “prescription”, so to speak, for poverty, violence, unemployment, environmental racism, etc., there is still potential for physician action to permeate the streets where the connection between structural disparity and ill health develops. The important question, however, is whether practice can and will keep up with rhetoric. Speaking of accountability in idealistic terms is both hopeful and necessary to provoke discussion and jumpstart change, but it is limiting if it perpetuates a mere cognitive understanding rather than substantive action. As it stands, physicians cannot be expected to act upon the principle of “greater physician accountability”, a term which remains obscure and comes with serious ethical implications. Moving forward, it should be re-conceptualized and re-strategized as a more collaborative approach toward establishing sustainable links between marginalized populations, health care institutions, and socioeconomic support systems.

 

References:

De Gruchy, Jeanelle, Baldwin-Ragaven, Laurel. “Serving Nationalist Ideologies: Health Professionals and the Violation of Women’s Rights: The Case of Apartheid South Africa,” in Globalizing Feminist Bioethics, Rosemarie Tong, ed. Boulder, CO: Westview Press (2000): 312-333.

Farmer, Paul. “New Malaise: Medical Ethics and Social Rights in the Global Era,” in Pathologies of Power: Health, Human Rights, and the New war on the Poor. Berkeley: University of California Press (2005): 196-212. Print.

Gottlieb, Nora, Dani Filc, and Nadav Davidovitch. “Medical Humanitarianism, Human Rights and Political Advocacy: The Case of the Israeli Open Clinic.” Social Science & Medicine 74.6 (2012): 839-45. Web.

Hafferty, Frederic. W., and Ronald Franks. “The Hidden Curriculum, Ethics Teaching, and the Structure of Medical Education.” Academic Medicine 69.11 (1994): 861-71. Web.

Hamdy, Sherine F. “When the State and Your Kidneys Fail: Political Etiologies in an Egyptian Dialysis Ward.” American Ethnologist 35.4 (2008): 553-69. Web.

Living in Emergency. Dir. Mark N. Hopkins. Prod. Mark N. Hopkins, Naisola Grimwood, Daniel Holton-Roth. Perfs. Chris Brasher, Davinder Gill, Tom Krueger, Chiara Lepora. Bev Pictures, 2008.

Turner, Leigh. “Bioethics, Social Class, and the Sociological Imagination.” Cambridge Q. Healthcare Ethics Cambridge Quarterly of Healthcare Ethics 14.04 (2005). Web.

 

*Note: At several points throughout this paper, I am indebted to lectures given by Professor Rachel Prentice at Cornell University (January-May 2015) in a course entitled “Ethical Issues in Health and Medicine”.