The 18th chapter of On Moral Medicine talks about the way medical professionals build their identity as practitioners and how the form relationships with other professionals and with patients. The author uses four unique terms to define his ideas on the four things these relationships can be based on: covenant, contract, code, and philanthropy. Using these concepts, he explores the current and the ideal relationships which define the medical field and experience. In the end, the author finishes by suggesting a change in the way doctor-patient relationships are conceived, but from the evidence of his own work one can see that he may not push this revolution far enough.
The idea of a covenant in this context is the idea of a deep commitment that transforms those who make it. Covenants are usually made through the exchange of gifts and responsibilities, and are defined by the inclusion of God or the divine in their formulation. Such a covenant changes those making it, so that from that moment forward they are affected not only in the area of their lives directly relating to the covenant, but also in those areas which might seem removed. For Doctors, the Hippocratic oath and the standards of the medical community tend to create covenant relationships with fellow professionals, so that gifts and confidences are exchanged. In regards to their patients, covenants are usually not made, though the author suggests they should be.
A contract, on the other hand, defines relationships not in terms of deep personal commitment and change, but it terms of rights, duties, obligations, and enlightened self-interest. In contract relationships, there is a large degree of equity, and authoritarian imagery is usually stripped away, relying on people's pure intention to appear on the page. Contract relationships between doctors and patients would result in doctors who were "hired" to do their jobs, and directly responsible for results to the patient, as opposed to having some moral authority over the patient or being employed by a hospital to which the patient has no other recourse. Contract theory is particularly important in terms of the Doctor/patient relationship, and less relevant to relationships between doctors.
The code spoke of here is the written and unwritten "rules" that govern professional behavior. The code is considered first and foremost to be that which dictates technical superiority and the ethics of medicine. However, it has evolved to also become a sort of "style" which doctors are supposed to show, instructing them in how to relate detachedly with patients, how to dress smartly and yet professionally, the importance of remaining free of emotion in the workplace, prohibiting advertising or community involvement on a personal (rather than professional) level. The code governs both doctor interactions and interactions with patients -- while it is very important, it also tends to be sterile and need to exist within other frameworks.
The final form of interaction is that of philanthropy. This particularly defines the way doctors interact with patients, and describes the generally perceived belief that doctors must maintain not only a sense of detachment but also a cool condescension. As the 1847 codes suggest blatant that doctors "should study, also, in their deportment so as to unite tenderness with firmness, and condescension with authority, so as it inspire the minds of their patients with gratitude, respect..." (129) The guiding theory of the philanthropist is that doctors are doing patients a great favor in helping them, that their work is a form of charitable benevolence. The public is obligated to honor and obey their physicians, while doctors merely have professional duties. The medical field, "does not really think itself beholden," and functions like a god that "draws its life from itself alone...wholly gratuitous." (130)
As these definitions alone suggest, the author has some problems with the current state of affairs. This chapter points out both a problem with the dominant form of doctor inter-professional relationships and with the dominant form of doctor-patient relationships. One sees that the medical field is very much functioning on a covenant basis which creates of doctors a cohesive social group that is self-protecting rather than self-regulating. Many examples can be cited on incompetent, addicted, or even dangerous doctors who have been allowed to continue practicing while their mistakes were quietly absorbed by the wider community. Price inflation, kickbacks, unnecessary surgeries, incompetence and malpractice, endless referral processes, and iatrogenic diseases have all shaken the public's faith in medicine, even as doctors close ranks and put on an outer show of normality. The laymen, this chapter suggests, is justified in asking if doctors are more loyal to their patients and public or two their peers. This close-mouthedness has several sources. It is partly the result of "a complex, interlocking network of relationships with fellow professionals; they extend favors, incur debts; exchange referral; intertwine personal histories. The bond with fellow professionals grows, while ties with patients seem transitory." Additionally, few Americans, let alone doctors, like the conflict that would be necessary to oust a poor professional peer. Self-regulation may seem outside the bounds of detached friendliness established as the medical norm. Finally, doctors may consider themselves precariously positioned in society and be afraid that the exposure of widespread corruption or incompetence could shake the public's faith in medicine.
There are equal problems in the philanthropy practiced on patients. The author suggests that doctors actually owe patients and society at large for years of public training, funding, and support, for the social privileges that allowed them to go to school and find such a job, for the many patients who let themselves be "practiced" on when the doctor was a young practitioner or a resident, and patients are even "owed" for their support of the experience practitioner who could not be a doctor if patients refused to come.
This article suggests that covenant relationships would be ideal for patient-doctor interactions, tempered by contractism to assure the safety of the individual, and by following the code in order to assure technical excellence. Philanthropy leads to patients not having choices or feeling put down and abused by the system. Contractualism may lead to the over commercialization of medicine and to doctors who only do the minimum contracted amount. Covenants should, however, make the doctor feel an intense (if detached) commitment to each patient and to their work at hand as every moment become that of "being the doctor" while work itself becomes fulfilling.
This chapter seems to have excellent insights on the nature of the sorts of relationships formed by medical professionals, and the way these relationship affect the quality of care. However, as a reader I tend to disagree with the author's conviction that covenants are the proper model for all of a doctor's relationships. The most obvious flaw in the argument for covenant-driven doctors is that provided by the author himself in describing the "guild" mentality which exists among doctors and prevents proper self-regulation and judgment in favor of protectionist actions. If covenants can drive doctors to allow innocent people to die in order to protect the incompetence or addictions of their friends, then it can hardly be considered an ideal model. Of course, the author admits this to some degree, but only suggests that this covenantism be expanded to include patients as well, rather than properly saying it should be rejected as the basis of relationships among professionals. The second problem with suggesting that covenants should be the basis of all relationships is that this model is outdated in a multicultural and egalitarian, but openly capitalist world. Covenants appear to be based blatantly on the inclusion of God or gods in the relationship between individuals. This deific presence, it appears, is supposed to create a transformation in the parties that inspires them to not only give gifts in self-interest but to continue to be motivated by selfless morality. Where a contract relationship between doctor and patient puts these two on equitable legal and social ground (where the patient is slightly disadvantaged by knowing less about medicine and the doctor by being the hired-man of the patient), in a covenant relationship the doctor maintains a sort of mysterious, religious authority. In fact, the author calls medicine a "profession of mystery" (133) which is closely related to being a priest, and that "malpractice then, is rather like the sin against the Holy Ghost, uncomfortable for those sinned against, but utterly negating the identity of the sinner." (133)
If the God(s) are sufficiently present to endow the doctor with such divine morality, this might work. However, what happens when one has an atheistic or irreligious doctor?
The covenant relationship is based on trust and faith. If a doctor had no concrete belief in a punitive god, and was not controlled either by social or legal "contractual" pressure or by the code of his fellow doctors (who were relating with him also on a covenant basis), then he could act against the good of the patient…