Medicine faces moral and ethical issues

Henry G. Cisneros, Mayor of San Antonio, Tex., set the ethical tone for the AAMC meeting by suggesting that three major changes will face society in the immediate future. * There will be massive changes in national

demographics. The changes will

occur in two major categories: the aged

and ethnic minorities. By 1990, there will be more U.S. citizens 65 years of age or older than there will be teenagers. The 85 and older age group win double by the year 2000, and, by 2010, baby boomers win reach the age of 65. The current suicide rate for those 65 years of age and older is already 50 percent greater than rates for the population at large. The increase in the youth of ethnic minorities is on a collision course with the increase in the aged. These increases are noted in specific locales and are mainly Asian, Black, and Hispanic in origin. For example, by the year 2000, 30 percent of California's population will be Asian, Black, and Hispanic. These populations have generally been underserved in health, education, and welfare. The economic survival of the nation depends on increased affirmative action for these groups. Increased intake into medical and other health field schools for ethnic minorities needs to be a high priority. n Economic changes are continuing to

point toward a world economic system. Our society has changed from a predominant emphasis on the manufacturing of goods to a service orientation. Unfortunately, this has resulted in a marked decrease in the hourly wage for the average worker. Presently, the top 20 percent of the working population receives 43 percent of U.S. income, while the bottom 20 percent receives only 4.7 percent. This results in a "permanent underclass" unable to bridge the widening economic chasm. A spin-off of this phenomenon is the necessity for 43 percent of women to work, creating a societal mandate for adequate child care programs. n Political solutions are increasingly decentralized. Political conservatism will continue because of the perception of the aged of their social insecurity", i.e, worries about unstable retirement income, housing, etc. Also, the need to resolve the federal budget deficit and maintain a strong military posture will result in decreased national funding for public services. Mayor Cisneros believes these issues will have to be addressed through state and local government as well as through private foundations and philanthropy. Mayor Cisneros believes that the health care industry will play a role in increasing economic development through the provision of jobs for teaching, research, and delivery of clinical services. For example, he says, San Antonio presently has 35,000 health-related jobs and is seeking to develop an integrated biomedical system that will double this number. John W. Colloton, Director and Assistant Vice President of Health Services, University of lowa Hospitals and Clinics, Iowa City, and Chairman of AAMC, used a similar emphasis in his presentation. The traditional covenant between academic medicine and society," he said, "had its origin in trust and was based on the premise that academic medicine's unique programs and commitments were substantial societal contributions and, thus, justified generous support and the privilege of self-regulation. Today, the societal trust underlying our long- standing covenant is rapidly giving way to a clarion call for accountability and shared decision making on many fronts in both the public and private sectors." Mr. Colloton said that academic medicine has made significant advances in its involvement in education, biomedical research, and patient care. In the education sector, academic medicine's enthusiasm in addressing the manpower shortages of the 1960s may have contributed to one of today's most pressing health system issues, the overabundance of physicians. Academic medicine's commitment to biomedical research has resulted in the advancement of knowledge and the betterment of mankind, he said. The patient care contributions of academic medical centers are unparalleled. Teaching hospitals provided more than $4.6 billion of "free" care to needy citizens in 1986, Mr. Colloton said, representing 40 percent of the total "free" care provided by all hospitals. Mr. Colloton stated that, in the past, society's part of the covenant has provided generous financial support for these educational, research, and patient care missions. In contrast, federal outlays for health services research in fiscal 1988 totaled only $46 million-less than one-hundredth of one percent of the estimated $525 billion expended in this country for health services during the same year. Calling for the "development of standards measuring and documenting the quality of patient care" in order to establish a more rational, efficient medical care system, Mr. Colloton stated that we must "meet society's needs, recapture the nation's waning trust in the medical system, and sustain medicine as a respected and sought-after profession." The issue of quality was further discussed by Robert H. Brook, MD, ScD, of the Department of Medicine and Public Health, UCLA Center for the Health Sciences, and the RAND Corporation. Dr. Brook stated that "advances in health services research, in general, and the science of measuring the appropriateness and outcome of care, in specific, have made it possible for studies of quality to move from the descriptive to the analytical and experimental level." Health services research has resulted in the development of better experimental designs for clinical evaluation and the advancement of health status measurement of patient function. To continue to perform such studies, academic health centers must aid in developing adequate funding and well-trained health services researchers. U.S. Surgeon General C. Everett Koop, MD, discussed the need for society to decry the type of behavior that has accounted for the spread of AIDS in the United States. He emphasized that AIDS is a disease and that we must fight it and be compassionate to the unfortunate who develop AIDS. He endorsed statements in an AAMC publication on AIDS*: Medical students, residents, and faculty have a fundamental responsibility to provide care to all patients assigned to them, regardless of diagnosis. A failure to accept this responsibility violates a basic tenet of the medical profession-to place the patient's interest and welfare first. Faculty members have a special responsibility to model the professional behavior and attitudes expected of physicians in training in their own willingness to provide competent, sensitive, and compassionate care to all patients. Each medical school and teaching hospital must accept the responsibility to help medical students, residents, and faculty address and cope with their fears and prejudices in treating HIV-infected patients. This responsibility includes providing the following: -an accurate portrayal to medical school applicants of the personal risks involved in medical practice; -up-to-date information on the modes and risk of transmission of the virus, -training in protective measures to be employed in the clinical setting, monitoring compliance with them, and defining procedures to be followed in the event of potential exposure; -appropriate facilities, equipment, and personnel to avoid unnecessary risk; -counseling to those who continue to express reluctance to participate in education and patient care programs with HIV-infected individuals. Further, each medical school and teaching hospital should articulate a clear policy emphasizing the physician's responsibility to provide care to patients without regard to the nature of their illness. Anthony S. Fauci, MD, Director of the National Institute of Allergy and Infectious Diseases and Associate Director for AIDS Research, emphasized that prescribing experimental drugs that have not undergone adequately designed clinical trials is not in the best interest of the AIDS patient. He noted that there is no "magic bullet" for AIDS. He believes there should be closer ties between the National Institutes of Health, academic medical centers, and community physicians. Rigidly designed clinical trials for new drugs are anticipated to link these three entities in cooperative testing programs in the near future. This would allow for descriptive epidemiology and treatment intervention studies on AIDS. Dr. Fauci stated there would be more than 300,000 cases of AIDS by the early 1990s. An overwhelming number of these cases will be among IV drug users in the Black and Hispanic communities. This is another reason, he said, that medical schools should endeavor to admit more Black and Hispanic students. The President of AAMC, Robert G. Petersdorf, MD, FACPE, told the audience, "We can no longer tolerate the dishonesty, cheating, fraud, and conflict that have invaded science and medicine. By choosing these professions, we have assumed a trust. We must not deviate from it." Dr. Petersdorf presented evidence that the problem of fraud in scientific investigation does not start at the faculty level and gave specific examples indicating that dishonesty had been documented by AAMC throughout the evolution of the physician. It starts during premed and medical school years with cheating on examinations, fraudulent transcripts, unauthentic letters of recommendation, and inaccurate and incomplete credentials. He stressed allegations by several hospital directors that residents often stole medical instruments during the month of June when finishing their programs. Additionally, several practicing physicians have submitted fraudulent insurance claims. Dr. Petersdorf further noted that faculty who were convicted of research fraud had received no significant punishment for their conduct. Dr. Petersdorf called for a code of conduct for the profession from training throughout the professional career. Admissions committees for medical schools need to pay more attention to the moral backgrounds of the students they admit," he said, "and look not only at medical college admissions tests, grade point averages, and interesting research projects that the student might have performed in college." William Carey, former head of the Office of Management and Budget, raised eight points addressed by President-Elect George Bush in the recent campaign as indicative of future trends in the economic issues of academic medicine. *There must be a strong federal investment in basic science research, with a doubling of the budget to $2 billion over the next rive years. *The present temporary research and development tax credit should become permanent. *The research and development budget should be detailed five years in advance, with appropriations made two years at a time. *Cooperation in research and development should be encouraged between the federal government and private business. *Programs should be developed to protect intellectual property in the world market (patents and copyrights). *The Science Advisor to the White House should be upgraded to Assistant to the President and should be an active member of the National Economic Council and the National Security Council.

The President should have a Council on Science and Technology Advisors. Government should stimulate local school boards to develop innovative programs in math and science, starting at the elementary school level and continuing through secondary school, in order to prepare students better for college and postgraduate schools.

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