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Balancing individual care with our social obligations

From the March ACP Observer, copyright 2005 by the American College of Physicians.

By Charles K. Francis, FACP

The tsunami that struck Asia and Africa in late December caused an almost unimaginable level of destruction. Nearly one quarter of a million people were killed, while more than 22,000 others are still missing.

The disaster also provoked an immense outpouring of global humanitarian aid. Governments, public agencies, private corporations and the world's citizens opened up their wallets and warehouses to send billions of dollars worth of relief to ravaged countries.

Why did the tsunami evoke such a massive and sympathetic response around the world? After the events of Sept. 11, Americans from all racial, ethnic and socioeconomic backgrounds united in one patriotic response to an external attack from an identifiable enemy.

However, the tsunami disaster seemed to stir even more deep-rooted emotions, reminding us that we are all powerless in the face of catastrophic natural forces. The scope of the devastation sparked an instinctive realization—one that transcended social, political and cultural boundaries—of just how vulnerable human life can be. The spontaneity and ubiquity of the worldwide response suggest that the event touched our collective unconscious, prompting us all to reach out to those whose lives were so tragically altered.

Physicians' response

As news of the disaster spread, physicians around the world rushed to ask how we could help. Many of us were compelled to try and contribute not only because we have skills to relieve human suffering, but also because we feel an ethical imperative to do so.

Medicine's core principles, as articulated by Hippocrates, remain the same today as when they originated in ancient Greece and Rome. Those principles include beneficence, altruism, relief of suffering, fidelity, honesty, compassion, humility, confidentiality, social responsibility and respect for patient autonomy. As was pointed out in the Dec. 1, 1998, Annals of Internal Medicine, those principles encompass our obligation to respond to sick and vulnerable people and spell out the unique ethical ties that bind the physician-patient relationship.

For physicians and medical organizations in the United States, the medical ethos has typically been applied to our obligations to individual patients. Do we likewise have an ethical obligation to society as a whole? Society, in fact, seems to think that physicians have an even greater social responsibility than other professions, one that extends beyond individual patient care to regional, national and even international health care issues.

Physicians' response to the Dec. 26 tsunami seems to indicate that we likewise feel called to a broader role. That made the tsunami crisis just the latest in a long line of historical challenges—including Nazism and apartheid—where physicians have to balance the needs of individual patients with demands created by political, social or cultural events.

Crises here and abroad

At the same time, physicians' response to the tsunami underscores the fact that other global medical crises have gone largely unnoticed by American medicine. While those crises haven't been caused by natural disasters, they continue to take an even higher toll on human life. Consider the following:

  • Malaria causes between 3 billion and 5 billion annual cases of clinical illness, and kills nearly 2 million people every year. More than half the world's population is exposed to malaria, an exposure rate that has jumped almost 10% over the past 10 years.

  • The global impact of HIV/AIDS is even more dramatic. According to projected estimates, more than 3 million people will die of AIDS this year, 78% of them in Africa.

  • According to World Health Organization (WHO) figures, close to 2 million people—most of them in Africa and Southeast Asia—died from tuberculosis (TB) in 2002.

That growing global burden of TB is closely linked to HIV infection. According to the WHO, "HIV is the single most important factor determining the increased incidence of TB in the past 10 years." The May 12, 2003, Archives of Internal Medicine reported that 9% of the 8.3 million new tuberculosis cases in 2000 were attributable to HIV infection.

Other health care crises are much closer to home. Here in this country, African Americans, Hispanics, and other racial and ethnic minorities continue to bear a disproportionate burden of disease, premature death and disability.

Racial and ethnic health disparities in the United States are associated with lower life expectancy, diminished quality of life, reduced economic opportunity, and ongoing social and cultural inequities.

These disparities contribute to the alarming growth of health care costs. They also provide vivid evidence that American health care has failed to dedicate enough resources to bridge what the Institute of Medicine has called "the quality chasm." That gap won't be closed until we fix the dysfunctional payment system and ensure access to quality care for all Americans.

Striking a balance

While many medical professionals wanted to provide direct medical care to tsunami victims, opportunities to do so were severely limited by the medical and training requirements of relief organizations. For most physicians, giving money to those organizations remains the most effective way to help.

But while few of us can treat survivors of international disasters, there is much we can do here at home to combine our broad social responsibilities with our commitment to care for individual patients. In our own practices, for instance, we can meet those social obligations by working to eliminate disparities, improve practice efficiency and preserve scarce health care resources.

While striking that balance is a formidable challenge, ACP can help. The College has developed policies that deal with health care reform, medical liability, pay-for-performance, health information technology and new approaches to revitalizing internal medicine. Each of these policies can have a major impact on our ability to meet the ethical challenges posed by American health care.

The new "Ethics Manual, Fifth Edition"—which will be published in the April 5, 2005, Annals—will offer additional guidance to physicians on human rights and ethical issues. And the "Physician Charter" produced by the Medical Professionalism Project—a joint effort of the ACP Foundation, the ABIM Foundation and the European Federation of Internal Medicine—provides a sound set of principles, based on the medical ethos, to help physicians weigh the competing demands of modern medicine.

We must continue to rely on medicine's ethical foundations as we address the complexities of ethical responsibility. Those principles are standards we have to constantly revisit as medical practice continues to evolve amid changing demographics, emerging infections, rapidly advancing science and technology, and the suffering caused by natural disasters.

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