Who Am I To Judge: Professional Solidarity, Amenable Mortality And Preventable Harm In Health Care*?

Italian journalist Andrea Tornielli, when interviewing Pope Francis, asked the pope how he might act as a confessor to a gay person in light of his now famous remarks in a press conference in 2013 when he asked: "Who am I to judge?" The pope answered. "I was paraphrasing by heart the Catechism of the Catholic Church where it says that these people should be treated with delicacy and not be marginalized.

In the healthcare system, we define or imagine as patient centered, the patients should be also treated with professional respect, care and delicacy. The cost of marginalization, disrespect and the lack of proper care is very high and its measurable in high avoidable mortality rates and burden of disease. In the health care systems with less developed quality control and assurance protocols, there is an intrinsic conflict between the professions efforts to maintain the solidarity of its members and its fiduciary relationship with patients, populations at risk and society as a whole. The concept that professional work has a moral value compels the physician to behave ethically in his or her personal and professional life. The greatest number of physicians adhere to high ethical and moral standards and principles of beneficence and non-maleficence. Physicians have a duty to do right and to avoid doing wrong. However, our greatest concerns are related to the method of sustaining the solidarity of the profession at the high expense of patients and lay people. We believe there is a strong link between certain types of professional solidarity, levels of the amenable mortality and preventable harm in health care.

As Freidson argues, even if the physician does shoddy work or malpractice in the most cases there is a reluctance to judge the work of a colleague physician or specialist. Physicians respond to societal needs, and their behaviors reflect a social contract with the communities served. The question is how the profession of medicine understands the fulfillment of social contract?

From the very beginning of its professional and social activities the American Medical Association (AMA) in 1847, primary intentions were to improve medical education. At this time, medicine had not yet become a science-based profession. It was somewhere in between the social organization, movement and layer organization inclining to support a scientific principle. That inclination helped the AMA to drive the medical reform at the beginning of XX century. The Abraham Flexner's report, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, was published with the intention of transforming medical education. It was that breaking point after which AMA accomplished the goal of establishing the monopoly over medical education. From that moment in history, medicine has been going through the profound changes. Which had to adhere strictly to the protocols of mainstream science in their teaching and research and was expected to be thoroughly grounded in human physiology and biochemistry. The movement toward an emphasis on basic sciences demonstrated that medicine was embracing science as its foundation instead of the earlier dogma of bleeding and purging. The disciplines of pathology, bacteriology, and clinical microscopy were considered the basis for the scientific method, and therefore were emphasized in the new medical curricula. The drive for scientific instead of dogmatic methods was a primary theme running through the Flexner report. Medical research adheres fully to the protocols of scientific research. The most important recommendation for the establishment of monopoly over the professional education was the recommendation that each state branch of the American Medical Association has oversight over the conventional medical schools located within the state. One of the immediate consequences was that medicine in the US and Canada had become a highly paid and well-respected profession. No medical school can be created without the permission of the state government. Variations in policies and organizations of health care around the world are influencing the power and practice of such professions as medicine and law.

What was the turning point in the historical development of the notion of professionalism in medicine and health care?

Eliot Freidson argues that professionalism is sustained if there are two essential elements: commitment to practicing the body of knowledge and skills of special value and to maintain a fiduciary relationship with clients/patients.

According to Freidson, the first and most distinctive condition is the ownership of the specialized knowledge not easily understood by the citizens with an average education. The medical profession holds the monopoly, argues Freidson, over the use of the medical knowledge and responsibility for its teaching. In the United States, medical profession developed institutions designed to control the selection, training, and credentials of their members and to gain privileges providing a marked advantage in the marketplace. What are the grounds on which the institutions implement the monopoly over the health care services and the strict professional rules? When the idea of professional approach appeared? The knowledge should be used in services of individual patient and society in an altruistic manner if we understand altruism as the performance of cooperative unselfish acts beneficial to others. However, physicians altruism towards their patients and others has not been a broad subject of studies, and there is fragile empirical evidence on what does it mean in everyday behavior of physician although it is often mentioned in statements about medical professional values and attitudes. It has been studied in contexts of the donation of organs and genetic material and patients' participation in potentially hazardous experiments and trials. Another distinctive condition of the medical profession is inaccessible nature of the knowledge and commitment to altruism. They are the justification for the professions autonomy to establish and maintain standards and practice of self-regulation. It is not only a technical knowledge and skills that assure quality.

To what extent we experience threats to the maintenance of this condition?

Studies dealing with quality assurance in health care and clinical risk management suggested that rates of adverse events in patients in the hospitals in the developed world were much higher than previously thought. Multiple sources and studies are showing rates of at least 8% of total amenable mortality rates. Of these adverse events, more than 50% were judged to be preventable. These reports suggest that the deaths of between 0.5% and 2% of patients in the hospital are associated with an adverse event, which was often, but not always, preventable. Reducing the number of deaths and injuries attributable to medical error is also related to favoring of a fiduciary relationship with professional colleagues instead to patients. The consequence is measurable in a report from the Institute of Medicine in Washington which estimated that as many as 98 000 deaths a year were caused by the medical error (BMJ 1999;319:1519).

These studies would rank harm from health care high on the list of all causes of death for the countries being considered. All published studies to date, however, have been from developed countries, with no reports from developing or transitional economies. In the whole region of South East Europe in last twenty, five years not a single case of hospital deaths was registered and attributed to medical error. The simple calculation, if the lowest US standard of o,5% would be applied, we would be speaking about vaste numbers of associated with the adverse event. This estimation shows extremely worrisome situation with negligence of medical profession and non-fiduciary relationship with patients.

Preventable harm to patients resulting from their healthcare is unacceptable at any time. Patient safety is first and foremost a clinical problem, but it is also an important cause of wasted resources.

The World Health Organization has carried out analysis of the world's health systems using five performance indicators to measure health systems in 191 member states. It finds that France provides the best overall health care followed among major countries by Italy, Spain, Oman, Austria, and Japan. The model taken from the OECD database shows how the health system in France, considered best healthcare system in the World, manages to establish a simultaneous relationship between different clinical procedures and clinical, economic and indicators and between structures, processes, and outcomes of health care.

We cannot escape from the proper ethical, professional, clinical and economic obligation to make decisions about fair, and efficient resources allocation. We are obliged to understand and implement the best practice of medical care not only to a single patient but as many as possible members of body social. And yes, we are obliged to make hard professional decisions and ethical judgments in the professionally and morally challenging situations.

*The broad version of this article, including data tables, charts and figures was concurrently published at Harvard Blog:

http://blogs.harvard.edu/oreskovic/2017/09/10/who-am-i-to-judge-professional-solidarity-amenable-mortality-and-preventable-harm-in-medicine/