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The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
A Mask Tells Us More Than a Face a
John Banja a
Emory University Published online: 15 Aug 2014.
Click for updates To cite this article: John Banja (2014) A Mask Tells Us More Than a Face, The American Journal of Bioethics, 14:9, 47-49, DOI: 10.1080/15265161.2014.935882 To link to this article: http://dx.doi.org/10.1080/15265161.2014.935882
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Downloaded by [FU Berlin] at 17:53 01 May 2015
Dual Agency and Expectations of Professionalism
is tied to a picture of physicians as individual professionals, Tilburt cannot do much more to resolve these issues. One way forward might be to explore two points from Kevin Gibson’s (2003) analysis of role morality. Gibson’s first point is potentially deflationary for Tilburt’s argument. Gibson contends that the concept of professionalism has no special moral significance in a role morality context; moral issues at work are merely one part of the “constellation” of moral demands that individuals must grapple with in their many roles (2003, 28). If Gibson is right, Tilburt’s recommendation of role morality to solve the dual agency problem would not work unless he sought to integrate physicians’ ethics across their personal and professional lives. Relatedly, as Gibson points out, one danger of role morality is that it may foster professional actions that individuals outside professional roles would not endorse (2003, 28). Gibson’s second point is that instead of thinking of people as professionals (for at least some of the time), we should think of individuals as people who are able to manifest power; the advantage of so doing is that assessment of individuals across personal and professional roles would be facilitated (2003, 28). This may be a better way forward and would, if coupled with Bleakley’s work, help Tilburt to pursue an account of the concept of professionalism as embedded in team and environmental systems. Tilburt’s exploration of the logic of professional expectations could also benefit from further analysis of the concept of responsibility, especially in connection to addressing social inequality in health care. In particular, Tilburt would have benefited from drawing on Iris Marion Young’s (2011) analysis of structural injustice and her social connection model of responsibility. Tilburt notes that improving access to care is specified in the ABIM Physician Charter on professionalism alongside pursuit of just distribution of finite health care resources. He also actively explores the need to ensure access to the benefits of basic health care for all via a sustainable and efficient model. Yet Tilburt’s acknowledgment that equitable distribution of finite resources and access to health care are both
important needs also seems to require that taking responsibility for structural injustice in health care is a professional ethical expectation for individual physicians (Tilburt 2014; Young 2011, 96). Young (2011) suggests that a social connection model of responsibility has a far better likelihood of dealing justly with social inequality than the more typical and individualist liability concept of responsibility, because the social connection model holds that all those who contribute to the relevant injustice share responsibility for it and are morally bound to join together to transform the unjust structures into just ones (96). In contrast, the liability model focuses on the relationship between individuals and harms (96). Young’s social connection model clarifies how social justice may be a reasonable professional expectation of physicians, and would address the functional insulation problem Tilburt (2014) identifies, as well as bolstering the significance and impact of physician advocacy and activism in and through professional organizations. &
REFERENCES ABIM Foundation. 2004. Medical professionalism in the new millennium: A physician charter. Available at: http://www. abimfoundation.org/Professionalism/Physician-Charter.aspx (accessed June 9, 2014). Bleakley, A. 2006. A common body of care: The ethics and politics of teamwork in the operating theater are inseparable. Journal of Medicine and Philosophy 31: 305–322. Gibson, K. 2003. Contrasting role morality and professional morality: Implications for practice. Journal of Applied Philosophy 20(1): 17– 29. Tilburt, J. C. 2014. Addressing dual agency: Getting specific about the expectations of professionalism. American Journal of Bioethics 14 (9): 29–36. Young, I. M. 2011. Responsibility for justice. Oxford, UK: Oxford University Press.
A Mask Tells Us More Than a Face John Banja, Emory University Oscar Wilde’s epigram (Redman 1959, 138) speaks directly to Jon Tilburt’s concerns about the sometimes contradictory obligations of professionalism (Tilburt 2014). On the one hand, “professionalism” is a mask that conceals the distressing reality of health providers occasionally withholding treatments from patients without the means to
pay. But state and federal legislatures may wear a more pernicious mask in handing down Medicaid budgets. Behind the masks of fiscal responsibility and individual accountability, legislatures pass Medicaid budgets whose limitations sometimes make it next to impossible for health professionals and their institutions to adequately care for
Address correspondence to John Banja, Emory University, Center for Ethics, 1531 Dickey Drive, Atlanta, GA 30322, USA. E-mail: [email protected]
September, Volume 14, Number 9, 2014
ajob 47
Downloaded by [FU Berlin] at 17:53 01 May 2015
American Journal of Bioethics
the poor. But if there is anything a patient, regardless of his or her economic means, should be able to claim, it is care that meets the professional standard, that is, what a “reasonable and prudent” health professional would ordinarily do or provide. Consequently, if the standard of care truly requires a gastric bypass for Tilburt’s hypothetical patient but there aren’t enough Medicaid dollars to reimburse its costs, then Medicaid beneficiaries have been twice wronged: by professionals obligated but failing to treat them according to what medical judgment requires, and by a state legislature that refuses to appropriate sufficient funds to reasonably compensate the delivery of that care. Health professionals have endured this ignoble situation for decades. Their resignation to it may in large part stem from the seemingly unresolvable problems that the poor pose to state and national governments. In his splendid book A Short History of Distributive Justice, Samuel Fleischacker (2004) notes three independent but seemingly intractable problems that have bedeviled distributive justice schemes for centuries. He points out that only since the mid-18th century has the idea become popular that the poor are poor because of social conditions rather than from hereditary factors rendering them “inferior” to the better off. However, once the Enlightenment idea of moral equality gained a foothold, especially among “liberal” or welfare-minded thinkers, it was but a short step to arguing that everyone, by virtue of his or her inherent dignity, is entitled to a limited but reasonable share of basic goods. Unfortunately, though, centuries of moral debate have failed to demonstrate exactly what “moral equality” requires that human beings make available to one another. In contrast to welfarist sensibilities that encourage income redistribution toward the poorly off, many political and economic conservatives instead turn to the just world hypothesis: “You get what you deserve, and you deserve what you get” (Scott 2008). Notice that Tilburt is exquisitely aware of that conservative bias by imagining his hypothetical gastric bypass patient being abused as a child, suffering from posttraumatic stress disorder (PTSD), and being harmed by a weight-loss drug. Presumably, we are to understand her as significantly handicapped by factors beyond her control that prevent her taking charge of her destiny and making responsible choices. To liberal sensibilities, that means that the better off have some degree of moral obligation to provide her with assistance. But conservatives will point to the countless number of human beings whose circumstances were worse than hers but who overcame adversity in heroic fashion by their own wits and initiative. So why can’t she, even if we grant her moral equality to everyone else? A second problem plaguing the Medicaid dilemma concerns whether distributive schemes, such as Medicaid, should be a component of justice. Even if human beings are “morally equal,” it is far from obvious that governments should take it upon themselves to redistribute the wealth of their citizens. For political conservatives, the primary function of justice consists of protecting individual
48 ajob
liberty and especially one’s private property (Nozick 1974). Instead of enabling everyone’s access to a “basic good” like health care, conservatives understand justice to insure that everyone enjoys equal freedoms, opportunities, and the right to their property. Social welfare programs like Medicaid therefore strike many as morally problematic political experiments that not only confiscate one group’s wealth and give it to another, but also usurp the private citizen’s right to decide just how “basic” a “good” health care is. But even if a society compels its government to redistribute wealth in support of welfare programs, a third problem concerns nitty-gritty questions over deciding who gets what and how much. Illustrating the challenge, Malcolm Gladwell (2006) authored a remarkable story in the New Yorker involving an individual he nicknamed “Million Dollar Murray.” For years, Murray had been homeless and hopelessly addicted to alcohol. It was estimated that over a decade he had personally cost the city of Reno, NV, a million dollars because of his frequent appearances in the city’s emergency rooms followed by brief periods of incarceration. Gladwell relates how Reno’s leadership approached the economic problems that people like Murray posed—people who constituted a very small percentage of Reno’s homeless but exerted an enormous drain on the city’s budget. The ultimate proposal was that the city should provide them with efficiency apartments, secure them full-time employment, and appoint each one a social worker who would insure the client’s compliance with the program. On paper, the plan anticipated saving the city millions of dollars yearly. In reality, both conservative and liberal voices loudly objected: Conservatives complained that their tax dollars would be going to bums; liberals objected that the proposal’s large welfare allocation would serve only a fraction of the city’s needy citizens rather than all of them. If we removed the masks of moral rectitude and political platitudes and squarely faced the problem of the poor, what would we find? I suspect we’d uncover an ungodly mess of moral intuitions and less than conclusive data. We’d find that liberals would regard the just world hypothesis as lunacy, while conservatives would argue that their property is sacrosanct. Liberals would point out that some of the most heavily “socialized” European countries also boast the highest quality of life in the world for their citizens. Conservatives, however, would refuse to engage in any discussion—no matter how scientifically grounded its data and proposals—that contemplates raising taxes. Liberals would encourage correcting irrational social practices with insightful, “compassionate,” and factually informed legislation, while conservatives would likely view the same as an abuse of government power. Of course, withholding the operation from Tilburt’s patient might increase the probability of her experiencing a serious stroke or cardiac event. That occurrence would hardly save Medicaid any money, not to mention the burdens and costs it would place on her family. Also, her physician’s withholding the operation from her might
September, Volume 14, Number 9, 2014
Downloaded by [FU Berlin] at 17:53 01 May 2015
Dual Agency and Expectations of Professionalism
seem strikingly discriminatory in that its rationale entails an entire subpopulation of citizens being deprived of the benefits of contemporary medical science (T. Sweeney, personal communication, June 3, 2014). Yet I believe that we have no “moral facts” to guide us in this case. Americans run the gamut of moral opinion, from Spencerian-like beliefs that we shouldn’t provide any aid to the poor, perhaps in the hope that they will succumb to evolutionary pressures and die off faster, to ultraliberal sensibilities that Americans don’t pay nearly enough tax dollars to enable the kind of decent life everyone is owed. There is no conclusive moral answer as to whether Tilburt’s patient should or shouldn’t get her gastric bypass operation, but rather a motley crew of moral intuitions that propel the debate hither and yon (Fleischacker 2004). Perhaps, then, “transparency” would represent an alternative to the masks we wear. Should Tilburt’s patient be bluntly told about the economic limitations that wind up denying her a gastric bypass operation? Should conservatives be persistently challenged to justify their belief that such denials reap more social benefit than burden? Do redistributivist sensibilities paradoxically maintain the existence of the poor and their ever-continuing need for welfare programs, or does history show those programs to be, in large part, abject failures? Or are the problems of poverty, especially as they challenge the moral pluralism of the United States, simply too heterogeneous and complex to manage? Must we wait instead for the hallowed day when a coincidence of social values occurs that enables patients like Tilburt’s to get the treatment they need
while not posing significant fiscal worries about their associated costs? Masks are what we hide behind. I believe that if I removed mine, I’d readily admit that something close to Tilburt’s patient’s situation could, but for a few variables, easily be mine. I would congratulate the brilliance, ingenuity, and pluck of the wealthiest of our society, but admit profound reservations over the ever-widening gap between the very wealthy and everyone else. And if I were her physician, I would throw equity to the wind, provide the operation, pray for a good outcome, and don a mask if asked to justify what I did. &
REFERENCES Fleischacker, S. 2004. A short history of distributive justice. Cambridge, MA: Harvard University Press. Gladwell, M. 2006. Million-Dollar Murray. Available at: http:// gladwell.com/million-dollar-murray (accessed June 4, 2014). Nozick, R. 1974. Anarchy, state, and utopia. New York, NY: Basic Books. Redman, A., ed. 1959. The wit and humor of Oscar Wilde. New York, NY: Dover. Scott, C. 2008. Belief in a just world: A case study in public health ethics. Hastings Center Report 38(1): 16–19. Tilburt, J. C. 2014. Addressing dual agency: Getting specific about the expectations of professionalism. American Journal of Bioethics 14 (9): 29–36.
Physicians’ Dual Agency, Stewardship, and Marginally Beneficial Care Kevin R. Riggs, Johns Hopkins University Matthew DeCamp, Johns Hopkins University The high cost of health care in the United States is commonly called a crisis. Nearly everyone agrees that physicians—by virtue of their prescription pens or, increasingly, their mouse clicks—should play a role in forestalling this crisis. But what role should they play: lead, supporting, background, cameo, or something else? In this issue, Jon Tilburt begins answering this figurative question, literally arguing that physicians should play numerous roles, each with its own moral obligations, in cost containment efforts and health care generally (Tilburt 2014). This “role morality” makes it possible for physicians
to begin to address the problem of “dual agency” (i.e., the potential conflict between a physician’s obligations to the patient’s best interest and to a just distribution of societal resources). Physicians can satisfy potentially competing obligations through recognizing the different roles they play, such as attending to their patients’ best interest in their clinical role and advocating for just societal resources through contributions to public health and health policy in their “citizenship” (i.e., societal) role. Tilburt’s analysis is a significant contribution in the effort to solve the dual agency problem. He not only
Address correspondence to Kevin R. Riggs, MD, MPH, Fellow, Division of General Internal Medicine, Hecht-Levi Fellow, Berman Institute of Bioethics, Johns Hopkins University, 2024 E. Monument Street, Room 2-604B, Baltimore, MD 21287, USA. E-mail: kriggs3@jhmi. edu
September, Volume 14, Number 9, 2014
ajob 49
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
A Mask Tells Us More Than a Face a
John Banja a
Emory University Published online: 15 Aug 2014.
Click for updates To cite this article: John Banja (2014) A Mask Tells Us More Than a Face, The American Journal of Bioethics, 14:9, 47-49, DOI: 10.1080/15265161.2014.935882 To link to this article: http://dx.doi.org/10.1080/15265161.2014.935882
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Downloaded by [FU Berlin] at 17:53 01 May 2015
Dual Agency and Expectations of Professionalism
is tied to a picture of physicians as individual professionals, Tilburt cannot do much more to resolve these issues. One way forward might be to explore two points from Kevin Gibson’s (2003) analysis of role morality. Gibson’s first point is potentially deflationary for Tilburt’s argument. Gibson contends that the concept of professionalism has no special moral significance in a role morality context; moral issues at work are merely one part of the “constellation” of moral demands that individuals must grapple with in their many roles (2003, 28). If Gibson is right, Tilburt’s recommendation of role morality to solve the dual agency problem would not work unless he sought to integrate physicians’ ethics across their personal and professional lives. Relatedly, as Gibson points out, one danger of role morality is that it may foster professional actions that individuals outside professional roles would not endorse (2003, 28). Gibson’s second point is that instead of thinking of people as professionals (for at least some of the time), we should think of individuals as people who are able to manifest power; the advantage of so doing is that assessment of individuals across personal and professional roles would be facilitated (2003, 28). This may be a better way forward and would, if coupled with Bleakley’s work, help Tilburt to pursue an account of the concept of professionalism as embedded in team and environmental systems. Tilburt’s exploration of the logic of professional expectations could also benefit from further analysis of the concept of responsibility, especially in connection to addressing social inequality in health care. In particular, Tilburt would have benefited from drawing on Iris Marion Young’s (2011) analysis of structural injustice and her social connection model of responsibility. Tilburt notes that improving access to care is specified in the ABIM Physician Charter on professionalism alongside pursuit of just distribution of finite health care resources. He also actively explores the need to ensure access to the benefits of basic health care for all via a sustainable and efficient model. Yet Tilburt’s acknowledgment that equitable distribution of finite resources and access to health care are both
important needs also seems to require that taking responsibility for structural injustice in health care is a professional ethical expectation for individual physicians (Tilburt 2014; Young 2011, 96). Young (2011) suggests that a social connection model of responsibility has a far better likelihood of dealing justly with social inequality than the more typical and individualist liability concept of responsibility, because the social connection model holds that all those who contribute to the relevant injustice share responsibility for it and are morally bound to join together to transform the unjust structures into just ones (96). In contrast, the liability model focuses on the relationship between individuals and harms (96). Young’s social connection model clarifies how social justice may be a reasonable professional expectation of physicians, and would address the functional insulation problem Tilburt (2014) identifies, as well as bolstering the significance and impact of physician advocacy and activism in and through professional organizations. &
REFERENCES ABIM Foundation. 2004. Medical professionalism in the new millennium: A physician charter. Available at: http://www. abimfoundation.org/Professionalism/Physician-Charter.aspx (accessed June 9, 2014). Bleakley, A. 2006. A common body of care: The ethics and politics of teamwork in the operating theater are inseparable. Journal of Medicine and Philosophy 31: 305–322. Gibson, K. 2003. Contrasting role morality and professional morality: Implications for practice. Journal of Applied Philosophy 20(1): 17– 29. Tilburt, J. C. 2014. Addressing dual agency: Getting specific about the expectations of professionalism. American Journal of Bioethics 14 (9): 29–36. Young, I. M. 2011. Responsibility for justice. Oxford, UK: Oxford University Press.
A Mask Tells Us More Than a Face John Banja, Emory University Oscar Wilde’s epigram (Redman 1959, 138) speaks directly to Jon Tilburt’s concerns about the sometimes contradictory obligations of professionalism (Tilburt 2014). On the one hand, “professionalism” is a mask that conceals the distressing reality of health providers occasionally withholding treatments from patients without the means to
pay. But state and federal legislatures may wear a more pernicious mask in handing down Medicaid budgets. Behind the masks of fiscal responsibility and individual accountability, legislatures pass Medicaid budgets whose limitations sometimes make it next to impossible for health professionals and their institutions to adequately care for
Address correspondence to John Banja, Emory University, Center for Ethics, 1531 Dickey Drive, Atlanta, GA 30322, USA. E-mail: [email protected]
September, Volume 14, Number 9, 2014
ajob 47
Downloaded by [FU Berlin] at 17:53 01 May 2015
American Journal of Bioethics
the poor. But if there is anything a patient, regardless of his or her economic means, should be able to claim, it is care that meets the professional standard, that is, what a “reasonable and prudent” health professional would ordinarily do or provide. Consequently, if the standard of care truly requires a gastric bypass for Tilburt’s hypothetical patient but there aren’t enough Medicaid dollars to reimburse its costs, then Medicaid beneficiaries have been twice wronged: by professionals obligated but failing to treat them according to what medical judgment requires, and by a state legislature that refuses to appropriate sufficient funds to reasonably compensate the delivery of that care. Health professionals have endured this ignoble situation for decades. Their resignation to it may in large part stem from the seemingly unresolvable problems that the poor pose to state and national governments. In his splendid book A Short History of Distributive Justice, Samuel Fleischacker (2004) notes three independent but seemingly intractable problems that have bedeviled distributive justice schemes for centuries. He points out that only since the mid-18th century has the idea become popular that the poor are poor because of social conditions rather than from hereditary factors rendering them “inferior” to the better off. However, once the Enlightenment idea of moral equality gained a foothold, especially among “liberal” or welfare-minded thinkers, it was but a short step to arguing that everyone, by virtue of his or her inherent dignity, is entitled to a limited but reasonable share of basic goods. Unfortunately, though, centuries of moral debate have failed to demonstrate exactly what “moral equality” requires that human beings make available to one another. In contrast to welfarist sensibilities that encourage income redistribution toward the poorly off, many political and economic conservatives instead turn to the just world hypothesis: “You get what you deserve, and you deserve what you get” (Scott 2008). Notice that Tilburt is exquisitely aware of that conservative bias by imagining his hypothetical gastric bypass patient being abused as a child, suffering from posttraumatic stress disorder (PTSD), and being harmed by a weight-loss drug. Presumably, we are to understand her as significantly handicapped by factors beyond her control that prevent her taking charge of her destiny and making responsible choices. To liberal sensibilities, that means that the better off have some degree of moral obligation to provide her with assistance. But conservatives will point to the countless number of human beings whose circumstances were worse than hers but who overcame adversity in heroic fashion by their own wits and initiative. So why can’t she, even if we grant her moral equality to everyone else? A second problem plaguing the Medicaid dilemma concerns whether distributive schemes, such as Medicaid, should be a component of justice. Even if human beings are “morally equal,” it is far from obvious that governments should take it upon themselves to redistribute the wealth of their citizens. For political conservatives, the primary function of justice consists of protecting individual
48 ajob
liberty and especially one’s private property (Nozick 1974). Instead of enabling everyone’s access to a “basic good” like health care, conservatives understand justice to insure that everyone enjoys equal freedoms, opportunities, and the right to their property. Social welfare programs like Medicaid therefore strike many as morally problematic political experiments that not only confiscate one group’s wealth and give it to another, but also usurp the private citizen’s right to decide just how “basic” a “good” health care is. But even if a society compels its government to redistribute wealth in support of welfare programs, a third problem concerns nitty-gritty questions over deciding who gets what and how much. Illustrating the challenge, Malcolm Gladwell (2006) authored a remarkable story in the New Yorker involving an individual he nicknamed “Million Dollar Murray.” For years, Murray had been homeless and hopelessly addicted to alcohol. It was estimated that over a decade he had personally cost the city of Reno, NV, a million dollars because of his frequent appearances in the city’s emergency rooms followed by brief periods of incarceration. Gladwell relates how Reno’s leadership approached the economic problems that people like Murray posed—people who constituted a very small percentage of Reno’s homeless but exerted an enormous drain on the city’s budget. The ultimate proposal was that the city should provide them with efficiency apartments, secure them full-time employment, and appoint each one a social worker who would insure the client’s compliance with the program. On paper, the plan anticipated saving the city millions of dollars yearly. In reality, both conservative and liberal voices loudly objected: Conservatives complained that their tax dollars would be going to bums; liberals objected that the proposal’s large welfare allocation would serve only a fraction of the city’s needy citizens rather than all of them. If we removed the masks of moral rectitude and political platitudes and squarely faced the problem of the poor, what would we find? I suspect we’d uncover an ungodly mess of moral intuitions and less than conclusive data. We’d find that liberals would regard the just world hypothesis as lunacy, while conservatives would argue that their property is sacrosanct. Liberals would point out that some of the most heavily “socialized” European countries also boast the highest quality of life in the world for their citizens. Conservatives, however, would refuse to engage in any discussion—no matter how scientifically grounded its data and proposals—that contemplates raising taxes. Liberals would encourage correcting irrational social practices with insightful, “compassionate,” and factually informed legislation, while conservatives would likely view the same as an abuse of government power. Of course, withholding the operation from Tilburt’s patient might increase the probability of her experiencing a serious stroke or cardiac event. That occurrence would hardly save Medicaid any money, not to mention the burdens and costs it would place on her family. Also, her physician’s withholding the operation from her might
September, Volume 14, Number 9, 2014
Downloaded by [FU Berlin] at 17:53 01 May 2015
Dual Agency and Expectations of Professionalism
seem strikingly discriminatory in that its rationale entails an entire subpopulation of citizens being deprived of the benefits of contemporary medical science (T. Sweeney, personal communication, June 3, 2014). Yet I believe that we have no “moral facts” to guide us in this case. Americans run the gamut of moral opinion, from Spencerian-like beliefs that we shouldn’t provide any aid to the poor, perhaps in the hope that they will succumb to evolutionary pressures and die off faster, to ultraliberal sensibilities that Americans don’t pay nearly enough tax dollars to enable the kind of decent life everyone is owed. There is no conclusive moral answer as to whether Tilburt’s patient should or shouldn’t get her gastric bypass operation, but rather a motley crew of moral intuitions that propel the debate hither and yon (Fleischacker 2004). Perhaps, then, “transparency” would represent an alternative to the masks we wear. Should Tilburt’s patient be bluntly told about the economic limitations that wind up denying her a gastric bypass operation? Should conservatives be persistently challenged to justify their belief that such denials reap more social benefit than burden? Do redistributivist sensibilities paradoxically maintain the existence of the poor and their ever-continuing need for welfare programs, or does history show those programs to be, in large part, abject failures? Or are the problems of poverty, especially as they challenge the moral pluralism of the United States, simply too heterogeneous and complex to manage? Must we wait instead for the hallowed day when a coincidence of social values occurs that enables patients like Tilburt’s to get the treatment they need
while not posing significant fiscal worries about their associated costs? Masks are what we hide behind. I believe that if I removed mine, I’d readily admit that something close to Tilburt’s patient’s situation could, but for a few variables, easily be mine. I would congratulate the brilliance, ingenuity, and pluck of the wealthiest of our society, but admit profound reservations over the ever-widening gap between the very wealthy and everyone else. And if I were her physician, I would throw equity to the wind, provide the operation, pray for a good outcome, and don a mask if asked to justify what I did. &
REFERENCES Fleischacker, S. 2004. A short history of distributive justice. Cambridge, MA: Harvard University Press. Gladwell, M. 2006. Million-Dollar Murray. Available at: http:// gladwell.com/million-dollar-murray (accessed June 4, 2014). Nozick, R. 1974. Anarchy, state, and utopia. New York, NY: Basic Books. Redman, A., ed. 1959. The wit and humor of Oscar Wilde. New York, NY: Dover. Scott, C. 2008. Belief in a just world: A case study in public health ethics. Hastings Center Report 38(1): 16–19. Tilburt, J. C. 2014. Addressing dual agency: Getting specific about the expectations of professionalism. American Journal of Bioethics 14 (9): 29–36.
Physicians’ Dual Agency, Stewardship, and Marginally Beneficial Care Kevin R. Riggs, Johns Hopkins University Matthew DeCamp, Johns Hopkins University The high cost of health care in the United States is commonly called a crisis. Nearly everyone agrees that physicians—by virtue of their prescription pens or, increasingly, their mouse clicks—should play a role in forestalling this crisis. But what role should they play: lead, supporting, background, cameo, or something else? In this issue, Jon Tilburt begins answering this figurative question, literally arguing that physicians should play numerous roles, each with its own moral obligations, in cost containment efforts and health care generally (Tilburt 2014). This “role morality” makes it possible for physicians
to begin to address the problem of “dual agency” (i.e., the potential conflict between a physician’s obligations to the patient’s best interest and to a just distribution of societal resources). Physicians can satisfy potentially competing obligations through recognizing the different roles they play, such as attending to their patients’ best interest in their clinical role and advocating for just societal resources through contributions to public health and health policy in their “citizenship” (i.e., societal) role. Tilburt’s analysis is a significant contribution in the effort to solve the dual agency problem. He not only
Address correspondence to Kevin R. Riggs, MD, MPH, Fellow, Division of General Internal Medicine, Hecht-Levi Fellow, Berman Institute of Bioethics, Johns Hopkins University, 2024 E. Monument Street, Room 2-604B, Baltimore, MD 21287, USA. E-mail: kriggs3@jhmi. edu
September, Volume 14, Number 9, 2014
ajob 49
