The Trusted Doctor: Medical Ethics and Professionalism

Those hungry for fresh and useful guidance while struggling through ethical issues in clinical practice will find a nourishing smorgasbord of ideas in The Trusted Doctor.

This book should be of special interest to readers of JMR because the author’s approach to medical ethics in clinical practice and in medical education, when clearly understood and taken to heart, is almost assured to help physicians preclude complaints to their respective medical boards, the majority of which involve broken-down communication and allegations of unprofessional conduct. Her focus is on decisions and actions physicians actually have to perform, rather than broad social policy. It is a practical book constructed on careful analysis and written in a style that gives easy access to the results of that analysis. (As an aside, there are a few amusing bloopers. My favorite: “…doctors should not venture down the foxhole of trying to sort out who is worthy… .”)

Rosamond Rhodes is a philosopher who has been a faculty member for 30 years at a prominent medical school in New York City. She states her aims for the book in these terms: “to demonstrate that the ethics of being a doctor is very different from the morality of everyday life”; and, “…to delineate the core duties of physicians… .” The first aim is a heterodox assertion in that medical ethics is commonly assumed to be in conformity with everyday morality. Even if Rhodes overstates the reaction she anticipates that she has committed “bioethics heresy,” she nevertheless has developed a novel approach to distinguishing certain elements of ethics in medical practice that sometimes require physicians to take actions that cannot be derived from everyday ethics. For example, society allows medical professionals certain powers, privileges, and immunities that are not allowed to anyone else. She provides many clarifying cases to illustrate her point.

Rhodes accomplishes her second aim by identifying 16 core duties physicians assume when they avow their oath of practice. The heart of this body of duties has two halves: “The first duty of medical ethics is to seek trust and be deserving of it. The second duty of medical ethics is to promote the interests of the patient and society.” These two duties, and especially the first, must be understood and accepted without qualification as the starting point for justifying the remaining 14 duties, each laid out in detail and illuminated with case examples showing success and failure in performing what the duty requires. Rhodes’s commitment to the centrality of trust in her approach is plain: “The fundamental and core guiding first duty of medical ethics is to seek trust and be deserving of that trust. It is the source from which all of the other more specific duties are derived.”

Given its generative importance it is a puzzle that no definition of trust is provided, although some necessary conditions are mentioned (e.g., honesty and truthfulness). Annette Baier’s definition, taken from her book, Moral Prejudices (“Trust… is reliance on others’ competence and willingness to look after, rather than harm, things one cares about which are entrusted to their care”) would, I think, meet with Rhodes’s approval.

While enumerating the 14 more specific duties is helpful for rounding out her approach (Rhodes insists she has developed a radically new theory), they somewhat undermine her claim of being distinct from other approaches (theories) and from everyday ethics. For example, some of the duties in the list are familiar, such as professional competence, mindfulness, commitment to science, confidentiality, truth-telling, etc. Nevertheless, the list is an apt reminder of what medical professionalism requires. While the first two duties must be understood and accepted at the outset, discussion of the remaining 14 duties can be read in any order. In a sense, each stands alone while being mutually complementary.

Chapter 8, on commitments to fellow professionals, will be of elevated interest to readers of JMR. Rhodes notes: “The thirteenth duty of medical ethics is peer responsiveness. The fourteenth duty of medical ethics is peer communication. The fifteenth duty of medical ethics is peer scrutiny.” She then provides a rich and provocative discussion of these three duties, as indicated by this excerpt:

“From childhood on, we learn not to be a tattletale and to stand by our buddies. In medicine, protecting the trustworthiness of the profession is, however, a moral duty. The residue of common morality leaves doctors feeling the familiar pulls of reluctance to report colleague impairment and the incompetent or unethical behavior of a fellow physician. For that reason, the radical difference between the common morality ‘don’t snitch’ mentality and the medical ethics commitment to uphold the trustworthiness of the profession and act in the interest of patients has to be made an explicit feature of medical professionalism and inculcated as part of the ethos of being a physician.”

The hard lesson here is that physicians have an obligation to be truthful with and about other providers, peers included.

The Trusted Doctor presents the reader with many more compelling issues and assertions that merit debate. Should “the patient’s best interest” standard be abandoned because “best” is an essentially contested concept? Is there an unacknowledged irony in autonomously choosing to assume obedience to 16 duties that foreclose the option of further free choice about self-governance? Along the same lines, does the exercise of conscience-based refusal to provide lawful and beneficial care count as an acceptable option, or is it, as Rhodes suggests, more fittingly described as selfish egoism?

This is a big-idea book but the author overstates the novelty of her approach.

The idea that trust is the anchor concept in medical ethics is not ‘radical,’ nor is it missing from earlier theories and myriad discussions. The Trusted Doctor is distinct, however, for situating trust as the heart of the matter and for showing in convincing arguments that it is the indispensable concept governing professional medical practice. It is an invitation to discussion and debate that will generate much that is good for the medical profession.