By Tom Koch, September 21, 2023
The recent pandemic highlighted the limits of healthcare systems in Canada and around the world. Overfull hospital wards with insufficient resources challenged practitioners and medical personnel as patients in respiratory distress poured into emergency departments.
Problems encountered during the Covid pandemic were a test of a new medical ethic, bioethics, that in recent decades replaced the traditional, Hippocratic ethics that had guided medicine for two millennia.
Nowhere was this clearer than with the well-reported resignations and early retirements of many doctors and nurses as the pandemic waned. Why the exodus? “Burnout” and exhaustion—the usual answers—are insufficient. Being tired from care and being tired of caring are two very different things; it is one thing to be exhausted by a cumbersome work schedule it is another thing to lose faith in your profession.
Doctors faced overloaded wards, a shortage of supplies and grueling work conditions in the plague years of the 16th and 17th centuries, during disastrous, 18th century yellow fever outbreaks in eastern US cities, and across repeated cholera pandemics in the 19th century. In the 20th century, this happened again during the influenza years of “Spanish Flu” and then, in the 1950s, with poliomyelitis. Every time practitioners were overworked, exhausted in the care of patients shuffled from overfull clinics and hospitals to make-shift wards in churches, gymnasiums, city buildings and other public spaces.
Resources were in short supply in every outbreak but workarounds always were devised as practitioners adapted to the exigencies of the day. In past pandemics, doctors and nurses were exhausted but not necessarily discouraged by the long hours required of them. Nor were most intimidated by the dangers they faced from caring for those with highly communicable, infectious diseases. Care in extremes was the demands of their vocation and to do less would have been to violate their vocation’s duties not only to patients but to society at large. As this or that pandemic ended there was no reported exodus of doctors and nurses from hospitals or clinics. Tired from caring but not tired of caring, the vocational sense of duty kept them in their practices during and after each pandemic.
This time, however, there was an exodus. It followed what the National Academy of Sciences described in 2019 as an already prevalent “epidemic of dissatisfaction” stemming from changes in the medical culture. Simply put, practitioners felt they could no longer provide the type of care they believed in. As a result, the satisfaction they had previously experienced providing care and the sense of purpose that sustained them was diminished and, for some, disappeared altogether.
The new framework: bioethics
Beginning in the 1970s, a group of medical amateurs skilled in moral philosophy declared that society needed a new ethic of clinical and social care. The old Hippocratic ethic, grounded in the physician’s knowledge and commitment to both the patient and society was deemed insufficient.
Instead, medicine was to be governed by a new, individualistic, consumerist ethic supervised by professional bioethicists. Practitioners were demoted from the role of knowledgeable expert at the forefront of care to that of technicians, servants in care rather than providers of care.
As anthropologist Annamarie Mol put it, they were transformed into salesclerks; and patients became customers in a system focused on autonomy and individual choice. The “good faith on the part of provider, patient, and the public as a whole,” as one critic put it, was if not lost at least radically diminished. What had been the essence of a rewarding, fulfilling vocation, described by one physician as “the exercise of discretion and judgment based on experience and training,” was reflexively condemned as unacceptably paternalistic.
The new bioethics, wrote Hasting Center cofounder Daniel Callahan, was grounded not in a service-oriented ideal but an entrepreneurial, for-profit business model. “The market was treated as a moral, not just an efficiency value … little interested in the common good.”
There was much that was self-serving in this movement. As a former head of the American Society for Bioethics and the Humanities, Mark Kuczewski, put it: “Ethicists have been a guest in the house of medicine and in order to survive in that environment have had to align themselves with money and power.”
For bioethics to succeed, Callahan wrote in is autobiography, the privileged status of physicians had to be diminished. After all, they were the competition if bioethicists were to become principal arbiters of both medical practice and social need. And so, in the words of another bioethicist, Robert Veatch, physicians were shorn of their status as ethical and moral actors, reduced to the status of mere technicians in a system overseen by the bioethicist-philosopher in which economic constraints dominated and patient autonomy the principal good.
The Conflict: bioethics versus traditional medicine
The result has been an existential conflict for medical practitioners. The older ethics’ vocational goals of care were frustrated by the realities of practice in an increasingly bureaucratic, impersonal and market-focused system. As Joanna Cannon put it in her book, Breaking and Mending, the outcome has been disastrous, at least in England: “It’s only when you arrive in the wards, when you are spat out into an NHS [National Health Service] that bends and breaks under the strain of the endless demands placed upon it, it’s only then that you realize you will never be able to be the doctor you want to become. The system simply won’t allow it.”
Morality and social structure are, as philosopher Alasdair McIntyre put it, one and the same. The values that underlie a practice become embedded in the means through which it is delivered. In the new bioethics, that structure was constructed around a new ‘professionalism’ in an unspoken, unwritten, never negotiated social contract, with businesses and government as senior partners. The physicians vocational ethics’ commitment to the life of each person, each patient, was challenged by medicine’s new governing partners. As one doctor put it, “We’re trained in our schooling to give our best possible care to our patient regardless of race or gender but then we meet the real world where it’s about insurance companies, bottom line, the hospital’s revenues … it’s all about throughput”.
The ethos of medical research as a social rather than a commercial good was lost in the process. Famously, Frederick Banting and Charles Best sold the patent for insulin for one dollar to assure, they believed, it forever would be available to all in need. In the 1960s, the developers of the Guthrie test for Phenylketonuria (PKU syndrome) in newborns, a metabolic disorder, was developed in Buffalo, NY. The test was patented and licensed in a deal that assigned profits from the test kit’s sale not to the doctors but to support medical services.
Research had been, as Roy Porter put it, first and foremost For the Benefit of Mankind (the title of his book) rather than corporate or personal profit. In the new ethic, researchers were transformed into entrepreneurs and new discoveries into profit opportunities for entrepreneurial corporations.
From its beginnings, bioethics promoted an ethic of limits in which quantities of system resources were fixed, never flexible. Whether the issue was hospital beds or ventilation machines, scarcity was a given. In the 1990s this became known “lifeboat ethics” that assumed, because resources were constrained, some must be left to die so others might live. Life—the principle good in the old ethics—was reframed as ‘life where possible’ in the new one.
It was what economists and philosophers call a utilitarian ethos in which the question becomes who is more worthy, whose life should be saved. It was thus inevitable that, at the outset of the pandemic in 2020 well-known bioethicists published triage protocols. They assumed a scarcity of resources would require that some patients be sacrificed so that others, presumed worthier, might be saved.
But the scarcity bioethicists accepted as inevitable was not immutable. At the bedside, in clinic and hospital, practitioners refused to accept the idea that they must choose between the equally needy. Yes, hospitals were filled beyond capacity but, as had happened in previous pandemics, makeshift wards were created to house the ill. New supply chains were devised; new, more efficient, ways to manage available materials were created.
The problem with the new ethic was its embrace of a business-like ethos. But medicine is not just another business. In the 1960s, Nobel Prize-winning economist Kenneth Arrow explained why the necessities of care were not compatible with market economics. The things that make a market efficient do not serve in the provision of healthcare in modern society. Because bioethics, like business, takes a short-term view of healthcare needs and resources. the new ethicists ignored the histories of previous pandemics, the needs that always surface whenever a new one emerges.
Denying the role of practitioners as experts they dismissed the elements of practice that had, in previous pandemics, kept doctors and nurses on the job despite the strain of their role. The epidemic of dissatisfaction was the result. It also invalidated what Jane Jacobs called the guardianship function of physicians in society.
Historically, the physician’s professional focus was both the person in care and the common weal, the health of all. Practitioners were, as such, advocates for change and whistle blowers when health systems were inadequate. Bioethics promoted a model inimical to both the practitioner’s sense of social purpose and their devotion to the unswerving care of the fragile patient.
This did not go unnoticed by the bioethicists themselves. “It is something of a miracle,” Callahan admitted in 2012, “that most physicians remain faithful to their professional values in a system that does all it can to turn them into better businessmen which in fact they must fit into the health care system.” And so, as the pandemic receded, many practitioners found the medicine they were trained to provide, and their sense of vocation, had little place in the new system. And so they said, as the pandemic waned: Enough.
“Burnout” was the name given to the practitioners’ sense their work was not simply exhausting but unrecognized and unrewarding. The resulting exodus of practitioners didn’t happen in the 1920s or 1950s or even, a century earlier, in the days of cholera. It was a result not of exhaustion but of discouragement with the commercialization of medicine and the degradation of professional status.
Buying into the fiction that Covid-19 was an unprecedented event freed officials—hospital administrators, directors, and politicians—from taking responsibility for short-term deficits and limited caring personnel. They were, we see today, the result of short-term profit and expediency over longer-term need.
Covid-19 revealed the limits of the health system and the ethics that underlie its priorities. Returning to Hippocratic values would not simply be a return to the medicine of yesterday. It would, however, insist on medicine as a bottom-up service in which the good of each person contributes to the good of us all. It would recognize and respect the role of those whose responsibility—legally and morally—is in the best care of the person. It would, ultimately, insist that life—every life—should be a primary societal value.
Tom Koch is a medical ethicist, historian, and geographer at The University of British Columbia. He is the author of fifteen books including, most recently, ‘Ethics in Everyday Places: Mapping Moral Stress, Distress, and Injury’.