 H.B. Augustine is a senior undergraduate student at Denison University studying Philosophy and Communication. He has started a publishing organization called "Integral Publishing House" - contact him at august_h@denison.edu if interested in publishing Integral material.A Subtle but Serious Fault of the American Medical IndustryH.B. AugustineI wrote this paper for my Bioethics Philosophy class. Therefore, I made the language, logic, and overall structure conform to resonate best with my instructor – excluding all Integral jargon, etc., whatsoever.
I. The Purpose of this EssayThe purpose of this essay is to shed more light upon an ethical issue that applies to the American medical industry. The issue at hand is this industry's familiarity with, or comprehension of, the ethical-philosophical framework of the Hippocratic Oath. By “ethical-philosophical framework,” I mean the extent to which American physicians are familiar with philosophy in general, namely the branch or school of ethics – and even more specifically, the subset of bioethics. In other words, how versed is the average American physician with philosophy, ethics, and bioethics apropos of the most influential thinkers, the main schools/branches, the general history and evolution of each, etc.? Other than the field of bioethics being an increasingly significant field of inquiry (for very practical reasons), my motive for this research topic begins with the medical industry as a whole being extremely powerful due to the (potentially) great service that it provides. Therefore, this sphere bares a proportionate amount of ethical responsibility. Just what is this responsibility, though, in relation to bioethics and ethics as such? If my underlying question here is, “Within the American medical industry, to what degree does the teaching/understanding of the Hippocratic Oath adhere to philosophical-ethical comprehension?,” then the thesis that I will defend, based upon sufficient intuitive and logical evidence, is that the American medical industry as a whole does not adhere to a morally sufficient philosophical-ethical comprehension of the Hippocratic Oath because within the medical sphere, the junior spheres of commerce and science are competing with one another with the ethical sphere devalued and placed on the bottom – when ideally, the ethical would be first in priority, followed by the scientific and then the commercial. In order to show the reader of this essay why the latter statement is true, I must address all aspects of it, in (chrono)logical order, that are not already self-evident to grasp and accept. The structure of my argument itself, naturally, will be in macrocosmic accordance with the aforementioned thesis. First, I will demonstrate that the medical industry has an immense moral obligation, whatever it may be. Second, I will demonstrate that the three most determining junior spheres within this industry are (what I define as) the ethical, the scientific, and the commercial. Third, I will demonstrate that, currently, the commercial and the scientific are competing for/at the top, the ethical (unfortunately) at the bottom. Last, I will demonstrate that, prescriptively, the ethical should be first, the scientific should be second, and the commercial should be third. My argument will consist of a healthy integration between intuitive analysis and textual conversation so as to maximize the importance of my scholarly contribution here by allowing the unique claim to rest optimally between “extreme intuitive analysis / greater claim, lesser credibility” on one end and “extreme textual conversation / lesser claim, greater credibility” on the other. Now consider why the (American) medical industry has such an immense moral obligation.
II. The Moral Obligation of the Medical IndustryIn order to establish that the medical industry has a crucial normative duty, I must first define what I believe constitutes any normative duty. The first step in this logical process lies in defining what “normative duty” means. First, anything that is normative or ethical is necessarily pluralistic or social in nature. What I mean by the latter statement is that something would not be a normative/ethical matter if it only involved one person, or one being, and literally no one else. Morality arises subsequent to the fact that we are indeed social animals and, through tribing together, we construct a set of principles or ideals of conduct that are of mutual benefit for everyone individually and collectively. Second, “duty” is itself normative, denotationally, for reasons upon which further explanation is unnecessary. Therefore, based upon the definition of “normative duty” based specifically upon the individual definition of “normative” and of “duty,” duty as such must be proportionate to how pluralistic or social something is, or how many lives something affects and/or the magnitude of such affection. With this relation of ideas in mind, consider now more tangibly the particular normative duty of the medical industry. Quantitatively, this industry affects many lives; in fact, it affects all lives because all humans, by definition, are (in part) biological creatures with corresponding biological functions and needs. Qualitatively, the medical industry treats and deals with life itself. It would be difficult for any sentient/reasonable human to deny that something involving all lives and life itself carries immense moral responsibility. Perhaps the American medical industry bears even more such responsibility considering the power and corresponding responsibility that this country bears in relation to all other countries and to the planet itself. This beginning principle is acceptable from an intuitive in addition to logical standpoint. As the famous truism/mantra goes, With great power comes great responsibility. The medical industry has a great deal of power and hence carries an equal degree of responsibility to use that power for maximizing its ethical greatness. Now that I have established why the medical industry has an immense moral obligation, I will move to the next relevant aspect of my argument, which is that within the medical sphere as a whole, three junior spheres most determine not only its ethical greatness but also its success in all other areas. These spheres, as mentioned, are the ethical, the scientific, and the commercial.
III. The Three SpheresIt is no coincidence why the ethical, the scientific, and the commercial spheres most determine or shape the flourishing, or lacking thereof, that the medical sphere overall experiences. These junior spheres are complementary to one another. While may not (necessarily) be inherently better than any other, there is still a right and true order, relative to the medical sphere, of which these three must be valued or prioritized. Before discussing this order, though, it is first appropriate to elucidate just what each one of these terms means, along with their relationship to one another and to the medical industry itself. The ethical sphere concerns the manner in which a person or group affects others' quality of living. I believe that this definition of the ethical sphere is the most general, neutral, encompassing and yet specific/accurate one possible: Morality fundamentally has to do with how the relationship between people affects quality of living. Of course, the questions arising from this classification beg what the terms “relationship,” “people,” and “quality” mean. Nonetheless, the ethical sphere is necessarily intersubjective, meaning it transcends and includes both subjectivity and objectivity (whatever these terms should mean). The ethical is equivalent to the good – for all ethical matters ultimately deal with what is good and how to achieve it. The ethical aligns not with “what” or “how” but with “why.” Specific schools of ethics within the (Western) philosophical tradition altogether include egoism, virtue ethics, utilitarianism, care ethics, and – most specifically/relevant – bioethics. The scientific sphere concerns the means through which external truth and understanding are realized through external manipulation and observation. Scientific inquiry transcends and includes the “natural sciences” alongside the “social sciences” and all other main branches. By “external,” I mean that which exists beyond private experience in terms of unshared feelings and thoughts, that which appears external to the body by means of direct physical perception. By “truth and understanding,” I do not necessarily mean truth and understanding in an all-encompassing, absolute sense, but rather in a relative sense (e.g., relative to the concept/theory of geocentricism, the concept/theory of heliocentricism carries more scientific truth and understanding). The scientific is equivalent to the true – for all scientific matters ultimately deal with truth, or what is “real” (objectively speaking). The scientific aligns not with “how” or “why” but with “what.” Specific schools of science include astronomy, physics, chemistry, biology, and, of course, medicine. The commercial sphere concerns the means through which a product or service gains popularity and success. Whereas the ethical and scientific spheres align with the good and the true, the commercial sphere, in my opinion, aligns most with the beautiful and with art, actually. Art and “beauty” – whatever that should mean – are not intersubjective or objective, but are subjective. Commercial activity, similarly, seeks to ignite within its potential customer or market audience a positive feeling associated with the product/service being promoted. The commercial sphere emphasizes communicating to the individual and subsequently inspiring this person to see value in the why/what that is, in this case, medical assistance. For this reason, the commercial aligns with “how;” it is how the artist, vendor, or industrialist sells his or her good(s). Specific schools of “commerce” include finance, marketing, distribution, economics, and – central to this discussion – management/leadership. I believe that these three spheres – the ethical, the scientific, and the commercial – are both necessary and sufficient components for the medical industry to actualize its potential and function. The ethical is necessary because medicine involves literally all human beings and, thus, normativity and procedural/principial rightness must be considered and enacted. The scientific is necessary because medicine is a science and owes its very existence to science, after all. The commercial is necessary because medicine must allow the public to know why it exists and what it has to offer. If any of these components were removed from the equation, then the medical sphere itself would not be able to actualize its potential and function. As I will demonstrate later in this essay, the inclusion of all three junior spheres is yet not adequate for the medical industry to flourish. In addition to being included, each sphere must also be utilized appropriately in terms of place and priority. Before getting to this point in the argument, though, consider what the status quo is with American medicine as far as how discordance with such optimal placement, priority, and consequent flourishing.
IV. The Status QuoIt is quite safe to say that the American medical industry is a broken or dysfunctional system – to whatever extent this may be true. According to the Nursing Online Education Database, “5 little-know giant healthcare issues facing the United States” include “uninsured millions affecting everyone,” “obesity dangerously on the rise,” “pharmaceutical companies controlling more than you realize,” “hospital staff shortages killing people,” and “veterans being neglected.” According to the official website for America's Union Movement, the United States enforces and provides “Wal-Mart- style healthcare” due to how commercialized and objectivistic it has become. Of the 47 million Americans without healthcare, 8.7 million are children. Pharmaceutical spending increased by 17.4 percent annually between 1999 and 2000 and another 16 percent from 2000 to 2001. On top of all this, “staffing levels are dangerously low in hospitals.” According to Health Care Problems, “The amount people pay for health insurance increased 30 percent from 2001 to 2005, while income for the same period of time only increased 3 percent,” “Healthcare expenditures in the United States exceed $2 trillion a year. In comparison, the federal budget is $3 trillion a year,” and, “Approximately 50 percent of personal bankruptcies are due to medical expenses.” Moreover, and strikingly, America remains the only industrialized country that does not provide some form of universalized healthcare to citizens. According to the American Hospital Association, the United States spends more per capita on healthcare than any other country. Uninsured people are less likely to get needed medical care. Perhaps the “system is broken and must be fixed,” in part, because of a “regulatory morass” induced collectively from a complex entanglement between “Federal Circuit Courts, Supreme Court, Departmental Appeals, OIG, PRO's, Carriers, PRRB, Intermediaries, Regional Offices, DME Regional Contractors, Medicare Integrity Program Contractors, Congress, FDA, DOT, OSHA, DOJ, Treasury, FBI, DOL, NCR, JCAHO, HHS/NIOSH, HHS/HRSA, FCC, FTC, EPA, IRS, SEC, OPO's, FAA, DEA, and Regional Home Health Intermediaries.” This broken system and regulatory morass may explain why more than half of Americans surveyed rate the healthcare system as fair to poor and nearly one in four Americans see healthcare as the most critical issue in America today. Contradictingly, “[America has] a clear policy, a 'social contract' for education – all children receive a free education through grade 12,” and yet there is no such policy or contract with regard to healthcare. The list of evidence and statistics continues: John R. Battista, M.D., explains why universal healthcare is not a right of citizenship in this country. The answer boils down to six dogmas or myths concerning the reality and repercussions of universal healthcare. According to Battista, Myth One is that the United States has the best healthcare system in the world. However, in fact, this system globally ranks 23rd in infant mortality, 20th in life expectancy for women, 21st in life expectancy for men, and between 50th and 100th in immunizations. Myth Two is that universal healthcare will be too expensive. However, in fact, we spend 40 percent more per capita on healthcare than any other industrialized country with universal healthcare; the Congressional Budget Office and General Accounting Office demonstrate that single payer universal healthcare actually would save 100 to 200 billion dollars per year. Myth Three is that universal healthcare would deprive citizens of needed services. However, in fact, universal healthcare systems have more doctors-visits and hospital-days than America, in which healthcare is directly related, unjustly, to income and race alone. Currently, America has a 30 percent oversupply of medical equipment and services while, (hypothetically) with a universal system, economists calculate that demand would increase roughly 15 percent. Myth Four is that universal healthcare would result in government control and intrusion into healthcare, resulting in loss of freedom and choice. However, in fact, a single payer system – as Battista contends – is significantly more democratic than is its alternative. Myth Five is that universal healthcare is nothing but socialized medicine and would be unacceptable to the public. However, in fact, the highest quality healthcare systems in the world have proven this myth wrong because they have proven themselves to be even more acceptable to the public for rather straightforward and plain reasons. Lastly, Myth Six is that the problems with the United States healthcare system are being solved by private corporate managed care medicine simply because they are the most efficient. However, in fact, corporations – for the most part – only look after themselves and could care less about the wellness of everybody else. In spite of all these numbers and supposed facts demonstrating how dysfunctional the American healthcare system is and has been, I must concede for the possibility that some portion of these statistics may not be entirely accurate circa the inception of “ObamaCare” in early 2010. As listed on the official website for the White House, The Affordable Care Act, passed by Congress and signed into law by the President in March 2010, give you better health security by putting in place comprehensive health insurance reforms that hold insurance companies accountable, lower health care costs, guarantee more choice, and enhance the quality of care for all Americans.
Essentially, the Act offers a third way between or compromise for the extreme views illustrating America's political continuum. Healthcare is significantly more publicized than before Obama implemented the policy, but at the same time, it remains much privatized. For instance: Before reform, cancer patients and individuals suffering from other serious and chronic diseases were often forced to limit or go without treatment because of an insurer's lifetime limit on their coverage. Insurance companies can no longer put a lifetime limit on the amount of coverage enrollees receive, so families can live with the security of knowing that their coverage will be there when they need it most.
While the present and future of American medicine may appear promising in light of the Affordable Care Act, what remains is that the system – internally – is far from being fixed. In short, a policy cannot necessarily change a culture just as a culture cannot necessarily change a policy. In the remainder of my work with this essay, I will present the remainder of my argument concerning why the Hippocratic Oath is not taught and understood with sufficient philosophical-ethical framework and what needs to change in order for this happen.
V. The Problem and the IdealThe biggest problem that I perceive in diagnosing the American system's dis-ease is that the three spheres are not in proportionate harmony with one another. Put differently (and to borrow from Aristotle), the “golden mean” between the ethical, the scientific, and the commercial has not yet been achieved within American medicine, “which has become greatly intertwined with business” (American Medical Student Association). As of now, more so than ever, the scientific and the commercial are competing with one another while oligarchically dominating and suppressing the ethical. These two spheres are the excessive and vicious product of physicians and people in general investing too much energy in their cultivation/maintenance while not nearly enough in that of the ethical. In reality, in an ideal setting, the ethical would receive most attention and focus, then the scientific, and finally the commercial. Each sphere would receive the appropriate degree or golden mean of energy investment, and, as a result, the three components would be prioritized in this particular order. The question, of course, is why. There are two reasons why the ethical must be first. For one thing, this essay is being written within the structure and for the purpose of an ethics, namely bioethics course. As noted, ethics values the good over anything else that philosophy could possibly discover and grasp. Just as the true is most important with regard to ontology and epistemology and just as the beautiful is most important with regard to aesthetics, so the good is most important with regard to ethics. Therefore, it would do much dishonor to the field of ethics as a whole, but especially to this bioethics course itself, to see or to say that the good is not most important in this case and in general. As the reader can agree, this first reason is more tautological/analytical/semantic than it is anything else. Similarly yet differently, though, the second reason for why the ethical must be first is that the good is best. One can arrive at this realization tautologically as well (i.e., the good is the good/best by definition), and one can arrive at it intuitively: What would one rather experience between infinite goodness from within and from others, infinite truth about the whole of reality, or infinite beauty coming in whatever shape, form, or mode? Perhaps answering this question is ultimately subjective and opinionated – but in my mind, the clear answer is that the good stands at the top of a philosophical triangle with the true and the beautiful as each leg/side. To disregard the good is to disregard goodness, to disregard goodness is to disregard value, and to disregard value is to plunge into a dark, treacherous, meaningless, tragic, and cold nihilism. Bringing these reflections back to the matter at hand, what American medicine needs is for its physicians to know why they do what they do. William Osler reminds, “Medicine is a calling, not a business” (“Progressive commercialization of American medicine”). American physicians must strive to maximize their potential to do the greatest possible good with the title/role that they have earned so industriously and fortunately. These individuals must have a healthy disregard for the impossible and share a lucid vision of a healthcare system with excellent integrity and abundant flourishing, a fervent passion for their profession and a deep reverence for their own life and for life itself. In the words of Steven H. Miles, I want my doctor to be as astute as Dr. Oliver Sacks and as altruistic as the medical missionary Albert Schweitzer. I want my doctor to be as all-around nice and accessible as television's Dr. Marcus Welby. I want a physician for whom medicine is more than a job, the kind of person who could swear an oath to uphold the highest possible professional aspirations. (2)
Integrity and goodness is the essence, indeed. The question that arises in response, naturally, is what does “integrity” and “goodness” even mean? Alas, answering this question is not the aim with my work here (and is impossible given the length requirement). The aim with my work in this essay is to demonstrate that the American medical industry needs to devote a significantly greater amount of care and consideration into the philosophical realm of ethics and bioethics, beginning with the Hippocratic Oath and extending well into the plethora of additional potential issues both within and outside medicine as such. Runciman et al states, “The Hippocratic Oath gave doctors their first code of ethical practice” (157). Greek Medicine explains, “[The Oath] requires a new physician to swear upon a number of healing gods that he will uphold a number of professional ethical standards. It also strongly binds the student to his teacher and the greater community of physicians with responsibilities similar to that of a family member,” although – as MedicineNet affirms – not only are there two main versions of the Oath (a classical/ancient one and a modern/contemporary one) but also there is no binding requirement even to use or swear by it in order to become a certified physician. Morrison et al contributes to this discussion by insightfully recognizing that the ethical sphere or component within American medicine is “trapped” in a state of relativism and, even deeper, perhaps a state of (ethical) nihilism, or agnosticism at the very least (3).
VI. Concluding RemarksThe fact that there is no unified version of the Hippocratic Oath – let alone any ritualistic swearing-by that establishes the inducted physician as ethically conscientious and accountable – reveals that the American medical industry as a whole does not in fact adhere to a sufficient philosophical-ethical of the Hippocratic Oath. If this industry did in fact adhere to such comprehension, then it would 1) more greatly emphasize the discussion and teaching of (bio)ethics throughout medical school and 2) maintain a unified version of the Oath with greater respect and honor for the most influential ethical thinkers and theories and their relation with one another (as opposed to their differences and disagreements). The simple fact that the system still is so dysfunctional singlehandedly proves that greater ethical consideration is required. American medicine must invest more time and effort into ensuring that its authorities, its physicians, old and new, are adequate philosophers and ethicists in both a classical and literary sense. These individuals, as of now, are primarily salespeople and scientists, but – for the most part – unfortunately lack the intellectual rigor imperative to know why they are alive and why they serve as physicians and what the greatest thinkers who ever lived have argued goodness is. Granted, there has been an increased interest in and stressing of medical industry ever since the 1970s. Still, in the words of Wiley W. Souba, “The commercialization of healthcare continues to undermine the deeply rooted ethical foundation of medicine as a profession that values service above reward,” and, “As key players and regulators in the distribution and consumption of healthcare goods and services, physicians have an ethical responsibility to step back and examine their personal leadership role in creating a just society.” The scientific and commercial spheres have value and are necessary, doubtless, within any medical industry. However, due to the magnitude of this system's power and corresponding ethical role, and due to the meaning and value of ethics, goodness, the good, and value itself, the most important of these spheres is necessarily the ethical. Because medicine began as a science, this sphere must follow. Given that the ethical and the scientific, the why and the what, are honored and acted upon in such a way as to allow the American medical industry to flourish, then the commercial, the how – the actual reaching-out to people and converting them into “customers” – should not pose any difficulty, whatsoever; in fact, given this change in energy and structure, it should be both easier and more lucrative than ever before. Works Cited“5 Little-Known Giant Health Care Issues Facing the United States | NOEDb.” Nursing Online Education Database – Online Nursing Schools | NOEDb. Web. 17 Apr. 2011. http://noedb.org/library/features/5-little-known-giant-health-care-issues-facing-the-united-states. “AHA : Issues : Creating a Better Health Care System.” American Hospital Association. Web. 3 May 2011. http://www.aha.org/aha/issues/CBHCS/index.html. Battista, John R., and Justine McCabe. “The Case for Universal Health Care in the United States.” Connecticut Coalition for Universal Health Care. Connecticut Coalition for Universal Health Care. Web. 1 May 2011. http://cthealth.server101.com/the_case_for_universal_health_care_in_the_united_states.htm. Cogan, John F., R. Glenn Hubbard, and Daniel P. Kessler. “Business In Medicine.” Welcome to AMSA. Web. 1 May 2011. http://www.amsa.org/AMSA/Homepage/About/Committees/BusinessInMedicine.aspx. “Greek Medicine | Hippocrates | The Oath.” National Library of Medicine – National Institutes of Health. Web. 17 Apr. 2011. http://www.nlm.nih.gov/hmd/greek/greek_oath.html. “Health Care Statistics | Health Care Problems.” Health Care Problems. Web. 15 Apr. 2011. http://www.healthcareproblems.org/health-care-statistics.htm. “Health Reform in Action | The White House.” The White House. Web. 26 Apr. 2011. http://www.whitehouse.gov/issues/health-care/. Miles, Steven H. The Hippocratic Oath and the Ethics of Medicine. Oxford: Oxford University Press, 2004. Print. Morrison, Eileen E., and John F. Monagle. Health Care Ethics: Critical Issues for the 21st Century. 2nd ed. Sudbury, Mass.: Jones and Bartlett Publishers, 2009. Print. Restrepo, Lucas. “Progressive Commercialization of American Medicine.” KevinMD.com | Social media’s leading physician voice. Web. 2 May 2011. http://www.kevinmd.com/blog/2010/12/progressive-commercialization-american-medicine.html. Runciman, Bill, Alan Merry, and Merrilyn Walton. Safety and Ethics in Healthcare: A Guide to Getting It Right. Aldershot, England: Ashgate, 2007. Print. Souba, Wiley W. “The Being of Leadership.” Philosophy, Ethics, and Humanities in Medicine. 24 Feb. 2011. Web. 21 Apr. 2011. |
