Abstract
Background:
A philosophical framework defines medicine. Multiple competing frameworks lead to varying and sometimes conflicting understandings of the physician–patient relationship, medicine’s goals, and physicians’ duties. The objective of this study is to categorize the various goals, identify the underlying philosophical framework, and determine inconsistency among US medical organizations.
Method:
Twenty-five American Board of Medical Specialties-related organizations, the American Medical Association, and the American Osteopathic Association were searched for key goal-related terms in their ethics-related statements. Direct goal statements were also analyzed. Key terms were grouped as physician-centric/objective (best interest, treat disease, prevent disease, cope with illness, health care/promotion) representing the traditional ends of medicine, patient-centric/subjective (welfare/well-being, patient benefit) reflecting social constructionist methodology, or relational (services to humanity, medical/patient care). Each organization was characterized overall as traditional, social constructionist, or relational. Inconsistency was defined as the smaller between the social constructionist and traditional with relational possibly inconsistent. Definitions of key terms and references to philosophical frameworks were reviewed.
Results:
Twenty-two organizations were included; 73 percent of statements as a whole reflected a social constructionist model with 18 percent having traditional ends and 9 percent a relational framework. There was an 18 percent to 27 percent inconsistency among organization statements as a whole; 68 percent of organizations had direct statements; 47 percent of direct statements reflected a social constructionist methodology, 33 percent the traditional ends, and 20 percent the relational model; 33 percent to 53 percent of direct statements were inconsistent among organizations. No definitions of key terms or explicit references to philosophical frameworks were found.
Conclusion:
There is substantial inconsistency regarding the direct goals of medicine without any definitions of key terms. This inconsistency and lack of clarity underlie disagreement regarding physicians’ roles and their duties. Clear core goals such as treat and prevent disease would consistently define the physician–patient relationship, restore medicine’s objectivity, and provide a distinct understanding of physicians’ obligations.
Summary:
American medical organizations use a multiplicity of terms and have substantial inconsistency regarding the direct goals of medicine with neither a clear underlying theoretical basis nor a definition of key terms. Our analysis suggests the most common theoretical basis for the goals of medicine was the social constructivist view followed closely by the traditional ends of medicine (e.g., treat and prevent disease) and finally the relational model. The authors contend that the traditional ends of medicine are the best option for a core mission of medicine whereby the physician–patient relationship is consistently defined, and a physician’s duties derived.
Keywords
There are several competing philosophical approaches to understanding the practice of medicine. The dominant philosophical approaches are predominantly goal directed; however, some authors promote predominantly a relational understanding of the practice of medicine. These competing approaches result in differing goals that affect the nature of the physician–patient relationship and the duties of the physician.
The traditional goal or purpose of medicine was derived from a teleological approach with an intrinsic telos or end (Schramme 2016). This end focused upon the encounter of an ill patient presenting to a physician for healing (Schramme 2016). The physician uses objective diagnostic criteria to assess the patient’s complaints and determine whether they meet the criteria for a disease (Pellegrino 2008b). Disease is understood as having both a somatic or biologic and functional component (Matthewson and Griffiths 2017).
The physician then offered medicine, surgery, or therapies toward the goal to alleviate and/or cure the disease in the best manner for a specific patient. Additionally, evidence-based medicine provides objective standards toward achieving the goal of treating and/or preventing disease or to restore and/or preserve health. Health is understood as a well-functioning human being without disease (Pellegrino 2008a). In this model, the well-known principles of medicine act as limiting or side constraints to the means of medicine. The physician is constrained in his choice of therapies by the principles of beneficence and nonmaleficence. Due to the principle of respect for patient autonomy, the physician cannot coerce a patient into receiving a specific therapy or any therapies. Justice prevents the physician from placing an unjust burden on a specific person or the use of unfair medical means from a societal perspective as in distributive justice. The patient then assesses the burden of disease and the possible benefits versus risks of the proposed therapy concerning their well-being.
We call this a physician-centric/objective model. The physician is the one who determines whether the patient meets the diagnostic criteria for a disease, and the physician is also the one who determines the direct and objective goal of treating and/or preventing disease. It is a disease-focused model, and the physician’s duty is to treat the patient to cure or mitigate their disease. These direct goals are understood to indirectly support the ultimate goal of improving the patient’s overall well-being (Brulde 2001).
The other dominant philosophical model of defining medicine’s goals is the social constructionist or consensual approach (Schramme 2016; Pellegrino 2008b). This model denies any intrinsic ends and through social agreement or consensus determines the goals of medicine that are specific for that society at that time. As opposed to the traditional ends of medicine, these goals can change in response to changes in society or medical means (Schramme 2016). Although goals derived from this methodology always incorporate the traditional disease-focused direct goals, they also add any other direct goals that the society deems valuable. These new goals are justified in several ways. The first is through redefining terms. Disease can be redefined by delinking the somatic or biologic aspect from function or health can have an expanded definition to include vital life goals (Brulde 2001; Callahan 1996; Nordenfelt 2001). The second way is through using medical means directly toward a nonhealth goal such as well-being that in our society is entirely and subjectively determined by the patient (Brulde 2001; ACOG 2007). The last way is by changing the limiting role of the principle of patient autonomy to be a value or goal (Varelius 2006). In addition to changing a principle’s role, the social constructionist model alters other principles of medicine by losing an objective standard or arguably violating a principle. Without an objective weighing mechanism of health, beneficence and nonmaleficence cannot be reliably balanced to determine whether the benefits outweigh the risks. Additionally, distributive justice or a just allocation of finite health care resources is violated because some of these procedures (e.g., cosmetic surgery) reside in a strict vendor–customer or business model that specifically excludes those who cannot afford to pay.
In the social constructionist model as manifested in the west, patients can essentially create their own diagnostic criteria for the use of some medical therapies in an attempt to realize one of several goals that the physician can frequently only guess at and is not required to know. We call this a patient-centric/subjective model. The patient is now empowered to determine whether diagnostic criteria are met for certain therapies such as cosmetic surgery, contraceptives, abortion, and physician-assisted suicide/euthanasia. This cumulative effect of transferring both the diagnosis and the goal of treatment from the physician to the patient is to change the role of a physician to a technologist or engineer and hence transform the physician–patient relationship into a vendor–customer one.
The patient-centric/social constructionist model increasingly pulls both the patient and physician into the vendor–customer world with its attendant focus on customer satisfaction and profit motives. The transformation of reconstructive surgery into the ever-increasingly common cosmetic surgery is a prime example. Instead of healing and alleviating anxiety in a patients who think they are ill, the physician is now a vendor who manipulates business-centered advertising inducing anxiety and creating unnecessary desires in prospective customers resulting in more people being ill at ease (Miller, Brody, and Chung 2000). Without an objective diagnostic standard, physicians now perform procedures on normal people with the goal to make them super-normal or even abnormal. This changes the normative reference standard making some people who were normal, now abnormal. Medicine is actually creating disease. The direct goals of these procedures are not always clear, and the bottom line is not health but customer satisfaction. The physician is now an aesthetic body engineer. The increasing vendor–customer relationship with its attendant focus on customer satisfaction has negative spillover effects. This mindset helped fuel the current opioid crisis (Christie et al. 2017; Humphreys 2017). Although the patients experienced some short-term increases in well-being, they were not ultimately healthier. A patient-centric/subjective model transforms medicine from a profession into a business inducing relational inconsistency in the clinical encounter with resultant medical harms and disagreement regarding the duties of the physician.
However, some authors define medicine not as goal-directed but as predominantly a relational understanding around an agreed-upon service between the physician and the patient (Pellegrino 2008b). This relational understanding highlights the importance of the relationship to the healing process and/or addressing the patient’s complaints or desires. The relational model of medicine does not usually identify any specific goals. Those who embrace the relational model usually also endorse the traditional understanding of a disease-centered understanding of medicine; however, some may also embrace a social constructionist or patient-centric/subjective understanding of the goals of medicine.
To add to the confusion, there is a multitude of terms that may be construed as a goal of medicine, in addition, to treat and prevent disease, health, or well-being. They include patient care, medical care, patient welfare, best interest, cope with disease, and services to humanity. Whether these are synonymous or are significantly different in kind must be based upon clear definitions and analysis. To our knowledge, no one has attempted to classify these frequently used terms to analyze which philosophical framework they would belong to and whether they are consistent with each other.
The objective of this study is to categorize the various goals, attempt to identify the underlying philosophical framework, and determine the degree of inconsistency among US medical organizations by analyzing their ethics-related statements.
Method
No institutional review board was required for this online research. No funding source was used. Twenty-five American Board of Medical Specialties-associated organizations along with the American Medical Association (AMA) and American Osteopathic Association (AOA) online websites were searched for ethics, code of conduct, or professionalism-related statements. Inclusion criteria were any of these medical organizations with an ethics-related statement. Any organization without its own ethics-related statement was excluded.
The ethics-related statements were analyzed for key goal-related terms regarding the goals of medicine. Direct statements were additionally identified and defined by any key term with any of the following additional words within the sentence: purpose, objective, goal, aim, primary, fundamental, imperative, or foremost. Direct statements were assessed for specialty specificity. Both authors reviewed the material and came to a consensus regarding the inclusion of all statements.
Online and published dictionaries were used to identify the meaning of these words. Also, the World Health Organization (WHO) and Centers for Disease Control (CDC) online sites provided further clarification on some terms.
To aid with analysis, these various key terms describing the goals of medicine were organized into nine categories as follows: treat disease, prevent disease, best interest, cope with illness, health care/promotion, patient welfare/well-being, benefit the patient, services to humanity, and medical/patient care.
Health care had several definitions all of which included some aspects of treating disease with varying additions of well-being. We could not identify any substantive difference between health care and health promotion and thus we classified them together. We placed welfare or faring well as synonymous with well-being or being well because the two had nearly identical definitions and common understanding. We grouped medical care and patient care together. Medical care had few definitions with a representative one being “the professional attention of medical practitioners” (Collins Dictionary n.d.). Additionally, we found no definitions for “patient care”; however, a mainstream definition for a patient was “One who receives medical attention, care, or treatment” (The American Heritage Dictionary of the English Language n.d.). Because medical care was intrinsic to most definitions of a patient, we grouped them together.
These nine categories encompassed other phrases as listed here. Treat disease: management of disease, treat disorders, healer, cure disease, restore function, alleviate pain and suffering, care for the sick, treat the ill, advocates for the sick, healing arts, treat injury, minimize pain and suffering, loss of function and loss of life, treat genetic disease. Prevent disease: preserve life, prevent injury, prevent genetic disease; and prevent pain and suffering, loss of function, and loss of life. Best interest: interest of the patient, the good of the patient, and betterment of the patient. Cope with illness, disability, and death. Health care/promotion: treatment of health problems, management of health, improve health, health advocates, and promotion of good health. Patient welfare/well-being: welfare and rights of the patient. Benefit to the patient was singular. Services to humanity: service to people, and benefit humanity. Medical and patient care: patient’s advocate, services for patients, neurologic care, care of eyes, and surgical care.
Based upon the definitions and understandings of each of the nine categories, each category was further aggregated into three groups: goal-directed physician-centric/objective (the traditional end of medicine), goal-directed patient-centric/subjective (aligned with the social constructionist or consensus methodology), and relational (Figure 1). Goal-directed physician-centric/objectives included the terms treat disease, prevent disease, cope with disease, disability and death, and best interest. Treat and prevent disease are the clearest physician-centric definitions and represent the traditional disease-centered focus of medicine. Best interest was included due to the ethical implications regarding a community standard of what was best for a particular patient that could be appealed to. Cope with disease, disability, and death are based upon objective disease standards although arguably coping is also a very subjective experience. Although health care/promotion had ambiguity including well-being in some definitions, it uniformly included treat disease and so we considered it physician-centric.
Overview of major categories and groups of key terms.
Goal-directed patient-centric/subjective group incorporated definitions where one or more of the goals were predominantly or entirely defined by the patient without clear objective diagnostic or goal-related standards. We placed well-being and patient benefit in this category. The CDC states that “…well-being is subjective…” (Centers for Disease Control and Surveillance 2018). Patient benefit was also included here due to the relational definition of a patient without a clear objective goal; thus, a benefit was unspecified and assumed to be seen from the patient’s perspective.
The relational group encompassed definitions that merely referred to a service relationship between physician and patient without a specific goal. We classified both services to humanity and medical/patient care under this.
The statements as a whole and the direct statements were further aggregated according to which philosophical model they most closely aligned with and subsequently analyzed for both the statement as a whole and any direct statements. The social constructionist model included any statement that had a patient-centric statement with or without relational or physician-centric elements. The traditional ends of medicine included any physician-centric statements with or without relational elements while excluding any patient-centric statements. Finally, the relational model included only those statements that included relational statements omitting both patient- and physician-centric ones. Thus, each organization’s ethics statements were then characterized overall as social constructionist, traditional, or relational. Our methodology considered each organization’s philosophical model to be internally consistent.
We then analyzed for inconsistency among the organizations. We defined the standard for consistency as whichever between the social constructionist and traditional categories were larger. The smaller of the two would then be inconsistent with relational statements being possibly inconsistent.
A search for definitions or a glossary defining any of the key terms was performed. A search for a reference to any underlying philosophical framework was also done. Descriptive statistics were generated.
Results
Twenty-two organizations were included (twenty specialties, AMA, and AOA): seventeen ethics statement, three codes of professional conduct, one statement on principles, and one set of college bylaws.
Only 68 percent (15/22) included at least one direct statement. Four included more than one direct statement. Two statements had specialty-specific direct statements (American Academy of Dermatology and the American Academy of Neurology). Table 1 has a summary of the key terms identified per each statement as a whole while Table 2 has a summary of the key terms for direct statements.
Summary of Key Terms in Ethics-related Statements as a Whole.
Note: X denotes present. O denotes absent (only used with categories including a forward slash).
Summary of Key Terms of Direct Statements.
Note: X denotes present. O denotes absent (only used with categories including a forward slash).
There was an 18 percent to 27 percent inconsistency among organization statements as a whole (Table 3). Additionally, there was a 33 percent to 53 percent inconsistency among organization direct statements (Table 4). Tables 3 and 4 reflect the essential methodology of categorizing each organization’s philosophical category based upon which categories their key terms fall under. Thus, the social constructionist can include key terms from all three categories, while traditional may include relational; whereas relational excludes both of the other categories.
Analysis of Consistency among Organization Statements as a Whole.
Analysis of Consistency among Organization Direct Statements.
No statement included a definition of key terms or made an explicit reference to an underlying philosophical framework.
Discussion
Our analysis shows at least 33 percent and up to 53 percent inconsistency concerning the direct goals of medicine among major US medical organizations. Additionally, our research suggests that looking at the ethics statements as a whole that there may be a substantial majority (73 percent) of organizations that appear to embrace the social constructionist or consensus philosophical framework. However, this percentage drops to 47 percent when looking at the direct statements. This difference may be related to the understanding in all philosophical frameworks that medicine at least indirectly serves broader human goals (e.g., well-being) and that those need to be acknowledged and taken into account even if they are not a direct goal. It should also be noted that none of the organizations expressly endorsed a specific philosophical framework. Furthermore, no statements defined any of these key terms. These findings indicate important disagreement regarding the goals of medicine, lack of clarity regarding key terms, and no acknowledgment of an underlying philosophical framework within medicine.
The key point in our analysis is the difference between patient-centric/subjective and physician-centric/objective groups. Physician-centric terms such as treat disease are objective. The physician determines whether the diagnostic criteria of disease are met or not. Furthermore, the goals of the treatment are also objectively understood and delineated by the physician. These two physician-centric features lie at the core of the traditional ends of medicine model and help distinguish it from socially constructed goals.
Treat and/or prevent disease was seen in 32 percent of statements as a whole with 33 percent of direct statements. A biologic basis for defining disease has been strongly supported as a bulwark against the medicalization of disease (Doust, Walker, and Rogers 2017). Medicalization of disease is a term that reflects the use of medicine as a political and/or social tool to suppress and marginalize people with positions contrary to those in power (Schramme 2016; Doust, Walker, and Rogers 2017; Pellegrino 2008c). Examples of this include the Soviet Union and other oppressive regimes that dot the historical landscape of medicine (Pellegrino 2008c). It should be noted that the theoretical basis for disease is not without controversy and diagnostic criteria continue to be refined even with some appeal to values (Matthewson and Griffiths 2017; Doust, Walker, and Rogers 2017). Nevertheless, the diagnostic criteria for disease are objective ones that physicians both agree upon and determine in a clinical encounter (Pellegrino 2008b).
The more general term of best interest is commonly used in two respects. The first is to remind the physician that the patient’s interests should precede the physician’s interests. Second, it can be appealed to regarding medical surrogates and the associated obligations that physicians have of challenging medical surrogates who make decisions not in the objective best interest of the patient. This objectivity can be appealed to even in areas that require a value judgment.
The American College of Physicians (2019) was unique including the phrase “…helping patients to cope with illness, disability, and death.” We classified this as physician-centric; however, it could have been grouped under patient-centric. Regardless of how this was classified, it would not have changed any of our statistics.
Health care and health promotion were included in 64 percent of statements reflecting the strong understanding in all models of the traditional importance of health as a direct goal of medicine. The definitions of health care uniformly had an objective element and thus our classification as physician-centric/objective. However, a minority also included well-being echoing the WHO’s (2005) broader definition of health reflecting a social constructionist viewpoint. If we had defined health care/promotion as being both physician-centric and patient-centric, then our results for inconsistency would have only changed for a single organization (American Osteopathic Association) and thus a negligible impact.
The patient-centric/subjective category best reflects the social constructionist model of medicine as it permits for medical means to be used outside of the traditional ends in service of other direct goals such as well-being. The goal of well-being is very common in statements as a whole (64 percent); however, this drops off significantly to only 27 percent of direct statements. This likely reflects the well-known understanding that well-being is an ultimate goal but commonly not a direct one. The CDC has an extensive list of elements of the human experience that lead to overall well-being. Pluralism and multiculturalism make a community standard of well-being nearly impossible, and thus, it is entirely up to the patient to define their own well-being and whether the costs of medical therapy are exceeded by the benefits. Thus, the diagnostic criteria for medical therapy largely reside with the patient while the goals of the treatment may be obscure to the physician. The locus of diagnosis and the selection of the goals residing with the patient thus defines the patient-centric/subjective category and clearly distinguishes it from the physician-centric/objective traditional ends of medicine model. It should be noted that other societies outside the west can embrace social goals that are objective, but they will lack an objective disease-based standard delineating it from the traditional ends of medicine (e.g., China’s one-child policy).
Relational terms were the most common throughout all statements both as a whole (86 percent had at least one) and within the direct ones (47 percent) likely reflecting the importance of a therapeutic relationship to the means of medicine. However, few statements were only relational (9 percent as a whole and 20 percent of direct statements) probably representing the inherent deficiency of a clear goal. Because the goals of the clinical interaction and their subsequent duties are entirely up to the individual physician and patient, an overall duty for physicians cannot be elucidated. Thus, our rationale for classifying the relational group as possibly inconsistent.
This inconsistency of the goals is important because it underlies the current identity crisis affecting medicine today. Are we body engineers or physicians? When the diagnosis and goals are placed entirely in the patient’s hands, then physicians become engineers of the body and we subsequently have a vendor–customer relationship. This results in an inconsistent clinical experience. For example, a patient may desire antibiotics for a sore throat or cough, but the physician may determine that it is not objectively indicated by appealing to evidence-based guidelines. On the other hand, a physician will perform a cosmetic procedure merely because the patient has requested it. An inconsistent physician–patient experience is not only frustrating and confusing but potentially dangerous as we have seen in the opioid epidemic.
This inconsistency in purpose results in sharp disagreements regarding our duties to our patients. Are we required to give any legal treatment to our patients because they request it? Some patient-centric/social constructionist therapies appear to be permissive but not required such as cosmetic surgery. However, other therapies, such as contraceptives and abortion, are increasingly advocated as being essential medical care. Without an objective and scientific basis for these patient-driven therapies, it increasingly becomes a political appeal. Even an appeal to a definition of medical care which falls under the relational category, would not make it obligatory on a physician to support these therapies. Only a very strong social constructionist view could mandate that physicians support or provide these services. Conversely, clear core goals would go a long way in identifying the obligations of physicians and would mitigate the subjectivity regarding the current rights of conscience debate. While some authors have proposed expanding the traditional disease-centered practice of medicine with other goals that they perceive as irreducible, we contend that any other objective goal can be subsumed under a reasonable understanding of disease (Brulde 2001; Callahan 1996). Although health has traditionally been the end of medicine, the current ambiguity in its definition limits its use as a clear goal. Therefore, we submit that a treat and prevent disease goal is clearer, easily understood and remembered, and would place the debate clearly on an objective definition of disease while relegating other non-disease-related treatments to the periphery of medicine. These peripheral or noncore treatments would then be placed under increased scrutiny due to their attendant risk of excesses and abuses inherent within their subjective and consumer-driven natures. Recognizing the inconsistency of the goals of medicine is a key to understanding the rights of conscience debate with a reasonable pathway forward in embracing a core goal or mission statement such as to treat and prevent disease.
There are several limitations to our study. We omitted many other specialty organizations that may have different views on the goals of medicine. Although our review was not exhaustive, we think it is very representative. We also confined our review to ethics-related statements. The websites for the various organizations have many other policy statements, slogans, strategic plans, and even definitions that may provide insight into medicine. However, in our review of all the websites, we did not think that including the entire website and all the policy papers would provide a significantly different picture. Another limitation is our selection of categorizing various key goal-related terms together. However, we think that we provided a solid rationale and approach using definitions, common understanding of words, and detailed explanations by recognized organizations. Our grouping of key terms into physician-centric, patient-centric groups, and relational can also be challenged including the specific groups as traditional ends, social constructionist, or relational. We think that our classification is reasonable and highlights the various tensions and inconsistencies that are present in medicine today.
Conclusion
The major US medical organizations’ ethics-related statements use a wide variety of terms when addressing the goals of medicine. There is significant inconsistency among the organizations’ direct statements when the various terms are grouped as patient-centric/subjective (social constructionist model) versus physician-centric/objective (traditional ends model). The patient-centric/subjective approach at times transforms the physician–patient relationship into a vendor–customer one. No key terms were defined nor was a specific philosophical framework explicitly endorsed. This inconsistency of the goals of medicine and lack of clarity of key terms has important implications regarding the nature of the physician–patient relationship to include a physician’s duties. Embracing a core goal such as to treat and prevent disease would keep medicine’s focus on objective standards, minimize the developing vendor–customer relationship while reducing medical harms, and provide a clearer understanding of a physician’s duties and obligations.
Footnotes
Authors’ Note
The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Air Force, the Department of the Army, or the Department of Defense or the US Government.
Acknowledgment
The authors wish to thank Samuel E. Lisanti for his thoughtful suggestions and encouragement.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
