This editorial can be found in the December 2023 issue of The American Journal of Bioethics
Since physicians began to formally professionalize in the 19th century, we have sought to set ourselves apart from other occupations through the adoption (and variable enforcement) of codes of ethics. The original Code of Medical Ethics of the American Medical Association (AMA), published in 1847, was the first national code of ethics for any group, and it contained three sections, explicitly addressing physicians’ duties to patients, to each other as colleagues, and to the larger communities we serve. Thus, the structure of our original Code implicitly recognized the potential for physicians’ duties to different parties to be in tension. But then, as now, the obligation to individual patients has generally taken priority. This tiered view of physicians’ ethical responsibilities was strengthened in the wake of Nazi medical crimes during World War II that were, in part, seen as examples of the worst possible outcome when physicians put the well-being of society above the well-being of individual patients. The most recent AMA Code of Medical Ethics, for example, says that “physicians’ primary ethical obligation is to individual patients, [though] they also have a responsibility to promote public health,” and its front cover prominently declares, “Patients First.”.
But, according to Doernberg and Truog in a provocative Target Article in this issue of AJOB, the increasing complexity of health care, the recognition of social determinants of health as key factors in human flourishing, and the integration of health care into broader societal structures should prompt a reconsideration of this tiered view of ethical responsibilities for physicians. With increasing attention to physicians’ roles outside of clinical care—they specifically list roles in human subjects research, population health, scientific knowledge generation, and the pursuit of profits—and with conflicts within and between these roles thrown into sharp relief by the COVID-19 pandemic, Doernberg and Truog suggest we should recognize that physicians often play these five distinct roles and that each has an equally legitimate and weighty “sphere of morality”. Each sphere should be seen as having its own ends and its own internal moral consistency, they say, though all are related to an overarching telos of medicine: improved societal health. So, for example, the core of their understanding of the ‘sphere of morality’ governing clinical care is that clinicians “treat those who are ill on behalf of society” (emphasis added).
The mere assertion that any other goals for physicians might hold equal moral weight compared to protecting the well-being of individual patients will probably make this article controversial enough, but the “spheres of morality” concept raises two additional important questions. First, presuming that considering ‘spheres of morality’ can be useful for improving ethical analysis and action among physicians, are Doernberg and Truog looking at the right spheres? That is, do their five proposed spheres reflect the actual core social roles for physicians? Second, what is the point of this new framework, or how can it be used to improve ethical analysis and action among physicians?
Are These the Right Spheres?
Several of the spheres identified by Doernberg and Truog—clinical care, research (on humans or otherwise), and improving population health—would be recognizable to writers of codes of medical ethics of the last two centuries. Each of these spheres is clearly related to improved societal health, and it is undeniable that physicians play key roles in achieving each sphere’s goals. Individual physicians regularly encounter conflicts between these spheres, and while the bioethics and medical literature contain numerous suggested methods for resolving them, Doernberg and Truog have added a potentially useful new framework for understanding these conflicts, especially for recognizing when a conflict is arising within the core values of a single sphere or as a conflict in values between distinct and competing spheres of morality.
Including the “Market” as a sphere of morality for physicians raises problems, however. The market is included as a sphere because “the pursuit of profit drives technological and organizational change in healthcare”. While it is undeniable that the pursuit of money can drive advancements in medicine, it does not follow that the market itself is an end related to the telos of improving societal health. Rather, the market is sometimes a method of achieving that telos. Indeed, though some may disagree with how Doernberg and Truog describe the ethics of the market, in their description the primary goal of the market is to maximize profit, even when that means bluffing, puffing, and spinning information in misleading ways. If this is the morality of the market, there are clearly times (perhaps even most times) when profit maximization works against the end of improved societal health. The market, then, might be better considered as a potential means to achieve goals within the spheres of clinical care, research and population health, rather than as a separate sphere of morality.
Adopting the moral sphere of population health as a core responsibility might also be problematic for many physicians. While clinical work and population health work certainly share a general telos of promoting health and well-being, public health is a distinct area of expertise. Physicians can be instrumental to achieving the goals of public health, but most physicians are not experts in public health and the work of most physicians, per se, is not aimed at achieving public health ends. To be sure, physicians have obligations imposed on them by public health policies, such as infectious disease reporting requirements, but adhering to those policies may be better understood as a communitarian obligation to follow societal norms, laws, and expectations than as a core moral role specific to physicians.
In fact, in many ethical conflicts within public health (including some of those cited by Doernberg and Truog), physicians have traditionally been deliberately distanced from making public health choices. For instance, in the case of scare resource allocation protocols developed during the pandemic, bedside physicians were often intentionally removed from final decision processes. Physicians were to provide accurate information to allocation teams, and they might have to help carry out decisions made by those teams, but we assiduously sought to avoid cases where physicians would have to decide to not offer a service to one of their patients so it could go to another. Similarly, in situations involving access to very-high cost drugs, resource-intensive therapies, and limited organs for transplantation, bedside physicians do not determine who should have access to the therapy. Instead, we make those decisions at a broader system level, such as via governmental or private insurer payment structures, organizational policies, or even legislation.
Still, physicians must sometimes make choices that balance the well-being of one patient against the well-being of others—if only because there is limited time in the day to help all of one’s patients. And there is an argument for including physicians’ knowledge at the level of individual patients to optimize rationing decisions when they must be made. Moreover, physicians function not just in health care systems, but in a broader array of systems created by society, many of which have direct impacts on our patients’ health and wellbeing. We noted above that physicians have general moral obligations to obey laws and policies that are justly enacted, but the current Code of Medical Ethics of the AMA also says we have an ethical “responsibility to seek changes in those requirements which are contrary to the best interests of the patient”. Thus, we see a place for a sphere of morality that calls out the fact that physicians are not solo actors but are deeply integrated into health care systems and societal structures.
Such a sphere would highlight our role in addressing social factors influencing health along with other contemporary ethical challenges, like what to do when one’s obligation to provide care to patients conflicts with a law that makes that care illegal. Similarly, a physician’s commitment to research might compel her to wish to study the effects of marijuana on a particular patient population, but such a study could conflict with laws banning the use of marijuana in studies. We would draw such a sphere of morality around societal obligations, or communitarian responsibilities, such that it could address these concerns that extend beyond Doernberg and Truog’s proposed ‘population health’ sphere.
How to Use the Spheres Framework
With or without our amendments, we are convinced by the examples provide by Doernberg and Truog that there is potential utility in the spheres of morality framework, especially for defining and exploring conflicts within and between key roles physicians may play. Identifying these roles and how they interact is a valuable contribution to our ways of thinking about physicians’ work and professional identity. The spheres might help physicians better understand the reasons they feel conflicted in some cases, and they might help physicians uncover previously unrecognized areas of conflict, which might help physicians become better equipped to negotiate their roles in an increasingly complex and interconnected healthcare system.
In some ways, however, this new framework is also reminiscent of Beauchamp and Childress’s Principlism framework. Each offers a valuable way to understand and explore physicians’ multiple priorities (Beauchamp and Childress) or roles (Doernberg and Truog). But it’s also reminiscent of Principlism in that it doesn’t provide a means to resolve conflicts within and between those values/roles. The “spheres of morality” are comparable to “mid-level principles” because neither come with an inherent implementation guide for how to use them to resolve conflicts.
We hope that Doernberg, Truog, and others will build on their work by proposing and testing mechanisms for using their framework to help physicians make difficult choices. Just as Principlism and other early elucidations of mid-level principles eventually spawned the development of a variety of approaches to resolving clashes between principles (whether in Four Boxes, Eight Steps, or CASES), conflicts among spheres of morality for physicians provide a fertile ground for developing new approaches to resolving conflicts in the real world. Even as we expect the spheres to be further clarified and delineated through discourse, we encourage rapid movement toward practical applications, using this framework to address real-life dilemmas beyond those identified by Doernberg and Truog.
Brian M. Jackson and Matthew K. Wynia