Medical Education

MEDICINE IS A VOCATION

Ronald McCoy

Medicine is the science and practice of preventing, diagnosing, and treating disease. It had its origins in ancient Greece in the 7th century BC and is one of the oldest and most respected professions in the world.

Perhaps the best known name in the history of medicine is that of Hippocrates, the Greek physician who gave his name to the Hippocratic Oath and founded the Hippocratic school of medicine, which greatly influenced medical science until the 18th century. Incredibly, his followers believed that health was governed by the balance of four body fluids or humours: phlegm, blood, black bile and yellow bile. Of course, medicine has come a long way since the “balance of four body fluids,” with recent advances in molecular biology and genetics which promise to revolutionise therapeutics in the future.

But today, we are going to look at the profession of medicine in terms of its philosophy and social responsibility, because medicine seems to have lost its way in a rapidly changing world. Both the profession and society are forgetful that medicine has an imponderable spiritual core that could be called its soul. Medicine is a profession, unlike any other. It is not a nine-to-five job, nor a trade or a business that brings in a respectable income to provide a comfortable lifestyle. It is an exquisite blend of science and art. Medicine is essentially a vocation or a calling, which demands a lifetime of dedicated care for the sick and infirm. A vocation is an occupation that is distinguished by altruism, a sense of social responsibility, and fulfillment of an ethical or spiritual need. The word “vocation” is derived from the Latin “vocare,” which means “to call.”

For the past five or six decades, we have witnessed a decline in the age-old values and ethical traditions of our healing profession. Perhaps, benign neglect of the philosophy of medicine and medical ethics in medical education, before and after graduation, has weakened professionalism and the ethical foundations of medicine.

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The core values of medicine are being submerged and lost in the materialistic paradigms of the modern world of private enterprise and business, marketing and advertising, wealth accumulation and consumerism. These paradigms are being embedded in a changing global culture, which has been largely subsumed by the concepts and methods of market economics. While medicine cannot change all aspects of global culture, nevertheless, the medical profession can and must exert its considerable influence in society and ensure that negative economic and cultural forces do not undermine or dismantle medical professionalism.

Professionalism is governed by an agreed set of rules and standards of practice and conduct, determined by the profession and society in the public interest. It is important that the medical profession does not interpret professionalism as a licence to serve the interests of the profession itself, rather than the population it has a duty to serve. It also has a duty to maintain professional standards, independent of political influence but accountable to the public it serves. Apart from knowledge, it is professionalism, ethical practice and compassion that transform a doctor into a healer.

Despite modern health systems and profound advances in medical science and technology, patient-care studies show a steady decline in public satisfaction and trust in the doctor-patient relationship. Although a significant number of patients are satisfied with their individual doctors, there is discontent with the total health care experience and a growing movement towards alternative and complementary medicine. A Mori poll in 1999 asked a random selection of the public to say which professionals could be trusted to tell the truth. The results were: doctors 91%, judges 77%, scientists 63%, businessmen 28%, politicians 23%, and journalists 15%.

In Malaysia, part of this disenchantment with modern medicine is related to the low morale of health professionals, particularly in the public sector. Overworked and underpaid doctors and nurses in public hospitals are experiencing exhaustion and

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disillusionment with a system that does not show sufficient respect and compassion for its workforce, a system that does not show enough commitment to providing health care for all, a system in dire need of radical reform.

Private health care is being set up in the marketplace and exploited for profit by businesses, insurance companies and managed care organizations. An emerging commercial culture is dehumanizing doctor and patient alike, causing glaring inequalities in health care and testing the moral leadership of the medical profession. If medicine is allowed to become a business, doctors will become businessmen. Doctors are being reduced to replaceable “providers” and patients to generic “consumers.” In managed care organizations, doctors resemble factory workers, processing patients as items on a conveyor belt. The Malaysian government is promoting health tourism and touting health care as a saleable commodity, calculated to increase government revenue and inflict a brain drain of specialists from government and university hospitals to the private sector.

The crisis in health care is partly an economic crisis of rising health care costs, but the profound crisis in medicine is a crisis of doctoring and the relegation of medicine as an occupation like any other. Education in general has become an institutional and mass production process. It is widely recognized and recommended that the needed improvements in the quality of health care require fundamental reforms in medical education. The two most important responsibilities of any government are the provision of quality education and affordable, universal health care.

In Malaysia, private medical schools are multiplying without stringent regulation of curricula, teachers, and teaching standards, often as a result of political and business pressures. The medical profession in Malaysia has a duty to respond to such challenges and ask decision-makers if they realize that the health of the next generation of Malaysians will be at risk from inadequately trained health professionals.

A three-thousand-year tradition, which forged a bond of trust between doctor and

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patient, is being traded for a new kind of relationship. Healing is being replaced with treating; caring is being displaced by the technical management of disease; the art of talking and listening to the patient is being supplanted by the hum of sophisticated medical equipment. The human body is seen as a repository of unrelated, malfunctioning organs, often separated from the doctor’s healing touch by cold, impersonal machines.

This is not to undervalue science and technology. On the contrary, healing is best achieved when art and science are conjoined, when the practice of medicine reveals a compassionate human face, when doctor and patient form a bond and a caring partnership of equals.

In developing the means for modern health care, society has forgotten the “meaning” of medicine. Medicine is primarily a humanistic endeavour, not a purely scientific one. Science and technology have a rightful place, but medicine is a healing profession, and the contribution of a doctor adds up to more than the sum total of his or her knowledge and skills. We often forget that the patient is a person who is far more important than the illness; that illness is far more important than the presence of disease; that, when a disease is not curable, the empathic care of the patient and grieving family provides hope and comfort. Our technological society is often blinded and carried away by a belief in the technological fix and fails to see how we might treat each other as ‘flesh-and-blood’ fellow human beings.

Another flaw in modern medicine flows from the application of mercantile imperatives to health care. The profession and society need to isolate and combat the contagion of materialism and commercialization of health care, by re-injecting core human values into the corpus of medicine. The soul of medicine is in dire need of redemption.

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Visions of health for all

The 1978 Alma Ata vision of Health for All and the World Health Organisation’s policy of Health for All in the 21st Century have laid down global priorities and targets which could create conditions for people worldwide to achieve and maintain the highest attainable level of health throughout their lives.

The medical profession has a moral and professional responsibility to champion and help to create the conditions that will provide the basic human right to life and health. As the social conscience of the international community, the medical profession must press governments to develop the political will to be focused and committed to turning the vision of health for all into a practical, universal, and sustainable reality.

It is in this context that the medical profession has a social responsibility to be committed advocates for the alleviation and eradication of poverty and inequity. At the same time, the profession also has a public health responsibility to support those working to protect the environment from the impact of ecologically unsustainable economic development and other human activities, which are now exceeding the physical and ecological limits of the planet and causing environmental damage, pollution, global warming and climate change, all of which have serious health consequences.

In addressing poverty as the largest single social determinant of health, the profession has a fundamental duty to monitor economic globalization and work with advocacy groups to ensure that it will bring benefits for all. Already, there is evidence that trade liberalization and capital flows are increasing inequality, within and between countries, and undermining the provision of quality health care.

Economic inequalities have been widening steadily for almost two hundred years. The difference between the richest and poorest countries was about 3 to 1 in 1820, 35 to 1 in 1950, and 73 to 1 in 1992. The total assets of the 200 richest people in the world amount to more than the combined assets of 41 percent of the world’s population of more than six

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billion people. Over half of the world’s population struggles to survive on less than RM7.00 per day.

Equitable public health systems, which offer affordable universal health care, are important expressions of social solidarity. But international policies and globalization of trade and services are removing protective barriers to enable foreign companies to participate in the privatization of health services for profit, putting affordable health care beyond the reach of all but the very affluent.

Although global health indicators are slowly improving, increasing inequality will reverse those gains. The rapid spread of HIV/AIDS has already lowered life expectancy in Africa and other countries and doubled the number of people infected with the disease in the last decade.

One quarter of the global burden of disease is preventable or easily curable. Seventy-two percent of the world’s population has access to safe water, but 2.6 billion people still lack access to basic sanitation. The following annual expenditures in US dollars tell the story of the world’s skewed priorities:

Basic education for all:$6 billion

Cosmetics in the USA:$8 billion

Water and sanitation for all:$9 billion

Ice cream in Europe:$11 billion

Reproductive health for all women:$12 billion

Perfume in Europe and the USA;$12 billion

Basic health and nutrition:$13 billion

Pet foods in Europe and the USA:$17 billion

Business entertainment in Japan:$35 billion

Cigarettes in Europe:$50 billion

Alcoholic drinks in Europe: $105 billion

World military spending:$900 billion

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The medicalisation of health

In his book, Medical Nemesis and Limits to Medicine, Ivan Illich, one of the most severe critics of modern industrialised medicine, censured iatrogenic diseases and coined the phrase, ‘the medicalisation of health,’ a derogatory term that is applied to over-investigation and unnecessary treatment of physiologically normal processes, such as normal pregnancy, normal childbirth, ageing and dying.

Although most doctors believe medicine to be a force for good and acknowledge that on occasion the practice of medicine can do harm, few would agree with Illich that the medical establishment has become a major threat to health. But many might agree with the concerns of the health economist, Alain Enthoven, who claims that unregulated medical procedures and treatments would at some point become counter-productive and result in more harm than good.

The question is whether we have already reached that point in the developed world, where health budgets are steadily increasing to provide expensive secondary and tertiary hospital care that only has marginal benefits. At the same time, many developing countries cannot afford simple, inexpensive public health measures, such as sanitation, clean water, adequate nutrition, immunization, vector control, and universal primary care, all of which would help to prevent thousands of premature deaths in children

Illich argued that there are limits to medicine, that death, pain and illness are part of being human, and that all cultures have developed ways of helping people cope with these inescapable realities of life. He has castigated modern medicine for undermining these cultures and medicalising health or ‘non-diseases.’ Although the concept of disease is not always clear and can be hard to grasp, it is easy to fashion new diseases or non-diseases and to medicalise many of life’s normal processes.

The Chambers Dictionary defines disease as “an unhealthy state of body and mind, a disorder, illness, or an ailment with distinctive symptoms caused by infection, for

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example.” Health is even harder to define than disease. The World Health Organisation (WHO) defines health as “a state of complete physical and mental well-being and not merely the absence of disease.”

The British Medical Journal has defined ‘non-disease’ as a ‘human process or problem that some have defined as a medical condition, but where people may have better outcomes, if the process or problem was not defined in that way.’ In other words, you would be better off to leave non-disease alone and not have medical treatment for it.

In a recent survey, members of the British Medical Association voted the following top non-diseases in descending order of ‘non-diseaseness’: ageing, work, boredom, bags under the eyes, ignorance, baldness, freckles, big ears, grey or white hair, lack of photogenic looks, childbirth, allergy to the 21st century, jet lag, unhappiness, cellulite, a hangover, pregnancy, road rage, and loneliness.

But there are some aspects of medicalisation that arise out of requests from families when they cannot cope with the ill-health of their loved ones. Some of these problems come within the scope of medicine, but there is a fine line beyond which medicine has only a minor role, if any.

De-medicalising health

Eventually, modern information technology and the internet will inform patients about the natural course of common conditions and enable them to assess the real value of medicine’s never-ending prescription of tests and procedures. This would enable patients to take charge and consciously weigh the costs and benefits of medicalisation. And eventually, doctors themselves will stop treating conditions that do not need treatment.

Although empowerment and education of patients may help to ‘de-medicalise’ health, advances in science and technology are at the same time making new discoveries that are being defined as diseases. For example, genetic science has made it possible to identify

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‘deficient genes’ that may predispose one to a specific disease. This has opened up the possibility of re-examining the concept of normality by showing that all genomes are different and that we are all in some sense ‘abnormal.’

Genetic science, with all its claims, tests and products, will probably propel medicalisation, unless it is vigorously evaluated and protected from commercial exploitation. The successful regulation of genetic medicalisation will depend on clinical evaluation, integrity, transparency, and the provision of accurate information to patients.

The medical profession has a responsibility to educate the public about interventions based on genetic science and discourage inappropriate responses that may lead to discrimination in employment and health insurance. Genetic technologies have the potential to provide major benefits, but they must undergo sound clinical trials and interventions must be regulated, reflect social and ethical considerations, and be based on best practice.

Unless medicalisation, unnecessary medical interventions and the market forces of the pharmaceutical industry are contained, there will be an unceasing growth in health care budgets, because the cost of trying to defeat inevitable outcomes will prove to be limitless and will diminish resources required for other more appropriate needs.

It would be more productive to expand public health and preventive medicine, restore the power of autonomy and self-care to patients, strengthen evidence-based medicine, help governments to make the right decisions in rationing health care, and reverse the medicalisation of health.

The pharmaceutical industry

The practice of medicine inevitably brings doctors and the pharmaceutical industry together. This important relationship is mutually beneficial, but it must be bound by

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ethical principles that guide policies and minimize the influence of the industry on independent, evidence-based patient care.

In the 1950s and 1960s, the range of pharmaceutical products was limited. To a certain extent, that protected doctors from the inducements of the industry. Today, the industry makes sure that there is a pill for every disease and a disease for every pill, and doctors are informed about it the next day.

The tendency to define causes of some diseases as ‘biochemical errors’ has led to the production of ‘designer’ drugs by the pharmaceutical industry. While the discovery of new drugs is valuable, there is unease over the power of drug companies to market, distribute and sell their products, control information about drugs, and also fund research and clinical trials. There are serious concerns that drug-company-funded research can be ethically compromised, including when doctors accept funding and sponsorship for attending conferences, linked with the use of specific drugs.

Until we can strengthen our continuing medical education programme by disseminating information about new drugs through impartial, independent medical practitioners, doctors will continue to learn about new drugs and the results of clinical trials, approved and sponsored by drug companies, from roving drug sales representatives. The story of the marketing of thalidomide in pregnancy, which caused fetal abnormalities, will always provide a powerful example of innovation and new drugs which went wrong. It’s a reminder that good intentions are not always sufficient to prevent the harmful effects of drugs.

The medical profession must also take issue with an industry that is eager to research and develop new drugs, which can be used to prevent and reduce morbidity and mortality in chronic diseases prevalent in the rich, developed world, but is less than eager to develop new drugs for the treatment of acute diseases in the poorer developing world, where profit margins are considerably smaller. As a result of such research, affluent Western

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societies are investing in expensive preventive treatments that will benefit only those who can afford to take expensive drugs over a long period of time. For example, the widespread use of statins is barely affordable in developed countries, but is beyond the reach of those in developing countries. And yet, the West of Scotland coronary prevention study (WOSCOP) showed that of 10,000 patients treated with statins for 5 years, 9755 would receive no benefit. In other words, 245 patients out of 10,000 (or 4.1 percent) were helped, at great cost to the community. The paradox is that these expensive therapies, that benefit only a minority, present a major challenge to health policy, as there are limits to health expenditure.

Another important pharmaceutical issue is the relationship between patent rights and generic drugs, and the question of parallel importing as a way to reduce costs. The nature of the pharmaceutical industry was revealed recently when patent rights were imposed on anti-retroviral drugs to stop the purchase of cheaper generics for the treatment of HIV/AIDS in South Africa.

There are often conflicts of interest when drug companies sponsor publicity about statistics of diseases. Behind every published statistic by the drug industry, there is often a vested interest. A few years ago in Australia, a director of the pharmaceutical company, Roche, admitted that his company often exaggerated the prevalence of disease in order to increase sales of drugs. This raises concerns that some pharmaceutical companies may be systematically seeking to portray certain conditions as serious, common diseases, in order to help expand markets for new products.

There is also evidence that some drug companies promote “disease awareness” campaigns and “medical education” programmes to shape medical and public opinion and create new perceptions of disease, which can be used in marketing strategies, by “establishing a need” and “creating a desire” for them. In Europe, the drug industry has been campaigning to loosen regulations on direct promotions to consumers, using disease-awareness campaigns and straight advertising.

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Pharmaceutical companies have a financial interest in ‘non-disease-mongering.’ Promoting and marketing drugs for the treatment of non-diseases, such as balding and ageing, will increase the use of their products and therefore increase profit margins. Pharmaceutical companies are becoming larger, wealthier and more powerful through mergers. In terms of market capitalization, the larger mergers are able to compete directly with some states, match their wealth and power on the world stage, and influence health policies in their favour.

The medical profession has to be aware and respond to the reality that the social construction of illness is slowly being replaced by the corporate construction of disease, for this has an impact on public consciousness, medical practice, and health expenditure.

Medical professionalism

Today, the pervasive global contagion of materialism and corporate culture is infecting the corpus of medicine and professionalism. In an environment of increasing privatization of health services, doctors will encounter financial incentives, intense market competition, and the diminishing trust of their patients.

In the first half of the twentieth century, doctors were inclined towards public service because they had a strong sense of vocation and were more interested in earning the recognition of their colleagues and community for their dedicated work. In such an environment, self-regulation was a success because it was based on a strong moral and ethical code.

In the 1960s, when professional self-interest began to surface and undermine the core values of medical professionalism, self-regulation was criticized as a ploy for self-interest. In the 1990s, self-regulation regained some of its former respectability, when it was acknowledged that professional regulation, although susceptible to abuse, served a necessary social function. In today’s changing, confused and uncertain world, it would be

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advisable for the medical profession to create space for a community role in regulation. This will give a transparent, coherent meaning to genuine medical professionalism.

Professionalism should be more than a concept that straddles market competition and government regulation. It should be much more than a portal for delivering a needed social good or service. Above all, medical professionalism should not be reduced to a “financial deal,” negotiated with society. We must think of medicine as an activity that ensures the universal, equitable distribution of health care, defined and strengthened by an ethical and moral covenant between the medical profession and society.

In that form, medicine could become a highly respected, morally protective force in society, intimately concerned with issues that affect the health and welfare of the community. The profession must therefore have the courage and will to confront social injustice, oppression and violations of human rights, remembering and learning from the failures and perversions of the medical profession in Hitler’s Nazi Germany, Stalin’s Soviet Union, and apartheid South Africa.

All professionals are influential and make up the cornerstone of a stable society. They therefore have a responsibility to protect vulnerable social and humanitarian values and to temper the excesses of government and private industry, whenever the sick are neglected, whenever there is violence and war, whenever human rights are abused, whenever the freedom of expression is stifled, and whenever there is inadequate support for education and health. Most societies limit and reverse such lapses, in part by entrusting the responsibility of safeguarding these values to special groups, such as doctors, lawyers, academics, teachers, religious leaders, journalists, writers and others. However, we should also be mindful that professionals, no less than politicians, entrepreneurs or government officials, can misuse their power. This is a danger inherent in any system that assigns authority to a group of individuals to regulate themselves.

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The primary responsibility of the medical profession is to ensure that doctors are properly trained and able to provide ethical health care of a high quality, through the establishment of high professional standards, continuing medical education, peer review, accreditation, audit, and credentialing.

Medical professionalism has three core elements: the ethic of service and duty of care, a public profession of values, and a social contract with society.

First, professionalism in medicine requires a moral commitment to the ethic of service and duty of care. Physicians, who value individual and public health more than other social services, must remain motivated to work hard, even when the financial rewards are modest. They must continue to provide health care even during an epidemic, at the risk of their own health. They must maintain their obligation to care for the poor and disadvantaged, particularly when the values of the market-place restrict access to health care.

Second, the word “profession” comes from the Latin for “speaking forth.” From medieval times, public testimony of values has been a distinctive feature of the professions. Although a doctor’s professional devotion to service is a form of public profession of values, it is not enough. It is the duty of doctors to speak out about health care values in the public domain and make a public collective commitment to fulfill legitimate societal expectations, for instance, by adopting a Patient’s Charter. This would imply acceptance of appropriate professional standards and accountability for one’s professional actions.

Third, the medical profession has a social responsibility to inject its humanitarian, ethical and professional values into health policies to ensure equity, equality and universal access in the delivery of health care. These would be the core values that the profession would advocate in the negotiation of a social contract between the medical profession, the public and the government.

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Conclusion

To improve the image of medicine, the medical profession, individually and collectively, must revive, re-evaluate and reiterate a meaningful philosophy of medicine. The profession has a social responsibility to stand with the community it serves and press for affordable, universal, equitable health care. In the Malaysian context, the profession, the government and civil society must come together and engage in a public dialogue about health care in all its aspects, including a national health financing authority.

Doctors must take advantage of every opportunity to act and be perceived as agents of positive change, rather than protectors of the status quo. The profession must ensure that high professional standards are attained and maintained through high quality medical education and regulatory and accreditation bodies. The ideals of ethical behaviour and empathic attitudes must become a functional and integral part of health care. Ultimately, it is the larger societal context and value system that will determine how medicine is practised. It is time to revitalize medical ethics and professionalism, reclaim a misplaced professional moral compass, and highlight the fading meanings of medicine, by combining the caring with the curing, the healing with the fixing, and the sacred with the science.

Presented at the Eminent Persons Lecture Series, Faculty of Medicine, Universiti Teknology MARA (UiTM) on 19 August 2008.

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