Unsung questions of medical ethics

Sot. Sri. Med. Vol. 21. No. 3. pp. 243-249. 1985 Prmred in Great Britain. All rights reserved

0277.9536/85 $3.00 + 0.00 Copyright ‘c 19X5 Pergamon Press Lid

UNSUNG QUESTIONS OF MEDICAL ETHICS

DAVID BARNARD

Institute for the Medical Humanities. The University of Texas Medical Branch. Galveston, TX 77550. U.S.A

Abstract-Official doctrines of medical ethics have become increasingly ‘patient-centered’: physicians are exhorted to respect patients’ autonomy and to encourage patient participation in decision making; physicians in general medicine and primary care, especially, are urged to develop psychosocial competence. cross-cultural sensitivity and communications skills. These official values are undermined and con- tradicted. however, by the routines and assumptions that physicians use to organize their everday work. These routines are taken so for granted as natural and required for the smooth, orderly practice of medicine that they escape evaluation for the implicit values they contain. Yet. they reinforce a particular view of appropriate roles and responsibilities for both physician and patient in the medical system, including the agenda and purpose of the medical interview; the level and amount of information to share with patients; and the power structure of the physician-patient relationship. These values, hidden in the routines of daily practice, are unsung questions of medical ethics. A fallacy in calls for greater patient participation in medical care is that this participation can flourish by simple addition, without reform of the ordinary structures of everyday practice. It is unlikely that these structures will change unless their normallv invisible value commitments are drawn out of the obscurity of routine. and made subjects for public scrutiny and choice.

INTRODUCTION

Despite growing attention to ethics in medicine, several aspects of ordinary medical practice raise value questions that are easily overlooked. Many of these are captured in Balint’s description of the physician’s ‘apostolic function’. Every doctor, according to Balint, “has a vague, but almost un- shakably firm, idea of how a patient ought to behave when ill. . . . It was almost as if every doctor had revealed knowledge of what was right and what was wrong for patients to expect and to endure, and further, as if he had a sacred duty to convert to his faith all the ignorant and unbelieving among his patients” [I]. Among the ‘articles of faith’ to which patients must be converted, Balint mentions the amount of discomfort to be tolerated by a mature adult, the amount of dependency to expect in the treatment relationship, the amount of gratitude to express for professional effort, the relative openness or resistance to psychological exploration, and the frequency with which the physician may be consulted.

Sociologists and anthropologists understand ‘the apostolic function’ in the context of the medical encounter as a social event. As such, the encounter is structured by rules and rituals which reflect and maintain a culture’s norms for social roles and interpersonal relations [2]. In the medical setting these rules and rituals range from the broad question of who gets to see the doctor and when. to the minute details of who speaks when. who interrupts whom, and who brings the consultation to a close. Rules and rituals help medical professionals routinize and carry out their daily activities. Freidson calls these aspects of the encounter ‘occupational usages’ [3]. They are dictated more by tradition and professionals’ con- venience than by medicine’s specialized technical and scientific knowledge.

Taylor has described how occupational usages in the hospital make patients feel helplessly irrelevant to

their own care [4]. She argues that procedures de- signed to insure smooth staff routines rob patients of identity and autonomy-with physiological as well as psychological effects. I will focus on, the occupational usages of general medicine and primary care. Exam- ining some of what is known about how physicians manage the routines of their everyday work will yield underlying value commitments concerning the boundaries of medical responsibility, the power structure of physician-patient relationships, and the physician’s role as gatekeeper in the allocation of medical resources.

The implicit value commitments embedded in medicine’s occupational usages are unsung questions of medical ethics. They are unsung questions of ethics precisely because of their nature as self-evident givens of orderly practice. They are unsung questions of ethics because these unarticulated, invisible commitments express powerful views of the appropriate relationship and mutual responsibilities of physician and patient. In this sense, occupational usages in medicine have the qualities Goffman attributes to ‘ceremonies’, the function of which “reaches in two directions, the affirmation of basic social arrange- ments and the presentation of ultimate doctrines about man and the world” [5]. In the medical setting, occupational usages function not only as ‘rules of practice’ [6]-necessary forms for playing a game- but also as statements of the overall purpose of the game, and who may play.

Professionals take occupational usages for granted as mere routine. They are seen, if brought into awareness at all, as neither more nor less necessary for the smooth, rational practice of medicine than are appropriate office furniture, instruments for physical examination, or an appointment secretary. They are taken for granted, in other words. in the same sense as the ‘chain of self-evidencies’ that constitute the ‘natural attitude’ toward the everyday life-world, analyzed phenomenologically by Alfred Schutz and

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244 DAVID BARNARD

Thomas Luckmann [7]. Perceived as simple. un- problematic givens of experience, these elements of the life-world are assumed to be the fixed precon- ditions for action. rather than occasions for choice. The taken-for-granted character of occupational usages thus precludes their scrutiny for implicit value commitments about right and proper conduct for both physician and patient, or their negotiation in cases where particular patients are not well served by the reigning occupational usages of a particular clinical setting.

I intend to draw connections between occupational usages and questions of medical ethics at two levels. First, occupational usages in medicine flow from assumptions about patients, disease. and the work of doctoring that are themselves value-laden and con- troversial. Many patients are well served by these assumptions and the physician behaviors that flow from them. This does not apply to all patients, however, and largely for this reason there has been a widening endorsement of physician-patient negotiation and mutual participation as norms for medical practice [S-l I]. Rather than imputing to patients an a priori acceptance of medicine’s values and expla- natory frameworks, a negotiation model encourages the sharing and sometimes mutual adjustment of perspectives, to increase self-determination and per- sonalized care. Here is the second level of my argu- ment. I will suggest that even for physicians who espouse the principle of negotiation, dominant occupational usages constitute a set of behaviors that actually undercut the possibility for genuine negotiation with patients. Implementation of the principle will thus require greater self-consciousness about the routine habits of day-to-day medical work.

ASSUMPTIONS ABOUT PATIENTS, DISEASE AND THE DOCTOR’S JOB

Many of the rules for physician-patient encounters derive from notions of the ‘sick role’, classically formulated by Parsons [12]. Patients are taken to suffer deviance or dysfunction that has arisen beyond their control, and to deserve exemption from normal responsibilities. In exchange, they are expected to desire to get well and to cooperate with professional authority. Physicians who operate within this frame- work adopt what Alexander calls a ‘curative premise’ [13]. They assume that patients consult them for removal of pain and underlying physical disease. The curative premise, in turn, supports further assumptions that the physician’s optimal approach to patients and their distress is materialistic, activist. and benevolently authoritarian.

Muteriulism

Engel [14] and Reiser [15] have cogently discussed the ascendancy of materialistic physico-chemical con- ceptions of disease in medical practice, combining their analyses of the limitations of the “biomedical model” with celebrations of its splendid accom- plishments. Under the influence of this materialistic stance, the doctor’s job has increasingly been seen as the task of sifting through patients’ complicated social, psychological, and somatic narratives in search of treatable organic pathology. This view ol

the ‘patient as syndrome’ causes the doctor to see through the personal values and associations that patients attach to their distress. to the presumably underlying physical causes. Personal and social history are solicited only to the extent that they shed light on the likelihood or nature of organic disease [l6. 171.

Acticism

As professionals dedicated to applying theoretical knowledge to solve concrete problems. physicians are predisposed to active intervention rather than tempo- rizing or contemplation [3]. This stance is augmented not only by fee-for-service reimbursement. but by important themes in modern Western culture. including the notion that the mastery of nature through technology is not only legitimate, but is a moral imperative [18]. When these predispositions enter the physician-patient relationship. they detract attention from such activities as conversation. emotional support and education, in favor of direct examination and manipulation of the body, laboratory testing and prescribing medications.

Benevolent authoriturianism

According to the Parsonian paradigm. patients cannot cure themselves, and must place themselves under the authority and judgment of the professional expert. Failure to do so may be taken as non- conformity with the socially sanctioned sick role, and lead to society’s withdrawing the privileges of exemption from blame and normal role responsibilities. The role of physician has historically included the responsibility to make judgments of what is in the patient’s best interests and to act accordingly, without the expectation that patients will participate in the physician’s.decision. Katz [8] has recently docu- mented the history of medical authoritarianism, and specifically the absence of concern for patients’ informed participation and consent as these principles have been developed in recent years. He further argues that despite these recent, theoretical devel- opments. information control and substituted judgments by physicians for their patients continue to characterize medical practice. Patients have been consistently viewed as incapable or unwilling to take major responsibility for their medical treatment, either by virtue of the esoteric knowledge required, or the physical and emotional deficits imposed by the very illness that prompts them to seek help.

The materialistic, activist. benevolently authoritarian slant of the curative premise is reflected in empirical findings. Physicians overestimate the pro- portion of their patients who expect to receive a prescription [l9]. Ninety per cent of consultations in one study included either prescriptions or a physical examination. as opposed to l8”,, that included reassurance or explanation and 7”,, that included discussion of personal problems [20]. While 76”” of parents of chronically ill children expected psychosocial problems to be discussed by their physicians, this occurred only 25”,, of the time. Moreover, SO’,< of physical symptoms were noted in the medical record in this study. as opposed to 25”,, of the psychosocial issues discussed during the visits [21]. Of 34 competent adult patients survtving cardio-

Unsung questions of medical ethics 245

pulmonary resuscitation in a Boston teaching hospital, 8 stated they had not desired CPR and would not desire it again. Yet. only 1 of the 16 physicians caring for these patients knew their attitudes, and only IO”,, of the study physicians who believed patients should be consulted about CPR actually discussed the issue with their patients in advance. One physician com- mented, “Who wouldn’t want to be resuscitated?’ [22].

The assumptions embedded in the curative premise are most appropriate and elfective for patients experi- encing acute episodes of physical illness. for the complex crisis-medicine of tertiary care. and for the application of esoteric knowledge to a pre-screened and presumably. consenting patient in subspecialty medicine. (Though even in these contexts strong arguments can be made for respectful consideration of the patient’s perspective and self-determination.) These settings are quite different from the environment of general medicine and primary care. Here the curative premise is in tension with the increasing prevalence of chronic illness in an aging population. for whom cure is often irrelevant. with the phenom- enon of the ‘worried well’. who consult physicians more for reassurance and education than for treatment of existing disease, and with the needs of the terminally ill. These patients do not conform to the classical sick role and its clear directive for physician authority and activism. It is thus not surprising that patients with multiple chronic conditions (especially the elderly), the ‘worried well’ (often pejoratively labeled ‘crocks’ or ‘hypochondriacs’). and the dying turn up at the head of many physicians’ lists of least satisfying or most difficult patients [23.24].

Physicians in primary care face two forms of variability in their patients. First, more than their subspecialist colleagues. they are likely to encounter a range of motivations for their patients’ consultations, and of concurrent problems of living that bear on the decision to seek medical aid. It is thus less feasible immediately to assume the decisive relevance of the assumptions of the curative premise. Second, primary care physicians share with all physicians the variability in patients’ preferences for involvement in information exchange. shared decision-making or psychological exploration.

Faced with this variability, an important dimension of the primary care physician’s approach to patients is flexibility. At the very least. the rules and rituals that structure practice ought to encourage some early assessment of the assumptions that most appropriately govern each consultation. and permit the patient’s agenda and expectations to be clarified as soon and as fully as possible. Judgments can then be made of the appropriateness of the patient’s expectations. or their fit with the personality, competence. and institutional constraints of the physician. Negotiation can often preserve a therapeutic alliance in the face of initial differences.

In reality. the occupational usages that flow from the curative premise give rise to behaviors that often rigidly extend its assumptions to all physician-patient encounters, Physicians actively seek to mold their patients’ behavior and expectations. much as Balint describes the apostolic function. teaching them, in effect. how to he patients ,in the official medical

system. The medical interview-the face-to-face communication between physician and patient-is the primary teaching site for this endeavor.

COMMUNICATION PATTERNS IN THE MEDICAL INTERVIEW

Many factors influence the communication process in medical interviews: personality characteristics of physician and patient, situational and environmental factors, the content of medical education, unconscious psychodynamics and cultural rules for language use and interpersonal behavior [25, 261. It will be sufficient for present purposes to describe some salient patterns of behavior and see how they support particular value commitments. Two prime aspects of the interview are the process of setting and controlling the agenda, and providing information about illness.

Setting and controlling the agenda qf the medical intervien

Stimson and Webb have characterized physician-patient interactions as contests for mutual influence: each party tries to influence the other to pay attention to his or her own concerns and to act in accordance with his or her definition of the situation [27]. Physicians may assert their influence non- verbally and verbally. Non-verbally, through main- taining or breaking eye-contact, chart-reading or note-taking. initiation of direct physical examination, and similar behaviors, physicians may signal to the patient that a particular line of questioning or nar- ration should be continued or broken off 127,281. Verbally. physicians control the agenda by the line of questioning they pursue in assessing a patient’s complaint, by the types of action they recommend, or- more forcefully-by interrupting a patient to change the subject or seek clarification of a particular point. Physicians tend to interrupt patients twice as frequently as patients interrupt physicians (except, when the physician is a woman, male patients interrupt her twice as often as she interrupts them) 1291.

Physicians may choose to engage in ‘character work’-a term used by Strong and Davis to denote the physician’s inquiry into aspects of the patient’s lifestyle or values that may affect health [30]. Mothers in a pediatric clinic experienced character work when physicians asked about regularity of bathing or feed- ing schedules, diligence in bringing children for vacci- nations, and the like. Strong and Davis found a correlation between patients’ lower socioeconomic status and physicians’ tendency to adopt a ‘detective- suspect’ model of character work, which focused on apparent laxity or failure in the mother’s role performance. Hostility and defensiveness could sometimes result. as in this exchange:

“Doctor: Where do you live? Patient’s Mother: Don’t worry. I hve in a real nice part of town.”

Strong and Davis observed that patients could engage in character work toward their physicians. too.

246 DAVID BARNARD

However, while the patient was usually ‘on the spot’ and expected to reply to the physician’s satisfaction, physicians could avoid uncomfortable challenges by changing the subject, or moving to another, strictly technical area of inquiry.

Finally. physicians may control the length of the interview, signalling both non-verbally and verbally that a patient’s time with the doctor is up. Physicians appear to have a concept of how much time overall they are willing to see patients, and how much to spend with individual patients [31]. In the midst of conflicting and contradictory studies of the factors influencing length of consultations [32], one consistent finding is the decreasing time spent with patients over the age of 65, compared to younger patients [33]. This is despite the fact that these patients have more illnesses and require more complex drug regimens than younger patients. The finding holds for consul- tant visits as well as visits to primary care physicians, so it is unlikely to be explainable on the basis of greater familiarity (and presumably less time required for specific visits) in the primary care setting. One possible explanation put forth by the authors of the study is that physicians are rationing their time according to their assessment of the presence of conditions they can do something about: a form of triage, in other words, based on the curative premise and possibly aggravated by ageism.

What is the effect of this maneuvering on the content of the interview? Many physicians tend to accept at face value patients’ physical complaints as the primary motivation for the consultation, despite substantial evidence that visits to the doctor are frequently motivated by social and psychological factors, and that patients have many hidden agendas and requests [34, 351. Because a physical complaint is seen as most likely to legitimate a contact with the medical system, these latent requests and concerns may not surface in the absence of tactful questioning’ by the physician. Yet the evidence suggests that patients’ narratives of distress are selectively reinforced-through verbal and non-verbal, active and passive behavior-to concentrate on organic pathology. Brody reports that physicians failed to recognize 76”,, of their patients’ stressful life events, 34”,, of psychiatric disturbances and 79”,, of failures to comply with medical advice [36]. His data are corroborated by several other studies [2 I, 37-391. The ritual of the prescription as the signal that the consultation is at an end may simply reinforce the unique legitimacy of somatization at the expense of further awareness of hidden agendas [ 191.

The issue here is not that physicians will miss opportunities to provide psychotherapy (for which they may neither feel nor be qualified). Nor is it whether patients’ problems are ‘really’ psychological or ‘really’ physical (a fruitless and unnecessary di- chotomization). Rather, the question is whether physician behaviors, guided by the assumptions of the curative premise. create an atmosphere in which patients feel reluctant or powerless to define problems in their own terms, and in which patients’ ‘compli- ance‘ with the physician’s agenda masks their con- fusion about--or avoidance of-other equally press- ing needs. Communication patterns in the medical interview may pre-judge precisely those questions the

interview in primary care is supposed to answer: what sorts of problems do patients think they have? what expectations do they have of the help they will receive from the medical system? whose professional competence is most likely to serve the patient’s interests- as the patient defines them? Unless these questions are clarified, the principle of physician-patient negotiation can have little force. because there can be no assurance they are negotiating about issues of genuinely mutual importance.

Proriding i?zformation about illness

The principle of negotiation also presupposes well- informed parties. Yet, physicians underestimate both the level of medical knowledge and the desire for

information among their patients [40,41]. When they do provide information, it is often at a lower level of technicality and specificity than the level at which patients formulate their questions [42]. Physicians’ reluctance to provide information about illness has been ascribed to a desire to maintain control over patients by manipulating uncertainty, and to a benevolent desire to shield patients from bad news [26]. There is good evidence to suggest, however, that their practice results from misinterpretation of patients’ behavior and use of language, and from occupational usages that reinforce the dominance of the physician’s technical and scientific agenda in the consultation.

Physicians often assume that if patients desire information they will ask for it, interpreting patients’ silence or diffidence as a positive message that the patient does not desire information [2,22, 261. In fact. information exchange in the physician-patient relationship is inversely related to socioeconomic status. Lower class patients, when surveyed, report a desire for information equal to that of higher classes. Lower class patients, however, ask fewer questions than upper class patients, and tend to communicate using a ‘restricted code’ of language, which is less verbal and relies on implicit expressions of intent. Upper and middle class people-from whose ranks come the majority of physicians-tend to use an ‘elaborated code’, which is more verbal and relies on explicit expressions of intent. As a result, physicians tend to judge lower class patients to be less linguis- tically competent, when what they are observing is linguistic performance. Low linguistic competence is further interpreted to mean less desire for information as well as lower comprehension [26].

Women appear to be subject to a different type of misinterpretation. Women ask more direct questions of their physicians than men. but physicians rate men and women equal on the desire for information [42]. This suggests that physicians interpret many women’s questions as expressing something other than a desire for information, such as dependency or anxiety.

These problems are aggravated by the dis- proportionate use by lower class patients of emergency rooms and hospital outpatient clinics for primary care [43]. Lack of continuity and the splitting of tasks among several work stations make it harder for patients to develop the rapport or confidence necessary for thorough information exchange. For many patients. rigid appointment systems. long travel

Unsung questions of medical ethics

time. unavailability of child care and difficulty getting time off from work make attendance at outpatient clinics burdensome. These features of outpatient clinics contribute to a system of ‘informal rationing’ of health care according to a middle class. bureaucratic mode1 of efficiency and cost-effectiveness [41,44,45].

able and coherent professional norms rclatcd to the boundaries of medical responsibility. distribution of power in the physician-patient relationship, and allocation of resources.

Physician-patient negotiation and mutual participation imply a measure of symmetry in the medical encounter. Clearly not all situations in medicine call for or permit symmetry. Szasz and Hollender [46]. in a classic analysis of models of physician- patient relationships. suggest a sliding-scale of symmetry. according to the medical circumstances. They argue that both physicians and patients must be prepared to relinquish one form of the relationship no matter how comfortable and familiar it has become-to accommodate changed circumstances. The unconscious victim of a myocardial infarction becomes the anxious inhabitant of the CCU, and then the concerned convalescent, needing information and support to integrate disability or vulner- ability into an ongoing life.

Studies of communication patterns in the medical interview reveal a pervasive asymmetry, however, beyond those critical care situations in which it is most appropriate. These studies suggest that many patients. for whom medical institutions and thought- forms are unfamiliar territory, are perpetually off- balance in their interactions with their physician. They frequently struggle to explain themselves to their own satisfaction. and must frequently attempt to follow a recommendation without full under- standing or agreement as to its rationale. Differences in cultural and social norms for communication and language use often reinforce the view that patients are passive, dependent, and deferential.

The evidence suggests that in many instances there is a discrepancy between physicians’ and patients’ views of the doctor’s job. The occupational usages and everyday behaviors of physicians are consistent with the curative premise: unilateral decision-making. related to active intervention. in the treatment of organic disease. For many patients these assumptions work well. Many other patients, however, appear to see the doctor’s job quite differently. desiring more information, and attention to personal. psychological, and social aspects of their lives and health [26,34,49]. Patients in lower socioeconomic classes appear to be particularly affected by this descrepancy. To a greater extent than upper class patients. they report the doctor’s affective behavior and attention to psychosocial issues as a leading criterion in choosing a physician [50]. Yet it is precisely these patients who are likely to receive the least information and evidence of the physician’s concern.

To be sure, patients have their own resources for asserting control in physician-patient encounters; the contest for mutual influence is not entirely one-sided. On the other hand. far more than the physician, patients must resort to indirect methods, akin to guerilla tactics. to assert their will: withholding information of their own. refusal to comply with recom- mended therapy, litigation [27]. Not only are these tactics often self-defeating and productive of conflict when people are already under considerable stress, they are substantially outweighed by the asymmetry of the physician-patient relationship. Moreover, the physician’s superior knowledge and socially sanctioned authority are bolstered by occupational usages that favor the physician’s definition of appropriate medical tasks.

The persistence of this discrepancy between many patients’ needs and desires-which have been docu- mented in professional literature for at least two decades-and professional practices, suggests that professionals have made a value judgment that patients’ agendas for medical care ought to yield to professionals’ agendas. The need to save time is among the most frequently cited reasons for this [36,39]. Time is the most carefully allocated of all medical resources. Medicine’s occupational usages insure that patients themselves will have little influence on how this time is spent. Most of this has already been decided for them in the very structure, pace, and progress of the medical interview. This structure, too, is outside the realm of patient choice: it is simply ‘there’--‘the way it is done’. Patients who challenge the orderly flow of this process are frequently labeled ‘problem patients’ or ‘crocks’ [51]. Thus, the occupational usages of medicine are a method of allocating or rationing medical services according to the profession’s definition of what services patients ought to desire, and the environment in which they ought to receive them. Implicit in the rigidity of these usages in the face of the difficulties many patients have in adapting to them is the further value judgment that such adaptation is the necessary condition for receiving care in the prevailing culture.

This judgment is rarely, if ever. articulated, much less submitted to patients or the public for debate. Rather, it is silently and implicitly enforced by the occupational usages of everyday practice. These rituals and rules support the professional construction of the agenda and purpose of the medical interview, the level and amount of information to share with patients, the flow of conversation and interrogation in the interview, and the time required for thorough assessment of patients’ problems. At the same time, these rituals and rules keep many patients off balance and poorly informed, while socializing them to expect a particular approach to their distress. even before they have become fully aware of the dimensions of that distress.

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DISCUSSION

The textbook progression from symptom recognition to medical consultation. from diagnosis to rational therapy to recovery, is complicated by social and ethical factors at many points [47,48]. A study of medicine‘s occupational usages reveals that practices taken for granted as self-evident and routine actually reinforce particular professional values. Their taken-for-granted character-as essential for the orderly and rational delivery of health care- precludes the recognition of these value commitments. Yet. analysis of these practices yields discern- This process undermines the implementation of the

248 DAVID BARNARD

principle of physician-patient negotiation, even by physicians who are positively committed to it. It is helpful to view these physicians’ situation in terms of Ladd’s distinction between the ‘internal’ and ‘external’ moralities of medicine [52]. A distinguishing characteristic of a profession, Ladd argues, is that its members regard its practices as following directly from its specialized, scientific knowledge. To adhere to these practices, then, is simply a condition for acting qua professional, irrespective of other possible reasons (moral or otherwise) for adhering to them. Refraining from indiscriminate use of antibiotics, or from untested treatment when standard. effective treatment is available, illustrate professional behaviors governed by this ‘internal’ morality. To act otherwise is simply unprofessional. The same is true of the occupational usages associated with the curative premise. Ladd’s account of the broad. unspoken consensus about medicine’s internal morality applies equally to the taken-for-granted character of occupational usages:

“Indeed, physicians are generally so completely convinced by the norms of the internal morality of medicine and so deeply committed to them that they are often not even aware that they are ethical norms. much less that they might be challenged and criticized ethically. Instead. they speak of them as ‘medical norms.‘ sometimes even assuming them to be ‘scientific”‘.

Ladd suggests that physicians are also guided by non-medical norms related to the personal and situational factors in patient care, such as the need to respect the wishes of competent adults, or to balance competing claims for limited resources. Norms of this type do not derive from medicine’s specialized knowledge, but from an ‘external’ (i.e. non-medical) morality. Physicians share their external moralities with all citizens, regardless of professional orientation. Currently, these norms include a strong em- phasis on the principles of physician-patient negotiation and mutual participation.

Ladd’s language must not be interpreted to mean that medicine’s ‘internal’ morality represents physicians’ true beliefs, while medicine’s ‘external’ morality is a cosmetic applied for public appreciation. The truth is that many conscientious physicians are pulled in two directions. The rigid application of the curative premise to the primary care setting runs counter to values of the profession which reflect an external morality of negotiation and shared decisionmaking. Textbooks exhort physicians to develop psychosocial competence. cross-cultural sensitivity, and respect for the patient’s self-determination. On the other hand, the norms of medicine’s internal morality continue to hold powerful sway, and. through dominant occupational usages, lead to a form of practice in which negotiation and mutual participation frequently fail to thrive.

By virtue of the taken-for-granted character of this internal morality. only the tirst of these directions is seen for what both actually are: value-laden assumptions and commitments which are subject to moral choice. This is precisely’ the point of occupational usages as unsung questions of medical ethics. They fall below the threshold of moral evaluation. Yet such

evaluation is required for physicians to bring the internal morality of their day-to-day practices into alignment with their commitment to negotiation and patient participation as professional norms.

A fallacy in calls for greater patient participation and negotiation in medical care is the assumption that these virtues can flourish by simple addition. without reform of prevailing occupational usages. The data reviewed here suggest that this is unlikely. It is equally unlikely that occupational usages will change unless their normally invisible value commitments are drawn out of the obscurity of routine, and made subjects for public scrutiny and choice.

AcknoM’/rdgemenfs-This paper was origmally presented to the Monthly Ethics Research Group at the Texas Medical Center, Houston, Texas. to whose members I am grateful for valuable criticisms. I am also greatly indebted to Alan Cross for his constructive comments. David Friedberg provided research assistance. and Patricia McRoberts prepared the manuscript.

REFERENCES

I

2

8

9

IO

II

12

13

14

15

16

Balint M. The Doctor. His Parienr. und the Illnrss. International Umversities Press. New York. 1964. Bochner S. Doctors. patients. and their cultures. In Docfor-Parienr Communication (Edited by Pendleton D. and Hasler J.). Academic Press. London, 1983. Freidson E. Pr&ssion of Medicine. Harper & Row, New York, 1970. Taylor S. Hospital patient behavior: helplessness. reac- tance, or control? J. sot. Issues 35, 156184. 1979. Goffman E. Gentler Adwrrisemenrs. Harper & Row. New York, 1976. Rawls J. Two concepts of rules. Phil. Rer. 64, 3-32. 1955. Schutz A. and Luckmann T. The Structures of‘ /he Life- World (Translated by Zaner R. ,M. and Engelhardt H. T.). Northwestern University Press. Evanston, 1973. Katz J. The Silent World of’ Docror unci Patient. Free Press. New York. 1984. Katon W. and Kleinman A. Doctor-patient negotiation and other social science stratepies in patient care. In T/ze Relewnce o/’ Socid Science for .Liedicine (Edited by Eisenberg L. and Kleinman A.). Reidel. Dordrecht. 1981. President’s Commission for the Study of Ethical Prob- lems m Medicine and Biomedical and Behavioral Re- search. Making Hedrh Care Decisions: The Erhicul and Lrgtrl lmpliurions uf Infiwmed Consent in rhe Polienr-Pracrilione, Relurionship. U.S. Government Printing OHice. Washington. DC. 1982. Subcommittee on Evaluation of Humanistic Qualities in the Internist, American Board of Internal Medicine. Evaluation of humanistic qualities in the internist, Ann. intern. Med. 99. 730-724. 1983. Parsons T. The Socitrl .~~~.srem. Fret Press. New York. 1951. Alexander L. Illness maintenance and the new Ameri- can sick role. In C’/inicd/~~ .Q~p/icd .4nrhropdo,~y (Edited by Chrisman N. and Maretzki T.). Reidel. Dordrecht. 19x2. Engel G. The need for a new medical model: a challenge for biomedicine. Scrence 196, I2Y- 136. 1977. Reisrr S. J. Medic+w wd the R&t1 of Twhnolo~sy. Cambridge University Press. New York. 1978. Press I. Witch doctor’s legacy. some anthropological implications for the practice of clinical medicine. In C‘linic~trlh, App’plwl An/hropo/~~,~~~ (Edited by Chrisman N. and Maretzki T.). Rcidcl. Dordrccht. 19x2.

Unsung questions of medical ethics 249

I7

18.

19.

20

21.

22.

23.

24.

25.

26.

27.

28

29

30.

31.

32.

33.

34.

Hahn R. A. “Treat the patient, not the lab”: internal medicine and the concept of person. Cult. Med. fs~~chiar. 6, 219-236. 1982. Barnard D. Religion and religious studies in health cart and health education. J. allied H//h 12. 1922201. 19X3. Stimson G. V. Doctor-patient interaction and some problems for prescribing. Jl R. Coil. gen. Pracr. 26. Suppl. I, 88-96. 1976. Scott R. et al. Just what the doctor ordered: an analysis of treatment in a general practice. Br. med. J. 5394, 2933299. 1960. Lau R. R. L’/ al. Psychosocial problems m chronically ill children: physician concern. parent satisfaction. and the validity of medical records. J. Communir. H/tit. 7. 250-261. 1982. Bedell S. E. and Delbanco T. L. Choices about cardto- pulmonary resuscitation in the hospital: when do physicians talk with patients? Nr~c, E?IR/. J. Med. 310, 1089-1093. 1984. Groves J. E. Taking care of the hateful patient. New, Eng(. J. Med. 298, X83-887. 1978. Askham J. Professionals’ criteria for accepting people as patients. Sot. Sci. Med. 16, 2083-2089. 1982. Pendleton D. and Hasler J. (Eds) Doctor-Patient Communication. Academic Press. London. 1983. Waitzkin H. and Stoeckle J. D. The communication of information about illness: clinical. sociological. and methodological considerations. Adc. Pswhosomat. Med. 8, 180-215. 1972. Stimson G. V. and Webb B. Going to See the Docror: The Consultation Process in General Practice. Routledge & Kegan Paul, London. 1975. Jaspers J. er al. The consultation: a social-psychological analysis. In Doctor-Patient Communication (Edited by Pendleton D. and Hasler J.). Academic Press, London, 1983. West C. When the doctor is a “lady”: power, status and gender in physician-patient conversations. In Women, Health. and Medicine (Edited by Stromberg A.). Mayfield. Palo Alto. 1984. Strong P. and Davis A. Who’s who in paediatric encounters: morality. expertise and the generation of identity and action in medical settings. In Relationships Between Doctors and Patients (Edited by Davis A.). Saxon House. Westmead. England. 1978. Mechanic D. The organization of medical practice and practtce orientations among physicians in prepaid and non-prepaid primary care settings. Med. Care 13, 189-204. 1975. Wolinsky F. D. and Marder W. D. Spending time with patients: the impact of organizational structure on medical practice. Med. Care 20, 1051-1059. 1982. Keeler E. B. er al. Effect of patient age on duration of medical encounters with physicians. Med. Care 20, 1101-1108, 198’. Barsky A. J. Hidden reasons some patients visit doctors. Ann. inrern. Med. 94, 492-498. 1981.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44

45.

46.

47.

48

49

50

51

52.

Mechanic D. Social psychologtc factors all’ccting the presentation of bodily complamta. Nc,N, Gtpl. J. Med 286, 1132-l 139. 1972. Brody D. S. Physician recognttion of behavioral, psychological. and social aspects of medical care. Arch.5 intern. Mc,d. 140, 12X6 12X9. 19X0. Stewart M. A. and Buck C. W. Physicians’ knowledge of and response to patients’ problems. Med. Care 15, 57X-585. 1977. Thompson T. L. (‘I ul. Underrecognition of pattents’ psychosocial distress in a university hospital medical clinic. Am. J. f’q&ict/. 140, 15X-161. 1983. DulTy D. L. (‘I a/. Communication skills of house officers: a study in a medical clinic. Ann. in/em. Med. 93, 354-357. 1980. Pratt L. er al. Physicians’ views on the level of medical mformation among pattents. Am J. pub/. H//h 47, 1277-1283. 1957. Shapiro M. C. (‘1 al. Informalton control and the exercise of power in the obstetrical encounter. Sec. Sci. Med. 17. 139-146. 1983. Wallen J. e/ al. Physician stereotypes about female health and illness: a study of patient’s sex and the informative process during medical interviews. Women Hlrh 4, 135-146. 1979. Kosa J. and Zola I. (Eds) Porerrj and Health: A Sociological Analysis. Harvard University Press, Cambridge, MA, 1975. Foster P. The informal rationing of primary medical care. J. sot. Policy 8, 4X9-508. 1979. Beggan M. P. and Drury M. I. Deficiencies in outpatient services: a case-study of a diabetic clinic. Ir. med. J. 76, 230-235. 1983. Szasz T. and Hollender M. A contribution to the philosophy of medicine. Archs infern. Med. 97, 585-592. 1956. Brett A. S. Hidden ethical issues in clinical decision analysis. Nen Engl. J. Med. 305, 1150-l 152, 1981. Eisenberg J. M. Sociologic influences on dectsion- making by clinicians. Ann. in/em. Med. 90, 957-964, 1979. Ben-Sira Z. Lay evaluation of medical treatment and competence: development of a model of the function of the physician’s affective behavior. Sot. Sci. Med. 16, 1013-1019. 1982. Wolinsky F. D. and Steiber S. R. Salient issues in choosing a new’ doctor. Sot. Sri. Med. 16, 759-767. 1982. Homung C. A. and Massagh M. Primary-care physicians’ affective orientation toward their patients. J. Hlth sot. Behac. 20, 61-76, 1979.

Ladd J. The internal mortality of medicine: an essential dimension of the patient-physician relationship. In The Clinical Encounter : The Moral Fabrrc qf the Patient-Physician Relationship (Edited by Shelp E. E.). Reidel, Dordrecht. 1983.

Unsung questions of medical ethics

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