There is a growing belief in the US that medicine is an altruistic profession, and that physicians display altruism in their daily work. We argue that one of the most fundamental features of medical professionalism is a fiduciary responsibility to patients, which implies a duty or obligation to act in patients' best medical interests. The term that best captures this sense of obligation is “beneficence”, which contrasts with “altruism” because the latter act is supererogatory and is beyond obligation. On the other hand, we offer several examples in which patients act altruistically. If it is patients and not the doctors who are altruistic, then the patients are the gift-bearers and to that extent doctors owe them gratitude and respect for their many contributions to medicine. Recognising this might help us better understand the moral significance of the doctor-patient relationship in modern medicine.
- doctor-patient relationship
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In a recent review of the advances in medicine in the twentieth century, the editors of the New England Journal of Medicine asserted that “medicine is one of the few spheres of human activity in which the purposes are unambiguously altruistic”.1 This assertion affirmed the conviction of the American Board of Internal Medicine, which, in its Project Professionalism, stated that “altruism is the essence of professionalism. The best interest of patients, not self-interest, is the rule”.2 But the pervasive belief among medical professionals that they are essentially altruistic is misguided because it depends on a misunderstanding of the meaning of “altruism”.
Perhaps the most fundamental feature of medical professionalism is fiduciary responsibility to patients, which implies a duty or obligation to act in patients' best medical interests. The term that best captures this sense of obligation is “beneficence”, which refers to the moral obligation to act for the benefit of others.3 The term “altruism” was first used by the French philosopher Auguste Comte in the nineteenth century to denote the interests of others as an action-guiding principle. Altruism was therefore formulated as the opposite of egoism, action performed solely in one's own interests.4 Both beneficence and altruism overlap to the extent that they are motivated by concern for others. Yet beneficence prescribes an obligation to act in a certain way, whereas altruism prescribes no such obligation but is instead optional and supererogatory, beyond the call of duty. In addition, altruism is directed toward individuals to whom one has no special ties and therefore no special obligations.5 But physicians have a special relationship with their patients, and this relationship does create specific duties, such that in their routine clinical practice, physicians are not altruistic.
Physicians are not and cannot be altruistic in their daily encounters with patients precisely because they are acting within a professional relationship, and professionalism entails obligations to specific others, in particular, their patients. Physicians have a responsibility to act in the best interest of patients, just as teachers have a responsibility to act in their students' best interest and lawyers have a responsibility to act in the best interest of their clients. As one commentator points out with respect to professionals in general, “the fact that a person occupies a professional role affects what he is morally required, permitted, or forbidden to do, and affects how his character and actions are to be morally evaluated”.6 This suggests a framework of obligation which is not part of the concept of altruism.
To be sure, becoming a doctor and thereby entering into a special relationship with patients is an optional act. Once one enters into this relationship, however, the obligations it entails are not the sort of thing the physician can choose whether or not to follow. A physician can choose not to treat a particular patient in a particular situation if doing so would compromise his or her beliefs or professional integrity. But once one is a physician, one effectively promises to promote the best medical interests of patients in general: treating them in accord with these interests is not optional but obligatory. Because altruism is not obligatory, and because doctors are obligated to act beneficently, doctors generally are not altruistic in their daily professional work. And to the extent that optional, altruistic actions are more praiseworthy than obligatory, beneficent ones, doctors' actions, while respectable and often deserving of praise, are not as praiseworthy as the opening statements would suggest.
There are exceptions to this, however. Physicians who join groups such as Medecins Sans Frontieres (Doctors Without Borders), for example, act altruistically to the extent that they are not obligated to put themselves in grave danger in order to treat patients to whom they have no special ties in politically volatile or otherwise unstable parts of the world. A physician who makes a house call to an indigent patient who could come to an outpatient clinic appointment but for whom the travel would be difficult, is acting altruistically because the physician has gone beyond the boundaries of professional obligation.
Still, the real altruists in medicine are not doctors but patients. This may at first blush seem contradictory, given that it is patients in medical need who generate the conditions for the relationship into which physicians enter and from which their obligations to patients are derived. A frequent example of patient altruism is the willingness of patients in teaching hospitals to allow medical students to treat them, with the benefit accruing to the students and to future patients rather than to the patients themselves.
This is not to deny that patients have obligations in the doctor-patient relationship and in the health care arena generally. Patients do have an obligation to collaborate with their physicians to ensure a timely and accurate diagnosis by providing honest answers to the physicians' queries, and patients have an obligation to comply with treatment after a diagnosis has been made. Some may argue that individuals who allow medical students to participate in their medical care are not altruistic because unless some patients do permit such training, the future supply of trained physicians will be threatened. If there is some imperfect duty7 on the part of patients to permit students to partake in their care, then presumably their action is not altruistic because the act is not fully voluntary, but has an obligatory, albeit imperfect, component. While medical students need to learn, however, they have no right to learn from any particular patient. As such, patients who do allow medical students to participate in their care are acting altruistically.
Even if the clinic patient has some degree of obligation, one cannot morally require that an individual offer to serve as an organ donor to a complete stranger. Bone marrow registries, which allow individuals in need of a bone marrow to call upon complete strangers who are immunologically compatible, have existed for over three decades.8 And in the 1990s, Matas et al implemented a programme that would allow an individual to donate a kidney to an unknown recipient.9 The risks of a nephrectomy are not inconsequential. These individuals are clearly acting altruistically because they donate voluntarily at some cost to themselves.
We believe that the clinic patient as well as the unrelated transplant donor are altruists, although one can differentiate the degree to which they act supererogatorily. Using the language of Urmson, we can call the patient who allows medical students to participate in her care a hero as distinct from the donor who is a saint.10
At issue here is more than a mere semantic quibble, because whether acts are beneficent or altruistic makes a significant difference in the ethical evaluation of actions. Altruistic acts are more praiseworthy than beneficent ones because of their optional nature. This is not to diminish the ethical importance of doctors discharging their duty of beneficence to patients. Indeed, this is one of the morally admirable traits of the medical profession. But promoting the best interests of patients is not optional, given the medical professional's role and the obligations it entails. Accordingly, doctors should disabuse themselves of the idea that they are altruistic, and refer to themselves and their profession as what they really are: beneficent.
If the altruists in medicine are not doctors but patients, then the patients are the true gift-bearers and to that extent doctors owe them gratitude and respect for their many contributions to medicine. Recognising this might help us better understand the moral significance of the doctor-patient relationship in modern medicine.