SPEECH NOTES FOR RICHARD SEARBY ORATION - DEAKIN UNIVERSITY, GEELONG
Posted on Monday, 3 September 2007
THE IMPORTANCE OF ETHICAL STANDARDS IN THE PRACTICE OF MEDICINE
It is an honour to give this address in tribute to the life and work of Deakin University’s former Chancellor, Richard Searby.
As Chancellor from 1997 to 2005, one of Richard Searby’s chief goals was the establishment of a medical school at this university. A medical school in Geelong, he thought, would be a sign that Deakin had come of age as a university. As well, a non-metropolitan medical school could help to produce more doctors in country practice. This goal happily coincided with the Government’s. The Howard Government has created five non-metropolitan medical schools because Australia badly needs more doctors, and especially needs them in country areas. Last year, the Government announced that the Deakin University School of Medicine would have 120 funded student places a year and committed $18 million towards its construction.
Still, there’s more to the desire for additional doctors and new medical schools than just demographics. Doctors, we feel, represent our best selves. Doctors’ work encapsulates the best and noblest instincts of humanity. While almost everyone’s work serves some useful purpose, doctors’ work concerns life itself.
As Health Minister, for instance, I am responsible for or influence federal government health spending of $52 billion in this financial year alone. All up, Australian federal government health spending is greater than the annual Gross Domestic Product of 65 per cent of the countries of the world. It’s about a third more than the entire annual budget of Victoria and seven times the Packer family’s entire fortune. Yet I don’t personally treat a single patient and will almost certainly never save a single life. By contrast, doctors and other health professionals save lives almost as a matter of routine.
Doctors could hardly fail to learn from their daily involvement with people’s most personal and intimate crises. If knowledge of life’s vicissitudes leads to understanding and ultimately to wisdom, the respect most people have for doctors is easily explained. As individuals, doctors have the usual range of faults. As a group, they are informed, articulate, committed and idealistic to a striking extent. The practice of medicine, it seems, usually brings out the best in people. I am privileged to have worked closely with doctors for four years. Who knows, even for a government minister, contact with doctors might help to promote a kind of virtue by osmosis!
In surveys of who people trust, doctors and other health professionals invariably stand out. According to the Morgan Poll, 81 per cent of Australians rate doctors “high” or “very high” for ethics and honesty. Similarly, pharmacists rate 85 per cent and nurses 91 per cent for ethics and honesty. By contrast, lawyers rate just 36 per cent for ethics and honesty. Law was Richard Searby’s first profession. His subsequent profession, company director, rates just 21 per cent for ethics and honesty. It’s good that he eventually became a university chancellor because academics rate 67 per cent for ethics and honesty. In fairness, I should also point out that my own occupation, federal MP, rates just 16 per cent for ethics and honesty. Equally uncomfortable for both of us, for a former editorial writer at The Australian no less than for the former Chairman of News Ltd, should be the standing of newspaper journalism, which rates just 12 per cent for ethics and honesty.
I am not dismayed by the gulf between the relative public standing of doctors and MPs because our roles are so different. Parliament has to decide the issues on which disagreement is greatest. Hard decisions can’t be shirked even though they tend to discredit the decision-makers. Someone has to make them and cop the consequences. For a politician, the point is not to be liked but to be effective. Happy the people whose discontents can be blamed on politicians. The high level of trust enjoyed by other professions, particularly those which naturally invite it, suggests that Australian politicians do not hazard their reputations entirely in vain.
The medical profession’s dedication to preserving life is not unreflective or merely instinctive, like, for instance, the occasional heroism of bystanders at disasters. From the beginning, it has always been part of the considered ethos of the profession. The Hippocratic Oath was the distillation of good medical practice rather than a system of rules imposed upon it. For the beginning, the foundation of medical ethics was not so much the law as the sacred trust created between doctor and patient. The Declaration of Geneva, a modern version of the Hippocratic Oath, was first promulgated in 1948 and has since been kept up-to-date by the General Assembly of the World Medical Association.
In its current form, it states: “At the time of being admitted as a member of the medical profession: I solemnly pledge to consecrate my life to the service of humanity…The health of my patient will be my first consideration…I will maintain, by all the means in my power, the honour and the noble traditions of the medical profession…I will not permit (anything) to intervene between my duty and my patient. I will maintain the utmost respect for human life (and) I will not use my medical knowledge to violate human rights and civil liberties even under threat”.
Nearly all United States medical students and about half of British medical students take a modern version of the Hippocratic Oath, most commonly the Declaration of Geneva. In 2000, graduating students from five of Australia’s then ten medical schools made a declaration of ethical commitment. As ethics is one of the four strands of Deakin’s medical course, to start next year, subscribing to the full Declaration of Geneva could be a fine way to distinguish this university.
Being a doctor is both an extraordinary privilege and a heavy burden. It is a privilege to be involved so deeply with other people in their most personal moments. To be professionally obliged to maintain the highest standards of knowledge and the most honourable standards of behaviour in the toughest circumstances is almost too much for mere mortals. Declarations of ethical commitment matter because they help to reinforce doctors’ best instincts.
To a greater or lesser extent, all doctors deal with life or death situations and have to make decisions about how to handle them and what advice to give to patients. Should a very elderly person be recommended for dialysis; at what point does cancer treatment become futile; when is it best for patients to reconcile themselves to the inevitability of death? For patients and their families there can hardly be weightier decisions and they invariably depend on their doctors for the information on which to base them. Most people are glad to have that counsel because they normally trust doctors’ judgment as well as their science.
The best answer to these types of questions normally depends on the character and circumstances of the patient. In these matters, “rule books” are less likely to be effective guides than the considered judgment of experienced doctors who want the best for their patient. That won’t always coincide with what the patient or the patient’s family first say they want. Often, what’s best will only become clear over time. However imperfect they are at it, this process of sympathetic and knowledgeable engagement with patients is the source of doctors’ public respect.
Doctors who know their patients and care for them are in a good position to understand the terror of a lonely, painful death or the fear and confusion of a teenage mother to be and to help their patients to cope. Sometimes, it’s said that doctors and their patients would be helped if the law were clarified in these matters. My problem with “reform” in this area is that it can shift the moral boundaries without really making them less blurred. There will always be hard cases on either side of any law which doesn’t say anything goes.
Would changing the law make questions of life or death less confronting or these transitions easier for patients? Would palliative care services or counselling services be strengthened by legal changes that could reduce the duty of care on doctors? I doubt it. Doctors and their patients would still have to face the most challenging questions of all with imperfect judgment, finite emotional resources, and uncertainty about the future. However unsatisfactory, at least the current law means that these circumstances are never viewed as routine. It has the effect of “solemnising” decisions that can never be easy and which good doctors would never want to be taken lightly. That’s why, in this area, prosecutions have been few, convictions rare and penalties, if any, very light.
The fact that they have to deal with the real situations of their patients lends humanity to doctors’ ethical discourse regardless of the conclusions they might ultimately reach. As the US medical ethicist, Edmund Pellegrino, writes: “However parlous the state of contemporary post-modern philosophy might be, ‘plain people’ such as doctors and patients will still ask: ‘What is the right and good thing for me to do? What is the good for patients and what kinds of actions will achieve it?’ No person making practical ethical decisions can easily escape these questions…There are no atheists in foxholes and there are no patients (even when they are ethicists themselves) who are truly nihilists or total sceptics when their own health or welfare is at stake”.
The public’s sense that doctors have a moral code that’s more-or-less stood from time immemorial is part of the medical mystique. It helps to reassure people that doctors have a sense of duty toward their patients superior to that, say, of financial advisers towards their clients. It’s part of what makes medicine a vocation rather than just a job and medical practice a calling rather than just a business.
After the federal Government announced emergency measures to restore civil society in remote Northern Territory townships, more than 800 doctors volunteered to serve on health teams. There are still nearly 1300 country GPs who do obstetrics, anaesthesia or emergency department work over and above their standard job. Doctors are hardly oblivious to financial security and work/life balance. They are normal human beings not supermen. Still, their instinct is to rise to challenges not leave them to others. This is why, for instance, the public hospital system continues to function reasonably well despite administrators’ incorrigible tendency to demand of people that they do more with less.
Doctors’ public standing in Australia has risen substantially over the past three decades. In 1979, doctors’ Morgan Poll ethics and honesty rating was only 62 per cent, four points behind bank managers who were then the most trusted occupation. Since then, doctors’ rating has improved 19 points while bank managers’ has plummeted 33 percentage points. Regardless of any controversies involving the profession and the profession’s own disagreements about what constitutes ethical practice, Australians seem to have grown more impressed with the doctors they actually deal with.
Still, the respect in which doctors are held doesn’t mean that the profession can ignore public concerns. The more respected a group is, the more disappointed people tend to be with any departure from high standards of behaviour. Bank managers’ public standing went into free fall when people began to suspect that they were more interested in the profit of the banks’ than in the success of their customers. In my view, the most lethal potential threat to doctor’s public reputation is any sense that the practice of medicine has become just another way to make money.
It’s important that the public continue to hold doctors in high regard. Any reduction in their standing could reduce respect for the whole health system. If people had less trust in clinical decision-makers, the system would find it harder to cope with difficult and complex cases. It would be harder to attract people to work in a system whose leading members were not placed on a pinnacle of public trust.
I hope that doctors will forgive the presumption of a mere politician seeming to lecture them on ethics. Perhaps a representative of one of the most scorned occupations can have something useful to say, even to the members of a highly respected profession, about the dangers of forfeiting public trust.
Right now, there are three significant areas in which the profession is vulnerable to the perception that sections of it might not be quite as committed as they should be to putting patients’ interest ahead of their own. One specialty, in particular, is vulnerable to the accusation that it’s escalating fees well in advance of any conceivable increase in costs. The procedural specialties generally still don’t adequately inform patients about the likely out-of-pocket costs of their operations. Finally, the explosion of medical advertising threatens to undermine confidence in the integrity of some sections of the profession.
Some years ago, obstetricians started to charge private patients an additional upfront fee on top of their standard consultation and delivery fees to cover high medical indemnity insurance costs. After the introduction of the Medicare safety net in 2004, some obstetricians started charging patients thousands of dollars for an initial consultation. This meant that patients could claim safety net benefits for what was, in fact, an insurance charge rather than a medical service.
In late 2004, the Government introduced a new Medicare item (for the overall planning and management of pregnancy) to regularise the conduct of the profession. This particular fee is generally about $300 in rural areas but can be $5000 or more on the North Shore or Eastern Suburbs of Sydney. Across Australia, the mean fee for this item was $1700 in the June quarter. For reasons which haven’t been explained, it’s still rising fast at a time when obstetricians’ insurance premiums have been steady or even falling.
No Australian government has tried to set prices for the medical profession and this Government certainly does not intend to be the first. On the other hand, the Medicare schedule fee has acted as a brake on doctors’ charging because it determines the patient rebate. For people in the safety net, however, the Medicare rebate does not depend on the schedule fee but on the actual fee and, in obstetrics, the fee charged generally takes people straight into the safety net.
Again, to its credit, the Australian Medical Association has always accepted that exploitation of the safety net will have to be policed. The AMA and the obstetric association need to exert some serious peer pressure over some of their members. Otherwise, it’s almost inevitable that some future government, less committed than this one to the principle of fee for service, will abolish the safety net and use the consequent burden on patients as an excuse to introduce a UK-style salaried profession. The Labor Party’s government-funded Superclinic proposal is a tentative step in this direction.
In Australia, unlike Britain or the United States, a strong private health system has been the essential complement of a strong public health system. The current Government’s policies have increased private health insurance coverage to almost 44 per cent. Still, people usually hesitate before buying a product for which the alternative is free. Paying private health insurance premiums (on top of tax and the Medicare levy) sometimes means paying a fourth time through hefty gap expenses for private procedures. This is especially galling if out-of-pocket expenses come out of the blue, the more so because many patients imagine that Medicare and their private health insurance will cover the full cost of having an operation in a private hospital.
A 2004 survey revealed that 21 per cent of patients faced gap expenses for their private hospital procedure which they had not been warned about in advance. These averaged $720 per episode. In about 800,000 cases a year, these bills would have been a nasty surprise after coming home from hospital.
To its credit, the AMA has always urged doctors to warn patients about potential out-of-pocket costs. In the wake of the 2004 survey, the Government and the AMA launched a campaign to increase the rate of informed financial consent. A survey last year showed a 20 per cent improvement in doctors telling patients about gap payments. Unfortunately, preliminary results from the latest survey, taken in May and June, show little further improvement. Fifteen per cent of privately insured patients still face gap payments that they were not warned about in advance. This is well short of the AMA and the Government’s objective that all patients be told in advance about reasonably foreseeable costs.
The Government is meeting this week with representatives of the private health sector, including the AMA, to canvass their ideas for ensuring that doctors tell patients about gap expenses. Otherwise, the Government will have to consider options for making it mandatory. It could be a presumption of practice that, where informed financial consent is not obtained, health providers would treat patients for the relevant rebates.
From early 2006, attentive listeners will have noticed a dramatic increase in medical advertising, mostly for heart testing and medical imaging. For a week in March, my department monitored medical advertising on two Sydney radio stations. Medical ads went to air on over 500 occasions on these two stations in a single week. That’s approaching two ads per hour for a sector that, until recently, never advertised at all in this way. On 162 occasions, the ads referred to Medicare funding or bulk-billing.
This ad blitz has corresponded with a large increase in Medicare funding for heart check items. In the financial year to April, this was 36 per cent higher than in the same period last year. I’m advised that services provided by Heart Check Clinics, the principal advertiser, accounted for 88 per cent of the increased volume of services.
The AMA says that medical ads should be “informative rather than persuasive”. Although the AMA’s position statement says “doctors should take care that their advertisements are not likely to exploit patients’ vulnerability or lack of medical knowledge”, the ads in question did not usually advise patients to consult with their GP.
For its part, the Government is a reluctant regulator and has no current plans to restrict medical ads. Even so, expensive ad campaigns raise suspicions of possible inappropriate clinical practice and over-servicing so I have asked the Professional Services Review to monitor clinics that advertise in this way.
By now you may be pondering the incongruity of a politician posing as ethical watchdog. Please note that I am not accusing doctors of breaching politicians’ standards. I am asking doctors to consider the extent to which a minority might, at least in some respects, be failing fully to uphold the standards of their own profession.
At the University of New South Wales, the students of each year draft a declaration of ethical commitment which is recited aloud on graduation day. By definition, a student-drafted declaration implies that medical ethics can be constantly and potentially limitlessly reinvented. On the other hand, student views of ethical practice may be less contaminated by commercial self-interest.
The 1998 graduating class at the UNSW declared: “I will practice my profession…in good conscience and with integrity…The care of my patients will be my first consideration…(and) I will not abuse the trust placed in me…for personal gain”. The 2000 graduating class declared: “Patients are my first concern…I will strive at all times to be worthy of my patients’ respect and never abuse their trust…My commitment extends beyond individuals to the health and well-being of the community…I hold myself accountable for my actions and will not stray from these commitments for personal gain”.
Is inflation of fees (even when a taxpayer funded safety net cushions the blow to patients), failure to warn patients of gap expenses (especially when fees are much higher than the Medicare schedule), and urging listeners to seek medical services “while your heart beats” consistent with putting patients first? I think not, in each case. When patients seek reassurance and insight on the hardest decisions of all, they must feel confident about whose interests doctors really have at heart.