Does your doctor practice politics? No, I don't mean running for office or giving money to super PACs. I'm referring to his or her medical judgment -- and the clinical decisions foisted upon your physician by insurers, bureaucrats, and sometimes the law.
The recent contretemps over contraception brings this to mind. I'm troubled by my own employer's actions: I teach law at Georgetown University, which refuses to cover the pill in the health plan it compels students to buy -- and forbids student health service doctors to prescribe it.
Georgetown's president, John DeGioia, offered an inspired defense of our student, Sandra Fluke, after Rush Limbaugh gave voice to his strange sexual imaginings. But the university ignored Fluke's plea for contraception coverage, disregarding an appeal from 66 members of the law faculty (including me) imploring DeGioia to reconsider the question.
The school elided Fluke's moving account of the harm its anti-contraception policy has done to students by announcing, through campus-wide email, a panel discussion on "The HHS Mandate and Religious Freedom." This recasting of its claimed right to limit personal choice as an assertion of freedom is disingenuous, to say the least, unless one buys into the premise that institutions have personal rights. ("Corporations are people"?) But my main concern here is that Georgetown has ducked the hard question of how morals and politics should bear on medical practice.
That morals and politics influence doctors' decisions is something neither liberals nor conservatives like to admit -- and that Hippocratic ethics denies. "In every house where I come," the Hippocratic oath promises, "I will enter only for the good of my patients."
But values are embedded in clinical practice. More often than not, these values are a matter of consensus. In the battle between bacteria and our immune systems, nobody wants the bacteria to win. Perhaps, from an ecological perspective, there's something to be said on the side of the microbes, but we humans are united in our unwillingness to say it. We're of one mind, also, in our struggles against cancer, clogged coronary arteries, and aging, though evolutionary theorists say limited lifespans may give species a survival advantage.
But when it comes to contraception, consensus breaks down. Some of us object to sex that's not meant to make babies -- and thus to medical intervention that allows erotic experience without reproductive consequence. Others celebrate sexual pleasure, as an experience in itself or as a way to deepen connection between spouses, lovers, or even friends.
Opinions on whether doctors should be free to prescribe birth control (and whether insurers should cover it) reflect these differences. So do views on the newest state dictates to doctors who perform abortions -- mandatory ultrasounds and penetration of women with fetal scanners -- measures transparently meant to provoke guilt. (That sometimes sex isn't voluntary seems of no moment to these measures' proponents, who seem willing to treat coerced women as collateral damage.)
Doctors who conform to these dictates, willingly or otherwise, practice a moral politics that fits poorly with their oath of loyalty to patients. Other clinical controversies pose similar problems. Conservatives quarrel with prevailing understandings of PTSD (post-traumatic stress disorder), arguing that this diagnosis discourages self-reliance. The horrors of war, they say, call for courage and resilience, not the makeover of warriors into victims. Within the military, some psychiatrists have pressed for fewer PTSD diagnoses; others, more inclined toward an ethic of solidarity, have pushed back against perceived Pentagon reluctance to acknowledge PTSD's extent.
The trial of Staff Sgt. Robert Bales for allegedly killing 17 Afghani civilians could pose the question of PTSD's proper scope in explosive fashion. Bales' lawyer suggests PTSD contributed to his rampage. But to many, the PTSD excuse is a travesty -- a reprehensible retreat from personal responsibility.
Battles over the breadth of autism and attention deficit hyperactivity disorder likewise reflect rival beliefs about the good. Are people who eschew sociability to focus on solitary pursuits "ill" with Asperger's syndrome -- a fashionable diagnosis in our networked era -- or inclined toward a lifestyle that's "normal," even productive of ideas that groupthink suppresses? And are kids whose concentration lapses during long lectures or tests "disordered," or is the "deficit" here to be found in schoolroom tedium and parents' pursuit of medical imprimatur for performance-enhancing drugs and extra time on exams?
Morals and culture influence therapy in less contested ways. Insurers won't pay for sex surrogacy despite evidence that it works for some who fear physical intimacy, but they'll cover Viagra. And social acceptance of sedentary living inclines them to cover Lipitor when lots more exercise might do as well for heart disease.
So we should ask our doctors about the politics with a small "p" that's embedded in their advice -- the moral and cultural leanings that weigh on clinical judgment. We should watch for efforts by employers and government to push moral and cultural agendas through decisions about the care they'll pay for. And when these agendas worry us, we should speak out -- to our doctors, employers, and political leaders. I just hope that no one sides with the microbes.
For more by M. Gregg Bloche, M.D., J.D., click here.
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