Wednesday, August 20, 2008

Shakespeare and Medical Ethics

In Act V of Romeo and Juliet, Romeo, heartbroken by his (mistaken) belief that Juliet is dead, offers an apothecary 40 ducats for "a dram of poison" that will end his life. When the apothecary replies that Mantua's law forbids dispensing poison Romeo plays upon his poverty:
Art thou so bare, and full of wretchedness,
And fear’st to die? famine is in thy cheeks,
Need and oppression starveth in thine eyes,
Contempt and beggary hang upon thy back;
The world is not thy friend nor the world’s law:
The world affords no law to make thee rich;
Then be not poor, but break it, and take this.
Romeo's reasoning does the job. The apothecary replies with a familiar distinction between ethics and business:
My poverty, but not my will, consents.
Romeo reinforces the distinction, hands over the 40 ducats, and goes off with the poison:
I pay thy poverty, and not thy will.
If I'd received 40 ducats for every class or consultation in which someone said "ethics is fine - now let's get realistic about business..." I would never have to fear "contempt and beggary" again. Bottom line considerations should be part of ethical deliberation. Sometimes they deserve to be given the greatest weight in the moral reasoning process. Sometimes other values will and should prevail.

Thinking of "business" and "ethics" as separate and unconnected realms contributes to our national paralysis in dealing with health care costs. The split tempts clinicians to see the finance folks as uncaring bean counters, while those attuned to finance can see physicians as naive idealists.

This distinction got personal for me shortly after I joined the practice at the Harvard Community Health, a not-for-profit clinician managed HMO, in 1975. A young patient of mine with alcoholism had been admitted to a nearby psychiatric hospital after cutting his wrists while intoxicated. While negotiating by telephone with the attending psychiatrist for what I believed was a prudent discharge to outpatient care, I was chagrined to hear him call out to the chief of service - who had taught me as a resident 7 years earlier - "I have Sabin on the line...he used to care about patients...but now he cares about money!"

Mother Theresa and Albert Schweitzer could set the psychiatrist straight about caring about patients and caring about money. They understood that without a financial margin, they couldn't pursue their mission. They would have told us that devoted caretakers don't put "ethics" in one bucket and "business" in another.

(My friend Russell Teagarden brought Shakespeare's 400 year old insight into the pernicious impact of splitting business and ethics to my attention via an excellent article in the American Journal of Pharmaceutical Education." For those who want to delve further into how to bring care and cost together in pharmaceutical ethics, see also "An Ethical Template for Pharmacy Benefits," by Daniels, Teagarden, and Sabin.)