Do doctors have a moral obligation to serve?

Since it strikes at the very core of what this blog is all about, I couldn’t pass up the opportunity to comment on Dr. Karen Sibert’s recent op-ed piece in the New York Times.

She argues that, especially given the current shortage of primary care doctors in this country, being part of the medical profession confers one with the moral obligation to serve and, as such, conflicting interests, such as raising a family, should take lower priority.  I worked with a radiology attending once who expressed a similar view of his relationship to his profession this way, “It would be irresponsible of me to have kids because I spend so much time working.  I wouldn’t be able to spend enough time with them.”

The notion that doctors have a moral obligation to serve – to make their profession their top priority, their “life’s work,” as Dr.  puts it, or their otherwise full-time endeavor – comes out of the still prevailing view that doctors have an obligation to the public as well as their patients.  There are, of course, ways in which this is absolutely true.  As licensed professionals, doctors do have certain obligations to the public, among them to maintain patient confidentiality, to practice in accordance with current standards of care and to address any dangerous or unethical behavior in their colleagues.  As Dr. Sibert correctly points out, the practice of medicine is a privilege.  Where I very strongly disagree with Dr. Sibert, is that being afforded the privilege of providing a particular service confers an obligation to do so.  What is the nature of this obligation?  How much medical care are doctors obliged to provide?  How many hours per week is enough?  What kinds of conflicting interests justify taking us away from the practice of medicine?  These are personal considerations which every professional must answer for him or herself, not questions for public to answer.

There are a subset of physicians who do have a unique service obligation.  The National Health Services Corps (NHSC) as well as many state funded organizations will pay back all or a portion of new physicans’ medical education debt in return for a commitment to practice in an underserved community for a specified time period.  Doctors in these programs enter into a very special contract with the state and therefore have a unique obligation to serve the public which other doctors do not share.  Yes, it’s true that residents’ salaries are paid largely by medicare.  But, far from conferring true financial or symbolic debt upon residents, this payment is in return for valuable services that doctors provide during residency.  If anything, it is the government who is indebted to new doctors for the years of nearly free service they are compelled to provide throughout the course of their training.

It is absolutely true that we have a current shortage of primary care providers in this country.  However, we cannot and should not depend on doctors’ intrinsic motivation to work more simply because it is needed, or to move to rural areas simply because that is where they are needed, anymore than we should any other professional to do so.  As much as we enjoy it when people voluntarily do things which are not in their own self-interest in order to benefit society, change needs to come through rational healthcare policy.  The Affordable Care Act represents a first step in this direction by increasing funding for NHSC scholarships and with new grants to increase the number of primary care residencies.  This is how the problem must be addressed.  A doctor’s relationship to his or her profession and the number of hours per week that he or she decides to practice is a matter of personal, philosophical reflection, not a matter of moral obligation or public debate.

James Logan is a resident in family medicine who blogs at his self-titled site, James Logan, M.D.

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  • Anonymous

    I get so tired of this absurd, irrelevant appeal to morality.  The entire line of discourse is a waste of time.  It is in reality a technical question:  How do we get doctors to do what we perceive to be in our own best interests?  Answer: appropriate incentives and disincentives.  Next case.

    • Anonymous

      Those who feel such moral obligation should follow their conscience, so long as it’s not imposed on me, too. 

      Try recruiting for unfilled positions with a banner ad touting “moral obligation.”

      “Moral obligations” have a nasty way of turning into policy or law.  (Example: taxes.)  Where would one stop in the name of social goodness?  Draft people into law enforcement?  Compel people to work in prisons or to collect garbage?  Squeezing people into service for the collective good hasn’t gone well so far in prior national implementations.

      It’s also been my experience that a monolithic, exclusively professional identity is about as unhealthy as a chair with one leg.  I’ve a number of aspects of my identity that precede “physician.”  Were this not the case, my ability to be a physician would crumble.

  • http://twitter.com/iamdoctord Richard McCrory

    Though I’ve only been a medical trainee for 4 years, I’ve become a great believer that I’m a human first, and a doctor second. Invariably our profession makes us have to deal with intra-personal conflict about our ‘life’s work’, but should our activity not be an outward reflection of our personal identity?

  • http://makethislookawesome.blogspot.com/ PamC

    We demand the same moral obligations from ALL our professionals, not just doctors. “Law is a jealous mistress,” the say. And there are mandatory pro-bono hours that come with a law practice.

    It’s true that we shouldn’t rely on emotional incentives for behavior. I’m an economic determinist. I get that. But to say it’s not a matter of public debate, well, that’s just silly. We live in a country of free speech. Everything is up for public debate. lol

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    “If anything, it is the government who is indebted to new doctors for the
    years of nearly free service they are compelled to provide throughout
    the course of their training.”

    Those free services don’t benefit the government. They benefit the hospitals, so maybe the hospitals should feel indebted to new doctors.
    Other than that, I don’t see what the big hullabaloo is all about either. Just educate more doctors. There is no shortage of adequate candidates and Medicare shouldn’t pay hospitals to exploit residents anyway.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    In reading her article Dr. Sibert particularly discussed the problem of medical school classes being filled with a minimum of 50% women. It then went on to point out how few of them are actually practicing full time or at all a decade after completing training. I believe other studies did  not implicate child rearing as the reason. In fact the reason behind this decision to walk away from the profession is not known and does need to be explored and reviewed to assess the best way to keep experienced physicians active in the profession providing hands on patient care. Dr. Sibert pointed out the sacrifices she made in order to practice full time as an anesthesiologist at a major university center. She pointed out how she was able to participate in her family despite the commitment to her profession. No one enters a fellowship training program in a specialty without knowing the post training lifestyle in academia or in the private sector. You do know what you are getting into and if you are not prepared to make the sacrifices required to deliver professional service than you shouldn’t choose that area of medicine or possibly medicine at all. I understand life circumstances can alter a persons choices and options but Dr. Sibert points out that in her opinion it is choice of people who knew the challenges and commitment of a specialty before they got in and then just decided not to honor those requirements. In my internal medicine practice pre- concierge days when I saw 30 plus patients per day , I made sure to align myself with a partner who understood the importance of covering each other so that we both could be human beings at the same time we were honoring our professional obligations. We managed to make most of  our children’s and families events by planning and being flexible with our time and pledge to cover each other. 

    The solution is to screen medical school candidates better. Discriminate in favor of students who will commit to the specialties we need for a ten year period post training and incentivize them financially and with benefits.  If we need more long term players than screen for them. At the same time increase the funding for training in  specialties we need and decrease the funding for specialties in abundance.

    The author of this piece is a resident in training. While I respect his opinion and choices he can not possibly have a feeling for  the pressures on practitioners that the professional / personal conflict creates. While hours are long and work hard with low pay as a house officer, the time and pressure in the real world make training look like exactly what it is school and training.

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