Moral Side of Medicine
An Ethical Tongue
by John David Kolter, MD
In 1964, Richard Thomas Barton, MD, delivered an address on“ medical morals” to the incoming freshman class at the UCLA School of Medicine. 1 His remarks, delivered during a period of immense social change and reprinted in a 1965 edition of JAMA, stated his intent to“ show the thinking behind today’ s moral issues” rather than“ go through a long list of rights and wrongs.” While his remarks did review the origins of ethical codes and the influence of several ethical theories, Dr. Barton attempted what any ceremonial speaker in academia worthy of his salt should attempt: deliver fertile fodder about which an audience could contemplate. In our current post-COVID-19 period of social change, controversial and political topics can seep into patient interactions, at times presented without regard to verifiable facts. Further, these seemingly inevitable patient interactions can be personally triggering and, however inadvertent, place physicians in difficult conversations. Physicians who work directly with patients( and other practitioners of medicine, for that matter) would be both without reproach in giving pause to consider how to ethically proceed in these conversations and also, may still today, take interest in Dr. Barton’ s remarks. What remains an unavoidable fact is that no physician, especially a primary care physician intent on developing longitudinal relationships with patients, will be able to avoid these fraught conversations or their attendant ethical quandaries.
Patient autonomy is implicit in defining the exam room as a democratic institution. In the last century a shift from the beneficence model to the autonomy model, governed by the informed consent doctrine, has permitted patients to make intelligent choices regarding treatment. 2 While patient autonomy may ultimately yield a one vote system, where the patient’ s vote is the one that ultimately stands, the notion is anything but autocratic. The oft utilized analogy, the patient as Chairman of the Board informed by physicians serving as Members of the Board, conveys well this pragmatic democracy of the exam room. In this analogy, physicians occupy a place of importance for the patient as a source of counsel and knowledge. More broadly, as Dr. Barton noted, medical practitioners have occupied a place of prominence in society from early recorded human history starting with the physician-priest healers versed in“ folklore and superstition.” As medicine over time was“ more influenced by the scientific method,” modern physicians, as we know them, evolved as non-theologians. Nevertheless, in this construct, where discussion should be primarily in service to the cause of the Chairman’ s best interest, what is a physician to do when the conversation drifts, however inadvertently or sharply, to the political or controversial?
12 LOUISVILLE MEDICINE