St. Camillus End-of-Life Conference in Milwaukee, WI

Julie Leveritt asked me to speak at yesterday’s End-of-Life Conference sponsored by the St. Camillus Hospice, the Catholic Medical Association, Wisconsin Pro-Life and the Nazereth Project. It was held at St. Camillo Assisted Living center in Wauwatosa, WI. I spoke on the Oath of Hippocrates. Specifically the title was “Dusting off the Oath of Hippocrates in the 21st Century” with acknowledgement of John Patrick, MD, as I used some of his material in the talk.

It seemed well received. As a speaker, I never know quite how my words are viewed. Looking at the audience of about 220 people, I didn’t see anyone asleep, which is a good sign, but whether or not the talk has an impact on the listeners–no way for me to know. Several came up after to thank me, which was gratifying.

I didn’t mention that  the talk was slightly shorter, but about the same as the talk I gave at Grand Rounds at Fairview Lakes in 2010, the talk that resulted in my dismissal.

Anyway, one person asked if I’d post the text on the internet. I gave her my blog address and what follows is more or less what I said yesterday. I edited the first talk I gave quite a little bit, because it needed editing. I’m a little better at that now.

Dusting off the Oath of Hippocrates in the 21st Century

First, I would like to credit John Patrick, MD for the inspiration for this talk, and, for some of the material I am using for this talk. Dr. Patrick is a now retired pediatrician from Ottawa, Canada who did research on pediatric nutrition for 25 years and is a gifted speaker. He is also the President of Augustine College in Ottawa, Canada. I’ve met him at a conference, though I doubt he would remember me. You can find him on the web at johnpatrick.ca.

The purpose of this talk is to inform you all about the Oath and why I think it is relevant even now, in the 21^st century. Medicine, as I tell students and residents, is a glorious profession with a rich history. So my prayer is that you would have a grasp of how far we’ve come as a society and as a medical community, or maybe the more accurate word would be how far we’ve fallen as a society and medical community. If, as a result of this talk, you are more inspired to provide care for those people God places in your path, that would be a wonderful side benefit.

Who was Hippocrates? He was a Greek born about 460BC and died about 370BC. He is known as the Father of Medicine or the Father of Western Medicine and established the Hippocratic School of Medicine. His approach to medicine revolutionized medical care and separated it from other fields of study. He is the one who established medicine as a true profession unto itself. In addition to his contributions on many diseases, he probably wrote the Oath attributed to his name, the writing for which he is most famous.

First, the oath. I’ll read it to you.

 

I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:

To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.

I will prescribe regimens for the good of my patients according to my ability and my judgme-nt and never do harm to anyone.

I will not give a lethal drug to anyone if I am asked; nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.

But I will preserve the purity of my life and my arts.

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.

All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.

Almost no new doctors recite the original oath which has some parts that were pertinent back then, but not so much now. Sadly though, most doctor’s oath do not even follow the main thrust of the original oath. Modern oaths add and subtract liberally from Hippocrates’s Oath. So, how have things changed? A study of 157 deans of medical and osteopathic schools in the US and Canada in 1993 found 43% promised to be accountable for their actions, 18% to do no mischief or harm, 14% included a prohibition against euthanasia, 11% invoked a deity, 8% foreswore abortion and 3% retained a ban against sexual contact with patients.

I’d like to now unpack the Oath briefly with a view of what I think may be less relevant in our day and age.

1) Teach the art to children of doctors.” Of course, that is no longer done. Medicine is taught to the best and brightest with consanguinity no longer a requirement. I’ll talk a little more about who gets taught medicine and who doesn’t a little later, because although consanguinity is not required, toeing the liberal line on abortion and euthanasia has become a defacto requirement. Regarding why Hippocrates put this requirement in, about only teaching medicine to children of doctors, my opinion on this—just an opinion—may be that he was emphasizing that students of medicine must be completely committed to medicine, as one may expect of a child of a physician.

2) “To do no harm.” This is probably the most famous line in the Oath. But, all doctors do harm to patients every day. Surgeries have inherent risks of bad results, medicines have untoward side effects, vaccines can cause severe harm in a very small percentage of patients, and chemotherapies cause obvious harm. It is important we all intend no ultimate harm—I’ll say that again—it’s important we intend no ultimate harm, but we as doctor do perform surgeries and give medicine that may cause short term harm to a patient so they may benefit in the long term. We explain the risks and benefits of a procedure and, if the patient agrees to proceed, we proceed, even with the small risk of short term harm.

3) “I will not cut for stone and leave that for practitioners of this art.” Doctors did not do surgery back then, but left it to the barber-surgeon whose main surgery was for bladder stones. Since surgery was nearly universally fatal in 400BC, it’s easy to see why he put this into the Oath.

When you boil the Oath down, Oath advocates find six underlying fundamentals of the Oath of Hippocrates, four of which I intend to concentrate on today. The six are:

Transcendence or the recognition of God in the medical relationship.

Medicine as a Moral Activity Acknowledgment that medicine is a moral, not a primarily technical activity.

Life Not Death A commitment to not intentionally kill or do harm.

Covenant Covenantal relationship between practitioner and patient through illness until death.

Practitioner Integrity Honest interaction determined by medical judgment, conscience and faith

Collegiality Moral consensus and enduring collegiality amongst like-minded practitioners.

My presentation will concentrate on transcendence, medicine as a moral activity, life not death and practitioner integrity.

Transcendence

The Oath starts by swearing to the Gods; Apollo, Asclepius, Hygieia, and Panacea. Why swear to the Gods? Why does the oath start with this? Why not pledge to consecrate your life to the good of the humanity as in the Declaration of Geneva? Or “In the tradition of Hippocrates and the men and women through the ages who have dedicated their lives to the art and science of medicine” as in the recitation of the University of Minnesota medical graduates in 2009 or “vow to that which you hold dear”, or just “agree with the Principles of Code of Ethics of the AMA’”

This appeal to the Gods represents a concept called transcendence, which means being beyond the limits of all possible experience or knowledge, or, in other words, acknowledging God. Now, you and I would not swear to those Greek gods, but to our own God, the triune God; Father, Son and Holy Spirit.

The concept of God means that someone or some supreme being exists outside of ourselves, outside of humanity. A fundamental characteristic of God now and in Hippocrates time was judgment after death, the concept that God will one day judge us for our care of our patients. This concept is important because it means that the physicians will, first and foremost be accountable for the care of his or her patients to God and judgment by God is not to be taken lightly. Hippocrates knew that rationally, a patient was safer under the care of a doctor who feared judgment after death than a doctor who did not.

I can’t overstate the significance of this concept. It means that the Hippocratic physicians would be accountable to a being transcendent to this earth, transcendent to any person and transcendent to any cause or idea. Such a physician would answer for the care of his patients to God, not the one paying him the most money, not the state, not the corporation, not the licensing boards, not the medical societies, not peer pressure, not the hospital or clinic protocols and not the economist or bean counter.

In Hippocrates time, the doctors not only healed but also killed at the request of anyone with the money to pay. Patients could not trust their doctors to have their best interest in mind and Hippocrates wanted to change that.

As you all know, our modern medical secular ethics do not include answering to God. Our ethic is based, not on God and judgment, but on a biologic-psychologic-social world view or ethic. This bio-pyscho-social model is beholding to whom? Accountable to whom? Good question. This model is underpinned by first, the so-called ethical principle of utility, which means whatever gives the most good to the greatest number is OK as long as it increases happiness. And second by the so-called situational ethic, which says love is the only ethic, that love and justice are the same and that right and wrong are determined individually in each situation. In situational ethics, the end always justifies the means if it increases happiness. From this over-arching model, medicine has developed the six ethical pillars or principles by which we function in medicine today. Those six principles are patient autonomy, beneficence, non-maleficence, justice, dignity and honesty. But the foundation of these six principles rest on an unpredictable and changeable foundation as utilitarian and situational ethics tend to be. And, since this foundation is not transcendent, not fixed, and does not have any anchor outside itself, it becomes a shifting sand, a moving target. So these current six principles guiding medicine can change from day to day. As a result, one can never be sure that the patient is placed first when receiving care from a doctor. The economist could muscle in dictating medical decisions to promote rationing of care. The administrator could gain control with the manipulation of a doctor’s income based on doctor behavior. The committee that establishes protocols could influence patient care in a negative way. Even the doctor himself could put personal gain first in the medical equation, a concept similar to Hippocrates day when the patient could not be sure whose best interest was in the doctor’s mind.

But I posit to you—Hippocrates got it right—transcendence is critically important, because rationally, patients are safer from harm.

This concept of transcendence has been echoed by others throughout the centuries. Thomas Sydenham, an English physician who lived in the 17^th century is regarded as the Father of Modern Clinical medicine and also as the English Hippocrates. He lived during the English civil war and as a young man had a cavalier point a revolver at him at point blank range and fire. The revolver exploded, killing the cavalier, but not Mr. Sydenham. So he had a feeling his life had some purpose. He was the first to recommend cooling for the treatment of smallpox. He was the first to recognize the problem of pain and brought opioids to England. He used a quinine-containing bark to treat malaria and, of course, described Sydenham’s chorea. He recognized the importance of accurate clinical observations and patient history in treating disease. And, this giant of clinical medicine wrote the following oath.

IT BECOMES EVERY MAN WHO PURPOSES

To give himself to the care of others,
seriously to consider the four following things:

First, that he must one day give an account
to the Supreme Judge of all the lives
entrusted to his care.

Secondly, that all his skill, and knowledge, and energy
as they have been given him by God,
so they should be exercised for his glory,
and the good of mankind,
and not for mere gain or ambition.

Thirdly, and not more beautifully than truly,
let him reflect that he has undertaken
the care of no mean creature,
for, in order that he may estimate the value,
the greatness of the human race,
the only begotten Son of God became himself a man,
and thus ennobled it with his divine dignity,
and far more than this, died to redeem it.

And fourthly, that the doctor
being himself a mortal man, should be

Diligent and tender
in relieving his suffering patients,
inasmuch as he himself must one day be
a like sufferer.

— Thomas Sydenham, 1668

Ultimately, as Sydenham understood, it is only this transcendent commitment, this submission to God and God’s truths which protects patients.

Transcendence, in Hippocrates mind, was not just a good idea, but requirement for physicians to practice good medical care.

Medicine as a Moral Activity

Second, I would contend, as does the Oath, that, primarily medicine is not a technical activity, but a moral activity. When a patient comes in to your office, do they have to take your advice? No, of course not. So what you are doing is trying to convince them what they should do. Bp 170/110—you should take a high blood pressure medicine. Blood glucose 450? You should take insulin. When you move into the “should” aspect, you are defining “good”. And that is a moral activity. The Oath says, “I will prescribe regimens for the good of my patients according to my ability and my judgment.”

But where does that leave us with utilitarian and situational ethics? With managed care, corporate care, rationing of care, cost-containment medicine and protocol medicine, this part of the oath is followed less and less. In fact, Ezekiel Emanuel, an American bioethicist and fellow at the Center for American Progress and formerly a Harvard Associate Professor, sees the Hippocratic Oath as one factor driving “overuse” of medical care, and therefore what he sees as the excessive cost of medical care.

When he was a policy adviser in the Office of Management and Budget (OMB) in 2001, he argued that

“peer recognition [in medical training] goes to the most thorough and aggressive physicians.”

He lamented that doctor in training were rewarded for being meticulous and thorough. I’ll say that again. He lamented that doctors in training were rewarded for being meticulous and thorough.

I hardly know what to say to that. When I go to my doctor, I would much rather he or she be sloppy and superficial, not meticulous and thorough, wouldn’t you?

“Hippocratic Oath’s admonition to ‘use my power to help the patient to the best of my ability and judgment’ as an imperative to do everything for the patient regardless of the cost or effects on others.”

So, what he is saying is the best and brightest students, the most thorough, the most informed, the most able to reach a diagnosis, the ones who received the best grades were led or encouraged to achieve and do well because of the Oath of Hippocrates. Of course, that is what patients hope their doctor will do. But, he wanted to change that part of the oath to include cost containment. He advocated those students who demonstrate the best cost-containment medicine receive the highest grades, not the ones who are the most thorough. Many oaths now include such language, such as the Principles of Medical Ethics by the AMA.

Fundamentally, in my mind and in my practice, and, also, what I try to teach students and residents, is that medical care is fundamentally a relationship with the patient and the doctor. If the patient leaves your office or exam rooms and believes in his or heart that you truly care about that patient, they will come back. One of the main pillars of caring is prescribing for the good of your patient, the one in the room with you, based on your best knowledge and judgment because it generates trust.

I’ll say that again. When a doctor prescribes medical care based on his or her best judgment, it generates trust. And trust is crucial. But modern medicine is doing everything they can, it seems to thwart this trust. One way is check box medicine or protocol medicine, which means practicing medicine based on what is good for a group instead of what may be best for the patient sitting in front of you. I means leaving your best judgement at the door and following a check list. The pressure on doctors to follow these protocols gets stronger each day. Hospitals and clinics carry a big stick to get doctors to comply. The insurance companies insist on them, the government wants them in place and ultimately the insurance companies and government want to base a doctor’s pay on how well they follow these medical cookbooks. Doctors employed where I used to work now have 60% of their income determined by their work product and 40% determined by pay-for-performance, or how well they follow the protocols. The State of Minnesota publishes data on how every clinic in the state meets the protocols it assigns. It’s what Obamacare wants to do. And heaven help you as a doctor if you step off the cookbook plantation.

However, these checklists mean the patient may get testing or medicines which are not needed in the doctor’s judgment or, worse, the patient may be denied needed care based on the doctor’s judgment. I believe in my heart that protocol medicine will be the horse rationing rides in on, and no one will complain. Why? Because they’ll call it a “best practice,” a protocol the doctors must follow. It’s how the death panels will work. They will be called a “best practice.” The checklist may say the patient is too old for treatment, not cost effective. Or too disabled for treatment. Nothing exists in modern medical ethics to prevent any of this. Our 21^st century shift to utilitarian, situation ethics means physician behavior will be dictated by the pronouncements of those with political power.

Now I wonder if I’ve caught a few of you physicians by surprise because many of you may see “best practices” as a good thing, a desired thing. You may not believe that protocol medicine designed to improve care for a group of patients, could have negative consequences or undermine patient trust. But, I would ask you to explain this system to a lay person and see what reaction you get. Whenever I explain the motivations behind protocol medicine which designs treatments based on what is best for a group of patients instead of the doctor’s best judgment for that patient, in the room, with that particular problem, I am met with near universal anger that a doctor would do this. Try it. Tell a married woman in a stable relationship that she must have STD testing because the doctor will lose income if he or she doesn’t test enough women her age, regardless of whether or not she needs the test. Try telling a mom with an 8 month old who has a fever of 104 degrees and is pulling at his ear that the ear infection isn’t serious and the child doesn’t need an antibiotic because if the doctor prescribes too many antibiotics, his or her income will be decreased. My wife already tried that. Her parents never took her in. She’s deaf in her left ear from chronic untreated ear infections as a child in spite of three surgeries as an adult. See for yourself if this system increases trust or undermines trust.

Can protocol medicine run even further amok? Of course. In England, there is the Marie Curie Institute which oversees the National Institute for Clinical Excellence (NICE), an irony not missed on you fans of C. S. Lewis. This NICE group developed an end-of-life protocol, or best practice. This best practice said that when the doctor determined the patient had less than 24 hours to live, the protocol would kick in. This protocol meant stopping all fluids and food (IV’s, tube feedings) and sedating the patient. And, guess what. They all died. Everything was good until two palliative care doctors—not religious folks—published an article critical of the protocol. They found that many on the protocol, when removed from the protocol, lived for quite some time. This created a public stir when families realized Uncle Joe was ushered out of this life prematurely. About 23% of the dying patients in UK were following this protocol. Since it was a best practice, it was not regarded as euthanasia and still is not regarded as euthanasia. Last I looked the protocol had been modified, but was still defended by NICE. That’s just one of the more egregious examples.

But many modern ethicists see no problem with calling a spade a spade. Why call it a “best practice?” Call it rationing. Rationing is good. It should be embraced openly. James Sabin who teaches medical ethics at Harvard Medical School argues that rationing is obviously necessary and mandatory for ethical health care in the 21^st century. He concludes, however, that “there’s no way that the need for rationing could have been part of the federal health reform process. We’re not yet mature enough as a body politic to deal with that piece of reality without going ballistic about “death panels.” But wishful thinking and political immaturity don’t change the fact that rationing happens now, will have to be acknowledged in the future, and is an ethical requirement, not an abomination.”

So Mr. Sabin thinks you are politically immature and engaged in wishful thinking if you oppose the death panels.

 

Privacy

I can’t discuss morality in medicine without discussing the covenant of privacy. The Oath covenants a doctor to keep private all he knows about his patient. Privacy, however, is out the window, both legally and illegally in this 21^st century. Today, I want to touch on the illegal violations of patient privacy, almost exclusively because of the electronic medical record.

As you all know, a computer terminal and a password are now the gate to unlock every patient’s record in what used to be called the medical records department. With the EMR, the government intends cross-platform access so every record in the country could be accessible to every medical care provider in the country. Now that takes a lot of trust. How hard is it to steal a logon name or password? They now make a pen with a small camera and flash drive which can record real time video and sound. The user name and password you use could be easily stolen at a visit. In California, a hospital fired many employees who accessed the record of a celebrity and sold the information to a tabloid. A medical transcriptionist in India hired by Stanford for medical transcription tried to blackmail Stanford for money by threatening to put all her transcriptions on the internet. Conceivably, your entire record could end up on the internet.

What if you were a pro-life politician running for office? One week before the voting, a doctor zealot from the other party accesses your record and alters it to say you’ve had two abortions all the while speaking against abortion. The record could be printed and given the local newspaper. By the time the dust settled the election would be over and you would lose. What about probate and a challenged will? The record of the deceased could be altered just prior to death to include a diagnosis of early Alzheimer’s. What about child custody and parental fitness? The list of serious harm from this lack of privacy chills my medical soul.

All of these instances violate the privacy charge of the Oath. Do patients care about privacy? When I worked for a large health care corporation, I had patients request I keep their records on paper in my office because of privacy issues. The EMR violates the Oath and undermines trust.

This concept, trust, is not a scientific or technical concept. In fact, all the concepts in life that are most important to us are not scientific or technical. They are moral. Concepts such as love, fidelity, courage, trust, loyalty, justice, honesty, truth and others. Hippocrates recognized that and made it clear in his Oath that medicine was indeed a moral activity and this moral activity garnered trust. Science, of course, has nothing to say about these moral concepts that are so important to us. But if these important concepts come from if they do not come from science? Well, these important concepts come from one of the religions or societal codes found in the world, including the ancient Greeks. Of course all societies from every continent and all the multitudes of people groups in each continent have rules and morality specific to their group. Although these rules of morality differ from society to society, all societies have them. A society cannot function without them.

But, we can say about medicine through the centuries, no moral code or ethic has influenced medicine more than that of the Jews and Christians. We are the product of Greek and Hebrew thought modified by the Christian church. This ethic derived from Jews and Christians has been the dominant guide for medicine throughout the centuries. Our care, to treat patients, is based on that. And it is this moral code that has allowed medicine to advance to where it is today. Why? Why did this Jewish and Christian moral ethic allow or encourage advancement in medicine? Because Jews and Christian believe in the fall of man into sin, that man is inherently sinful and in need of redemption. And the redeemer, their God, has commanded these Jews and Christians to care for the poor, the sick, the traveler and the disabled and relieve suffering on this earth. And it is this ethos has allowed for medicine to progress to its current state today. Other moral systems tend to have problems for medicine. For instance, they may have a fatalistic ethos, one which does not recognize a God of order. That ethos, a fatalistic ethos, and in fact any fatalistic ethos, rationally prevents advancement in medicine and is unacceptable to us.

As a sidelight, when it comes to medicine, physicians only respect the opinions of other physicians or physician researchers and generally pride themselves on their medical knowledge. Of the patients who walk into a doctor’s office today, depending on location and practice type, most doctors would have patients who would self-identify themselves as Christian. So a doctor to be culturally relevant, should understand the basic tenants of Christianity. Jesus is the central figure of the new Testament and the Sermon on the Mount is probably Jesus most famous sermon. Yet, if you as a physician what’s in the Sermon on the Mount, few can tell you anything about it. So our emphasis on cultural relevance breaks down when physicians have only a kindergarten knowledge of Christianity.

 

Protection of Life

Another important concept of the oath was the protection of life. The Oath says, “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.” It is this sentence more than any other that has led to the Oath’s disuse since about 1973 when abortion was legalized. So you can see, abortion and euthanasia are not new concepts and are as old as medicine itself.

But why did Hippocrates include this prohibition? Why was this important? Well, to understand that, as I mentioned earlier, you have to understand medicine in Hippocrates time. Since the sorcerer and the physician were often the same person, he could kill as well as heal. You never knew if someone had paid more for your death than you had paid for your life. Hippocrates wanted to change that. He wanted patients to recognize that there would be a group of doctors, Hippocratic doctors, who would never kill and always try to heal. He knew that rationally, patients would trust doctors who valued life more than those who did not. This safety has been recognized by Margaret Mead, the anthropologist. She wrote.

For the first time in our tradition there was a complete separation between killing and curing. Throughout the primitive world, the doctor and the sorcerer tended to be the same person. He with power to kill had power to cure, including specially the undoing of his own killing activities. … With the Greeks, the distinction was made clear. One profession, the followers of Asclepius, were to be dedicated completely to life under all circumstances, regardless of rank, age, or intellect – the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child. . . . [T]his is a priceless possession which we cannot afford to tarnish, but society always is attempting to make the physician into a killer – to kill the defective child at birth, to leave the sleeping pills beside the bed of the cancer patient. . . . [I]t is the duty of society to protect the physician from such requests.

But society does push us to kill. Abortion has been legal in the US since 1973. Euthanasia is legal in many European countries and also in Oregon, Washington and Montana. And even if you are not in one of these states, euthanasia goes on. As you all know, doctors can kill patients with the greatest of ease. And can do it without detection by the most astute forensic pathologist. You may know of doctors whose old and sick patients seem to die earlier than you would expect. And killing can be addicting. The British GP, John Bodkin Adams, in the 1940’s and 1950’s killed 160 of his patients with medicines and 132 left him money in their wills. He became the richest GP in England, quite famous, and treated the nobility of the day. He was finally caught, but was acquitted at trial of murder. The Dutch now have legal euthanasia. But the government can’t get a handle on the numbers of euthanized patients. They surveyed doctors and more than half of the time, doctors do not report euthanasia because of the paper work hassle. Who would have thought that the Dutch physicians who gave their lives under the Nazi rule in WW2 rather than euthanize those with disabilities would have developed the Groningen Protocol which contains directives with criteria under which physicians can kill disabled infants, infants in no danger of imminent death, infants whose lives fit a protocol, or best practice, (which determines their lives are not worth living), all without the threat of legal prosecution or punishment.

Peter Singer, the Princeton University ethicist and atheist, argues that killing a child in the first year of life should be legal if the child has serious disabilities and also argues that health care rationing is desirable. Of course, he also sees no differences between humans and animals and that sex with animals should be fine if it doesn’t hurt the animal.

I think I can illustrate this concept of safety for patients whose doctors value life. Suppose you are dying of cancer and I am your doctor, and unknown to anyone else, I have the cure for your cancer in my pocket. What should I do? Give the cure. But suppose you are very rich and have made me heir to your money when you die. And, I am a committed social Darwinian, situational ethicist who determines right and wrong on the fly, one who does not follow any transcendent law or code, one with no commitment to life. What should I do then? Of course. Keep it in my pocket. Therefore, when you die, I collect my winnings, and then can market my cure for great monetary gain. I could even dedicate the cure to you, my dear friend. You see, one can’t say it is right to give you the cure unless one can say that saving life is good. And that’s the problem. We now think that only saving some life is good.

 

Physician Integrity and Conscience

Finally, the Oath speaks to the concept of practitioner integrity, or conscience. The oath says, “I will preserve the purity of my life and my arts.” What that means, I think, is that the doctor will not violate his or her purity of conscience in life and in medicine. In other words, be true to conscience at all times. What does that mean and why is it significant? It means that a doctor has to know the difference between right and wrong and has to do what is right. That is the true basis of the rights of conscience. Where are the attacks coming? Mostly on the right to life issue. They want doctors to do abortions, refer for abortion, or perform or refer for euthanasia.

But the worst thing you can be or say in this multicultural age is that you know what is right and what is wrong, because that undermines the foundation of the so-called utilitarian ethic and the situational ethics. Right and wrong are supposed to depend on where you sit, what your viewpoint is. What is right for you may not be right for me. What is good for you may not be good for me. Right and wrong, like beauty, are in the eyes of the beholder. All views are supposed to have validity.

But in practice, we all live as though objective right and wrong exists. Example: A student wrote an essay on existentialism which made the point that there is no absolute right or wrong. When the student handed in his excellent paper, the professor gave him a C. The incensed student returned to argue for a better grade, to which the professor gave his reason for the C. He didn’t like blue folders. To make a point, the professor’s individual preference defined right and wrong. The student got the point. So you can see, for justice to exist for that student, an ethic beyond individual preference must exist. If preference determines justice, political power will remove the blindfold from lady justice. And justice is critical to medicine.

To illustrate this further, I’ll tell you about Arthur Leff, a Yale law school professor, who died in 1981, wrote an essay entitled, “Unspeakable Ethics, Unnatural Law”. He was worried about this problem or right and wrong and how it applied to the law. And in this article, he starts with this:

“I want to believe – and so do you – in a complete, transcendent, and immanent set of propositions about right and wrong, findable rules that authoritatively and unambiguously direct us how to live righteously. I also want to believe – and so do you – in no such thing, but rather that we are wholly free, not only to choose for ourselves what we ought to do, but to decide for ourselves, individually and as a species, what we ought to be. What we want, Heaven help us, is simultaneously to be perfectly ruled and perfectly free, that is, at the same time to discover the right and the good and to create it.”²

Leff states that absent an ultimate authority figure (i.e. God) handing down moral laws from on-high there is no reason for any person to prefer one set of behavior identified as “moral” to another. Leff terms this “the Grand Sez Who.”

The conclusion of Leff’s essay lands wrongly but dramatically illustrates the dilemma.

“All I can say is this: it looks as though we are all we have. Given what we know about ourselves and about each other that is an extraordinarily unappetizing prospect; looking around the world, it appears that if all men are brothers the ruling model is Cain and Abel. Neither reason, nor love nor even terror, seems able to make us good, and worse than that there is no reason why anything should. Only if ethics is something unspeakable by us could law be unnatural and therefore unchallengeable. As things stand now everything is up for grabs.

Nevertheless napalming babies is bad, starving the poor is wicked, buying and selling each other is depraved. There is in this world such a thing as evil.”

But I would ask, would you want a doctor with moral integrity or without moral integrity providing your care? If a doctor caved on his strongly held belief just so he could make money, or keep his job, or maintain medical prominence, or be on the “in group” of his doctor peers, what would you think? Would this be a doctor you would seek out to provide your care—someone you know will compromise if the need is great enough? Would he cover up a medical error he made? Would he lie about what constituted the best treatment when he knew it was not? I know who I would want and it would not be the compromiser. So the conscience of physicians, their moral integrity, is under assault, to medicines detriment. Hippocrates knew that, and insisted on moral integrity, on the purity of the physician’s life of art.

What the Hippocratic Oath gave us was a vision of doctors with moral character and high ethical standards who deserved trust.

 

Conclusion

So that is my take on the Oath of Hippocrates. This Oath provides safety for patients from a doctor’s other allegiances; provides dignity to patients in the medical encounter; fosters confidence to patients, knowing their very personal and private information will be safely held by their doctor; and enables trust to develop, knowing that their doctor’s morality and ethics are based on the hard truth of principles which have stood the test of time, not the soft sincerity of recent conventions, conventions with no anchor, conventions beholding to those in power, conventions which, in my mind, have been weighed in the balance and found wanting. The Hippocratic Oath, taken seriously, places us in a timeless framework in which we can practice medicine with the most benefit to our patients.

 

Matt Anderson, MD

 

 

 

 

 

 

The Sweet By and By

Following is a tongue-in-cheek story of, well, you’ll see if you read it. It’s not exactly a Christian story and has in it dishonesty, theft, lying and mention of some bodily fluids. I thought it was a fun story to write, however, so I hope you get a smile.

 

The Sweet By and By

A drop of grease fell from Bill’s chin on to the paper plate. “Who’s the deceased again?”

“Who cares?” Naomi nudged him in the side. “Is there another wing in that bucket?”

He tipped the bucket and checked. “Yeah, but it’s not extra crispy.”

Her eyes perused the Fellowship Hall at Bethany Baptist Church. “See two tables over?” She gestured with her head. “They can’t be eating much. They all have gray hair and lousy teeth. Go switch buckets with them.”

“Good idea.” He grabbed their nearly empty bucket, placed the lid on it and walked over. “How’s your chicken, folks, good?”

A woman wearing three large diamond rings frowned and spoke. “It’s so greasy. I wish they served gluten-free, organic salads.”

That’s a first world problem if ever I heard of one.

“Well, here’s a bucket if anyone is interested, and hey, I’ll check about that salad, folks.” With that he put his nearly empty bucket on the table, took their mostly full bucket, walked to the kitchen, turned around and went back to his table. “Here it is. We’re back in the chicken. Extra crispy, too.”

“Have you seen the desserts?” She pointed to a man carrying a bowl of vanilla ice cream drenched in homemade hot fudge sauce.

“Ice cream? Hot fudge? We better get some before it’s gone.”

Two minutes later, they sat back at their table with ice cream and hot fudge spilling over the sides of their bowls.

He savored each bite. “Anybody ask you how you knew the deceased?”

“One woman asked.”

“What’d you tell her?”

She sniggered. “The usual. I teared up, sobbed and said I missed him so much. Then I hugged her and whispered, ‘And the sex—to die for.’ My nose ran on her shoulder. When I pulled back, I snuffled, coughed up a ball of…well, you know, and held it in my mouth while I searched for a wastebasket.”

He hooted. “You’re kidding me! Did it work?”

“Like a charm. After I spit, I said, ‘Whew! I thought I’d have to eat that one.’ The poor soul turned ashen white, put her hand to her mouth, coughed and ran to the women’s rest room.” Naomi took another bite of ice cream. “She didn’t make it though. I went in later and almost slipped on the, um, stomach contents.” She glanced at the front food table. “They just put out some cookies. Anyone ask you?”

“Just a minute.” He rose from his chair, walked to the front and came back with a plate full of cookies. “Yeah, a couple guys did.” He stuffed half a cookie in his mouth. “I told them I met him at a bowling tournament in Oklahoma City.”

“A bowling tournament?” She took a cookie from the pile and nibbled at it. “In Oklahoma City?” She smirked.

“Yeah, then I said, ‘He so loved bowling. Bowling and beer.’ I hesitated and said, ‘And meeting guys, of course, but you knew that.’ Then I pulled out my cell phone, glanced at it, said, ‘Excuse me,’ and made a hasty retreat.”

“Ha. Did you see how they reacted?”

One dropped his plate and the other’s said, “Bowling? Beer? Guys?”

She grinned and leaned in. “They’ll be thinking about that for a while.”

He looked up. Chicken, chips, cookies and brownies graced the food table. “I’d love to take that food home.”

Her eyebrows pinched together. “There’s got to be a way.”

He glanced over. “You ever tried a diversion?”

“No, but I’m game.”

“Okay, I’ll fake a fall along the tables farthest from front door. You take your—” He looked down. “Is that a purse?” A red bag as big as a small suitcase sat beside her.

“Hey, it’s a purse.”

“Anyway, you sweep the food table and stroll out the front door. Get the car and have it running by the south exit. I’ll be out a couple minutes later and we’re off.”

He stood and glanced around the Fellowship Hall. A low din of conversation sounded from the 100 or more guests. “Wish me luck.” He walked to the side of the room away from the front door. She ambled to the front table gripping her red portmanteau. They locked eyes and she nodded.

With a loud “Whoooaaaa!” he slipped, kicked a folding chair forward so it crashed against the concrete wall, spun in the air and hit the floor on his hands. He rolled and moaned with gusto, “My back! My back!” Three men dashed to his side.

“Help me, oh, ow, help me!” He heard someone call 911. He rolled back and forth and increased his moans to screams. “Help me up, please.” They lifted him and held him up.

He stood hunched over, then shook off their hands. “Let go of me. This place is dangerous. My back, oh, my back.” He hobbled toward the south exit with one hand on his back, turned and pointed his finger. “You’ll hear from my attorney about this!” He pushed open the south door, let it close and slid into the passenger’s seat. The car sped away.

The red bag sat between them filled with cookies, brownies, chips and bucket of extra-crispy. “Spectacular work. Anyone notice?”

“How could they with your screams?” She laughed, and adjusted her rear view mirror. “No one following. I’ll drop you off at your place.”

She stopped in front of a white one and one half story house and turned off the car.

She turned toward him, the warmth in her voice palpable. “I have to tell you, Bill, that’s the best first date I’ve ever had. It’s so wonderful to have a friend who shares the same love.”

He smiled and touched her hand. “I feel the same way, Naomi. Next week?”

She beamed. “Sure. I wouldn’t miss it.”

“I’ll check the obits, and we can take my car.” He leaned over and kissed her cheek. “Thanks for a wonderful evening.”

Story Time

When I was in grade school, our newspaper published a story one chapter a day for about three weeks. I guess it would be called a novella these days. Our teacher would read it to the class every day before lunch. We’d all be on the edge of our seats waiting to hear what came next.

I do some fiction writing. I’ve had a flash fiction piece published and actually made money on it. It’s my only published fiction. But learning the craft of fiction writing is not an easy task. It takes thought, work, planning and a grasp of prose and the human condition. You know you’ve written good fiction when the reader is so engrossed in the story that he or she doesn’t even think of the writing. In other words, the story takes over. No typos, poorly constructed or confusing sentences, no confusion about the point of view, no grammar errors like moving from past tense to present tense for no good reason and no boring, over-bearing descriptions of details not crucial to the story. Every word counts.

I’m not that good, but, I’m close, I think.

So, I think I’ll post some stories for you to read. Some are Christian. Some are stories with Christian themes, but not overtly evangelical or gospel oriented. Themes like redemption, forgiveness, mercy, hope, courage, perseverance and love.

I hope to post something weekly. If I post a novel, it will be one chapter a week.

I’m going to start with a flash fiction piece called, “The Blather and Claptrap of Christmas.” Flash fiction is a short, short story, usually 1,000 words or less. This one is a little over that. Hope you enjoy it.

Matt Anderson

Results of My Arbitration Hearing

Some of you who are reading this are aware I formerly worked for Fairview Lakes in Wyoming, MN. I was there from 3/8/04 until 9/16/10 at which time I was told to resign or be fired by Vicki Stevens, head of human resources (HR) and Dr. Barry Bershow from corporate. I resigned realizing resignation was my only hope to ever work again. Dismissal for cause would have meant an investigation by the Minnesota Board of Medical Practice and a report to the National Practitioner Data Bank. In addition without any discussion, Dr. Bershow said my dismissal was because of my talk and a “few other things.” However, the “few other things” made me sound like I was not worthy to be a doctor. He said Fairview had concerns about my patient care, about my respect for diversity, about my ability to get along with others and about a refusal to follow guidelines recommended by Fairview.

When this happened, I had just a couple of weeks earlier, given a talk to the medical staff on medical ethics–the Oath of Hippocrates. When I asked Dr. Barry Bershow, the doctor who was dismissing me, if this was because of the talk, he said yes.

I had trouble finding a job. Only one place even gave me an interview, and then turned me down. I eventually joined the AALFA Family Clinic, a small pro-life clinic in White Bear Lake with three family doctors and one internal medicine doctor. They welcomed me with open arms. I’ve never worked in a clinic like this, one in which the doctors are kind, sincere and consistent. What you see in the exam room is who they are. They are not at all cynical. I’ve never heard them speak poorly of a patient–ever. As a lay person, you may not realize that doctors tend to be cynical types who may speak poorly of the patients when they think they are out of ear shot! I am so blessed to be at AALFA!

In any event, Fairview was contractually obligated to notify my patients of my new business address, phone number etc. in a letter. I sent them a letter in January 2011 asking them to do that and they did not respond. I sent it again in February 2011 by certified mail and they responded 5 weeks later, saying they had already done that. They had sent out a generic, “Dr. Anderson isn’t here, please schedule with our other doctors, etc.” the day after I left, but it had nothing to do with my contractual obligation as came out at trial. But they refused to send out an appropriate letter. Because of that, I decided to sue for a forced resignation. My contract specified any employment dispute had to be adjudicated by binding arbitration, so that’s what I asked for. My goal in suing was to hold Fairview accountable for violating my contract. I hoped to win a money award, not to enrich myself, but to get Fairview’s attention so that when another pro-life physician came along and took a moral stand, Fairview would think twice before dismissing him or her.

I learned several things because I sued. The first big surprise was their contention I was a bad doctor and that the talk was not the only reason I was dismissed! They had a list three pages single-spaced of my supposed sins, from doing to many hysterectomies to prescribing too many narcotics, to arguing too much in meetings, to not playing nice with some of the staff on the floors–and more.

At the trial, I was able to refute every charge they made quite effectively. Documents at trial proved I did fewer hysterectomies than my partner, Dr. Mericle, per hour worked in the clinic. That means I was just worked more hours than the rest which is why I did more surgery. The whole narcotic canard was based on rumor of the medical assistants. Dr. Mericle, my “dyad leader” didn’t even review a chart to see if that was true. I argued in meetings about the direction Fairview was taking to which their own witnesses admitted was the appropriate place to bring up disagreement. My yearly evaluations were always good. My re-credentialing for hospital privileges was never questioned. Their witness, the chief of staff, admitted he asked me to serve another term on the medical executive committee after he knew of all these charges against me because he viewed me a valuable member of the committee who made good contributions. Their witnesses tried to say my contract had been fundamentally changed by a reorganization Fairview went through in 2009, but then on cross exam also had to admit that my contract could not be changed except in writing by both parties and that it had never been changed. They brought up some conflict I had with another doctor, a head nurse and the clinic manager from years earlier like it just happened yesterday, events that had been long resolved.

One phrase they all said was this: Dr. Anderson was just not a good fit for Fairview. They based that on my arguing in meetings and e-mails against the path Fairview was taking. I argued against “cookbook” medicine in which a doctor is graded on how well he or she follows a protocol of medical rules with each patient. I explained it fundamentally changed the doctor patient relationship to make the doctor beholding to the protocol in order to get paid more instead of deciding what would be best for that particular patient in that particular setting. I argued against the lack of privacy with the electronic medical record (EMR). I argued against the poor communication with the EMR because the doctor’s notes were generated by templates that were generally ignored and I argued against the “bill-padding” that resulted from higher codes which the EMR easily generated which fraudulently increased income for the doctor and corporation. (I didn’t use the templates–I dictated with voice-recognition software. As a result, I billed honestly, my notes were easy to read and communicated well. Just practicing good medicine meant I was meeting the standards they set with rare exception.)

At trial, my attorney asked their witnesses about this arguing in meetings against the protocols and then would ask their witness if they checked to see if I had met the measures or used the protocols in the hospital in general. No one had checked. They just assumed since I didn’t want to follow a cookbook that I couldn’t possibly be practicing good medicine when the truth was most were easy to meet and I met them. Then my attorney would ask if the witness had known I was meeting the protocols, would that have mattered in their determination of my performance. They had to answer yes, of course.

The 800lb gorilla in the middle of the room the entire trial was my talk. They contended I was disrespectful of diversity. I contended my talk informed them of the need to truly understand the diversity of various religions and cultures, including the culture of conservative Christians. In addition, my talk illustrated how the Oath of Hippocrates was pro-life, how the Oath insisted medicine was a moral activity, how a belief in God was required by the Oath–all that and more. Each witness Fairview presented was asked if my dismissal had anything to do with my pro-life stand or my religious views. All said ‘no’. I don’t believe that for a minute. I met no pro-life conservatives in leadership in my 7 years there. Dr. Mericle charged me in her document and testified at trial that my pro-life views caused me to not counsel OB patients on the availability of genetic testing (False. But I did tell my patients the purpose behind the testing.) and caused me not to put in IUD’s under the false notion that the IUD caused abortion. (The IUD does cause early abortion by preventing implantation of the already formed embryo.) Those were two of the reasons I was fired. Vicki Stevens recorded notes of the phone conversation the 4 of them had at noon on the day they dismissed me. One phrase no one would claim which was part of that four-way conversation was that Dr. Anderson had “very right wing extreme radical viewpoints.” (This is just tongue-in-cheek conjecture on my part here, but I think that means I was a pro-life Republican. I’m just guessing.)

On and on it went with their witnesses actually helping my case more than their case. It was something to behold. By the time the trial ended, I felt completely vindicated.

Most importantly, I learned that my liberal, politically-left-leaning radical feminist pro-abortion partner, Dr. Mericle, was the one who started this whispering campaign behind my back about 6 months before I was dismissed. During that time, she developed this list of how terrible I was as a doctor, this list I knew nothing of until I filed suit. Also, she admitted at trial that she was the one who made the final decision that I should be fired, she and the clinic manager, Wendy Young. Also, the one who actually dismissed me, Dr. Bershow, had taken her word on everything and had not done any independent investigation at all into my performance as a doctor. Also, he and Vicki Stevens would have not fired me, but tried to discipline me, a course Dr. Mericle and Wendy Young rejected.

Dr. Mericle and her husband also owned the Nesting Grounds restaurant and coffee shop in Wyoming. They placed it for sale two months before my dismissal.

The trial boiled down to one question and one question only and that was this: Did I voluntarily resign or was I forced to resign? I contended that Fairview lied in presenting me with those two options of resign or be fired because they had no justification to dismiss me. Since they had no justification to dismiss me, I made my decision based on their lie, not on the truth of the situation. Therefore, I was forced to resign knowing that a dismissal for cause would end my medical career. They contend that my resignation was voluntary and that I had no standing to even bring the lawsuit.

The judge agreed with me and I won the case on its merits. The judge’s words were a joy to behold. He agreed with me completely. Fairview did violate my contract. They had no justification to fire me. All the charges they supposedly had against me were refuted at trial. My talk was clearly my own opinion, not Fairview’s opinion and did not warrant discipline or dismissal. The meeting at which I “voluntarily resigned” was based on subterfuge (Dr. Mericle lied to me to bring me over to the clinic). The judge concluded that since Fairview had no justification to fire me, they gave me a false choice of resign or be fired. I was forced to resign.

The judge awarded me a money amount less than my request. He contended my writing in WORLD magazine and in my church newsletter made me undesirable as a doctor and, as a result, no one would want to hire me. I was responsible for what I written, therefore Fairview was not. Also, he said I didn’t try hard enough to find similar employment.

Although his logic escapes me, I remain vindicated. The amount Fairview will pay will be noticed. And, through the providence of God, I found probably one of the only practices which would hire me–AALFA–a solidly pro-life clinic populated with doctors all of whom have a moral compass. God bless them all! A day doesn’t pass without me thanking God for this wonderful clinic where patients–all patients of every religious persuasion, even conservative pro-life Christian patients and devout Catholic patients–are treated with respect and dignity.

So that is what happened with my departure from Fairview. I am so thankful for all the prayers people have lifted to God on my behalf. I know I never could have survived the whole affair without them. It’s not easy to listen to former colleagues say bad things about you, but God sustained me. My family, God bless them all, supported me through this as well as they could.

My hope and stay through this entire event has be Habakkuk 3:17,18. It says,

“Though the fig tree should not blossom, nor fruit be on the vines, the produce of the olive fail and the fields yield no food, the flock be cut off from the fold and there be no herd in the stalls, yet I will rejoice in the Lord; I will take joy in the God of my salvation. Habakkuk 3:17,18 (ESV)

I know that God works out everything for good for those who love Him and are called according to his purpose. But I also understand quite well that God’s good for me may not be my concept of God’s good for me. From a human perspective, I would expect “good for me” to be finding a wonderful job with little effort after my dismissal from Fairview, that I would soon have a satisfying, growing practice, that if I sued, I would win and win a large money award with little emotional strain or trauma.

But that’s not necessarily how God works. He could have decided I find work in rural South Dakota in the middle of nowhere, that I move away from my children and grandchildren, that I sue and lose totally to Fairview, or that I never find work again as an OB/GYN doctor and live the rest of my life in poverty. That could have been God’s “good” for me. Who can know the mind of God and who can be His adviser?

As a student of Christian history, the stories of great Christians helped me so much during this time.

I think of William Tyndale, a brilliant scholar who translated the scriptures (much of them anyway) from the original Greek and Hebrew into English. The king of England put a price on his head for doing that and he fled to France, where he was eventually betrayed by a close friend, spent two years in an unheated prison and was then burned at the stake as a heretic. The king of France did have some mercy on him, however, allowing him to be killed with one blow to the head prior to being burned at the stake. Shortly thereafter, the king of England allowed Tyndale’s translation. It was all casual politics for the king of England for which William Tyndale gave his life.

Adonirom Judson lost three wives in Burma, nearly lost his faith and then eventually became ill himself and died somewhere in the middle of the Indian Ocean, the only Christian on the boat–no family, no friends–and was dumped in the sea.

The stories go on and on of followers of Christ who died or suffered horribly with no recognition, no compensation. But living to bring glory to the King of Kings is enough. And death is only the beginning of glory. And that also is enough. It was enough for saints of old. I prayed then and pray now that it will be enough for me. Knowing that whatever happens, I will someday gaze on the face of God and rejoice for eternity in His presence means God is good, all the time, God is good. I know I deserve nothing but His wrath, but because of His great gift of Christ’s sacrifice on the cross, I can live for Him now and I will, one day, experience heaven and worship Him forever, experience constant and complete joy, all for the temporary trial in this life.

My poor little problem seemed minor when compared to the suffering of these heroes of old!

So the Fairview chapter of my life is now closed. I’ve had two huge regrets about leaving Fairview like I did.

First, I left all my former patients with no word as to why I left or where I went. Even now, Fairview won’t tell my former patients when they call the Fairview OB/GYN clinic where I now practice. I saw two former patients just last week who had called the OB/GYN clinic at Fairview and were told Fairview could not/would not tell anyone where I was. That is despite testimony at trial that Fairview has been sharing my practice location with my former patients who called since April of 2011!

Second, I had no chance to say goodbye to so many people who worked there, friends whom I held dear. So many nurses, techs, anesthetists and others were such good friends. It came out in trial that, had I tried to walk back on the Fairview Lakes campus, security was at the ready to hammer-lock me and throw me off the premises (slight exaggeration). They were to be called to escort me off the premises if I showed up. As far as I know, that order has never been rescinded.

In this post, I’ve been careful to write what is accurate, true and documented in depositions, trial testimony under oath or the judge’s ruling. (Except the part about the Nesting Grounds. That information I found on the internet and make no conclusions about it.) I’ve no interest in harming my former employer as most of the people I worked with at Fairview were wonderful hardworking people delightfully committed to patient care.