There are two significant and related threats to the future of medicine as listed in the preamble that prompted this declaration.
Firstly there is the pressure from consumer groups, groups with specific agendas (e.g. abortion, euthanasia), and health bureaucracies to redefine the doctor/patient relationship as a service provider/consumer relationship where the doctor provides what the consumer wants or needs according to the consumers perspective and consistent with legality.
The related threat that arises from that understanding of the relationship is for this provision of service to become compulsory by law as has happened in Victoria with the 2008 Abortion Reform Law.
The doctor/patient relationship is so much more than mere service provision and is at risk even without being subject to compulsion by the law. The uniqueness and complexity of this is reflected in the Hippocratic Oath and in recent times with Michael Balint and the International Balint Federation.
Balint did not invent the doctor–patient relationship; however, he was the first to explore this in the context of general practice, in which that relationship remains central despite the huge social and political changes that have affected the delivery of health care in the half-century or so that has passed… A commercially driven, materialistic society has also served to alter our relationship with patients, with defensive medical practice the most extreme example. Yet for all this the empathic awareness of the doctor remains a key tenet of practice. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1464079/
Empathy and intuition add to the doctor/patient connection in a way that cannot be known unless it is experienced or observed closely. Einstein wrote of this: Intuition is a sacred gift; rationality its faithful servant. When the doctor has met the patient’s point of need as the patient perceives it, intuition helps a doctor to move beyond that to meeting the unexpressed and often unrealised point of need. The ideal doctor/patient relationship enables the doctor to add something to the patient’s life – for the patient to leave the surgery richer than before, not only with more knowledge and understanding and responsibility to their part of the relationship but also strengthened to face another day. The rapport that is established with this kind of personal relationship also gives strength in the patient’s last illness particularly if the treating doctor is able to keep the dying patient at home.
Health bureaucrats concerned with economic rationalism may not understand this kind of professional relationship unless they have experienced it for themselves. Our primary, concern must always be with patient health and not just be providers of Government-defined medical services on demand.
But the threat to the relationship is not only from consumers and health bureaucrats, it is from ethicists in high places. Expatriate Australian Professor Julian Savulescu, Director of the Oxford Uehiro Centre for Practical Ethics has said
“If people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors” (BMJ 2006;332:294-297 February 4).
Conscience in Medicine considers any application of the ethos behind this statement to be to the detriment of the doctor/patient relationship and to the future of medicine ultimately reducing doctors to a mechanistic role. Fortunately codes of practice still support the value of the doctor/patient relationship as the following excerpts show:
Good Medical Practice: A Code of Conduct for Doctors in Australia — July 2009 (AMC)
1.4 Professional values and qualities of doctors
Doctors have a duty to make the care of patients their first concern and to practise medicine safely and effectively. They must be ethical and trustworthy. Patients trust their doctors because they believe that, in addition to being competent, their doctor will not take advantage of them and will display qualities such as integrity, truthfulness, dependability and compassion.
The opening sentence of the declaration preamble on the home page is based on the phraseology in this excerpt.
AMA Medical Professionalism 2010.
3.1 Medical professionalism embodies the values and skills that the profession and society expects of doctors. Through adherence to medical professionalism, doctors fulfil their duties to patients and the wider public.3.2 Although individual doctors have their own personal beliefs and values, the medical profession upholds a core set of values, including (but not limited to):
- respect,
- trust,
- compassion,
- altruism,
- integrity,
- justice,
- accountability,
- protection of confidentiality,
- leadership, and
- collegiality.
3.3 The profession upholds a commitment to:
- teaching and mentoring,
- participating in and promoting medical research,
- collaborating with colleagues and other health professionals, and
- advocating for social justice and the public health.
3.4 Doctors are also expected to commit to the highest ethical and professional standards of conduct and performance. This involves continuing self-appraisal, ongoing professional development, taking responsibility for one’s own health and well-being, supporting impaired colleagues, and protecting patient safety.
The loss of liberty of conscience is probably the biggest challenge facing our future as doctors and is why this declaration exists. It has been truly said that
The obligation to practice conscientiously is the obligation on which all other medical ethics are built. (Dr Farr Curlin, MacLean Center for Clinical Medical Ethics, University of Chicago).
As a specific response to the Victorian legislation a conference on Conscience Laws & Healthcare was held in Melbourne in July 2009 http://www.vimeo.com/7809169.
A good overview of the Victorian legislation was given by Senator Julian McGauran in a Senate speech in August 2009.