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Dr Pies is Professor in the psychiatry departments of SUNY Upstate Medical University, Syracuse, NY, and Tufts University School of Medicine, Boston. He is Editor in Chief Emeritus of Psychiatric Times (2007 to 2010).
Autonomy grew up as a street fighter, and was bloodied in some genuinely noble battles against medical paternalism. But like so many rulers . . . it has quickly forgotten its democratic roots, and grown fat and brutal in power.
Charles Foster, Ethicist at Oxford University1
“Yes, Father, I’ve been taking my medicine.”
Marie’s social worker and I had to suppress a chuckle. For a moment, Marie had been transported back 50 years to her French Catholic girlhood, and I—her psychiatrist—had momentarily become her Father Confessor. Marie suffered from some mild cognitive deficits and a history of psychotic episodes, but her moment of role confusion was not the product of mental illness—in fact, she laughed at her faux pas and quickly corrected it. And in an important sense, Marie’s misidentification of me as a member of the clergy was quite understandable. For, once upon a time, the role of physician and priest were intimately connected. I use the term “priest” in the broadest sense, without reference to a particular religion, to denote “. . . one authorized to perform the sacred rites of a religion, especially as a mediatory agent between humans and God.”2
In this essay, I contrast the physician’s priestly role with that of the modern-day, medical “provider.” I then develop a third way of seeing the physician that preserves the gravity, dignity, and authority of the medical profession while recognizing that the patient’s autonomy is an increasingly important medical-ethical value.
The physician as priest
According to the Encyclopedia Judaica, medicine and religion were closely connected for Jews in ancient times. Priests were “the custodians of public health,” and Jews in biblical times regarded the physician as “the instrument through whom God could effect the cure.” Accordingly, “Jewish physicians . . . considered their vocation as spiritually endowed and not merely an ordinary profession.” Moreover, Jewish history is replete with a “. . . long line of rabbi-physicians that started during the Talmudic period [ca. 2nd to 6th century BCE] and continued until comparatively recently.”3
Hippocrates—the “Father of Medicine”—also practiced in a context that fused medical and priestly roles. Indeed, Hippocrates “. . . learned through a network of physicians belonging to an established guild…in a master-apprentice relationship among a cadre of priest-physicians known as the Asclepiads. The cult of Asclepius, the hero-god of medicine and healing, would eventually gain widespread acceptance in Greek and Roman culture, with devotion to this deity lasting well into the fourth century.”4
The intertwined medical and spiritual functions of the physician are also found in the writings of the early Christian Church. Thus, St. Basil (ca. 329-379 CE), in a letter to the physician Eustathius, describes the “ambidexterous” role of the physician: “. . . your profession is the supply vein of health. But in your case, especially, the science is ambidextrous, and you set yourself higher standards of humanity, not limiting the benefit of your profession to bodily, but also contriving the correction of spiritual ills.”5
Although the priestly functions of the physician have largely disappeared in modern times—with some justification, as discussed below—the religious and spiritual needs of patients have received increasing attention in the recent literature. As one review concluded,
For many patients confronted with chronic diseases, spirituality/religiosity is an important resource for coping. Patients often report unmet spiritual and existential needs, and spiritual support is also associated with better quality of life. Caring for spiritual, existential and psychosocial needs is not only relevant to patients at the end of their life but also to those suffering from long-term chronic illnesses.6
1. Foster C. Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law. Oxford, UK: Hart Publishing; 2009.
2. Merriam Webster Dictionary. https://www.merriam-webster.com/dictionary/priest. Accessed March 14, 2019.
3. Jewish Virtual Library. Encyclopedia Judaica: Medicine. https://www.jewishvirtuallibrary.org/medicine. Accessed March 14, 2019.
4. Love J. The Concept of Medicine in the Early Church. Linacre Q. 2008:75;225-238. https://www.tandfonline.com/doi/pdf/10.1179/002436308803889503. Accessed March 14, 2019.
5. Basil. Letter 189. In: Letters (trans. Sr. Agnes Clare Way, C.D.P.) New York: Fathers of the Church, Inc.; 1955, 25.] https://www.tandfonline.com/doi/pdf/10.1179/002436308803889503. Accessed March 14, 2019.
6. Büssing A, Koenig HG. Spiritual Needs of Patients with Chronic Diseases. Religions. 2010:1;18-27. https://www.mdpi.com/2077-1444/1/1/18. Accessed March 14, 2019.
7. Goroll AH. Eliminating the Term Primary Care "Provider": Consequences of Language for the Future of Primary Care. JAMA. 2016;315:1833-1834. https://jamanetwork.com/journals/jama/article-abstract/2506307. Accessed March 14, 2019.
8. Goroll AH. Primary Care "Provider" and Professional Identity-Reply. JAMA. 2016;316:1412. https://jamanetwork.com/journals/jama/article-abstract/2565284. Accessed March 14, 2019.
9. Dhand S, Carbone WJ. Physicians are not providers: An open letter to the AMA and medical boards. Kevin MD. November 30, 2015. https://www.kevinmd.com/blog/2015/11/physicians-are-not-providers-an-open-letter-to-the-ama-and-medical-boards.html. Accessed March 14, 2019.
10. Saenger P. Jewish Pediatricians in Nazi Germany: Victims of Persecution. IMAJ. 2006;8:301–305.
11. Who We Are. Consumers International. https://www.consumersinternational.org/who-we-are/consumer-rights. Accessed March 14, 2019.
12. Pies RW. Physician-Assisted Suicide and the Rise of the Consumer Movement. Psychiatric Times. 2016;23(8):40-43. https://www.psychiatrictimes.com/couch-crisis/physician-assisted-suicide-and-rise-consumer-movement. Accessed March 14, 2019.
13. Zimmer S. Comment. Medscape. June 2, 2015. http://www.medscape.com/viewarticle/844541#vp_4. Accessed March 14, 2019.
14. MacKenzie CR. What would a good doctor do? Reflections on the ethics of medicine. HSS J. 2009;5:196-199. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2744764. Accessed March 14, 2019.
15. Komrad MS. A defence of medical paternalism: maximising patients' autonomy. J Med Ethics. 1983;9:38-44. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1060849. Accessed March 14, 2019.
16. Pies RW, Geppert CMA. Deferring to the Mastery of Death: Hippocrates, Judge Gorsuch, and the Autonomy Fallacy. Psychiatric Times. April 3, 2017 https://www.psychiatrictimes.com/couch-crisis/deferring-mastery-death-hippocrates-judge-gorsuch-and-autonomy-fallacy. Accessed March 14, 2019.
17. Yang T, Curlin FA. Why physicians should oppose assisted suicide. JAMA. 2016;315:247-248. https://jamanetwork.com/journals/jama/article-abstract/2482333. Accessed March 14, 2019.
18. Kass LR. Neither for Love nor Money: Why Doctors Must Not Kill. Public Int. 1989;94:25. http://philosophyfaculty.ucsd.edu/faculty/rarneson/Courses/KASSwhydoctorsmust.pdf. Accessed March 14, 2019.