BOOKS DECEMBER 3, 2008
Trusting Doctors: The Decline of Moral Authority in American Medicine
By Jonathan B. Imber
(Princeton University Press, 275 pp., $29.95)
Even the advent of a growing scientific basis for medical practice--which we can most accurately date from the middle third of the nineteenth century--has not lessened by an iota the degree to which medical authority has traditionally depended primarily on a well-recognized code of morality. As that authority has been in a state of decline for the past several decades, countless commentators have sought to identify the most significant of the congeries of reasons for which the steady downward slope continues. Has the profession sold its soul to science?
In a thought-provoking dissertation, Jonathan Imber seeks to convince his readers that, at least in America, medical morality--and, consequently, faith in doctors--can be traced to the righteous influence on the profession of Protestant and (to a somewhat lesser extent) Catholic clergy during the latter part of the nineteenth century and the first two-thirds of the twentieth century. He believes that the waning of this influence and the parallel rise of medical technology are to be indicted as having created the situation most directly leading to the loss of doctors' authority. I would argue to the contrary: that it was always the physician's morality, more than his technical competence, that provided the basis for his authority during the many centuries before scientific medicine began to bring the full fruits of its discoveries to ever larger numbers of patients. Moreover, that morality originated in religious principles long preceding Christianity--to a large extent, those derived from the ancient Mosaic code.
Imber has written a scholarly book crammed to the margins of each page with the facts that in his view support his argument. It is not in his facts that I find fault, but in his interpretation of them. The fundamentals of his argument can be summarized by quoting a few selections from the opening pages of his book:
"For more than a century--from the 1860s to the 1970s--the American medical profession relied on a combination of commitment to rigorous training in medical science and a dedication to professional ethics that made it a revered and respected vocation.... In the first half of this book, I will examine a connection between the rise of trust in physicians and the role played by Protestant and Catholic clergymen and thinkers in the second half of the nineteenth and first half of the twentieth centuries. These members of the religious community defined and bolstered the moral authority of modern medical professionals, whose responsibility to patients was grounded in the willingness of patients to trust their individual doctors. Protestant clergymen, in particular, helped to shape that trust by insisting that the physician was and would be a person of integrity and high moral character, while the Catholic perspective focused on specific moral dilemmas that physicians face in everyday practice.
"In the second half of the book, I will present an account of how doctors, who were once publicly perceived in this country as healers engaged in a sacred vocation, began to lose their moral authority as they increasingly became more valued for their technical competence than for their noble character....
"Historians of nineteenth-century medicine in the United States have long taken for granted its white, Protestant character, so much so that one key to understanding the nature of the public's almost universal trust in medicine, beginning in the middle of the nineteenth century and lasting until the middle of the twentieth, was the near uniformity of its practitioners not only in terms of their race, class, and gender, but also in terms of the kinds of cultural expectations that pertained to how they should act with respect to society, colleagues, and their patients....
"Even as its influence waned, the Protestant establishment's insistence that the physician must be first a believing Christian, and thus a righteous person, gave added public credibility to the rising status of the physician's office, that is, his position of authority in society."
Reading the first half of Trusting Doctors, one might indeed be persuaded that "the rise of trust in physicians" was the result of "the role played by Protestant and Catholic clergymen and thinkers in the second half of the nineteenth and first half of the twentieth centuries." Imber supports his thesis by quoting a number of sermons and medical addresses--commencement and other sorts--in which these men make what is to them the obvious connection between their religious beliefs and the ethics of the medical profession. In other pronouncements that Imber adduces, the divines and the devouts, in ringing inspirational phrases, exhort their medical audiences to follow Christian principles in all their interactions with patients.
One would hardly expect otherwise. Protestantism was to all intents--except the official--the American national religion during the period under discussion. The concept of medical authority having been created and bolstered by its practitioners' acceptance and absorption of a "faith-based" morality would have been very attractive to devout Protestants, and they can hardly be blamed for claiming that it arose from their own preachings and example, prior to which it was either non-existent or had attained only a much lower level.
But Imber, a sociologist and an ethicist, should know better. Medical morality has roots far deeper than those shared with Protestantism, and so does the recognition that it was the foundation for trust and accordingly for authority. In fact, it goes back to the origins of Western medicine in the Hippocratic period that began a bit before 400 B.C.E., and it was already the code of behavior for Jewish physicians almost a thousand years earlier.
The Jewish relationship between medicine and religion has been close since the time of Moses and continuing forward until the modern period. When Maimonides, a physician who wrote voluminous medical works, composed his authoritative code of Jewish law, the Mishneh Torah, in the twelfth century, he placed strong emphasis on compassion, as well as charity in its broadest sense of beneficence to others. It is worth noting that approximately half of all Jewish physicians of the time were also rabbis and jurists, a condition that had probably existed since the Talmudic era, when it was commonly understood that the physician, though acting independently and with free will, was the individual messenger or deputy of God. For centuries, the principles of Maimonidean morality and ethics exerted such a powerful influence on Jewish doctors that the famous "Physician's Prayer" was attributed to the medieval sage until approximately 1914, when it was discovered that its true author was Markus Herz, a German-Jewish physician and philosopher and a friend of Kant, who composed it in 1783.
That Jewish doctors were hardly the only ones whose upstanding professional behavior predated Protestantism and was laced with religious principles is also made plain by invoking some of the codification of righteous behavior to which Imber himself refers, starting with the Hippocratic Oath. It is generally held that the greatest contribution of the school of physicians called Hippocratic was their separation of the causes and treatments of disease from any supernatural source. The introduction of this new philosophy enabled their accuracy of medical history-taking and physical examination, as well as their recognition of environmental influences on illness. For the Hippocratics, the origins of sickness were to be sought only in natural causes, and the same was true of methods of healing. And yet, when they enunciated their historic oath, they swore it to "Apollo the Physician and Asclepius and Hygieia and Panacea and all the gods and goddesses," signifying the sacred nature of the obligation of doctor to patient, and the trust that was meant to derive from it.
At all times and in all places, the elevation of an individual to the status of physician was understood to carry with it obligation of a sacralized nature. When Imber correctly points out that the dominant Protestant culture of nineteenth-century America saw medicine as a "vocation or calling," he overestimates the role of the church in promulgating such a view. All Western religions, including the pagans of Greece and Rome, regarded the profession of healing as a vocation or a calling. And the more organized the profession, the more likely it was to be regarded in this way. Late nineteenth-century Christianity endorsed such a view and promoted it, but was in no way its source. Its religious basis had been laid down more than two thousand years earlier. And so had the notion that trust in a doctor's righteousness led to the authority that had a role in healing. Thus, there is found in one of the books of the Hippocratic corpus of writings the following statement: "Some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician."
In America, officially sanctioned statements of righteous medical behavior can be traced to the founding of the American Medical Association in 1847, when the organization's code of ethics was written. The code was based largely on the language of Thomas Percival's Medical Ethics, published in 1803, which carried even more influence in the United States than it did in Percival's native England. In the form of practical maxims and moral aphorisms, Percival laid down rules of medical conduct and etiquette based on virtue and personal character--the sort of behavior one might expect of a good man motivated by a sense of beneficence. Though Percival's notions of morality arose from his deep religious faith, he did not burden his text with any reference to that fact, except from time to time when he promoted the Sabbath as a day of rest for physicians.
By the dawning of the twentieth century, the purely scientific aspects of medicine had become so far advanced that they contributed a great deal to the profession's authority, but they certainly did not replace the role of benevolence in society's image of the doctor. The refinement of the germ theory and the rapid development of surgery after the medical acceptance of antisepsis were the primary factors in what might be called the "scientization" of medicine, but even the laity could discern that much more was on the way, though most patients were not yet benefiting from it--nor would they until approximately the middle of the century. The trend toward research and the ever-greater influence of science was accelerated in America by the Flexner Report of 1910, called Medical Education in the United States and Canada, as medical schools increasingly patterned themselves on the model of Johns Hopkins University, which stressed high academic standards in addition to its rigorous scientific curriculum. Since the influence of Christianity on daily life was beginning its decline at that time, it is Imber's belief that science gradually took over and then surpassed faith-based morality as the source of medical authority. He cites the rise of technological competence as the main source of the trust in physicians that increased until about the 1960s. But it was an overemphasis on such competence and the waning influence of the church, he asserts, that has led to the profession's loss of authority.
Yet what is subsequent is not necessarily consequent, and I find Imber's inferences to be misguided. Skepticism about medicine's powers made its appearance in the 1960s not least because that was an era in which the same attitude flowered about all sources of authority, especially among the younger segment of the population. At the same time, a certain bureaucratization was beginning to have an increasingly wider influence on the care of patients, having first manifested itself several decades earlier by the increase in hospitals as the place where that care was being given, replacing the home and the one-on-one attention that was paid by the practitioner. In fact, if there is a single unifying element that may be indicted as the ultimate cause of "the decline of moral authority in American medicine," I believe it to be this one: a change in the quality of interaction between the individual patient and his or her physician.
For more than two thousand years, that interaction, and its setting of medical morality, was the primary basis of the trust and the authority placed in the members of the medical profession and the profession as a whole by those who depend on them for healing. Now the uniqueness and intimacy of the interaction has been allowed to fray. That is the moral crisis. It behooves the profession and the laity to recognize its gravity and to seek measures to restore as much of the old relationship between patient and physician as is reparable.
Some of this change is doubtless due to the ever-greater complexity of the diseases being treated, and to the explosion in knowledge requiring finer and finer separation into specialties, with the consequence that more personnel are involved at the bedside. But there are other causes that might be thought of as social, such as the shared responsibility that comes with the widening phenomena of group practice, and the evolution of more impersonal health insurance. Note must also be taken of the greater--much greater--level of patient awareness than existed at mid-century: America now buzzes with the information provided by health columns in newspapers and magazines, health articles in all sorts of publications, television commentary and advertising, and the ubiquitous presence of books on various health topics. Today's patient, who often goes straight from a doctor's diagnosis to the Internet to see for himself, has become the consumer of a product--health care--and his level of sophistication is high, as is his level of skepticism.
The profession of medicine has now and then given the public reason for skepticism beyond its relatively new awareness of the uncertainty of even the most scientifically rigorous care. I refer to such outrages as the Tuskegee Syphilis Study, begun in 1932 and continued for forty years; the experimental injection of the hepatitis virus into retarded children at Willowbrook Hospital in New York state; and the implantation of cancer cells under the skin of debilitated elderly patients at the Jewish Chronic Disease Hospital by researchers from the prestigious Sloan-Kettering Cancer Center. The public has been incensed by such revelations, and rightly so. The examination of the circumstances in which these crimes were perpetrated contributed to the emergence of the modern field of bioethics, whose philosophical and moral judgments are meant to be completely secular, though contributions by members of the religious community have been significant and many.
It is increasingly difficult to tease out from modern bioethics the religious principles upon which codes of morality were originally founded. Nor is there any need to make the attempt. Though various religious communities have somewhat modified certain bioethical injunctions to suit specific aspects of their beliefs and dogmas, the fact is that the modern field as it has existed in recent decades is a secular one, in the same way that science is secular in its approach to the phenomena of nature. And its secularity in no way damages its authority. Though the role of religious thinkers will remain very significant in the analysis of moral-medical dilemmas, their contributions must be expressed, if they are to influence the relevant practitioners and institutions, in terms acceptable to all scholars who wrestle with the same complex ethical problems presented by contemporary medicine and science. It has been centuries since medicine needed an overtly religious justification for its moral code. Its authority as a profession has been independent of faith far longer than Jonathan Imber would have us think.
Sherwin B. Nuland is a contributing editor for The New Republic.
This article originally ran in the December 3, 2008, issue of the magazine.