Capitalism and the Crisis in Medical Ethics
Dr. Gerry Lower, Keystone, South Dakota

If one asked a group of typical Americans what they know about "Bioethics," most would claim to have never heard of the term. Nevertheless, there are currently several thousands of programs in medical "bioethics" at colleges, universities and medical centers across America and the western world. Given their role in maintaining medical ethics, these programs certainly deserve public awareness and comprehension.

As a matter of history, the term "Bioethics" was coined in 1970 by Dr. Van Rensselaer Potter, a pioneer in molecular pathology and experimental oncology at the University of Wisconsin (Bioethics: Bridge to the Future, Prentice-Hall, NY, 1970). Bioethics was a rigorous conceptual effort to extend the scientific ethics of Aldo Leopold (Sand County Almanac, The Land Ethic, Oxford University Press, NY, 1948) directly into the medical realm. Van's motivation stemmed from his conviction that medical ethics was, at that time, in a state of "crisis". He was correct 30 years ago, of course, and the situation has only continued to deteriorate as capitalism has increased its control over medical decision-making in America.

The term "Bioethics," however, was quickly borrowed (pilfered) by the eastern medical establishment as their very own, a new label for an upscale ethics designed mostly to deal with increasingly high-tech approaches to diagnosis and therapy. Programs in medical "bioethics” appeared all over America and the term was popularized in the western world without even mentioning Van’s name or his seminal publications. So much for the ethics of American medical ethicists. Who watches over these people?

As self-admitted entrepreneurs, eastern medical ethicists had found a fitting label for ideas that they could sell to the establishment, e.g., the need to watchdog medical high technology, divine the ethical ramifications of it all and advise medical practioners. That need was seen as overriding.

Accordingly, the type of bioethics promoted in America was pragmatic and nonconceptual and it bore little relationship to the scientific ethics which Van Potter had envisioned. Indeed, it bore even less relationship to the scientific ethics which Leopold had defined. The newly emergent medical "bioethics" addressed itself not at all to the actual decades-old crisis in medical ethics.

As a result, medical bioethics has had precisely the same impact on the capitalization of American medicine as the Harvard Business School's program in business ethics has had on the Enronization of American business, i.e., no impact at all. No core ethical considerations have been allowed to impose themselves in any way upon the agenda of medical capitalism.

Van Potter was always quick to point out that a scientific ethics must be, by definition, based upon an adequate scientific knowledge base. It goes even deeper than that. A scientific ethics must be based on the best available theoretical views of disease, the best conceptualizations of the problem as a whole. It must be based on natural historical views of both causation and clinical course, views that provide for the identification of both preventive and therapeutic interventions. There must be balance, and that balance was and remains utterly missing in American medicine. Due largely to marketplace demands, the bulk of effort in national cancer policy has been aimed at diagnosis and therapy, where there was money to be made. Even the victims of neoplastic disease did not care about causes, they wanted cures. In truth, until we know the causes of disease, there is no hope for cause/defect-specific diagnoses or cause/defect specific therapies. That much we have learned from our experience controlling infectious diseases.

The western medical marketing managers took over and American medicine was capitalized under the old notion of "one ill, one pill, one bill." It is this move that has destroyed medical ethics at the clinical level, where traditional ethics have been overruled by the institution's ethics (essentially capitalistic business "ethics"). It has made our physicians unprofessionally silent and inordinately wealthy.

We end up with a market-driven biomedical "community" which has been operating for decades without benefit of any cohesive biomedical philosophy, apparently believing that biomedicine is best defined by bean counters, lawyers, and policy wonks. In the beginning, it was Aristotle who argued that medicine is not a business but “the highest calling of philosophy.” To make it otherwise is to destroy the very concept of physicians as healers and to affirm the notion of medicine as just another "growth industry."

This entire matter distills down to the simplest, most self-evident ethical principles, those principles that have been ignored on a daily basis while medical bioethicists deal with the myriad real and esoteric problems associated with medical high technology.

One of those ethical principles requests the physician to "do good and avoid harm." This is, however, a difficult principle to abide in capitalism's exclusionary medicine. While it is unlawful to deny uninsured patients medical attention, it is not unlawful to deem patients as being beyond therapeutic help. It is a simple fact that many institutions, as a matter of unspoken policy, provide uninsured patients with the minimal diagnostic work required and then, especially in the case of patients with terminal disease, they provide the bad news that little can be done.

Seldom, if ever, do such patients hear about available therapeutic options, certainly not those available in competing institutions. Seldom, if ever, do such patients hear about the likely course of events they will experience as their disease progresses in the absence of therapy. Seldom, if ever, are such patients provided hope. More commonly, that important personal aid to regaining health is simply destroyed, and this is to do no good if not harm.

But the most fundamental ethical principle requests the physician to help those in need of help (remember the physicians on M.A.S.H.?). In this regard, the healer helps first and then worries about recompense. Under capitalism, physicians can actually be found who make fun of those healers from yesterday who would brave a winter storm to deliver a baby in return for a chicken and two dozen eggs. A bunch of losers, one must presume.

A good deal of attention has been recently paid to the problem of physician depression and suicide (Confronting Physician Depression and Suicide, Laurie Barclay, MD, J Am. Med. Assoc., 289: 3161, 2003). These studies are, however, typically too shallow in inquiry to have explanatory value. Of course, physicians succumb to the same personal problems and suicidal pressures afflicting everyone else, but the denial of their chosen role as healers is an especially difficult burden to bear.

Nowhere are physicians asked how they feel about having sacrificed core ethical principles in order to participate in exclusionary medicine. No where are physicians asked how they feel about short changing those without medical insurance, treating the uninsured victims of both capitalism and disease as second rate citizens. No where are physicians asked how they like having their decisions made for them by bean counters and policy wonks, most of whom could likely not even define ethics.

If physicians fall into depression and alcoholism, they are fully expected to blame no one but themselves. As there couldn't possibly be anything amiss with JudeoRomanism's exclusionary religion, there couldn't possibly be anything amiss with capitalism's exclusionary medicine. This oppression of the physician's freedom is a literal requirement to maintaining an unethical, wonked-out, over-commercialized, assembly-line medicine. As a result, physicians seldom discuss their loss of core ethical issues, it being easier to abide the oppression that nourishes denial.

The only real obstacle to returning medicine to its rightful place and role in society is greed-driven capitalism, the "American way" that places itself above all human values and all ethical principles, of both medicine and democracy. It was a mistake to allow this commercialization to commence after World War II, and it is a mistake to allow it to continue.

What is one to suppose? Do America's ruling crony capitalists really believe that the other western democracies (which do see to their people's educational and medical needs) will someday see the capitalistic light and abandon their social programs? Do capitalist's really believe that medicine is better if denied to the poorest citizens who must work for a living? Do capitalists really believe that personal wealth is the sole criteria for distributing the right to medical care? Do capitalists really believe that a greed-driven marketplace is a better dictator of national health policy than physicians immersed in medical philosophy, ethics and clinical care? Do capitalists really believe that physicians ought get a money kick back for prescribing therapies that are typically inadequate (Cancer Doctors Profitting from Drugs, Robert Bazell, MSNBC, June 27, 2003)? What exactly do they believe?

In order to accommodate greed-driven crony capitalism, American medicine has had to compromise the core ethical principles established since scientific medicine emerged in Greece some 2,500 years ago. Hippocratean ethics be damned. This is not medical bioethics, of course, it is medical bullshit. On these grounds, European physicians have been badmouthing American physicians for decades.

America houses the first generation of physicians in the history of medicine who are content to allow the marketplace to direct their practice of medicine. The result is a life of extraordinary personal income and professional denial which is simply not condusive to professional meaning and mental health.

Certainly one does not need to be a Harvard bioethicist to understand the nature and depth of the current crisis in medical bioethics. Despite the "complex" nature of high-tech medicine, the core principles of medical ethics are very down to earth and elegantly simple, having been around for millennia. Your valued physician ought be allowed the freedom to honor these ethical principles. It is his way of assigning value to you and fulfilling the ethical requirements of his job.

Those who have traditionally defiled temples have long defiled the halls of medicine as well. To oppress American physicians in thought and action is an overtly criminal act, perpetrated by shallow capitalists who have no right to do so. As in the beginning, these people simply know not what they are doing.

Most of us have a better chance of being appointed Surgeon General than seeing greed-driven capitalism provide a balanced, ethical program of quality research and health care and an equitable program of health care delivery. That would require a fully developed medical ethics, built once again upon Hippocratean and nascent Christian ethical principles, rigorously related to current medical theory and nourished by a medical community comprised of healers. Van Potter, the Father of Bioethics, pretty much knew all of this 30 years ago. What medical bioethicists have been doing since, under that label, is simply not bioethics at all. It is Bush's right wing religion and crony capitalism as usual.