Today's generation of doctors are "the most challenged by moral choices in perhaps a century"—and physicians must break their silence or "assist the harm" that silence perpetuates because "there is no third choice," former CMS Administrator Don Berwick writes in JAMA.
According to Berwick, "Those choices come in three tiers: personal, organizational, and societal." He adds, "Some moral choices arrive with drama, but most do not. Most come unannounced, silent in arrival—on little cat feet—and are gone almost before we notice."
Personal moral choices
Berwick recalls a time he faced and "failed" a test of his character. During his interview for residency at Peter Bent Brigham Hospital, which is now Brigham and Women's Hospital, Berwick explains he was asked a question that he could not have independently answered, but that he had learned the night prior from his own resident—who had previously gone through that interview process and had been asked the same question.
Instead of relaying the "coincidence," Berwick decided to pass the answer off as his own.
"This is the moral choice in its simplest, purest, most elemental form. To tell the truth, or not, when 'not' is perhaps in your short-term self-interest," Berwick writes. Ultimately, he decided to drop Brigham from his match list, but even that decision, in Berwick's opinion, "has never, not to this day, felt like absolution."
Organizational moral choices
Physicians also are faced with "proper organizational citizenship," or "the choice between being a hero and being a citizen," Berwick writes. He explains that because "physicians have the power to look and act like we know what to do, even when we do not," it can be tempting to go into "hero mode" and assert "prerogatives denied to others: 'my schedule,' 'my OR time,' 'my air time,' 'my excellence.'"
But the world of health care isn't about being a hero, it's "an exercise in interdependency," Berwick writes, and "physicians simply cannot do the right job alone." Rather than focusing on being a hero, Berwick writes that physicians should be asking themselves, "What am I part of? ... Who depends on me? And how am I doing in their eyes?"
Societal moral choices
Berwick explains that in this day and age, the ethics of health care institutions "cannot be taken for granted, not when the interests to be served are those of society as a whole."
As an example, he cites rising prescription drug prices, writing, "the drugs patients depend on are experiencing price increases that cannot withstand the scrutiny of public interest or moral compass." Berwick also notes that hospitals are taking advantage of "an opaque and fragmented payment system and … the concentration of market share to near-monopoly levels" to "elevate costs and prices nearly at will" and take "resources from other badly needed enterprises."
Further, citing broader issues such as mass incarceration and climate change, Berwick writes, "The work of a physician as healer cannot stop at the door of an office, the threshold of an operating room, or the front gate of a hospital. The rescue of a society and the restoration of a political ethos that remembers to heal have become the physician's jobs, too."
He concludes, "To try to avoid the political fray through silence is impossible, because silence is now political. Either engage, or assist the harm. There is no third choice" (Berwick, JAMA, 12/5; Zimmerman, Becker's Clinical Leadership & Infection Control, 12/8).
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