First do no harm . . . As Robin Hanson has said, what does that mean? In contrast, the rule illustrated by this story, from Bryan Castañeda, who works for a Los Angeles law firm, is quite clear:
At the old firm I used to work at, I was talking to one of the senior attorneys and the topic of medical malpractice cases came up. He said he avoids them. Why, I asked. He said — I’m paraphrasing here — “Because you won’t find a doctor who will testify against another doctor in open court. They may advise you in private, ‘Oh yeah, so-and-so definitely screwed up,’ but you won’t get them to say that on the stand. They all protect each other.”
Judging by this story, if your doctor makes a mistake, the only person who will suffer consequences is you. Thank heavens the rest of us have more power than ever before. A recent survey of doctors found that “more than a 10th (11.3%) admitted to telling patients something that was not true.” The survey did not ask about lies of omission (when silence is misleading); unwillingness to testify that someone else made a mistake is that sort of lie. The survey also showed that doctors (at least, those who took the survey) have a self-serving interpretation of the term not true. Although only about 10% said they had said something “that was not true” — meaning something that they knew wasn’t true — “more than half had described a patient’s prognosis more optimistically than warranted.” Apparently they consider such descriptions not instances of “not true”.
In Systems of Survival, Jane Jacobs described two moral systems (lists of rules/values): The guardian syndrome and the commercial syndrome. In certain areas of life (e.g., military), the guardian syndrome prevailed; in other areas (e.g., small business), the commercial syndrome prevailed. Loyalty (e.g., “never testify against a fellow doctor”) is a guardian value — indeed, the main guardian value. In contrast, honesty is the main commercial value. Jacobs said that the two syndromes corresponded to two ways of making a living: taking and trading. Doctors do not represent themselves as predatory (= taking). But, according to Jacobs, this sort of rule (“never testify against a fellow doctor”) puts them squarely in that camp.
I asked Jim Jacobs, one of Jane Jacobs’s sons, for comment. He replied:
Exactly right. Jane experienced this herself, unfortunately. It’s really a major problem. I see the very same behavior among medical researchers too.
Doctors are squarely in the “guardian” group, and (mostly) operate under its morality as described by Jacobs. This includes accepting money only at arm’s length (indirectly via insurance), and active deception “for the greater good,” as you have described here.
This is fine if we trust these men as the most intelligent, moral, and capable beings on earth. If not, we have a serious problem, which is further exacerbated when doctors begin operating under a blend of both moralities–protecting each other and maximizing profits–without concern for the welfare of the patients they are sworn to protect.
If understood in light of Jacobs’ theory, this is the most rational argument, in my mind, for placing healthcare completely in the hands of (local) government, along with all other guardian functions, like military and police. As I argue at length at my blog, there is little difference between viral invaders that plan to kill us, and men with guns planning our demise. We need guardians to protect us from both dangers, regardless of their size.
The other thing that doctors do is give you a negative diagnosis, deliberately saying things are worse than they are. If you survive or do well, then you have done better than expected and will be happy. If you don’t, then you did as predicted and are less likely to blame them.
This, in spite of the research indicating that positive predictions improve patient health. I remember sitting there, listening as a faculty member at a medical school explained that to me, in between his classes teaching ethics.