Tuesday, March 11, 2008

Elliot Spitzer, Health Care, and the Placebo Effect

The big topic of conversation today has been – “should Elliot Spitzer resign?”

In principle I don’t think he should, any more than I thought Bill Clinton warranted impeachment for his folly with Monica. Spitzer is certainly guilty of poor judgment. And, as someone who prosecuted a prostitution ring as Attorney General, he is guilty of profound hypocrisy. But let him or her who has never committed hypocrisy cast the first impeachment vote. There is far too much sanctimoniousness about private life and far too little accountability for true derelictions of duty in U.S. political dialogue.

So how do I account for my sense that if Spitzer were the leader of a health organization, resignation would be called for? Perhaps my reaction is simply old fashioned medical narcissism. I know that I am capable of seeing health care as even more special than it is. But I think there is more to the reaction.

In a famous New York Court of Appeals case (Meinhard v Salmon, 1928) Justice Benjamin Cardozo defined fiduciary responsibility this way:

Many forms of conduct permissible in a workaday world for those acting at arm's length, are forbidden to those bound by fiduciary ties. A trustee is held to something stricter than the morals of the market place. Not honesty alone, but the punctilio of an honor the most sensitive, is then the standard of behavior.

Health care clinicians and health organizational leaders (including those who are not clinicians) are responsible for being healers. The healer role requires a "punctilio of honor the most sensitive..." The expectation of healing is the power that underlies the placebo effect. Health organizations, like clinicians, are looked to for healing. If Spitzer headed a hospital or medical group, he would have to go.

I don't think this places health care on a pedestal. The same expectations apply to other social roles, such as judges. Airline pilots and airlines have even more life and death responsibility, but it is the pilots' skills, and not our suppositions about their characters and private lives, that is the source of our trust.

Some of those I spoke with agreed that our political culture is itself hypocritical and overly sanctimonious, but felt that Spitzer has made it impossible for himself to govern, by defining himself as a uniquely ethical crusader. His ability to lead may depend on a view of him as "healer," not just "politician."

If Spitzer stays in office his public humiliation may ultimately make him a more effective political leader. As Governor his effectiveness has been reduced by being seen as a holier-than-thou bully. Shame could help him learn to use his talents in a more collaborative, less arrogant, manner.

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