The Danger to Our Democracy in Moving Nurses and Doctors From The Front Line.

Posted on | June 21, 2023 | 2 Comments

Mike Magee

The 4.2 million registered nurses and 1 million doctors in America who are agents of democracy are being sidelined, with a noticeable negative impact on the health of our representative democracy. As such, we must be careful how we select, train, and utilize this resource, and take care to expand rather than diminish their personal human contact with our citizens.

The three most prominent missteps are:

Corporate Dislocation – To assure maximum reimbursement, doctors and nurses are routinely asked to prioritize time and contact with data over time and access to patients.
Health technology and AI Substitution – Rather than engineering solutions to expand real-time patient contact, most innovations are further distancing patients from healthcare professionals.
Legislative Intrusion – Complex medical decisions, long entrusted to the patient-health professional relationship to negotiate, are being transferred to ultra-conservative legislators.

We live under a constitutional and representative democracy, as do two-thirds of our fellow citizens in over 100 nations around the world. The health of these democracies varies widely. Winston Churchill famously wrote, “Democracy is the worst form of government, except all those other forms that have been tried from time to time.”

The case for democracy emphasizes its capacity to enhance dignity and self-worth, promote well-being, advance equal opportunity, protect equal rights, advance economic productivity, promote peace and order, resolve conflicts peacefully, hold rulers accountable, and achieve legitimacy through community based action.

The argument against democracy is that it is inherently inefficient and corrupt, makes unwise decisions, handicaps excellence and ingenuity, overplays equality, over-encourages dissent and division, and erodes authority.

One of the challenges of democracy is to find the right balance in pursuing “the common good” which has dual (and often competing) arms. One arm is communitarian well-being and the other, individual well-being.

Nations tilt one way or the other. America clearly leans toward individualism, while a country like Japan favors the communitarian version of democracy. Blending personal and public interests is complex. In health, one might argue, this tension led to our dual system – one, largely profit driven, interventional and science discovery based, and the other largely public, preventive and focused on communitarian public health.

Both nursing and medicine have embraced professionalism, and launched new graduates by voicing “oaths” or promises to themselves, their colleagues, and our society as a whole. These lists of promises or pledges, their language and priority ordering, helps reveal both the history and intent of these noble professions.

Of course, the most famous oath in Medicine is the Hippocratic Oath reaching back some 2000 years to Greece. In pledging to a grouping of ancient deities, it recognized that interventions should “do no harm,” and that confidentiality was paramount. By 1964, this oath was sufficiently out of date that many medical schools embraced an updated version written by Louis Lasagna, MD, an historical luminary in the creation of the Medical-Industrial Complex.

Not surprisingly, top line status in that Oath reads: “I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.”

The “art of medicine” and the avoidance of human arrogance earn line 3 and line 4 mentions:

(3) “I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.”

(4) “I will not be ashamed to say ‘I know not,’ nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.”

The final pledge in the Lasagna oath suggests a role in communitarian democracy: “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”

Over the past half century, the Oath has continued to be refined, and in some cases rewritten. For example the Penn State 2022 Oath gives top billing for the first time to the patient, with the oath to them, not to the gods: “By all that I hold highest, I promise my patients competence, integrity, candor, personal commitment to their best interest, compassion, and absolute discretion, and confidentiality within the law.”

Arguably the most balanced, comprehensive, and modern Oath for Medicine however dates back to 1948, and has undergone six revisions since then. It is the work of the Geneva based World Medical Association. Its list of pledges in their Declaration of Geneva in order of appearance include:

the service of humanity
patents first
patient autonomy and dignity
respect for human life
absence of bias or prejudice on any basis
commitment to patient privacy
guided by professional conscience and dignity
honor the noble traditions of the profession
respect and gratitude to teachers, colleagues and students
share knowledge to advance health care
commit to personal health and well-being
never violate human rights.

Nursing has also relied on professional Oaths. The first was the Nightingale Pledge, created in 1893 by the Farrand Training School for Nurses and named after Florence Nightingale. It is believed to be based on the Hippocratic Oath, and was modernized in 1935. In the 1950’s, the American Nurses Association (ANA), created a formal Code of Ethics, which largely supplanted it, and in 2015 added 9 pledges to its four pillared Code which celebrated Autonomy (patient self-determination), Beneficence (kindness and charity), Justice,(fairness) and Nonmaleficence (do no harm).

Nursing’s 9 Provisions (or Pledges) commit to: compassion and respect, patient-focus, advocacy, active decision making, self-health, ethical environment, scholarly pursuit, collaborative teamwork, professional integrity and social justice.

John J. Patrick PhD, in his book Understanding Democracy, lists the ideals of democracy to include “civility, honesty, charity, compassion, courage, loyalty, patriotism, and self restraint.”

It is largely self-evident that the more than five million health professionals, engaged and embedded in communities across this land, possess stated values that closely align with those of a healthy democracy,

These health professionals should be encouraged to live up to the values they pledged in their Oaths. After all, these jobs are tough on body and soul. But this is the job they signed up for.

At the same time, we as a nation should guard against the destruction of our Democracy from within. One of the surest ways to do that is to, by profit-driven design or political malfeasance, remove our nation’s nurses and doctors from the front line.

Comments

2 Responses to “The Danger to Our Democracy in Moving Nurses and Doctors From The Front Line.”

Dan Ostergaard
June 23rd, 2023 @ 6:31 pm

Thanks, Mike, for these last two excellent posts on professionals, professionalism, and our necessity and responsibility to stay on the front lines to promote and exemplify democracy!
Your thorough review of our ethical principles and oaths, and those of nursing, were a call to action to restore them into our daily pursuits in this system as it devolves into commercialism, greed and corporate medicine.
We need to save the soul of medicine!

Would that politicians and justices would live up to their oaths!
Dan Ostergaard
PS Enjoyed Art’s post yesterday!
Mike Magee
June 24th, 2023 @ 11:08 am

Thanks, Dan. As you know so well, being a hands-on caregiver (whether as a health professional, family, or friend) is extraordinarily demanding on both body and soul, but also undeniably appreciated by the recipient and valued by all. What concerns me the most is that the role of this caring as a collective positive stabilizer of democracy is so under-appreciated and misunderstood. We need to correct that! Best, Mike