Priests, Providers, and Protectors: The Three Faces of the Physician

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COMMENTARY

Dr Pies is Professor in the psychiatry departments of SUNY Upstate Medical University, Syracuse, NY, and Tufts University School of Medicine, Boston. He is Editor in Chief Emeritus of Psychiatric Times (2007 to 2010).

Autonomy grew up as a street fighter, and was bloodied in some genuinely noble battles against medical paternalism. But like so many rulers . . . it has quickly forgotten its democratic roots, and grown fat and brutal in power.
Charles Foster, Ethicist at Oxford University¹

Introduction

“Yes, Father, I’ve been taking my medicine.”

Marie’s social worker and I had to suppress a chuckle. For a moment, Marie had been transported back 50 years to her French Catholic girlhood, and I-her psychiatrist-had momentarily become her Father Confessor. Marie suffered from some mild cognitive deficits and a history of psychotic episodes, but her moment of role confusion was not the product of mental illness-in fact, she laughed at her faux pas and quickly corrected it. And in an important sense, Marie’s misidentification of me as a member of the clergy was quite understandable. For, once upon a time, the role of physician and priest were intimately connected. I use the term “priest” in the broadest sense, without reference to a particular religion, to denote “. . . one authorized to perform the sacred rites of a religion, especially as a mediatory agent between humans and God.”²

In this essay, I contrast the physician’s priestly role with that of the modern-day, medical “provider.” I then develop a third way of seeing the physician that preserves the gravity, dignity, and authority of the medical profession while recognizing that the patient’s autonomy is an increasingly important medical-ethical value.

The physician as priest

According to the Encyclopedia Judaica, medicine and religion were closely connected for Jews in ancient times. Priests were “the custodians of public health,” and Jews in biblical times regarded the physician as “the instrument through whom God could effect the cure.” Accordingly, “Jewish physicians . . . considered their vocation as spiritually endowed and not merely an ordinary profession.” Moreover, Jewish history is replete with a “. . . long line of rabbi-physicians that started during the Talmudic period [ca. 2nd to 6th century BCE] and continued until comparatively recently.”³

Hippocrates-the “Father of Medicine”-also practiced in a context that fused medical and priestly roles. Indeed, Hippocrates “. . . learned through a network of physicians belonging to an established guild…in a master-apprentice relationship among a cadre of priest-physicians known as the Asclepiads. The cult of Asclepius, the hero-god of medicine and healing, would eventually gain widespread acceptance in Greek and Roman culture, with devotion to this deity lasting well into the fourth century.”⁴

The intertwined medical and spiritual functions of the physician are also found in the writings of the early Christian Church. Thus, St. Basil (ca. 329-379 CE), in a letter to the physician Eustathius, describes the “ambidexterous” role of the physician: “. . . your profession is the supply vein of health. But in your case, especially, the science is ambidextrous, and you set yourself higher standards of humanity, not limiting the benefit of your profession to bodily, but also contriving the correction of spiritual ills.”⁵

Although the priestly functions of the physician have largely disappeared in modern times-with some justification, as discussed below-the religious and spiritual needs of patients have received increasing attention in the recent literature. As one review concluded,

For many patients confronted with chronic diseases, spirituality/religiosity is an important resource for coping. Patients often report unmet spiritual and existential needs, and spiritual support is also associated with better quality of life. Caring for spiritual, existential and psychosocial needs is not only relevant to patients at the end of their life but also to those suffering from long-term chronic illnesses.⁶

The physician as “provider” »

The physician as provider

As internist and Harvard professor Allan H. Goroll, MD, explained in a recent editorial, “. . . the term ‘provider’ first appeared in the modern health care lexicon as a shorthand referring to delivery entities such as group practices, hospitals, and networks. More recently, its use has expanded to encompass physicians, nurse practitioners (NPs), physician assistants (PAs), and perhaps others, especially those engaged in delivery of primary care.”⁷

Dr Goroll notes that, on one level, this expansion “. . . is both logical and convenient, as it reflects the importance of a multidisciplinary approach to modern primary care delivery, extending beyond the traditional dyad of patient and physician.” But Goroll goes on to note that “. . . the term ‘provider’ has the potential for adverse consequences for primary care, calling into question the wisdom of its expanded use.”⁶ Specifically, he argues, “Designating all as ‘providers’ blurs important distinctions and creates confusion among team members as to roles, responsibilities, and specific contributions, compromising effective team functioning.”⁸

I agree with Dr. Goroll. But there are even more troubling problems with the term “provider,” as applied to physicians. As internist Suneel Dhand, MD, and William J. Carbone (chief executive officer, American Board of Physician Specialties) argued in a letter to the American Medical Association,

The word “doctor” is over 2000 years old, aptly derived from the Latin doctus, meaning to teach or instruct. . . . In almost every country in the world, a medical doctor is considered to be among the most noble and prestigious professions, the title only conferred after one of the most rigorous university courses in existence. It is a privilege and honor to be one. . . . The word “provider” is a non-specific and nondescript term that confers little meaning.⁹

Dhand and Carbone call for restoration of the “courtesy and respect that is due to a hardworking and dedicated profession.” That the term “provider” shows neither courtesy nor respect to physicians is revealed in a little-known but telling example from the history of Nazi Germany (for which I thank my colleague, Dr Mark Komrad). As related by pediatrics professor Paul Saenger, MD: “In the 1937 issue of the Reichs Medizinal Kalender, a directory of doctors, the remaining Jewish doctors in Germany were stigmatized by a colon placed before their names. Their medical licenses were finally revoked in 1938. They could no longer call themselves ‘Arzt’ or ‘doctor.’ They were degraded to the term ‘Behandler,’ or, freely translated, ‘provider.’”¹⁰

I am certainly not comparing the status of US physicians to that of Jewish physicians in Nazi Germany. However, I am comparing two usages of the term “provider,” and suggesting that, in both cases, there is a “degrading” of the physician’s status and stature. It is not merely that the ancient priestly mantle is stripped from the physician’s persona, which some might argue is a change long overdue. Rather, the term “provider” renders the physician little more than a functionary-a specialized and obedient drone who carries out the wishes and instructions of others.

The origin of the term “provider” (as applied to physicians) is roughly contemporaneous with the later years of the consumer movement, which began in the early 1960s and continues to this day.¹¹ As I have argued elsewhere, this movement-notwithstanding its notable merits-has attempted to replace the term “patient” with the terms, “client” or “consumer.” Specifically,

. . . contemporaneous with the rise of the term “consumer,” the term “provider” has become a substitute in many settings for the terms “doctor” or “physician.” By labeling physicians as mere providers of services, the consumer movement-abetted by insurance companies, and sometimes by physicians themselves-may have undermined the historical role of physicians as teachers and healers who have answered a calling.¹²

The great frustration engendered by these consumer-driven trends is summed up in these comments by family medicine physician Dr Stephen Zimmer:

[Patients] often just call in and actually TELL me what I’m SUPPOSED to call in for them. The physician’s role is to call the insurance company and ask permission to order a test . . . or to start a medication. . . . I have been a physician for several years and have seen the system change such that the doctor is actually a “Provider” and no longer a physician. And if I do actually suggest a treatment, medication, or procedure (which again, contrary to popular belief, does not benefit me in a financial way) I am often told by the insurance company that this cannot be done unless I can prove the benefit [emphasis is Dr Zimmer’s].¹³

The physician as “protector” »

The physician as protector

I believe there is a “third way” of viewing the role of the physician-one that neither elevates the physician to the exalted (grandiose?) position of “priest” nor demotes us to the level of mere “providers.” In the role I call the protector, the physician’s chief obligation is the safeguarding of the patient’s physical, emotional, and spiritual well-being.

As the patient’s protector, the physician does not embrace a false equality between his or her medical knowledge and that of the patient: the physician as protector is still the medical expert. However, the patient’s views, wishes, and perspectives are always treated with the utmost respect, and are never dismissed on the pretense of the physician’s “priestly” authority. Indeed, respect for the patient’s autonomy is a foundational value in the physician’s role as protector. As surgeon C. Ronald MacKenzie, MD notes, “. . . the notion of the respect for autonomy of the patient has come to lie at the heart of Western medical practice and its ethics, replacing the legacy of medical paternalism of the physician.”¹⁴

And yet, Marie’s addressing me as “Father” suggests that some older patients may find it difficult to relinquish medical paternalism. As Dr Mark Komrad has noted, “The priest-like status of doctors historically encouraged paternalism to which patients readily acquiesced.”¹⁵

To be sure, there are good reasons for abjuring the “priestly” role and affirming the patient’s autonomy as a central principle of medical ethics. On the other hand, some medical ethicists believe that the principle of autonomy has been carried too far in modern medical practice, sometimes compromising the other three foundational principles of medical ethics: beneficence, nonmaleficence, and justice. Komrad has observed that “. . . all illness represents a state of diminished autonomy. The ill are dependent on others such as physicians, if not for outright therapeutic ministrations then for their expert legitimation of their illness.”¹⁵

Komrad goes on to argue that “. . . some paternalism is not only justified but is required in all therapeutic relationships due to the nature of illness and the sick role . . . [furthermore] Paternalism is not always incompatible with the principle of autonomy.” Komrad notes that medical paternalism may actually serve the justifiable goal of restoring the patient’s autonomy-and that this restorative function is medical paternalism’s sole justification. Indeed, a degree of benign paternalism toward, say, an acutely psychotic patient may be the only feasible means of restoring the patient’s autonomy.

Other medical ethicists have observed that autonomy is susceptible to over-valuation by some physicians. This privileging of autonomy runs the risk of ignoring the ethical constraints that have defined Hippocratic medicine for centuries, ie, ignoring the deontological (duty-based) nature of medical ethics. For example, we would never tolerate a physician’s engaging in sex with a patient under active treatment, on the theory that the patient “autonomously” consented to, or sought out, a sexual relationship with the physician. On the contrary, we would view the physician as having committed a serious boundary violation, based on the principle of non-malfeasance. In short: the patient’s autonomy must sometimes stop at the border of the physician’s fiduciary duties as protector.¹⁶

Indeed, some ethicists have applied this argument to the very controversial issue of physician-assisted suicide. Thus, as Yang and Curlin put it:

If physicians were solely service providers who accommodated the self-determining choices of patients, then physician-assisted suicide would be logical if assisted suicide were justified. But the heart of the medical profession is not providing services. Rather, the physician’s constitutive professional role is to attend to those who are sick and debilitated, seeking to preserve the measure of health that can be preserved, and to help them bear the pain and progressive loss of autonomy and bodily function that illness often brings.¹⁷

Conclusion

The professional role described by Yang and Curlin is at the core of the “third way” I have described-the role of the physician as protector. We are not priests, and we should not lay claim to the “God-given” power or authority of priests-which, as we well know, may be subject to abuse and exploitation. On the other hand, we are not simply providers of services, bowing obediently to an overvalued notion of the patient’s autonomy. In Dr Leon Kass’s pungent phrase, the physician is not merely “a highly competent hired syringe.”¹⁸

Somewhere between the extremes of priest and provider beats the protective heart of medical healing.

For further reading:
Geppert CMA, Pies RW . Compassion in Clinical Care. OBM Integrative and Complementary Medicine. 2019;4:8.

Acknowledgment-Thanks to Dr Mark S. Komrad for his comments on an early draft of this paper; and my appreciation to Dr Komrad, Dr Cynthia M.A. Geppert, and Dr Annette Hanson for their ongoing efforts in behalf of our patients.

This article was originally published on 3/15/19 and has since been updated.

References:

1. Foster C. Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law. Oxford, UK: Hart Publishing; 2009.

2. Merriam Webster Dictionary. https://www.merriam-webster.com/dictionary/priest. Accessed March 14, 2019.

3. Jewish Virtual Library. Encyclopedia Judaica: Medicine.https://www.jewishvirtuallibrary.org/medicine. Accessed March 14, 2019.

4. Love J. The Concept of Medicine in the Early Church. Linacre Q. 2008:75;225-238. https://www.tandfonline.com/doi/pdf/10.1179/002436308803889503. Accessed March 14, 2019.

5. Basil. Letter 189. In: Letters (trans. Sr. Agnes Clare Way, C.D.P.) New York: Fathers of the Church, Inc.; 1955, 25.] https://www.tandfonline.com/doi/pdf/10.1179/002436308803889503. Accessed March 14, 2019.

6. Büssing A, Koenig HG. Spiritual Needs of Patients with Chronic Diseases. Religions. 2010:1;18-27. https://www.mdpi.com/2077-1444/1/1/18. Accessed March 14, 2019.

7. Goroll AH. Eliminating the Term Primary Care "Provider": Consequences of Language for the Future of Primary Care. JAMA. 2016;315:1833-1834. https://jamanetwork.com/journals/jama/article-abstract/2506307. Accessed March 14, 2019.

8. Goroll AH. Primary Care "Provider" and Professional Identity-Reply. JAMA. 2016;316:1412. https://jamanetwork.com/journals/jama/article-abstract/2565284. Accessed March 14, 2019.

9. Dhand S, Carbone WJ. Physicians are not providers: An open letter to the AMA and medical boards. Kevin MD. November 30, 2015. https://www.kevinmd.com/blog/2015/11/physicians-are-not-providers-an-open-letter-to-the-ama-and-medical-boards.html. Accessed March 14, 2019.

10. Saenger P. Jewish Pediatricians in Nazi Germany: Victims of Persecution. IMAJ. 2006;8:301–305.

11. Who We Are. Consumers International.https://www.consumersinternational.org/who-we-are/consumer-rights. Accessed March 14, 2019.

12. Pies RW. Physician-Assisted Suicide and the Rise of the Consumer Movement. Psychiatric Times. 2016;23(8):40-43. https://www.psychiatrictimes.com/couch-crisis/physician-assisted-suicide-and-rise-consumer-movement. Accessed March 14, 2019.

13. Zimmer S. Comment. Medscape. June 2, 2015. http://www.medscape.com/viewarticle/844541#vp_4. Accessed March 14, 2019.

14. MacKenzie CR. What would a good doctor do? Reflections on the ethics of medicine. HSS J. 2009;5:196-199. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2744764. Accessed March 14, 2019.

15. Komrad MS. A defence of medical paternalism: maximising patients' autonomy. J Med Ethics. 1983;9:38-44. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1060849. Accessed March 14, 2019.

16. Pies RW, Geppert CMA. Deferring to the Mastery of Death: Hippocrates, Judge Gorsuch, and the Autonomy Fallacy. Psychiatric Times. April 3, 2017 https://www.psychiatrictimes.com/couch-crisis/deferring-mastery-death-hippocrates-judge-gorsuch-and-autonomy-fallacy. Accessed March 14, 2019.

17. Yang T, Curlin FA. Why physicians should oppose assisted suicide. JAMA. 2016;315:247-248. https://jamanetwork.com/journals/jama/article-abstract/2482333. Accessed March 14, 2019.

18. Kass LR. Neither for Love nor Money: Why Doctors Must Not Kill. Public Int. 1989;94:25. http://philosophyfaculty.ucsd.edu/faculty/rarneson/Courses/KASSwhydoctorsmust.pdf. Accessed March 14, 2019.