Code and Covenant or Philanthropy

Code and Covenant or Philanthropy and Contract?

In his chapter entitled: "Code and Covenant or Philanthropy and Contract?," William F. May considers the concepts mentioned in the title in the context of the medical profession and its accountability, or lack thereof. In this process, May highlights the fact that the medical profession tends to be largely unaccountable for its often serious efforts. This is both to the immediate detriment of the patient and the indirect disadvantage of the profession in terms of reputation and public accountability. The chapter is then devoted to seeking reasons for this tendency, as well as a remedy for the situation by means of paradigm shifts in terms of the doctor-patient relationship.

The chapter is structured well, with each concept thoroughly explicated for its relationship to the medical profession. The chapter begins with an introduction that clearly explicates the problem in terms of accountability. May appears to blame the concepts inherent in the Hippocratic Oath, and how they are viewed by the modern medical mind, for the current situation. According to May, the concepts of code and covenant and how they relate to the medical profession and patients respectively, are specifically at fault.

The author notes that the Hippocratic Oath requires three obligations from the medical professional, two of which appear in conflict with each other. These include the obligation to the patient, the obligation among doctors and their instructors, and the obligation of the doctor towards divinity. The latter is fairly irrelevant in terms of the problem addressed in the chapter. Code and covenant are related to the relationship between doctors and patients, and doctors and their instructors, respectively.

Code" refers to the code of ethics that doctors are required to follow in their relationship with their patients. This entails a rather one-sided relationship in which the doctor is required to provide patients with a particular type of care according to a set of rules. However, the problem is that the doctor also often feels obliged to act protectively towards his or her fellow medical professionals. This falls in the "covenant" category. Originally, the covenant occurs between the doctor and his or her instructors, to whom the medical professional is beholden for knowledge. This translates to the interrelationship between members of what May refers to as the medical "guild." While not inherently problematic, it does become an issue when doctors become incompetent or negligent. In such cases, doctors observing such incompetence feel themselves more obliged to protect the doctors involved than the patients who might be harmed. The reason for this is the difference in the relationship required by the covenant and that by the code of ethics. The former is stronger than the latter, with patients often disadvantaged by this.

May notes that, in order to remedy the lower importance given to the code, philanthropy has been implemented in the doctor-patient relationship. The author is however highly critical of this concept, as it indicates a condescending attitude from the medical professional. The term appears to imply that the patient has no autonomy as a human being once he or she enters the doctor's office. As such, the patient is the recipient of selfless charity, with the doctor the noble actor in the relationship. This also leaves the patient with no recourse should the doctor act in a harmful or unethical way. Furthermore, it places the doctor in a godlike position of authority over the patient, with little obliging the professional to act according to the code of ethics or indeed the code of philanthropy.

In order to remedy the situation, May suggests the concept of the doctor as contractor. A contract implies an agreement between two equal parties, which is to the advantage of each. Furthermore, a contract would also equalize the relationship between the doctor and the patient with that between the doctor and members of his or her guild. The problem that May however identifies in terms of the contract is two-fold and apparently contradictory: a contract has the inherent danger of minimilization or indeed of doing too many tests and diagnoses in order to avoid legal action from the patient. In this sense, a contract reduces the doctor-patient relationship to a mechanical set of actions, which is also not acceptable in the profession.

Nonetheless, much more than the code and philanthropy concepts, the contract elevates the patient to the level of the doctor in terms of mutual need and reciprocity. In the doctor-patient contract, the doctor and patient need each other mutually, and enter into a relationship of exchange. It also enforces accountability, by means of which the patient has legal recourse should something go wrong.

In his conclusion, May suggests that a covenantal relationship that extends not only to the guild, but also to the public, might provide the remedy for the problem of minimilization. He explicates this by means of a comparison between the concepts of the contract and the covenant. The main difference is that the contract is based upon time limitations, while the covenant focuses on building a long-term relationship between the partners involved. While not a perfect solution, doing away with the code of ethics and philanthropy to be replaced by an all-encompassing covenantal relationship, would provide a greater sense of accountability for the relationship of doctors with their patients.

As mentioned above, the author explicates each concepts at length and very clearly. His style of writing is such that it tends to draw agreement from the reader. Indeed, I find myself agreeing with almost all of his concepts. This is not only so because of his seductive style of writing, but also because of the general concept of medical ethics, and the demonstrative episode of the two drug-addicted gynecologists he introduces the chapter with. The medical profession faces many difficulties, including maintaining accountability in an environment where a shortage of doctors often dictates the opposite.

I am not however sure that the code of ethics as explicated in the Hippocratic Oath is as entirely useless as May suggests. The majority of doctors I have been involved with take their code of ethics extremely seriously. Furthermore, I have never felt any sense of condescension from these professionals. I therefore find the author's comparison of condescension with the concept of philanthropy somewhat invalid. This is not however to say that I disbelieve him, or that I believe he is just making a point to substantiate his conclusion. In reading the piece, the author communicates his belief in his concepts and words to the utmost degree, which is why it is initially so difficult to find anything to disagree with.