Medical Ethics in the AMA and AAPS

Author: 
Franklin E. Payne, MD
Article Type: 
Feature Article
Issue: 
Spring 1997
Volume Number: 
2
Issue Number: 
2

The American Medical Association (AMA) has become a chameleon in its medical ethics. Examples abound. Long after the cancer- and other disease-causing effects of cigarettes were known, the AMA continued to accept money from tobacco, even promoting particular brands.(1) Not until 1981 did the AMA finally sell investments in tobacco stocks under heavy pressure from the news media and anti-tobacco groups of young physicians. Now, the AMA has reversed itself and joined the vigorous and freedom-quenching, anti-smoking campaign that has been in vogue for a decade or more. Hypocrisy.

While the AMA prides itself on its former black president, Dr. Lonnie Bristow, the AMA track record on racial discrimination is anything but progressive. In 1895, "a group of black physicians founded the National Medical Association in part because they were not allowed to join the AMA. It wasn't until 1968 that the AMA adopted bylaws banning racial discrimination."(2) The first black delegate did not enter the House of Delegates until 1949, "and there have been few since."(3)

When the infamous Tuskegee experiments were begun in the1930s and "sterilization was proposed as a way to prevent those who were 'unfit' from reproducing," the AMA as an organization was silent. Physicians in Nazi Germany "admired" the United States and the AMA for these positions.(4) Where was the "progressive" leadership of the AMA then? More hypocrisy.

One of Dr. Bristow's agendas is "to push for legislation to end 'managed profiteering' by corporation-run health maintenance organizations (HMOs)." Dr. James S. Todd, retiring Executive Vice President of the AMA, referred to the health-care marketplace as "nasty, amoral, and siphoning off huge amounts of money to pay investors."(5)

However, the AMA itself contributed to the present (perceived) need for corporate-run health-care. While "bitterness and anger" described the AMA's battle against health-care legislation from 1957-1965, the AMA was enticed to accept Medicare when President Lynden Johnson "opened the government checkbook" as "a conduit for cash to doctors and hospitals," along with promises of "no government interference" and allowing the AMA to "help write" Medicare's rules.(6)

The severe inflation of medical costs can be attributed largely to Medicare and subsequent government policies.(7) Eventually, these inflated costs drove the marketplace to find solutions in the alphabet soup of HMOs, PPOs, etc. Thus, the AMA was a considerable contributor to the very problem that it now decries. More hypocrisy.

A Journey Further Back in Time

In its Transactions of 1859, the AMA included this condemnation of abortion:

That while physicians have long been united in condemning the act of abortion, at every period of gestation, except as necessary for preserving the life of the mother or child, it has become the duty of this association, in view of the prevalence and increasing frequency of the crime, publicly to enter an earnest and solemn protest against such warrantable destruction of human life.(8)

In 1871, the AMA Committee on Criminal Abortion essentially reaffirmed this position, "and did not concern itself with the matter (abortion) again until the 1960s."(9)

At that time, the AMA's position began to promote abortion rather than to condemn it. Initially, its Committee on Human Reproduction allowed for abortion for the mother's physical or "mental health,"(10) in spite of the fact that the mother's "mental health" was just an excuse to allow her to abort for convenience.(11)

While the AMA vigorously defends itself as "neutral" on the abortion issue, it has repeatedly filed "friend of the court briefs" to the Supreme Court to defend the rights of physicians to perform abortions.(12) "Neutrality," however, that does little or nothing to decrease the availability and prevalence of abortion is effectively pro-abortion. More and terrible hypocrisy.

From time to time, a reader of publications of the AMA (e.g., The Journal of the American Medical Association and American Medical News) finds writers appealing to the Hippocratic Oath for support of their position. One wonders just how they can make an appeal to an oath which has had one of its major tenets ---abortion --- dropped at the whim of medical and social mores.

We could continue with other hypocrisies and ethical failure of the AMA: measures against AIDS, organ transplants from anencephalic babies, gun control, legislation against alternative medical practices, and others.(13) The AMA is in bed with big government, is protective of large physician incomes, and takes ethical positions that promote those agendas. Great hypocrisy!

By What Standard?

In condemning the AMA, however, we need to be careful that we do not create our own hypocrisy. While the condemnation of hypocrisy is possible by simply contrasting the AMA's statements with its actions, the greater issue is by what standard can one policy or action be decried as immoral?

We need standards that do not shift with social trends or the advancement of our own personal agendas. Such standards can only come from traditional, time-honored and -proven absolutes and universals. The late, great philosopher-theologian, Francis Schaeffer, clarifies the issue.(14) There are only three possible alternatives to such standards.

The first is hedonism --- namely, that every individual does exactly what he wants to do. Hedonism can function as long as you have one man. But as soon as you have more than one person in society, chaos immediately follows. Imagine two hedonists meeting each other over a swift stream on a single log....

The second possibility, if you do not have an absolute, is the dictatorship of 51%, with no controls and nothing with which to challenge the majority. This is sociological law --- the law of averages, the law of majority opinion. In the United States, Oliver Wendell Holmes and the Yale University were the first to act upon such open sociological law.... But one must see where this leads: It means that if Hitler was able to get a 51% vote of the Germans, he had a right to kill the Jews.

The third possibility is an elite or a dictator, that is, some form of totalitarianism wherein a minority, the elite, or one man tells the society what to do....

We see all these approaches at work today. The elite of Hillary Clinton et al attempted the takeover of the entire health care industry of the United States. Hedonism has led to the value of a life free of inconvenient children, just abort them. A ruling elite, the Supreme Court, made social mores the law of the land. While not a 51% vote, a plurality (of the people who voted in one of the lowest election turn-outs this century) of 43 percent (1992) and 49 percent (1996) did elect Bill Clinton president, a man who is a thorough-going hedonist who exercises dictatorial powers whenever he can escape the courts of statutory law and public opinion.

Returning to Self and the AAPS

It's easy to criticize! It's easy to cast stones. It's easy to talk about the moral high ground.

The choice of a standard, its defense, and its implementation are extremely difficult. In the role of David with a slingshot, AAPS challenged and won against the powerful Executive Branch of the U.S. Government. AAPS is a longstanding defender of freedom in medicine, constitutional freedom of private contracts between physician and patient. But, should we be about more than economic freedom?

In the 1996 elections, there is much talk about being an "economic" conservative, but not a "moral conservative." But, there is the challenge that one cannot be an economic conservative without being a moral conservative. For example, abortion is not only an ethical issue (above), but an economic issue. Large industries are necessary for child care, education, recreation, home building, etc., as well as the entrepreneurial creativity and productivity of those children when they become adults. These industries comprise a considerable portion of the any country's Gross Domestic Product.(15)

At the 1995 annual meeting of AAPS, abortion was a sore spot, and an agenda item concerning it was tabled. The question must be asked, "Is AAPS to be about economic freedom only, or is it to be about the whole of ethics?"

To our credit, the AAPS starts the Preamble to our Principles of Medical Ethics with, "Being aware that a physician's religious and moral principles are the source of his ethical behavior..." And, Section 3 follows:

The physician should not condone the taking of human life in the practice of his profession, but at all times respect the sanctity of human life and seek to preserve or improve the quality of life.

This section was intended to be "pro-life," but from the discussion in 1995, one wonders whether it is sufficiently explicit. It seems that many who are "pro-choice" find themselves comfortable with the above statement. Do we really and practically have higher moral ground that the AMA?

Surely, a professional organization may choose to limit its ethical scope. Such limitations are reasonable. However, does AAPS come under similar criticisms that we have for the AMA? Can we not stand on the Hippocratic Oath complete and unchanged? Can we not stand upon the Code of Geneva? Can we not stand with some absolute, unchanging standard? Can we avoid the winds of social change and ambiguity of ethical positions?

Uh, oh! The Religious Connection

By Schaeffer's criteria, we may choose the standards of men (hedonism, the 51% majority or plurality, or an elite). Either one or any combination of the three are politically correct today. What is not politically correct are the Ten Commandments or other religious tenets.

Laws are necessarily based upon ethics and ethics upon some belief about morality --- what people should and should not do. This belief is inherently religious. Atheists, agnostics, secular humanists, and proponents of natural law have their beliefs about right and wrong, and thus are religious as well. Ethical debate is therefore necessarily religious debate. Whose beliefs will be the standard for all? Indeed, whose beliefs will become law and enforced by the power of government?

Our Founding Fathers knew this truth. American freedom was established with the Declaration of Independence, "All men are created equal and endowed by their Creator...." American freedom is religious in its foundation!

What we must discern is who that Creator is and what standards He has set for us. If there is no Creator, there are no absolutes and any arguments for "unalienable rights" like freedom of contract are moot and only an exercise in frustration.

AAPS stands for valuable freedoms, and we may choose to limit ourselves to economic freedom alone. However, we should understand that religious beliefs are fundamental to ethical debate, something the overwhelming majority in our society and politics do not understand. This link is true whether one holds to atheism, natural law, or belief in a supernatural being.

Ethics is most importantly about what is right, but it is also about production of goods and services. What is right always produces the greatest benefits for everyone. This cause-effect explains why we are now discovering the severe side of unintended consequences of the "common good," such as an environmental cleanup that directly saves one life and costs 14 lives in heart attacks and suicides due to loss of jobs from that money that is not available in the economy.(16)

Finally, there is a more somber side that even religious people do not often mention --- God's curse. The cry of the French Revolution was "liberty, equality, fraternity" without God. The guillotine became their symbol. The wages of man's genius without God is death. The wages of today's society without God is death: abortion by the millions, infanticide, euthanasia, physician-assisted suicide, etc.

When Moses was about to enter the promised land, he was given a choice: blessings of obedience or curses for disobedience.(17) The choice has never been any other.

Perhaps, AAPS needs a more clearly defined religious connection. Otherwise, we may cause unintended consequences in spite of noble ideals. Ayn Rand writes of a rugged individualism that is appealing, but is actually godless and self-centered. When we cite another authority on one or two specific issues that correspond to our own, we may inadvertently bring principles that do not correspond to those of AAPS in that writer's total philosophy of life.

Ultimately, the debate is about truth --- which religion is true and therefore can be trusted to produce right means and ends. My hope is that AAPS will take the high road of religious debate and dialogue to arrive at those principles bought with the lives of our Founding Fathers, as it continues to attack Goliath with its well-aimed missiles.

At least, we ought to understand that the ultimate issue is religious. On the one hand, there is secular humanism vs. traditional religions. On the other, there is the debate among these religions concerning which one of them is true. The AMA is no paragon of virtue to say what is right to anyone. May AAPS not make that same mistake and grow not only in numbers, but in this enlightenment as well.

References/Notes

1. Wolinsky H, Brune T. The Serpent on the Staff: The Unhealthy Politics of the American Medical Association, New York, G.P. Putnam's Sons, 1994, pp. 147-173. I have made considerable use of this book for documentation about the AMA. However, I disagree with many of the obviously liberal (collectivist) ethical positions of the authors. Thus, I use their "facts" frequently towards a different end than they intended.
2. Chicago Tribune, June 21, 1995, Section 1, p. 4.
3. Wolinsky and Brune, op. cit., p. 310.
4. Panush RS. Upon finding a Nazi anatomy atlas: the lessons of Nazi medicine. The Pharos 1996;59(4):18-22.
5.O'Connell M. Dr. Todd looks back at landmarks, land mines, and "greatness of the AMA." AMNews 1996;39(26):7-9.
6. Wolinsky and Brune, op. cit., pp. 47-51.
7. Ibid., pp. 66-67.
8. Transactions of the American Medical Association, XII:75-78, 1859.
9. Wolinsky and Brune, op. cit., pp. 178-179.
10. Ibid., p. 181.
11. Robitscher J. The Powers of Psychiatry, Boston, Houghton Mifflin Co., 1980, pp. 303-308.
12. Wolinsky and Brune, op. cit., p. 190.
13. Ibid., various pages.
14. Schaeffer FA. The Church at the End of the 20th Century, Downers Grove, IL., Inter-Varsity Press, 1972, pp. 33-34.
15. Roberge LF. The Cost of Abortion: An Analysis of the Social, Economic, and Demographic Effects of Abortion on the United States, Lagrange, GA., Four Winds, 1995.
16. Howard PK. The Death of Common Sense: How Law Is Suffocating America, New York, Random House, 1994, pp. 47-48.
17. Deuteronomy 28:1-69.

Dr. Payne is an Associate Professor of Family Medicine at the Medical College of Georgia. His address is Department of Family Medicine, Medical College of Georgia, Augusta, GA 30912-3500.

Originally published in the Medical Sentinel 1997;2(2):61-63. Copyright ©1997 Association of American Physicians and Surgeons.

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