Amid all the political rancor and media hoopla currently surrounding the American healthcare system and the clamor for reform from all sides, one question has gone unasked; what exactly is this thing we call healthcare? Is it the local hospital with its giant façade and ambulances coming and going all hours of the day and night? Is it the clinic where you sit and wait to have your blood pressure taken? Is it the pharmacy on the corner where you go to pick up your prescriptions? Is it that radiation treatment center you pass going to and from work everyday? Is it your employee services director at work, asking you to choose your insurance plan for next year? Well, the fact is healthcare is none of these things. Rather, it is a personal service provided by one human being to another, and since ancient times the provider of the service has been called “physician” and the recipient simply “patient.” Their relationship has changed somewhat over the centuries, but it has always been based on trust. Today that relationship is being threatened by a variety of controlling interests.
Recently my friend Dr. Ralph Kristeller, a retired New Jersey Internist, reminded me of the history behind the development of the modern patient-physician relationship and with his permission and encouragement I’d like to share portions of his medical history lesson. It is critical to understand this evolution and as a wise man once said “the best place to begin is at the beginning.” The problem is that the beginning of medical care took place in different places in the world at different times. However, it is reasonable and very important to say that “medicine” began when the science and the healing art were disassociated from magic, superstition, and religion.
In ancient times two separate healthcare systems developed around two different concepts, one legal and the other ethical. The first was created in Babylon and was based on a legal writing called the Code of Hammurabi. He was the ruler and able administrator of that city-state. Some 282 provisions were carved into a Dolite obelisk 3,800 years ago; truly “chiseled in stone”. In Babylon, the medical profession had advanced far enough in the public esteem to be rewarded with adequate fees that were carefully prescribed and regulated by laws, which empowered the patient and the state. For example, if the patient was a “gentleman” 10 shekels in silver was the statutory fee for treating a wound or opening an abscess of the eye with a bronze lancet. If the patient was a poor man or a servant the statutory fee was 5 shekels; for a slave the fee was 2 shekels. In addition, if the patient lost his life, or his eye, the law also regulated penalties for the physician. If the patient was a “gentleman” the physician had his hands cut off, but in the case of a “slave,” the physician only had to pay for the slave.
In ancient Greece another guiding principle led to a different healthcare system whose foundation was the social contract established by the Oath of Hippocrates. This system empowered the physician based on a standard code of ethics. Hippocrates was born 2,500 years ago on the Greek island of Kos into a clan of privileged people, the Asclepiads, descendants of Asclepius, “the Doctor-god.” He is given credit for separating the practice of medicine from Greek theory and philosophy, and he crystallized the loose knowledge of the day into a systematic science. Hippocrates preached clinical inspection and observation as the basis for medical care and alerted colleagues to be ever on the lookout for sources of error. In developing the art and science of medicine he employed a logical mind and all his senses together with a transparent honesty. Hippocrates also promoted the dignity of the physician’s calling, along with a seriousness and deep respect for his patients, making him by common consent “the Father of Medicine.” And, of course, he is given credit as the author of the Hippocratic Oath, which states in essence, do no harm, always do what is best for the patient, consider the patient before self, create no mischief and keep confidential what you see and hear. The oath adds at the end, almost as a foot note, “if you keep this oath, it will be granted to you to enjoy life and the practice of this art, respected by all men in all times.”
With the Oath of Hippocrates, medicine took a giant leap forward from the written legal code, which regulated all practices through authoritative edicts, to one that involves a “social contract” between the patient and physician directly. Most importantly, this social contract is far more empowering than the law because, with it, society entrusted the independent ethical practitioner to do what was best for each individual patient. But in recent years, our system has been drifting back toward a legalistic system. This move has been driven first by “managed care” (more accurately called managed resource care) that empowers neither the patient nor the physician, but instead empowers corporate entities offering insurance as a means of payment. Now, the system is morphing into one of managed government resources, which takes power away from the patient, the physician, and private companies and places it in the hands of the lawmakers.
The question facing the American public, both physicians and patients, is whether we choose a system that closely resembles the Code of Hammurabi or one based on the social contract of Hippocrates? It would seem that before we can answer that question we must first address the more fundamental question that is the title of this writing “What is Healthcare Anyway?” If one ascribes to the idea that healthcare is a basic human right, then it only makes sense to have it provided for and regulated by the state. But, if one believes that healthcare is the most personal of all human “services” then control must remain solely in the hands of those who are directly involved, patients and physicians. Under this view both parties must remain free to engage in an independent “social contract” to pursue their mutual goals of alleviating suffering and promoting individual well-being without interference from anyone who would inject themselves into this sacred relationship for their own economic or political gain.
Robert Sewell is a surgeon who blogs at The Spirit of Healthcare.
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