Chapter 4: Professionalism, Elitism and Health Care

Section 4. Readings

How do physicians see their role?

Here is material from a medical school.

 On the Physician Patient Relationship

Answers at: http://depts.washington.edu/bioethx/topics/physpt.html

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codes and covenants by Jon Shobin (2002)

In the code model, professional behavior is inwardly directed, towards those who share and practice the code. The code aims to foster proper behavior between members of the guild, for example, physicians. One's duties toward another guild member come before other considerations. There's a lot of self-interest, as the code is not directed toward society's welfare. In contrast, the covenant model is outwardly directed and is based on the doctor's indebtedness toward society. Here, he has a gift that must be shared. The covenant model is care-driven and service-oriented. In the example given, if a physician sees a colleague making a medical mistake, there is a theoretic difference in how the first physician would react. The codal physician might seek to protect his fellow doctor and gloss over or cover up the mistake. The covenant physician would first consider service owed the injured person, and he therefore might tell others what happened. (I say "theoretical" because I don't think contemporary physicians usually ask themselves about covenant or codal models as guides them in professional decisions.)

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code vs covenant by Douglas Graudons (2002)

Whether a nurse or physician is operating out of a code or covenant model would make a huge difference to me. First off lets state some key points about code and covenant models. With a code model the "knowledge and skill of its members are of greatest importance." The code model states that members have a duty towards one and other, not towards who they serve. In the code model the concern for colleagues is greater than for those served. This reminds me of "The Blue Wall of Silence" that you hear associated with the police. When a scandal erupts (ie: Abner Louima) the police always stick together, with indifference to the individual that was harmed.

The covenant model is quite different. The covenant model states that the physician/nurse is in debt to society, they are obligated to the society. "They physician under the debt to society is obligated to provide society with the truth and be faithful to the promise to provide care." The aim of the model is not proficiency, but genuine care.

So if a MD/nurse was operating out of a code model and observed a colleague make a mistake that lead to the harm of someone, they would not report the incident or advocate for the person. Their allegiance would be to their colleague not to the person that was harmed. By not reporting the incident, it may allow the same problem to arise again and cause more people to get harmed.

If the MD/nurse was operating out of a covenant model, their concern would be for the innocent person that was harmed by the mistake of the professional. The MD/nurse would report the incident and advocate for the person. They would want the problem fixed so someone else in the society is not harmed by the same mistake.

If I was the person that was harmed by a professional, I sure would hope that they are operating out of a covenant model; for my benefit as well as the rest of society.

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covenants, obligations, and magic medicine Jon Shobin (2002)

A seventy year old dermatologist told me two stories yesterday. First, while he was a med student in Buffalo, he had an unscrupulous pharmacist friend named jack. Jack used to sell both prescriptions and quack remedies to the neighborhood's poor. One day a man came in and said to the pharmacist, "Doc, please -- I have a test coming up and need something to make me smart. You got anything?" Jack, who was about to throw out some worthless oils, put some in a dropper bottle and told the man to rub a few drops in his scalp just before the test. True enough, the man came in the next week, saying he passed the test and wanted some more drops! Second, the dermatologist himself was new in practice and had a woman with an incurable itch. He didn't know what to give her so instead gave her a shot of salt water, saying it would definitely make her better. Indeed, a week later the woman called back and said she was cured.

Now, I have a lot of problems with what these two professionals did. I see a lot of ego, some utilitarian concern, some paternalism, but no code, contract, or covenant. But I also think there's a lot to be said for placebo effect.  I mean, how can you argue with success?

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CONSCIENCE PROTECTION LAWS

In some countries and in some states there are laws to protect people who refuse to follow orders and to do procedures that violate their moral conscience.

http://www.consciencelaws.org

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Copyright Philip A. Pecorino 2002. All Rights reserved.

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