MANAGED CARE October 1998. ©1998 Stezzi Communications
The recent Associated Press report that hundreds of physicians nationwide grow 7 million pounds of tobacco in 23 states made me wonder: How much should our private lives reflect our public ones?
One of the first times I noticed that there was a difference was about 15 years ago while training with a prominent medical ethicist and clinical professor.
A 92-year-old man had lived a life filled with travel and scholarship. His existence had soured 18 months before, when his wife of 55 years died. Gamely, he continued his pursuits. He even had a cataract extracted and lens replaced. Still, he was unable to find a reason to live.
Then, one day, after his housekeeper had left, he trained his World War I pistol on his tonsils and pulled the trigger. He missed, as is so often the case, and wound up blinded, in pain, and in a hospital.
We were asked whether his suicide attempt ought to be honored, and whether the medical team ought to code him should he die. We spoke with the patient — articulate, thoughtful, bloodied — for nearly two hours. Wouldn't we try to kill ourselves, he asked, if all of our friends were gone, if we could no longer read, if we were completely dependent on others? Couldn't his first cousin — now flying in from New York — be permitted to take him home, and let him conduct his own affairs in peace? Of course he was lonely — wouldn't we be if our wives died? And could we think of any reason that he shouldn't be allowed to choose to die?
I had heard the professor lecture to students and colleagues about precisely this subject: Suicide attempts are nearly always signs of psychiatric illness, especially depression. Patients who are depressed have impaired decision-making capacity, are not competent and can not reliably decide to dismiss life-sustaining treatment without a therapeutic trial of antidepressant therapy. This patient's case was a textbook example and to accede to the man's request would be to assist him in suicide.
Surprising reaction
But my professor surprised me. "Who are we to revive him if he should die in the hospital?" he asked me. There was no evidence of impaired decision-making capabilities. The patient was competent: He knew and understood the proposed treatment of CPR and the consequences of refusing it. He could give a reason and make a choice.
We suggested a DNR order, release of the patient to his cousin upon her arrival, and a consultative evaluation of whether neuroleptic therapy could achieve any of the treatment goals.
Tragically, the patient remained on the psych unit for several weeks, recovering from presumptive depression, until he suffered an arrhythmia, coded and died.
What my professor had said publicly is not what he did privately. He maintained his public, professional stance against assisted suicide, while privately recommending that this patient be allowed to take matters into his own hands. The details of an individual case, he told me, allow for an exception to the rules.
Acceptance of professionalism makes physicians different from others who hold themselves out to offer care and treatment. Professions have publicly available codes of ethics. Professions regulate themselves. Professions create, accept, meet and monitor standards of competency.
The greater good
Publicly, professionals say that they will hold the good of those they serve to be greater than their own good. Acceptance of medical professional duties and privileges implies acceptance of the medical ethical principles that underlie them. Medical ethical principles guide how professionals interact with their constituents — patients, other providers, professional associates, business associates — in their professional roles.
Private actions are not the subject of codes or principles of medical ethics, generally speaking. Should some private actions (say, tobacco growing and selling) be ethically foresworn by medical professionals? What makes some private actions seem outrageous and others just disappointing? Which private actions are relevant to the public practice of medicine?
Conversely, are some private actions (say, becoming fit) morally obligatory for medical professionals? Or are these private actions just good things to do and not what good doctors do?
Professionally private?
The obesity management literature demonstrates that physicians who change their own lifestyles spend more time with obese patients and are more often successful at helping those patients change than those physicians who do not. There is overwhelming evidence that increased moderate daily physical activity benefits people, especially older people, by improving balance, increasing walking speed and reducing cardiovascular morbidity and mortality.
Why should patients pay attention to physicians who insist that they stop smoking, eat less fat and more fiber, exercise adequately and take antioxidants if physicians don't have these habits themselves?
To be more effective with patients and potential patients, physicians should come clean about their private lives. But how clean and to whom? Do we have to apologize to our patients about an affair with a nurse, or for accepting a $10,000 honorarium merely to attend an "educational" Barbados conference on industry's tab?
I think these questions should be thought of in a patient-centered, population-based way. Assume that our hospital, office and health-related personal behavior is publicly known. Will that behavior harm the patients in our care? Could it help them? Will trust, respect, adherence, quality of life or survival likely rise or fall?
Individual physicians still retain the trust of their patients, despite the profit-at-any-price behavior of many managed care organizations over the last decade. Physicians who practice what they preach, and who personally reject anything less, can only be thought of as truthful, honest and persuasive.
As for the leading causes of mortality — drug and alcohol abuse, sedentary lifestyle, high fat/low fiber diets, smoking — our public and private lives should be consistent. Whether we choose to tell our constituents about our private lives — and whether we use those disclosures as therapeutic tools — is an option that each of us as physicians should have.