Doctors are not healthcare vending machines, but professionals who understand the difference between negative rights, such as the right to refuse treatment or be left alone, and positive rights, including entitlement to treatment. – David Stevens¹

Abstract

As innovative technology replaces more and more of what physicians do, the question arises whether there is any limit to the potential medical capabilities of technology at the bedside. Drug-dispensing kiosks, robotic surgery, computerized sedation devices, and other novel medical technologies bring practical advantages while also raising philosophical questions about the nature of the relationship between the patient and technology that serves as a proxy for the healthcare professional. Moreover, the shift in language from “professional” to “provider” accommodates a detrimental attitude that regards technical performance and human care to be interchangeable. This paper unpacks the meaning of professionalism from the perspective articulated by the Christian Medical & Dental Associations and examines its technical, ethical, and spiritual aspects vis-à-vis surrogate technology. A close examination of the meaning of professionalism finds that there are aspects of medical practice that are irreducibly human.

 

Introduction

“The hard part is giving up control,” said I to the anesthesiologist. Astonished, he looked up from the chart and saw that I was still awake. Moments before, he had injected carefully measured doses of midazolam and propofol into my intravenous line. That is the last thing I remember.

 

Trust

The moment I went unconscious, my life was in the hands of my anesthesiologist, who throughout the surgical procedure diligently watched my vital signs, monitored my oxygenation, and ensured that air reached my lungs and that my blood pressure and heart rate remained stable. Anesthetic agents are no candy; they can cause breathing to stop and blood pressure to drop. If anything were to go wrong, he possessed the knowledge and skill to respond, reassess a complex situation moment by moment, and implement any of numerous medications or procedures as the condition required. Ingrained in that response would be care and concern. Later, when I awoke from surgery, I knew that I had been kept safe by my physician colleague who has dedicated his career to preserving life. The year was 1998.

 

Enter Automation

If I had had the procedure done 15 years later, my anesthetic might have been delivered and monitored, not by a physician, but by a computerized sedation system. In 2013 Johnson & Johnson introduced an innovative device called Sedasys®, a computerassisted, personalized sedation system that administers intravenous propofol during select procedures, such as colonoscopies and upper endoscopies. The device monitors the patient’s physical signs that indicate the level of sedation and adjusts the rate of drug delivery automatically. Designed to shorten the time of recovery from anesthesia, reduce cost, and increase efficiency, its workings feature alarms and safety locks to prevent dosing errors.^2,3

In 2016 Johnson & Johnson pulled Sedasys from the market.⁴ One reason the device did not gain acceptance may have been the published findings that same year of a study that found a 13% increase in the risk of complications in patients who underwent colonoscopy with anesthesia services-typically with propofol- as compared to standard sedation with a benzodiazepine and narcotic.⁵ As the determining factor in the study was the choice of drug, not the delivery system, in principle the prospect of replacing the anesthesiologist with a machine remains.

Additional surrogate technologies knock at the hospital door. Increasingly, healthcare consumers are accessing healthcare resources via self-service interactive kiosks that assist with health data entry and provide health screening, including tests of vision, weight, blood pressure, and symptom checkers.^6-8 The FDA has even considered authorizing the use of prescription drug vending machines where consumers could enter a few answers to an online questionnaire, self-diagnose, and receive pharmaceuticals that currently require a medical examination and a prescription from a physician.^9,10

Future generations of these and other technologies that substitute for tasks previously performed by physicians are likely to offer even more sophisticated capabilities. Like many past technological innovations, if used wisely, they can enhance efficiency and make possible new and better ways of delivering healthcare. Unlike previous technologies, they may have the potential to substitute for physicians personally. Can physicians be replaced by technology, or is there an irreducibly human aspect of medicine that should be defined, and preserved?

 

Professionalism

Physicians and other healthcare workers are professionals. They avow that they are competent and willing to care for the sick, and they commit to healing as their way of life. Professionals are not the same as service providers.

Physician ethicist Robert D. Orr has pointed out the confusing recent usage of the word “professional” to denote anyone who does something for money.¹¹ Widespread misapplication of this word has reduced the perceived meaning of professionalism in medicine. At the same time, the term “provider” has slipped into the culture of healthcare. Although the shift to calling physicians “providers” is well-intentioned as language inclusive of midlevel caregivers such as physician assistants and nurse practitioners, linguistic demotion to “provider” is, in fact, dismissive of the professionalism of all these groups.

Word choice matters. A provider, Orr observes, develops a contractual relationship with a consumer, whereas a healthcare professional develops a covenantal relationship with a patient. A provider learns a trade, gets a job, and pursues a business to gain a market share. A healthcare professional, by contrast, undergoes many years of difficult training and sacrifice, develops a practice, and pursues a vocation for the purpose of serving others.¹¹

With that distinction in mind, one can more easily imagine technology stepping in to fulfill the role of a provider than a professional. Many of the functions of a provider can be approximated, if not replicated, by technology that stores and retrieves information, executes well-defined tasks with minimal error, and performs utilitarian services for monetary profit.

Considering the trajectory of innovation, it may be tempting to imagine that future improvements in technology will eventually bridge the gap between provider and professional. If the difference between a machine as provider and a human as professional is merely one of a difference in the degree of functional capacity, then there would seem to be no reason why a sufficiently advanced computer wired to mechanical attachments could not, in principle, satisfy the definition of a medical professional.

Furthermore, the belief that that gap had been bridged would likely erode the integrity of medicine. Attitudes toward human professionalism would be influenced even by the erroneous perception that an artificially intelligent robot with a stethoscope had nullified the practical distinction between a provider and a professional.

To explore this question explicitly, this essay will examine the meaning of professionalism as articulated by the Christian Medical & Dental Associations (CMDA).¹² A corresponding document for understanding the meaning of a provider might be the owner’s manual that comes with the purchase of any automobile, computer, internet service device, vending machine, or coffee brewer, and will not be considered in detail here.

 

The Technical Aspect

Professionalism has, first of all, a technical aspect.¹² This begins with the acquisition of a large volume of knowledge that draws from multiple complementary disciplines. The technical aspect comprises a system for organizing and integrating this information, a method for analyzing evidence and assessing its reliability, and a way of evaluating its relevance to specific clinical problems. The professional continues to add to this knowledge, learns from experience, is prepared to reevaluate and, when appropriate, reject previously held theories when confronted by conflicting yet convincing new evidence.

In addition to knowledge, professionalism consists of technical skill. Examples include the exquisite dexterity required to thread a fine catheter safely through a patient’s arterial arborizations and the precision of the surgeon’s scalpel when slicing through living tissue to excise a tumor. Technical skill also involves communication, for example, the delicate choice of wording required to probe into sensitive topics of personal health or convey bad news.

Years of rigorous study are required to gain and perfect this technical competence. Scholarly learning continues throughout the lifetime of the professional, who seeks new knowledge and improvement in the skills of application with ever-advancing proficiency. Aiming always toward excellence, professionals establish and enforce standards of practice.¹³

Each component of the technical aspect of professionalism could, in principle, be performed by sufficiently advanced technology. Already robotic surgery is gaining widespread acceptance based on a variety of outcome measures.^14,15 Advances in artificial intelligence might one day push the boundaries of some types of technical performance beyond human capability. As measured by technical competence, a robot might become at some future time an adequate medical provider, but technical competence alone does not make a medical professional.

 

The Ethical Aspect

Secondly, professionalism has an ethical aspect.¹² Professionalism involves the judicious application of technical knowledge and skill in order to heal and not to harm, in keeping with the principles of beneficence, non-maleficence, respect for persons and their autonomy, and justice. In other words, professionalism requires wisdom. Aristotle called this type of wisdom “phronesis,” meaning practical virtue, which involves an ability to discern how and why to act morally as well as excellence of character. Neither sheer information, no matter how voluminous, nor mechanicallyguided instrument movements, no matter how precise, are sufficient for phronesis, because clinical judgment and moral probity are also required. Phronesis entails vigilance in avoiding harm, whether that be preventable adverse outcomes or the use of immoral means to a desired end. Phronesis entails acting “with caution and forethought, protecting the patient’s health, safety, and confidentiality.”¹² Phronesis extends to “a stewardship responsibility to foster affordability and availability of care by applying medical or dental resources prudently.”¹²

Phronesis is also concerned with the professional’s personal character. Technology may be morally neutral, but the professional must not be. In relation to the patient, the healthcare professional possesses special expertise, and this asymmetrical power over the patient “must always be exercised for the patient’s good.”¹² The relationship of the healthcare professional to the patient is also one of moral equality. As a fellow human being, the healthcare professional is sensitive to the patient’s vulnerability and responds with empathy. Professionalism also entails the discipline of communicating “respectfully with colleagues and team members, acknowledging the contributions of all.”¹²

The CMDA position on professionalism states: “The doctor has the moral responsibility to respect the worth and dignity of all patients, who at all times are his or her equals as persons. Moral equality mandates mutual respect; there must be trust and integrity of communication combined with cooperation in giving and receiving care.”¹² Accordingly, the healthcare professional “should treat patients without favoritism or discrimination”¹² and choose treatments that “accommodate the patient’s perspective, as health is integrally related to the patient’s life goals, needs, and personal values.”¹²

This ethical aspect of professionalism departs from and surpasses what is possible through technology alone. Technology by its nature lacks the competence to weigh questions of value and purpose; this competence is held and exercised by technology’s human designers and users.¹⁶ Ethics, unlike a computer program, assigns to each possible action varying levels of priority according to moral judgments. The physician will drop whatever he or she is doing to respond immediately and assist someone who has suddenly stopped breathing. The computerized sedation system responds only in the way it has been programmed. To the computer, all electron pathways along its circuits are accorded equal weight. All available actions are morally equivalent. All programmed actions, whether injecting an ampoule of epinephrine or dispensing a cup of espresso, are accomplished with equal readiness.

The new field of affective computing challenges some of the distinctions between human communication and automatic computer programming. By decoding patterns of facial muscle activation and voice inflection, computer programmers can write code that adds to computer-generated speech a layer of intonation imitating human emotion.¹⁷ Such software impersonates but does not reflect genuine compassion. Computers can be programmed to provoke emotional responses in humans but ultimately cannot comfort. Algorithms cannot care. This is why the CMDA statement exhorts the healthcare professional in attitude not to be “limited to the reductionistic tendencies of science or economics” but to “strive for ever-increasing moral discernment and knowledge of life’s higher meanings and obligations.”¹²

 

The Christian Aspect

In addition to the two previous aspects, which apply to all healthcare professionals- but not necessarily to robots-the Christian healthcare professional recognizes a third and transcendent aspect to medicine.¹² The CMDA statement on professionalism states that the Christian healthcare professional “appreciates and encourages a deeper meaning of health and illness in the context of the special value and eternal destiny of human life.”¹² From this worldview perspective, “The Christian doctor appreciates that the patient’s dignity derives from having been created in the image of God.”¹² The significance of this truth for medicine, both historically and personally, is profound, for it means that every patient is a person of inestimable worth.

Through the Judeo-Christian tradition comes the principle that, in their actions toward all others, people of faith are responsible to a righteous, merciful, and loving God who is deeply concerned for the sick and suffering.¹⁸ The Christian healthcare professional, therefore, is motivated by the expectation of divine judgment to do what is right and to do it well. But unlike the dictates of healthcare policy or law that enforce compliance through rules and out of fear, and unlike the cold, calculating code of computer programs, God’s commands are backed by love, which infuses the Christian healthcare professional with an ethic of care that reaches farther than would be possible through one’s own strength.

Furthermore, CMDA acknowledges that the Christian healthcare professional is imperfect. Knowing that he or she is accountable to God for the care provided fellow human beings, and despite diligent effort and the best of intentions, “medical care is sometimes imperfect or inadequate. Faith in Christ provides the doctor with humility, encouragement, and the inspiration to improve and persevere.”¹²

Finally, the CMDA statement affirms that the Christian healthcare professional “knows that true wholeness consists not only of physical health and emotional wellbeing but ultimately in being in a right relationship with God through faith in Jesus Christ.”¹² The Christian who is called to a healthcare profession “is given a ministry: humble service of others in a spirit of self-sacrificial love for all, including the neediest and the lowliest.”¹²

Alongside the inspired and compassionate healthcare professional, technology made to function as a medical provider falls flat on its face. The swiftest and sleekest robots are spiritually inert. Machines cannot aspire. Erroneous automatons feel no remorse. Whereas technology might be crafted to imitate, and perhaps eventually substitute, for a provider, technology that mimics the professional can never be more than a caricature. As one physician news commentator put it simply, “Medicine needs human contact.”¹⁹

 

Conclusion

Several months later I happened to pass my anesthesiologist colleague in the hallway. Embarrassed at my impoliteness for having fallen asleep during our conversation, I apologized. Graciously, he smiled. In that moment of shared humor, we acknowledged a uniquely human experience. We knew that undergoing anesthesia was something more than a temporary cessation of cerebral information input and output. We understood that delivering anesthesia to a human patient meant something more than flipping a switch and counting numbers.

 

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References

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2. Frankel TC. New machine could one day replace anesthesiologists. The Washington Post, May 11, 2015.

3. Rockoff JD. Robots vs. anesthesiologists. The Wall Street Journal, October 9, 2013.

4. Reader T. Anesthesia use for colonoscopy attracts new scrutiny. HealthLeaders Media, April 13, 2016.

5. Wernli KJ, Brenner AT, Rutter CM, Inadomi JM. Risks associated with anesthesia services during colonoscopy. Gastroenterology 2016; 150(4): 888-894.

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8. Couret J. FDA approves SoloHealth station. BizJournals.com, June 5, 2012. Accessed at: http://www.bizjournals.com/atlanta/news/2012/06/05/fda-approves-solohealth-station.html

9. Mercola J. FDA wants prescription drug vending machines. Mercola.com, May 21, 2012. Accessed at: http://articles.mercola.com/sites/articles/archive/2012/05/21/fda-patient-kiosks.aspx#!

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11. Orr, RD. Will you be a provider or a professional? Ethics & Medicine 2013; 29(3):147-150.

12. Christian Medical & Dental Associations, Professionalism Ethics Statement, April 24, 2014. Used with permission. The primary author was the author of this paper. Archived at: https://cmda.org/resources/publication/professionalism-ethics-statement

13. Cheshire WP, Hutchins JC. Professionalism in court: The neurologist as expert witness. Neurol Clin Pract 2014; 4: 335-341.

14. Jeong W, Kumar R, Menon M. Past, present and future of urological robotic surgery. Investig Clin Urol 2016; 57: 75-83.

15. Foote JR. Valea FA. Robotic surgical training: Where are we? Gynecol Oncol 2016 Jun 2, epub ahead of print.

16. Cheshire WP. When moral arguments do not compute: prospects for an ethics checker. Ethics & Medicine 2012; 28(2): 71-76.

17. Luneski A, Konstantinidis E, Bamidis PD. Affective medicine. A review of affective computing efforts in medical informatics. Methods Inf Med 2010; 49: 207-218.

18. Cheshire WP. Twigs of terebinth: The ethical origins of the hospital in the Judeo-Christian tradition. Ethics & Medicine 2003; 19(3): 143-153. 19. Alvarex M. Will doctors be replaced with robots under Obama Care? FoxNews.com, September 30, 2013.