Current Controversies: Politics in Medicine

By Ira L Goodman, MD, FACS, FAARM

Given the national focus on politics during the presidential election and beyond, it is appropriate for physicians to look at how this affects your practices and patients. It seems as though the media is obsessed with politics, with every move or word spoken by the key players, every proclamation, executive order, new law, or the latest flap. And why not? These things affect the way we live, our economy, taxes, real estate values, and so much more. It appears mandatory to pay attention to politics, even before science. Before exploring the specifics in relation to medicine, let’s step back and ask: what is politics?

Politics is one of the five branches of philosophy. The others are metaphysics, epistemology, ethics, and aesthetics. Without going back and referencing the books written by Aristotle, which you undoubtedly have at your bedside, these terms can be understood with a simple thought experiment. Imagine you and a fellow astronaut have been placed in suspended animation and sent into space for approximately 10 years in a deep sleep not knowing where you would land. This experiment begs the question of who would volunteer for such a trip. At first glance, it seems no one would; but in actuality, there was a long line of applicants consisting mainly of primary care physicians who were insurance based. Anyway, back to the thought experiment. The space ship lands safely, the occupants awaken. What are the first three questions they ask each other? The first one is obviously “where are we?” That is metaphysics. One may say this looks like planet X, and the other may say planet Y. The second question is “how do we know that?” That is epistemology. They look at the instruments, make some calculations, and may even have radio contact with earth to help them figure this out. The third question is “what do we do now?” That is ethics – the branch of philosophy dealing with action. Do we stay put, venture out, return home? Morals are not the same as ethics. Morals are a culturally defined subset of ethics concerned with good and bad.

These are the important questions in life and, indeed, in medicine. Isn’t this what you do with every patient at every visit? When a patient comes to you with entry forms filled out, the physician attempts to discover where they are or what they have (metaphysics)- their symptoms, past history, medications, main complaints, etc. The diagnosis answers the metaphysical question. Then, he or she tries to answer the second question which is how do we know that the diagnosis is accurate? Well, you look at the past medical history, examine the patient to collect the physical signs, listen to the symptoms, look at the labs, order more labs, and basically collect whatever objective data you can. This is epistemology and a critical step in the thoughtful physician’s inquiry. A physician’s epistemology is perhaps the most crucial step in a patient encounter. Is the diagnosis based on evidence, facts, or just intuition? Then, of course, there is ethics: what do you do for this patient? More tests, what treatment, what follow-up, etc., etc. The treatment decisions (ethics) come after the metaphysical and epistemological inquiries, which are hopefully done de novo each time. Unfortunately, many physicians’ epistemology is based on whatever big pharma tells them or whatever they see their colleagues do. As physicians, we are all philosophers.

Aesthetics has a limited place in medicine except if you are a plastic surgeon or dermatologist. Most physicians in private practice concern themselves with decorating their offices or facilities to make it more pleasant for the patients or as a marketing tool; but clearly, for most doctors, aesthetics is secondary to metaphysics, epistemology, and ethics. Or at least it should be. What about politics? This should be the last and least important consideration for the wise physician; but unfortunately, it has usurped the number one role! It has become paramount in most physicians’ minds to consider politics, which concerns itself with laws, regulatory agencies, and the rules of man as opposed to science. Who could survive without considering what is legal to do, what your medical board would allow, what your specialty board considers the standard, what the malpractice attorneys are likely to pounce on, or what your fellow physicians would do? Ah, the community standard!! I hate that term. I guess it’s better than the Betty Crocker cookbook of internal medicine or whatever your specialty is. Betty Crocker has a book for every specialty. As long as you stay within the bounds of these cookbooks, you are safe; and after all, isn’t that what it’s all about – protecting number one?

I say politics should be the very last branch of philosophy a good physician should be concerned with; but as we all know, it has become the first and most important. A good physician should be concerned about controlling the laws of nature not being controlled by the laws of man. We are upside down. The courageous physicians practicing so-called alternative medicine (another term I hate since it really is just medicine that works safely) are attempting to place metaphysics, epistemology, ethics, and aesthetics above politics, which periodically gets them in hot water. I have always thought there are two kinds of people in this world—those who produce goods or services and attempt to control physical reality, and those who attempt to control other people (the politicians). Let’s put metaphysics, epistemology, and ethics ahead of politics. We would all be better off.