Oaths for Physicians – Necessary Protection or Elaborate Hoax?

Abstract

The ritual of taking an oath upon graduating from medical school is, with a few exceptions, a routine requirement for graduation. Albeit that many students believe that they have taken the Hippocratic Oath, this is virtually never the case. Very often students themselves write many of these oaths, and taking such an oath impresses the student as well as the public, who are potential patients. It sketches the ethically proper way for physicians to treat their patients. Such an oath is meaningful only when it is not coerced but in reality sketches the physicians' obligations toward patients, society, and each other. The question and problem of a coerced oath are discussed. It is concluded that students when first entering medical school know that such an oath will be a requirement for graduation, and because much of the time the persons taking the oath are writing it, I believe that coercion is not a factor. It is an unfortunate fact that throughout the nation students who are known to behave in ethically inappropriate ways are nevertheless allowed to graduate. Possible ways of addressing this troubling situation are discussed. Equally troublesome is the fact that we who administer the oath as well as the students who swear to it are aware that the system of medical care makes it extremely difficult and at times impossible to truly adhere to the full implications of this oath. According to the oath, physicians (in virtually all formulations) swear that social standing (and by implication economic factors) will not change the way in which patients are treated. This becomes impossible when uninsured patients are sent away at the front desk long before the physician can interact with them. Furthermore, the current fact that physicians often are confronted with not doing what they consider a necessary test (or prescribe what they think would be the best medication) raises the problem of either lying or suggesting to the patient that he/she do so – a fact that in the long run cannot help but damage the physician's veracity and the trust which patients put in their physicians. That virtually all codes of the American Medical Association (AMA) as well as the various specialties insist that physicians work toward universal access is stressed.

Introduction

One of the reasons frequently given by physicians to justify the standing and respect that they enjoy in society is that they have (in general) taken a patient-centered oath (similar to but not necessarily identical to the “Yale” oath) that has the Hippocratic Oath as the forefather. The old Hippocratic Oath is no longer suitable for modern times and is, therefore, subject to a variety of interpretations.[1–5] Depending on the individual, such oaths may be perceived critical to the way in which a particular physician perceives himself or herself, or it may be seen as another rite of passage, important in form but unimportant in detail. Even, however, if it is believed to be merely a symbolic rite of passage that does not become a part of what an individual thinks he/she is, it does constitute a public avowal and a public pledge. These oaths almost invariably promise, above all, fealty to one's actual or potential patients and to work for their good regardless of religion or lack thereof, race, ethnicity, gender, party or socioeconomic considerations. It is said to be “freely” taken and not to have been coerced.

In this article I want (1) to examine the concept of “oath” and try to differentiate an oath publicly made from a promise given to another individual; (2) to cast a somewhat skeptical eye on an oath that some may view as being essentially coerced and ask whether it is reasonable to make such an oath a condition of graduation; (3) to ask why the profession so frequently fails to sanction persons violating their oath; (4) to discuss the regrettable fact that we who administer the oath and the fledgling doctors taking the oath know fully well that the way in which society is constituted today, part of that oath is bound to be violated; and (5) to conclude from this that physicians who take such an oath are at least obligated to work for conditions making its implementation possible.

On Oaths in General and Medical Oaths and Codes, in Particular

An oath is a public statement or promise to behave or not to behave in certain ways. It is sworn by some thing or things that are precious to the taker of the oath. A promise, one would think, would be something that honorable men and women would keep as a matter of course. Unfortunately (and I am afraid increasingly), this world is hardly made up of honorable men and women of whom a handshake suffices to seal a bargain or who, when such a bargain is complicated, are satisfied with an initialed note spelling out the particulars. That this is not the case in today's culture is obvious.

Oaths, as Sulmasy so well puts it, are like promises: They are “performative utterances” that in general have “more moral weight” because they (1) are “public utterances,” (2) appeal to something held sacred, and (3) appeal to “consequences should they fail to be kept.[5,6]" To swear before a court “to tell the truth, the whole truth and nothing but the truth” implies that, in our culture, without such an oath a person might well feel at liberty to lie: yet the prima facie duty not to lie is, and should be (for otherwise discourse would be pointless), an obvious obligation no matter what ethical theory one might subscribe to or in what culture one finds oneself. Swearing in court, however, carries the additional weight of consequences for such a lie – a charge of perjury.

Perhaps an oath is useful in impressing the gravity of the situation, and perhaps the fact of swearing to such an oath and knowing that not keeping it may have consequences (in self-esteem if not also in the eyes of colleagues) is at least as important as its contents. The medical oath, adapted as it is to modern situations, may well serve this purpose. An oath is a public declaration by which someone promises to adhere to certain ways of behaving as well as to ethical standards and/or activities. Oaths are generally not legally binding, but exist alongside legislative restrictions. In essence, they are a declaration of intention, a public promise of fidelity sworn no longer in the name of the “Gods” in which many of us no longer believe but on our honor (which, one would hope, is precious to us). Persons taking this oath bind themselves to being sanctioned should they fail to keep to the oath (the stick) and in return (in most oaths), to have the reward of a long experience in the joy of healing (the carrot). I have picked out two of several oaths not because I think them superior but because they seem to encapsulate briefly what almost all modern oaths are about, and what, in my view, being a physician – no matter in what field – is all about.

Yale Oath

Now, as a new doctor, I solemnly promise that I will to the best of my ability serve humanity caring for the sick, promoting good health, and alleviating pain and suffering. I recognize that the practice of medicine is a privilege with which comes considerable responsibility and I will not abuse my position. I will practice medicine with integrity, humility, honesty, and compassion working with my fellow doctors and other colleagues to meet the needs of my patients. I shall never intentionally do or administer anything to the overall harm of my patients. I will not permit considerations of gender, race, religion, political affiliation, sexual orientation, nationality, or social standing to influence my duty of care. I will oppose policies in breach of human rights and will not participate in them. I will strive to change laws that are contrary to my profession's ethics and will work towards a fairer distribution of health resources [italics mine]. I will assist my patients to make informed decisions that coincide with their own values and beliefs and will uphold patient confidentiality. I will recognize the limits of my knowledge and seek to maintain and increase my understanding and skills throughout my professional life. I will acknowledge and try to remedy my own mistakes and honestly assess and respond to those of others. I will seek to promote the advancement of medical knowledge through teaching and research. I make this declaration solemnly, freely, and upon my honour.[7]

Weill Cornell Medical College's Hippocratic Oath

I do solemnly vow, to that which I value and hold most dear: That I will honor the Profession of medicine, be just and generous to its members, and help sustain them in their service to humanity; That just as I have learned from those who preceded me, so will I instruct those who follow me in the science and the art of medicine; That I will recognize the limits of my knowledge and pursue lifelong learning to better care for the sick and to prevent illness; That I will seek the counsel of others when they are more expert so as to fulfill my obligation to those who are entrusted to my care; That I will not withdraw from my patients in their time of need [italics mine]; That I will lead my life and practice my art with integrity and honor, using my power wisely; That whatsoever I shall see or hear of the lives of my patients that is not fitting to be spoken, I will keep in confidence; That into whatever house I shall enter, it shall be for the good of the sick; That I will maintain this sacred trust, holding myself far aloof from wrong, from corrupting, from the tempting of others to vice; That above all else I will serve the highest interests of my patients through the practice of my science and my art; That I will be an advocate for patients in need and strive for justice in the care of the sick [italics mine]. I now turn to my calling, promising to preserve its finest traditions, with the reward of a long experience in the joy of healing. I make this vow freely and upon my honor.[8]

The AMA Code of Ethics,[9] although not an oath but a statement of ethical conduct, is accepted by physicians as a legitimate statement of duties of behavior to which all physicians should subscribe. The AMA statement is not an oath but a model, which those belonging to the AMA (or even those not belonging) accept as a fair statement of behavior and duties of all physicians. It does not differ essentially from what is considered proper behavior in other Western democracies:

Preamble

The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct that define the essentials of honorable behavior for the physician.

Principles of Medical Ethics

1. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.

2. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.

3. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.

4. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.

5. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.

6. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

7. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.

8. A physician shall support access to medical care for all people.

These oaths together with the AMA Code of Ethics are what most of the public not unreasonably expects of its physicians today. When I received my bachelor of arts from New York University (NYU) all divisions of NYU graduated together – undergraduate, medicine, law, doctorate, master of arts, etc. Mrs. Eleanor Roosevelt was speaker for the graduating medical students. I remember what she said: “The Gods are different, the times are different but the underlying precepts of caring for the sick wherever or whoever they may be remain the same.” Consistent with her remarks, I believe that the cardinal points of all such oaths are as follows:

1. Service to humanity, caring for the sick, promoting good health, and last but not least alleviating pain and suffering.

2. A promise of integrity, honesty, humility, and – above all – compassion.

3. A realization that although harm is inevitable it must be outweighed by benefit.

4. Gender, race, religion, political affiliation, sexual orientation, nationality, or social (and in some oaths by implication and in other oaths in so many words) financial standing shall not influence the physician's judgment.

5. A promise to oppose policies in breach of human rights and a promise not to participate in them. Physicians will strive to change laws that are contrary to their profession's ethics and will work toward a fairer distribution of health resources.

6. A promise to recognize mistakes in self and others, and to learn from them.

7. A statement that teaching those who come after us as well as our colleagues and learning from them as well as research leading to better patient care in the future shall have an equal standing as does patient care today.

8. This promise is made freely and without coercion.

An Oath Made Freely

I think that the prospective physician having to take an oath that promises to place the biopsychosocial interests of the individual patient first while at the bedside and to work for a healthcare system that is accessible to all is not coercive to students as long as students are aware before they enter medical school that taking such an oath will be one of the requirements for graduation – no more and no less than anatomy or a clerkship in medicine. After all, the medical profession owes to society a promise that the physicians who the profession ultimately licenses not only have sufficient technical knowledge but that, to the best of our knowledge, he or she is an honorable person. The problem with such an oath is that to pass anatomy or the medicine clerkship, the student has to have a minimum of knowledge as determined by the faculty. It is very difficult to ensure that students have character traits that allow them to prescribe poisons or cut patients. We, the faculty, have been delinquent in setting ethical standards that if violated will cause a student's dismissal. Over the years I have clearly seen students who were sociopath or psychopath graduated because they were “technically” good students. I have no proof, but I am quite sure that some students take the oath “tongue in cheek.” I am quite sure that Dr. Swango (an MD who was a serial killer of patients and who, although suspect and even fired, easily found another job),[10] had no intention of keeping this oath, nor do the small number of students who are sociopaths or psychopaths.

Finding a way of detecting students who are ethically questionable and then dealing with them effectively is by no means an easy task. For example, cheating on examinations is certainly one of the more frequent occurrences rendering the individual ethically problematic. Is it, however, an obligation for other students to report their suspicions? On the one hand, one is certainly ill-advised to encourage students to report each other, and one may get into a greater mess than we bargained for. It can, for example, lead to falsely reporting a colleague of whom someone wishes to wreak vengeance for a variety of reasons. On the other hand, detecting such persons may be most difficult but not impossible.

When I was an undergraduate at NYU, I was certain that the person sitting next to me was copying the answers. It was a multiple choice examination, and he seemed to me to be checking the same boxes as I was. The professor – one of the best I have ever had – had distributed the test with exactly the same questions but in completely different order. Not only did my neighbor fail the test abysmally, but it was also quite evident from whom he had copied.

We should – as a faculty and with the help of students – set up a clear standard of ethical behavior that would, if breached, result in dismissal. Serious ethical breaches are not something that can be remedied by repeating a year or by learning more “facts.” A cognitive deficiency, if possible, should be remedied early. If, despite every effort on the part of the faculty, the student still does not meet the expected criteria, dismissal will not be seriously challenged. It could, conceivably, be remedied by repeating a year. There is, however, no point in trying to remedy ethical failings cognitively. Taking a course in healthcare ethics is not liable to make an ethically sounder and more empathetic physician. On the contrary, because teaching ethics is properly teaching students to think clearly and to make good and sound arguments, intensively teaching ethics above and beyond what other students have learned could easily make such a student merely more dangerous.

After all, we teach students “medicine” not in order to make them healthier (albeit that we may hope that they will themselves adhere to a healthier lifestyle), but to handle their patients' biomedical problems more successfully. Likewise, we teach them healthcare ethics not to “make them more ethical,” but to make them more sensitive to ethical problems in their practice and to give them the tools that are necessary to deal with them. It is a most difficult problem that has never, to my knowledge, been adequately handled. However, it is a problem that we must at least start to recognize as an imperative and consequently to work on setting up fair but strict criteria, which are known to the student.

For example, it seems obvious that convicted felons should – even after they are released from prison – not be allowed to enroll in medical schools or practice. This sounds harsh: After all, the felon “has paid his price to society” (whatever that means) and should now be able to engage honorably in an honorable profession. Against this, we on the faculty have 2 duties, both of which in the final analysis are social: (1) We must make sure that students have learned enough cognitive material to practice under supervision as interns and (2) – perhaps even more importantly – that students are persons who can be reasonably counted on to act ethically and not take advantage of their power over patients. We can derive this from common sense or from the oath's provision to keep patients from harm. As usual, there is an ethical quandary: (1) We can protect society by not giving a prior felon the chance to harm patients, or (2) in fairness to the previous felon, who has “paid his debt to society” (whatever that is supposed to mean), we may consider his slate wiped clean and protect the aspiring student.

I would argue that our duty to society and to future patients is greater than the obligation we have toward the freed felon and that, therefore, erring (and erring it certainly and unavoidably is) protecting patients and society is the lesser of 2 evils. However, that is an unusual situation, and not one of those we are likely to encounter. We will and do meet situations that, although not as egregious, may be far more dangerous in the long run. I think here of students who cheat, lie, falsify clinical records, and treat patients or fellow students of a different ethnic background or sex differently from they would others or are caught in other fraudulent situations. In my experience – and that of many of my colleagues – we have graduated the undoubted sociopath or psychopath, and have graduated students who falsified records, stolen books, and repeatedly made obviously demeaning remarks about patients or colleagues.

I remember serving on a “promotions committee” (a wonderful euphemism for committees constituted to deal with inadequate students) when we graduated a lady who had, on several occasions, lied to the dean, been involved in a murky credit card deal, had assaulted her husband so that he landed in the emergency department, etc. Although the chair of the committee remarked that she was “probably more dangerous than Swango,” everyone except myself voted to allow her to graduate because she had good grades and they feared a suit. I insisted that my “nay” vote be recorded: I can foresee the day when a medical school is justifiably sued for graduating a known ethically unacceptable physician. Over the years, I could mention a number of other such problems, but almost anyone who has been actively involved in teaching in medical colleges or in residencies knows whereof I speak.

The medical oath taken upon graduation is not legally binding but has a powerful psychological influence both on the person who took it and on those who trustingly place their lives in these persons' hands. However, because of the way medicine is practiced today, we who administer the oath as well as those who take it know fully well that some portions of the oath cannot be adhered to. Most of the oaths imply (but do not state) that patients will be cared for regardless of their financial standing. This is, I believe, implied when the oath clearly states that I will not permit considerations of gender, race, religion, sexual orientation, nationality, or social standing to influence my duty to care for those in need of my service. Although this is the language taken from the Yale Oath, it nevertheless in almost the same form appears in all oaths examined. It is somewhat disturbing that the explicit injunctions not to be influenced by gender, race, etc, skirt the economic issue by tacitly sweeping it under the rug of “social standing.”

Because economic standing is virtually implicit in social standing, we who administer the oath and our colleagues who take the oath are fully aware that because a majority of physicians will practice in a health maintenance organization/managed care organization (HMO/MCO) setting, they will not even be able to make a judgment about a patient's illness (the receptionist at the outer desk will have sent away the uninsured – that is those whose social standing was not of an adequate level to be seen until refuge in an emergency department had to be sought, and often too late). Further in our reality today, physicians are not free to treat their patients in the way that their judgment suggests: Before many tests, referrals, interventions, and medications can be prescribed for patients, HMOs, MCOs, and various insurance companies have to approve. Often these approvals or disapprovals are done by laypeople who follow a given set of rules, and physicians are forced to literally fight their way up the ladder until they can speak to a physician who then makes the final judgment over the telephone without ever having seen the patient.

A law never intended for this purpose (Employee Retirement Income Security Act [ERISA]) makes it possible for these arbiters to claim that they were not engaged in the practice of medicine when they make the use of a given procedure, medication, or intervention impossible or limit a patient's access to a consultation deemed necessary by their physician. On the issue of universal access, the AMA code is quite explicit. Whatever system we finally decide on – and the current state of affairs is not a system, but chaos – we are, in the interim, ethically compelled to work for a system in which every patient who feels the need for medical care has complete access to it.

Professional Sanctions

It is surprising – and disheartening – that medical boards are quite ready to either reeducate or otherwise sanction physicians who have a record of consistent malpractice or to give help to those who are substance abusers, but that medical societies are hesitant to deal with ethical violations. This is very similar to the problem at medical colleges I mentioned above. Trying to reeducate physicians who have a record of malpractice is, I think, as it should be – especially if every effort to reeducate the physician or to “bring him up to speed” is successfully made and his performance monitored. It is certainly necessary to give as much help as we can to our colleagues who have become substance abusers. Unfortunately, there is little that can be done to educate physicians who grossly violate medical ethics – we may possibly change outward performance but will probably do little to change inward intention.[1] It is well and good to change behavior, but if the change is purely one of outward performance without any inward change, then physicians will adhere to what they consider “silly rules” while they are watched and promptly violate them when they think that they are not being watched.

It is, likewise, disheartening that other gross failings to keep the oath rarely call forth an investigation. For example, a physician in California was found guilty of allowing a terminal patient to die in agony by refusing him the narcotics necessary to obtund pain. This is, unfortunately, not a rare occurrence. While dealing with the pain of cancer has substantially improved in the last few years, the pain of other and at least equally painful chronic diseases continues to be inadequately controlled. Pain control is badly done in most of the world, and while it is physicians who routinely deal with pain control, it has been shown that their callousness oftentimes increases through the years. And yet the chief complaint of most patients visiting a physician is pain. We have improved in treating the pain of malignancies, but we have improved little in the treatment of the pain of other chronic and very often equally painful diseases.[11–17] That, too, is not merely a medical error; it is likewise ethically unsound and violates the oath physicians take. Thus, it not only constitutes malpractice in the sense of deviating from what is accepted as proper practice, but malpractice in an ethical sense as well. To cure sometimes, to relieve often, to comfort always is a precept to which all physicians pay lip service but frequently fail to act upon.[18]

The medical board, while making note of it, failed to sanction this physician for what clearly was malpractice because there had not been repeated complaints. Had this physician knowingly failed to treat pneumonia or urosepsis with antimicrobials, there is little doubt that he would have been censured. There is little question that this was not only an instance of malpractice but – and at least as egregiously – a failure to live up to the oath and an act of sheer callousness, a state of affairs that should never be tolerated.

There are many reasons for hesitating to censure a colleague for what amounts to moral failure. It is easier and somehow less embarrassing to call someone on the carpet for making a technical error than it is to do so for a moral failure. All of us are far more ready to admit (if only to ourselves) to having made a medical error. Repeat technical errors can often be corrected by reeducation – I have serious doubts that an ethical failure can. Most of us cannot claim to be “without sin” – and our knowing this makes us hesitate to point out an ethical failing to a colleague and perhaps friend.

I was personally involved in a case in which the local medical society had finally succeeded in having the license of 3 physicians revoked. These physicians had had their staff privileges withdrawn from all hospitals in the area and were, we felt, practicing dangerous medicine. Since virtually all patients received injections of some sort, they were called “shot doctors.” It happens that I became involved when a patient chanced to come into my office because she felt horribly ill. She arrested in my office, where I luckily had a defibrillator and other necessary items to resuscitate her. It turned out that this group of physicians tried to keep patients in digitalis toxicity as an aid for suppressing their appetite and that just about half an hour earlier, this woman had received intravenous cedilanid.

After admission to the hospital and after she had been stabilized, we very bluntly and repeatedly pointed out to her what had happened and warned her not to return to these physicians. She did well and was discharged – only to return to the very physicians who could easily have cost her her life. In the meantime, the local medical society had amassed a large amount of data demonstrating failure to practice within acceptable limits and recommended to the State Board that their license be withdrawn. The Medical Society was promptly sued for “restraint of trade” and the physicians promptly regained their license. Such an experience makes physicians as well as their societies hesitant to act even in situations in which there is evident poor medical practice – let alone to try to do this on some sort of ethical failing.

The Physician as Advocate of the Poor in Today's Managed Care Environment

The function of medical colleges (as it is of all schools) is to foster good habits in their students: habits of proper history taking and physical examination, habits of critical thinking, habits of proper behavior while engaged in their professional duties, habits of “keeping up with the literature”, etc. I reiterate that I strongly doubt that subjecting a physician to a course in healthcare ethics will change their habits – when they believe themselves observed, their behavior for purely prudential reasons may change; that what we call their “character” is, in my view, unlikely to change. In some respects, we who are their teachers or preceptors are at fault.

In the managed care environment, physicians are no longer free to order medications or clinical tests or procedures, are no longer free to send patients for a consultation (which today, after all, constitutes an admission by physicians that they may be in over their heads) or free to do procedures they deem necessary. In order to have certain tests done, for example, the patient must fulfill certain predetermined criteria. And, after a while, physicians get used to acting in a way they know to be wrong and shrug it off as a “system error.” By “system,” I mean something that has internal coherence and controlling elements – the CV system or governments are examples. A brief paragraph from the holocaust literature points out the danger of the “system”:

…a political, economic, or cultural system insinuates itself between myself and the other. If the other is excluded, it is the system that is doing the excluding, a system in which I participate because I must survive and against which I do not rebel because it cannot be changed. … I start to view horror, and my implication in it, as normalcy.[19]

A system is not a “natural occurrence” such as a tsunami or a hurricane. It is something that – especially in a democracy – we construct and then are expected to continue to monitor. Imagine a patient whom you suspect of possible cancer of colon or stomach and you, the primary care physician, feel that he or she needs a colonoscopy or gastroscopy. The patient, however, denies ever seeing blood with defecation. Unfortunately, that happens to be one of the criteria. There are 3 roads open to you: (1) you can spend countless hours arguing with the clerk who denied the request and finally battle yourself through to a physician who may or may not permit the procedure (It is not something that a physician in a busy practice can do often); (2) you can refrain from doing what you think necessary and violate your oath, which quite clearly states that you will do what you consider best for every patient; or (3) you can lie and put down bleeding or coerce the patient into lying and admit to seeing blood. The first option is time-consuming and in many practices simply not possible; the second option clearly violates your oath; and the third either causes the physician to lie or encourages the patient do so. Lying, or suggesting to another that he or she lie, is hardly a habit that one should encourage in anyone – especially not in physicians!

You can, of course, choose a fourth road and tell the patient why you think a particular investigation, medication, or procedure is indicated but that the insurance company will not allow it because it does not meet all of its criteria. This may result in causing undue anxiety to patients; encourage them to lie in your stead, deluding yourself into believing that you have kept your hands clean, and send the message that lying to your physician so that he can lie for you to the insurance company is perfectly all right. The message that lying is not so bad after all is loud and clear. For a physician to knowingly distort the patient's history is, furthermore, destructive to the whole enterprise of patient care. Honesty is a keystone of mutual trust and confidence.

To Keep From Harm

A conversation with a neighbor (who certainly does not live in an impoverished area) at a pharmacy, as quoted by Dr. Miles, should send shivers down our spine:

Dr. Miles, I would like to ask you a question. My husband and I are on blood thinners. We share those pills – each of us gets half a dose because we cannot afford two prescriptions. But, what I really want to ask you is this: I have both congestive heart failure and breast cancer, for which I am taking two costly medicines. I cannot afford them both and am planning to stop one of them. So, I'd like your opinion on which one to stop. Is it less painful to die of breast cancer or congestive heart failure?[20]

It is obvious that this is a system error. My wife, picking up my medications from the drug store, was preceded by a gentleman who takes only what medications he considered to be “essential” and regretfully gave back those he simply could not afford. We do not live in an impoverished area, and that this even happens to residents here leaves one imagining what happens in poverty-stricken areas. My wife inquired the clerk at the pharmacy counter what was going on, and she shrugged and said this happens several times a day. When asked how she felt about this, she shrugged her shoulders and said, “That's the way it is; it isn't my problem.” This is a beautiful example not only of what the “system error” has done to our character but a sad reflection on the way we feel about the plight of our neighbor. Simply accepting the “way it is” without trying as a citizen to make at least others aware of these repetitive tragedies but simply “shrugging our shoulders” is unbecoming to a society, which appears to have lost its sense of outrage.

The average pay in the United States is $8.50/hour, which is a little under $16,000.00 per year – or well below the poverty range of a small family. Usually such jobs carry no health insurance and other benefits, and even if they do, patients often cannot meet the copayment. When they do carry health insurance, which permits them hospitalization, laboratory examinations, x-rays, etc, they appear as “fully insured” in our statistics. Yet this is a lie if the copayment for each visit, each test, and each procedure is so formidable as to make it impossible for them to do many of the things the physician ordered. It is quite likely that such patients become labeled as “noncompliant.” Very often they are too proud (whether that is reasonable or not, it is so, since an emotional response cannot be dictated) to tell their physician that they are too poor to buy the medication. This is a humiliating shame and one which we as physicians – since it affects health, disease, and the ability to buy medications – cannot ignore if we are to act ethically. There are many ways in which we as single physicians and as an organized body of physicians can work to alter this state of affairs.

When confronted with a “system error” it is not enough to call it that, shrug, and comply. If we are to follow the oath we take or if we pay any attention to the AMA code of ethics, we are obliged to do something about such recurring system errors. In this case we have an obligation both as citizens and as healthcare professionals. What we can do varies with the position we occupy: we can lecture, write, persuade our professional association to lobby, speak to our patients and to civic groups – physicians, like other people, have different talents. But to simply shrug off something you feel is necessary for your patient that your patient agrees to but the HMO/MCO will not approve is akin to abandoning your patient and violating the fiduciary relationship you have. Above all, we should stop seeing ourselves merely as individual selves and realize that if we unite to bring about a change in our inequitable, inefficient, costly, and basically inhumane approach to healthcare or other social systems, we can truly act as a “we,” forcing the legislature and the politicians to come up with a system of uniform access – not the details of a solution but a recognition of the fact that we have egregious social problems of which healthcare is one, and that it cannot be properly dealt with if we see it as unconnected to the others.

If we take our oath and our commitment to our profession seriously instead of feeling that we are merely employees who are ethically committed to do a good job within the limits set by our employer, we are violating our oath – or, even worse – believe that we are discharging our obligations to the best of our ability. The oath we take (tacitly or explicitly) not only enjoins us to “serve the highest interests of our patients through the practice of our science and our art” but likewise expects us to be “advocates for our patients in need and to strive for justice in the care of the sick.” Shrugging our shoulders when our patients cannot afford to pursue what we and our colleagues feel are necessary tests, procedures, or medications because we are confronted with a system error, or resorting to habitual lying in dealing with a recalcitrant system, is treason to our patients, to our art and not least to ourselves.