The health world has undergone a number of profound changes in recent years, from population ageing and the fact that people are increasingly well informed, to industrialisation of healthcare, squeezed budgets and the biotech revolution. These changes have raised serious questions for all those involved in healthcare. Is there a code of ethics regarding choices? And if so, how does it compare with the criteria on which the philosophy of medical practice has been built from antiquity to today?
In fact, it is the very purpose of the medical profession and the doctor’s role that is at stake today. Time and again doctors are forced to question the purpose of their actions and accept the limited extent of their knowledge in the face of the dizzying array of new discoveries in molecular biology and genomic sciences. At the same time they must weigh their sense of compassion and altruism as they help the sick who entrust their lives to them, against the pressure to use community resources responsibly.
Increasing legal complications and the media spotlight do not help either. All of this has been compounded by the gradual breakdown of traditional social structures, and the doctor’s diminished status in society.
In the midst of all these changes, what is a doctor, really? A learning machine supposed to know everything? An economic player whose sole job is to control the costs of treatment? A practitioner who must protect his livelihood from legal attack by practising a defensive form of medicine? Or is a doctor simply an illusory buffer against the suffering, anguish and solitude of his fellow human beings?
The answer would be easy if medicine were a science. But unfortunately (or perhaps fortunately), it is only an art. That is to say, a permanent quest for a philosophical absolute: Health, Well-being or perhaps even to some degree, Happiness.
And the problem does not stop with doctors. Hospitals are faced with an identity crisis of their own. How can they cope with the impossible task of providing an excellent, efficient service while remaining local, familiar and human?
We should not forget that it was to the hospitals that thousands of homeless turned at the height of the last economic crisis in the early 1990s, appearing in casualty departments in search of human contact or simply a bowl of food. They were not thinking about the high financial cost of appealing for help in this way. In 2000, 49% of the 80 billion euros spent on the French health system went on hospitals. A hospital like the one where I practice costs nearly FF 5 000 (760 euros) a minute to run, or almost a month’s minimum wage.
And families turn more and more to hospitals to look after their loved ones at the end of their lives, so that they can be as free as possible from suffering. But this means dying as far away as possible from the places where people have spent their lives – more than 80% of people nowadays die in hospital.
But these crises and contradictions are only on the surface, for it is in the outstretched hand, in the bowl of soup and in the silent support for the terminally ill that the essential meaning of the practice of medicine really lies. Just being there and showing compassion as life slips away is still a form of medical treatment.
Science alone cannot provide a definition of medical practice. It is just a tool. Indeed, the whole purpose of medicine would probably be lost, if in considering the illness the doctor were to forget the patient, or if in considering the pain he were to forget the suffering, or the hope. Another issue that is going to crop up increasingly in the future is the question of power.
Medical power was at its apogee after the Second World War, as symbolised in the relationship between an upright, healthy, clean and well-dressed doctor and an innocent, uneducated and silent patient confined to bed.
The doctor was all-powerful in his hospital world, at once terrifying and unintelligible. This status was underpinned by an absence of laws on ethics or respect for people subjected to biomedical research. There were no patients’ associations capable of standing up for the legitimate and inalienable rights of individuals entering hospital or putting their lives in the hands of a doctor.
Fortunately, the vast majority of doctors used their power wisely, with the sole object of helping their patients. However, we have seen the perverse effects that unbridled, inappropriate and inadequate use of such power and authority can have.
So where does the era of the Internet, lobbies and the media leave us? Doctors are seen by many as primarily those responsible for running up social security deficits and higher social charges, and as a heartless and incompetent lot.
This grotesquely inaccurate picture of the medical profession may conceal an underlying desire to destroy the origins of medical power at source. But it offers no concrete proposals for establishing a system capable of promoting health, eradicating suffering and respecting the life, value and dignity of all human beings.
France spends 10% of its GDP on health, but are the French satisfied with their health system? It is questionable whether they agree with spending so much on what seems to them to be a fairly remote asset, especially if they are of an age that does not actually need its services.
Nor can it be said that the French health system itself is happy with the resources it has, when 50 000 of its 800 000 staff end their careers early, and 3 000 of the 39 000 jobs for hospital doctors remain vacant. Can we say that we have answered the legitimate hopes of young people in terms of equity and compassion when we tacitly accept that people with AIDS or cancer in Europe will be cured whereas if they were African or Asian, poor and submissive, they would be left to die uncared for?
Answers will have to be found to such questions. Otherwise our health systems risk collapsing under the cumulative burden of budget squeezes, a crisis of conscience among doctors and the emergence of a patients’ lobby that is filling the void left by medical power.
Yet despite the difficulties of a world in the throes of far-reaching change, there is no reason to be pessimistic. Other values are helping us find answers to the pressing challenges facing a system that no longer knows which way to go. For in reality, power and purpose can only make sense through sharing.
Sharing means the individual, unique and privileged relationship between doctor and patient, it means respect for others, the right for all to equal access to quality care, the right to share knowledge, the patient’s right to dignity and hope.
Through sharing patients and doctors, administrators and economists, businesspeople and researchers can forge an unbreakable alliance and at last create the conditions needed for a health system that lives up to everyone’s hopes and makes proper use of scientific achievements and potential. As a result, all can be sure that every effort will be made, within the limits of available resources, to ensure that human beings live fulfilling, happy and healthy lives.
Each country and each region will of course have to define its own health priorities by democratic means, taking account both of requirements and resources.
In the same way, it is vital that overall “governance” of these issues involves sharing between North and South. Lastly, encouragement must be given to schemes to back the right of young people to become involved in health-related charities.
Economics, whether national or global, cannot be a substitute for ethics. Economics imposes choices and ethics helps us to make them.
We need a renewed code of ethics, based on choice, shared power and an efficient health system open to all. Everyone can then assume his or her share of that power with one principle in mind: that everybody in the world should have the same rights and the same opportunities in the face of sickness, suffering and adversity.
©OECD Observer No 229, November 2001