|Science and Technology in the Transformation of the World (UNU, 1982, 496 p.)|
|Session III: Biology, medicine, and the future of mankind|
|Human aspects of medical sciences: Medical technology and the responsibility of the physician|
The ethical and legal aspects of human behaviour always coincide to some extent but they also always differ. To act in harmony with the law - to do something you are obligated to by the legislative power and to not do what is expressly prohibited by law - is sufficient for securing civil loyalty and civil tranquillity. The ethical dimension, besides this social and institutional dimension internalized by individuals, contains also 8 human dimension, a feeling both social and individual which can make us less worthy both in the eyes of the society and in our own eyes even in those cases when our behaviour is strictly in harmony with generally accepted regulations The physician is not rarely restricted by the regulations of the institution in which he works and whose facilities and capacities he utilizes in the diagnosis and treatment of his patients. If all that he does complies with the accepted norms but he does not do all that he should do, it certainly represents a burden to his individual conscience. Torn between rigorous regulations, the exceptionally great expectations of the society, his own human needs, his other obligations and tasks, and his own conscience, the contemporary physician is in the most complex existential situation, burdened with dilemmas that confront other professions. And what are those specificities without understanding of which one cannot establish the physician's responsibility In the treatment of patients?
It was Talcott Parsons who stated a long time ago that one specific and, let us add, rather neglected form of socialization of modern man is the socialization that implies also training of a healthy man for playing an undesired role, the role of a patient. The basic specificity of this role is that the society has not - at least not always - clearly and precisely defined the obligations and behaviour of the patient either towards the society or, which is in this case the most important point, towards himself. For the problem of the physician's responsibility presupposes his exact and humane performance of a definite role which can bring about a cure only if there is at least a minimum of co-operation from the patient and his surroundings. But that does not make the situation simpler in the least - even when legally the physician bears no responsibility, he is responsible for the state of the whole surroundings, for the existence of the cultures that are in conflict with modern medicine, with health and healthy living of man. for illness, which makes it impossible for man to perform his social roles in the manner in which the society expects him to do, represents not only a physical and physiological handicap but the limitation of man's creative capabilities, his human freedom which is the basis and condition of his human living (Marx).
Another specificity of the physician's role in his diagnosis, treatment, and all other forms of activity derives from the exceptionally high level of social expectations. Truly, such expectations (at least in certain situations) the society places also in other professions whose performance of definite tasks is connected with high risk in the preservation of the life, dignity, and moral integrity of other people or even the whole nation. That is the reason society shows a high degree of tolerance for smaller legal and moral of fences while it reacts very rigorously to any behaviour of the physician that does not accord with the social expectations. Public opinion has become accustomed to the submissiveness and passivity of man regarding his rights, to conformity and apathy, and even to pathological behaviour. But if the public detects the absence of sympathy with man in affliction, bureaucracy and formalism in the medical organization, it reacts very severely. It would certainly be wrong to advise contemporary man to show the same patience in waiting for urgent medical aid as that shown in the slow rhythm of work of today's administrators. The corpus of legal and moral norms regulating behaviours in medical institutions does not express the exceptional importance of medicine itself in man's life. A specific ethical code expresses also a basic social need - in order that the society can function, the behaviour and responsibility of the physician must be exceptional. And yet modern sociology warns us that the contemporary medical organization is nothing else but a functional part of a social totality that has common economic bases, common ideological bases, a complete system of values, a system of stimulation and sanction. In a society in which, to paraphrase Parsons, money represents a means by which messages are transmitted and all values are measured, the medical profession will also be subjected to these influences and measured by the same criteria as other professions, no matter how high its system of values is set. If in the society there is disparity between a humane man's needs and the needs of the given type of society, if there is a split between human essence and human existence, this disparity will inevitably be expressed in the controversial functioning of medical institutions and behaviour of the physician. But independent of the forces that are outside us, in the nature of man and in the humane character of medicine lies the intention of searching for chances to overcome ourselves and the situations that limit us, for higher forms of unity with our own nature and with other people, and this intention corresponds both to the humane and to the exact character of medicine. The sphere of medicine is an area of creation. It is not a passive consequence but an instrument of constant broadening of the sphere of man's power, his sphere of creation, and his freedom.
The specificity of the medical profession is also contained in special skills, knowledge of special techniques whose application in diagnosis and treatment is indispensable. But, as in all other fields, in the field of medicine also an explosive development of new knowledge has occurred, producing such a body of information that what makes up the corpus of modern medicine cannot possibly be encompassed by any individual's knowledge or experience. The constant development of investigations and the application of their results in diagnosis and therapy have brought about continuous specialization and constant narrowing of specialist skills, but it has also brought deeper and deeper penetration into the phenomena that are the subject of investigation and greater and greater exactness and increasingly greater efficiency. The naive mythology of the patriarchal society is gradually replaced by confidence in science, which sometimes does not even rest on positive and rational foundations - we doubt that nowadays there is a physician who has not realized that the expectations of patients very often exceed the actual possibilities of present-day medicine. But what is today beyond our power will tomorrow quite certainly become reality, so in this regard the modern myth contains in itself more realism than all the scepticism of conservatives. However, this situation, ethically and even medico-technologically, makes the role of the physician, especially his share in responsibility, complicated. First of all, In all countries that are in contact with scientific progress, regardless of whether medicine is socialized or based on private practice, in more serious and complicated cases the patient seeks access to first-rate medicine. The foremost medical institutions, university clinics and other renowned institutions, are objectively not in a position to treat all interested patients. Sociological investigations show that patients with more favourable social status, i.e., people with more education, income, and political power and with higher social status and reputation generally seek out medical institutions whose status is also more favourable. It should not particularly be emphasized that most often these are institutions of high reputation, well equipped and with an architectural appearance that inspires confidence. To tell the truth, one should admit that at many institutions whose external appearance, reputation, and even status are in considerably lower esteem, the treatment of patients, from a scientific-medical standpoint, is the same as in those institutions of higher standing. However, among medical institutions there are also those whose reputation is in accord with their discouraging appearance.
The material, technological factor is undoubtedly a limiting factor when speaking about both professional possibilities and the responsibility of the physician. The way out of this situation certainly does not lie in some administrative manipulation of patients but in the scientific, technical, technological, and personnel advancement of all medical institutions to a high level corresponding to the standards of modern science. The initiative which in this regard doctors can and must display will certainly be supported by all democratic forces in society.
Constant specialization, narrowing of the scope of work of specialists, the fact that a precise diagnosis cannot be made only on the basis of personal contact, knowledge, and sympathy, have resulted in a relationship between the physician and the patient which in itself expresses relationships between things to a greater extent than between living people. The present-day patient, if he is in a more complex and better-equipped institution, in many respects reminds us of production material which travels on the assembly line. "Undress," "Get dressed," and "Go to the laboratory" are repeated mechanically, data are heaped up, and the picture becomes more and more complete, but nobody knows what has brought the patient to hospital, what is troubling him, and even what his name is. Let us add that the economic factors demand efficiency from medical institutions, that is, rational expenditure of time, energy, materials, the greatest possible speed at work. The relationship between the patient and the physician has become quite impersonal, and the modern organization attended by powerful bureaucratic trends shows also in medicine a tendency towards "collective irresponsibility" among responsible experts, a phenomenon which Wright Mills revealed in the sphere of political decision-making a long time ago. Who bears direct responsibility for the wrong diagnosis or wrong treatment when in the treatment of the patient twenty, thirty, or fifty experts have participated? This is no literary fable - from medical institutions into judicial institutions are brought cases which even the best legal experts cannot clear up. Obviously, the solution must be found in the medical organization itself which, by using modern techniques and technology without which there is no efficient medicine and by observing the principle of economy of work, has to return the human character to the relationship between the physician and the patient. Not only the biological, chemical, and other techniques but also words, human attitudes, and understanding in the hands of the physician must become again the means by which health is restored.
These several aspects of responsibility seem to us to be sufficient to show that responsibility contains in itself also professional-expert dimensions, that the social dimensions contain in themselves legal, political, ethical, and psychological components, and that what we would call the individual dimensions of this problem have far-reaching consequences for the future not only of the individual but also of the human community. We shall try to define this more precisely.
First of all, what has been established in the medical profession is that there is a tendency towards high professionalism, towards an ideal of the expert who acquires a good reputation through irreproachable work. Although this concept is a remnant from the time when medicine was a trade, it contains in itself very important elements without which one cannot build the internal feeling of responsibility towards the object of one's work, i.e., the patient. This concept implies constant observation, acceptance, and application of the results of science and technology, and any instance of lagging behind modern developments, and thus also of ignorance and inefficiency, it proclaims unethical. Although this ethic takes for its norms the exact principles of science, it represents a very important accelerator not only of scientific progress but also of the humanization of medicine.
However, acceptance of this professional ethic, its intention directed towards innovations and modernization of medicine, does not solve the problem completely. All ethical norms, as a matter of fact, express tendencies in human behaviour around which the actual human behaviour oscillates. Where high professionalism in medicine is concerned, oscillations in the behaviour of the physician can be caused by objective circumstances which restrict or even handicap the physician in his personal development. It is obvious that for certain ways in which medicine lags behind we cannot solely blame the physician. In some environments even with backward technology and relatively obsolete knowledge the physician can play a pioneer and indeed a heroic role in the preservation of man's health. But both he and the social environment should accept neither heroism nor self-sacrifice as compensation for retardation and conservatism. Professionalism implies also criticism towards oneself and others, constantly attaining a higher and higher level. But this attitude sometimes gives rise to pseudocritical forms, becomes an expression of commercialization and rivalry, and leads to the destruction of interpersonal relations within the profession. Instead of constant improvement, security, confidence in oneself and in others, it spreads feelings of fear, distrust, and insecurity, and ultimately deprives the patient himself of his faith in the physician. Colleagueship and understanding which are as important as responsibility do not result only from ethical principles but also from the practical needs of everyday life.
Without underestimating the professional concept of the responsibility of the physician and the role which he has played in the development of medical science and medical organization, and which he will play in the future, it seems to us necessary to emphasize that he alone is not enough to meet the needs of modern society and the needs of progress. In addition to the exact dimensions of professional responsibility ("l've done all I was able to"), the principle of responsibility should also gain dimensions of responsibility to other people, responsibility to the community - not only the local or national community but a universal community in which the physician is responsible for searching for new and higher forms and higher levels of its unity. This conceived principle of responsibility to the community includes, first of all, the responsibility of the physician to himself as a human being who seeks his affirmation and his happiness in bringing about the health and happiness of other people, of the society as a whole. This conceived responsibility does not permit reduction of the physician's responsibility to the professional and routine performance of duties, to the separation of his personal form his social life, but expands it to a creative, critical attitude towards oneself and others, towards the society as a whole. Although these words sound very pretentious, medicine by itself cannot have any destructive pretensions, nor can it become a starting point of deeper social transformation. It has always been part of the given society, a functional part. But in medicine, more than in any other area, as through a prism there are refracted and resolved the problems of the individual, who is to the same degree strangled by the deprivation which time lag brings on and crushed beneath the advancing wheel of modern civilization. With the necessary ability to appreciate the pains, desires, anxieties, needs, and capabilities of modern man, the physician can become an important factor in the solution of his existential problems, which not rarely drive man into illness and death. And this openness and human determinedness of the physician, his critical engagement in the struggle to change the world to which he belongs, that entrance upon the broad social stage, and the increased load of responsibility can be equally useful both to mankind and to medical science.