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Notebook Medicine

Tyranny of the majority

Ezekiel Emanuel (Neilson Barnard/Getty Images for Klick Health)

Medicine

Tyranny of the majority

A modern medical assault on conscience rights

Bloodletting. Lobotomy. Treating a smoker’s cough by switching cigarette brands. What do all of these have in common? Two things. First, each is a once-popular idea that ceased to be accepted practice long ago. And second, had Ezekiel Emanuel’s ideas been national policy, skeptical doctors might once have been required to offer such treatments.

Emanuel, a Philadelphia oncologist with an interest in bioethics, rose to fame as an architect of Obamacare. He’s still active in the political realm, most recently meeting in March with President Donald Trump to discuss paths forward if his previous healthcare legislation ends in repeal. Amid his medical practice and political projects, Emanuel has also made time to weigh in on whether the government should force doctors and nurses to participate in procedures they find morally repugnant, such as abortion. His answer, in a paper co-authored with Ronit Stahl in the April 6 issue of The New England Journal of Medicine: a definite yes.

Emanuel’s argument compares what he terms “conscientious objection in health care” to the same idea in military service, arguing that as “physicians, not conscripts,” doctors are in the same position as soldiers who have volunteered to join the army, agreeing to be part of its world.

But the analogy breaks down quickly: Soldiers face ethical questions that have been around for centuries, whereas in the medical world, the transgender movement has introduced sharply politicized changes over a very short period. (An internist or family practitioner, for example, may now face his first-ever request to give estrogen to a man.) And if doctors are soldiers, who is their commanding officer? Emanuel proposes doctors answer to the “reflective equilibrium” of the medical world—in plain English, he believes they are obligated to do whatever the consensus of the moment happens to favor.

Emanuel focuses on questions of conscience, but his insistence that doctors bow to consensus illustrates how different medicine is from army life. For an army to function, soldiers must obey the chain of command, following orders without second-guessing them. In medicine, the opposite is necessary: Doctors must combine their training with their personal experience—and yes, their beliefs—to evaluate each new idea critically.

The government of Ohio is currently suing five drug companies, alleging they fueled a surge in opioid addiction by promoting their pain medicines too aggressively. They certainly got the word out: An army of sales representatives visited doctors, bearing gifts and touting potent opioids as a treatment for almost any kind of pain. Most doctors listened, and Emanuel’s “reflective equilibrium” quickly shifted toward prescribing generous quantities of opioids. Those who questioned the consensus faced criticism: Did they want their patients to suffer? Years later, the nascent opioid crisis vindicated them—their reluctance to prescribe had spared patients from addiction.

Long before the opioid debate, physician Ignaz Semmelweis met with an even more vehement response when he questioned medical consensus. His patients fared well, but colleagues saw his views as unscientific at best—if not personally offensive. They did not reconsider until decades later, by which time Semmelweis had died in a Viennese insane asylum. His unpopular idea: that doctors ought to wash their hands between patients.

Out of memory

Handout

Michael Lemonick (Handout)

What happens when a person can’t form new memories? In The Perpetual Now, Michael Lemonick chronicles the life of Lonni Sue Johnson, a former New Yorker cover artist whose bout with encephalitis left her with severe amnesia. He delves heavily into the details of brain research and neuroanatomy, but one recurring theme has universal appeal: He restores the humanity of a woman researchers are tempted to see as a scientific curiosity, letting his book frequently describe her childlike joy at simply experiencing life. Mildly bad language mars this tribute to a woman he clearly admires, in all her beautiful imperfection. —C.H.

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  • Trumpetly Speaking
    Posted: Fri, 07/14/2017 10:45 am

    Doctors of medicine are not made virtuous by their profession.  We should stop seeing them as anything other than what they reveal themselves to be.   Using Goebbels as an example, let us be wary of those who use the bully pulpit the way this man has to further their own carreer and life destroying aims.