As I thought a bit more about the doctor who wrote the letter to the editor we discussed yesterday, I wondered how two similarly-trained doctors (he and I) could come to such different conclusions about ethical behavior.
The generally agreed upon set of medical ethics we work with has developed over centuries. Patient confidentiality, for example, was demanded by Hippocrates of Kos. But many of the medical ethics we work with are fairly modern developments that reflect the thinking of our surrounding society. The changing weight of patient dignity and autonomy vs. physician paternalism is such an example.
Of course, not everyone agrees on all ethical principles. Ideally, formal ethical statements for a profession are developed as part of a continuous, representative discussion. Not all ethics are the result of a formal process however. In the U.S., there is no one organization that represents all doctors; doctors generally operate independently, with the only legal requirement to practice being a state licence.
Decisions about ethics (or meta-ethics) should normally be made transparently. The American Medical Association (a group that many doctors---including me---do not belong to) publishes a code of medical ethics. They keep an online public record of past codes of ethics and of the process itself. Though the AMA isn't representative of all doctors, it does represent many, and has had an ongoing discussion on ethics for well over a century. Many other professional groups, including my own (the American College of Physicians) also have detailed ethics manuals.
There are currently nine core principles listed by the AMA, principles reflected in the more specific ethical statements published in the Code. And while laws may reflect ethics, ethics aren't laws. Just as there are no universally accepted set medical ethics, there is no universal mechanism for enforcing ethical behavior. When an ethical violation intersects with a legal one, doctors may be punished. Beyond that, what makes an ethical physician?
Why should physician's adhere to any code of ethics? Can't we just each rely on ourselves as individuals to do what's right?
As doctors we are given extraordinary privileges and responsibilities. Physicians have always recognized that this demands high standards of behavior. The way we act professionally must take into account not just what we each believe, but what our patients and our society believes. Ethics are easy if we all have the same values. Ethics get hard when we don't share beliefs. And when we don't share beliefs, we must at the very least remember our core principles, those of helping our patients, and not causing them harm; of granting them autonomy and privacy; of treating them with basic human dignity.
One of the more modern ethics in medicine is that of justice, especially justice as it relates to supporting the availability of health care for everyone. I know many physicians who would look at AMA principle #9 ("A physician shall support access to medical care for all people") and think, "that sounds a lot like socialism. I hate socialism." The justification for this ethic is laid out in detail, and reminds us that health care is a societal good, and that it should be available to all, especially the most vulnerable. What it doesn't say is how we should provide this care, only that these decisions should be made through an ethical process.
Some doctors bristle at any ethics that appear on first glance to conflict with their personal political beliefs. What these doctors must remember is that their responsibilities as doctors is to their patients and to society. If they truly believe the poor are more likely to receive adequate, affordable health care when it is delivered without a contribution from a public welfare system, then they are wrong, but not necessarily unethical. If they simply wish to abolish government provision of health care for the poor because they don't approve of certain behaviors, they are behaving in a way that does not best serve their patients or society.