VeatchR. M., A Theory of Medical Ethics (New York: Basic Books, Inc., 1981): At 6, 92–107 (discussing the inadequacy of reliance on any profession to determine its own moral foundation through agreement among its members).
4.
The 1847 AMA code states that, “There is no profession, from the members of which greater purity of character and a higher standard of moral excellence are required, than the medical.”Id. at 93.
5.
MacKenzieC. R., “Professionalism and Medicine,”History of the Human Sciences Journal3, no. 2(2007): 222–227 (citing OslerW. O. “On the Educational Value of the Medical Society,” in Aequanimitas, with Other Addresses to Medical Students, Nurses and Practitioners of Medicine (Philadelphia: Blakiston, 3rd ed., 1932): 395–423).
6.
ChurchillL. R., “The Hegemony of Money: Commercialism and Professionalism in American Medicine,”Cambridge Quarterly Healthcare Ethics16, no. 4(2007): 407–414.
7.
FadenR.KassN.GoodmanS., “An Ethics Framework for a Learning Health Care System: A Departure from Traditional Research Ethics and Clinical Ethics,”Hastings Center Report43, no. s1(2013): s16–s27.
8.
Editors, “Looking Back on the Millennium in Medicine,”New England Journal of Medicine342, no. 1(2000): 42–49.
9.
American Board of Internal Medicine, Project Professionalism (Philadelphia: American Board of Internal Medicine, 1998): 5.
10.
Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine, “Medical Professionalism in the New Millennium: A Physician Charter,”Annals of Internal Medicine136, no. 3(2002): 243–46.
11.
Id. (preface by SoxH.C., editor).
12.
For a discussion of the medical professional literature on definitions and invocations of professionism and altruism, see HaffertyF. W., “Definitions of Professionalism: A Search for Meaning and Identity,” Clinical Orthopaedics and Related Research 449 (2006): 193–204.
13.
Hafferty notes that British definitions of professionalism “do not highlight altruism as a core concept or an organizing principle.”Id. at 199.
14.
SwickH. M., “Toward a Normative Definition of Medical Professionalism,”Academic Medicine75, no. 6(2000): 612–616.
15.
GibsonD. D.ColdwellL. L.KiewitS. F., “Creating a Culture of Professionalism: An Integrated Approach,”Academic Medicine75, no. 5(2000): 509.
16.
BardesC. L., “Is Medicine Altruistic? A Query from the Medical School Admissions Office,”Teaching and Learning in Medicine: An International Journal18, no. 1(2010): 48–49.
17.
French philosopher Auguste Comte coined the term in the 19th century to describe an ethical obligation “to live for others,” renouncing self-interest. Stanford Encyclopedia of Ethics, s.v. “Auguste Comte,” available at <http://plato.stanford.edu/entries/comte/#EthSoc>(last visited September 29, 2014).
See also MacIntyreA., “Egoism and Altruism,” in BorchertD. M., ed., Encyclopedia of Philosophy, vol. 2 (New York: MacMillan, 1967): At 442–466.
20.
MacIntyre explains that altruism is often considered the opposite of egoism and describes the resulting preoccupation with determining which of these two motives, or ways of living, govern our actions. He provides a contrary view, writing that, “…if I want to lead a certain kind of life, with relationships of trust, friendship, and cooperation with others, then my wanting their good and my wanting my good are not two independent, discriminable desires.”Id.
21.
GlannonW.RossL. F., “Are Doctors Altruistic?”Journal of Medical Ethics28 (2002: 68–69.
22.
For discussion of physicians' fiduciary obligations, see MehlmanM. J., “Dishonest Medical Mistakes,”Vanderbilt Law Review59, no. 4(2006): 1137–1173.
23.
RodwinM. A., “Strains in the Fiduciary Metaphor: Divided Physician Loyalties and Obligations in a Changing Health Care System,”American Journal of Law & Medicine21, nos. 2 & 3(1995): 241–257.
24.
Id. (Glannon and Ross).
25.
Id. SimilarlyR. S. Downie writes that “Morality enters medicine through the quality of the individual doctor's work, not by the definition of that work.” R. S. Downie, “Supererogation and Altruism: A Comment,”Journal of Medical Ethics28, no. 2(2002): 75–76.
26.
Id.
27.
OrentlicherD., “The Influence of a Professional Organization on Physician Behavior,”Albany Law Review57, no. 3(1994): 583–605.
For an early essay presenting a moral argument for understanding the practice of medicine as a business, see SadeR. M., “Medical Care as a Right: A Refutation,”New England Journal of Medicine285, no. 23(1971): 1288–92. (Sade compares the physician to a baker.
31.
American Bar Association, Model Rules of Professional Conduct, Rule 6.01 “Every lawyer has a professional responsibility to provide legal services to those unable to pay. A lawyer should aspire to render at least (50) hours of pro bono publico legal services per year.”) Because the requirement to provide pro bono services is somewhat general, it would be difficult to enforce, even in those states that have adopted Rule 6.01 as part of the regulations governing the conduct of lawyers. New York, however, has recently adopted a rule “requiring applicants for admission to the New York State bar to perform 50 hours of pro bono services.” New York State Uniform Court System, available at <http://www.nycourts.gov/attorneys/probono/baradmissionreqs.shtml>(last visited September 29, 2014). Moreover, courts can appoint lawyers to serve particular clients in a case and when they do so, the lawyers' compensation for such representation will be fixed by the court. See ABA Model Rule 6.2 (“A lawyer shall not seek to avoid appointment by a tribunal to represent a person except for good cause.”).
32.
See GlannonRoss, supra note 15.
33.
BlackburnS., Being Good (New York: Oxford University Press Inc., 2001), at 48–49. Millennial medical student graduates may not be as inclined to support and promote altruism as a core value.
34.
HaffertyF. W., “What Medical Students Know about Professionalism,”Mount Sinai Journal of Medicine69, no. 6(2002): 385–398. Hafferty writes that classroom discussion with medical students as part of a professionalism curriculum revealed little support for the principle that physicians should subordinate their own interests to the interests of others. The students expressed a need for “balance” in their lives, the importance of taking care of oneself in order to help others, and a lack of commitment to vague and general professional codes and oaths imposed by others. He writes, “Students certainly verbalized a commitment to doing good, but they were unremittingly clear that the who, what, when, where, and why would remain under the control of the ‘do gooder.”’ While some of these attitudes are not particularly problematic under the thesis of this article, we might nevertheless be concerned that once “altruism” is rejected or discredited as the lesson to learn, students may not be taught or may not understand and internalize what their true and more specific ethical and legal obligations are to patients. Most concerning is Hafferty's statement that the students” [m]ost clearly and emphatically… rejected the notion that they were obliged to do anything. Period.” Id. at 391.
35.
See also Hafferty, supra note 12.
36.
CoonsS., “The SUPPORT Trial: Risk and Consent Questions Divide the Clinical Research Community,”Research Practitioner14, no. 5(2013): 112–117.
37.
AnnasG. J.AnnasC. L., “Legally Blind: The Therapeutic Illusion in the Support Study of Extremely Premature Infants,”Journal of Contemporary Health Law & Policy30, no. 1(2014): 1–36.
38.
MacklinR.ShepherdL., “Informed Consent and Standard of Care: What Must Be Disclosed,”American Journal of Bioethics13, no. 12(2013): 9–13.
39.
WilfondB. S. Compare, “The OHRP and SUPPORT,”New England Journal of Medicine368, no. 25(2013): E36. DOI:10.1056/NEJMc1307008.
40.
MacklinR., “The OHRP and SUPPORT–Another View,”New England Journal of Medicine369, no. 2(2013): e3(1–(3). DOI: 10.1056/NEJMc1308015.
DrazenJ. M.SolomonC. G.GreeneM. F., “Informed Consent and SUPPORT,”New England Journal of Medicine368, no. 20(2013): 1929–1931.
45.
See Wilfond, supra note 26.
46.
See MacIntyre, supra note 14 (writing about our misguided preoccupation with understanding actions as taken either in self-interest or benevolence, either with bad motives or good motives).
47.
See BazermanM. H.TenbrunselA. E., Blind Spots: Why We Fail to Do What's Right and What to Do about It (Princeton: Princeton University Press, 2011): At 20–21“[M]ost smart, well-educated doctors are puzzled by the criticism against them, as they are confident in their own ethicality and the ‘fact’ that they always put their patients' interests first …. But the more pernicious aspect of conflicts of interest is clarified by well-replicated research showing that when people have a vested interest in seeing a problem in a certain manner, they are no longer capable of objectivity.”).
48.
Although a full exploration is beyond the scope of this essay, paternalism is an additional concern that often flows from the best of intentions but, nonetheless, raises concerns about which a well-meaning physician may not even be aware. An overblown sense of altruism may, at least in part, contribute to the pernicious self-rationalization that the doctor always knows best.
49.
OrlowskiJ. P.WateskaL., “The Effects of Pharmaceutical Firm Enticements on Physician Prescribing Patterns: There's No Such Thing as a Free Lunch,”Chest102, no. 1(1992): 270–273.
50.
WazanaA., “Physicians and the Pharmaceutical Industry, Is a Gift Ever Just a Gift?”JAMA283 (2000): 373–380.
51.
HarrisG.RobertsJ., “Doctors' Ties to Drug Makers Are Put on Close View,”New York Times, March 21, 2007, at A1.
52.
See Editors, supra note 8.
53.
FisherJ., Medical Research for Hire: The Political Economy of Pharmaceutical Clinical Trials (New Jersey: Rutgers University Press, 2008);
54.
see HarrisRoberts, supra note 34.
55.
PerryJ. E., “Physician-Owned Specialty Hospitals and the Patient Protection and Affordable Care Act: Health Care Reform at the Intersection of Law and Ethics,”American Business Law Journal49, no. 2(2012): 369–416.
56.
See generally ShepherdL.RileyM. F., “In Plain Sight: A Solution to a Fundamental Challenge in Human Research,”Journal of Law, Medicine, and Ethics40, no. 4(2012): 970–89 (discussing the physician-researcher conflict of interest).
57.
JohnsonS. H., “Five Easy Pieces: Motifs of Health Law,”Health Matrix14, no. 1(2004): 131–140, at 131.
58.
Id.
59.
AppelbaumP. S.RothL. H.LidzC., “The Therapeutic Misconception: Informed Consent in Psychiatric Research,”International Journal of Law & Psychiatry5, nos. 3 & 4(1982): 319–329 at 321.
60.
LidzC. W.AppelbaumP. S.GrissoT.RenaudM., “Therapeutic Misconception and the Appreciation of Risks in Clinical Trials,”Social Science & Medicine58, no. 9(2004): 1689–1697, 1691.
Id. See also HochhauserM., “‘Therapeutic Misconception’ and ‘Recruiting Doublespeak’ in the Informed Consent Process,”IRB: Ethics and Human Research24, no. 1(2002): 11–12 (explaining how the ubiquitous “brand names” of clinical trials contribute to a research subject's therapeutic misconception).
63.
“Clinical Trial Subjects: Adequate FDA Protections?”Hearing Before the Committee on Government Reform and Oversight House of Representatives, 105th Congress 152–53 (1998) available at <http://www.gpo.gov/fdsys/pkg/CHRG-105hhrg49827/pdf/CHRG-105hhrg49827.pdf>(last visited October 10, 2014).
