Prescribed Ethics

Dr. Wael Haddara

Altruism is heralded as a central principle of the profession of medicine, but are societal pressures and systemic inequalities changing the construct of this idea? Dr. Wael Haddara says changing language in the Canadian Medical Association’s Code of Ethics seems to suggest so.

By Ciara Parsons, BA’15

Any physician will tell you that the road to becoming a medical professional is not easy. With medical schools receiving thousands of applications each year, candidates are carefully examined and reviewed when deciding who to accept into the profession. Achieving a high grade point average is simply not enough to make it into medical school – applicants must demonstrate that they also possess the personality and altruistic traits necessary to be a physician.

Altruism is accorded as a central status in the profession of medicine and revolves around the idea that physicians must be inherently selfless for the betterment of their patients and the practice of medicine as a whole.

The Code of Ethics, prescribed by the Canadian Medical Association (CMA), includes a set of altruistic principles for physicians to adhere to, but in recent years has seen a reduction in the volume of these selfless ideals as a result of numerous revisions and updates.

Intrigued by these revisions and the idea that altruism is on the decline within medicine, Dr. Wael Haddara, associate professor Medicine, took aim at this subject in his recently published journal article, ‘Exploring the Premise of Lost Altruism: Content Analysis of Two Codes of Ethics’.

Using a content analysis approach, Dr. Haddara, and co-investigator Lorelei Lingard, PhD, analyzed the Canadian and Australian Medical Associations’ Code of Ethics to examine the pattern of appearance and disappearance of altruistic statements over time.

Dr. Haddara divided the content of the Codes of Ethics into themed categories, such as ‘professional identity,’ ‘personal behaviour,’ ‘financial probity’ and ‘non-altruistic statements,’ with the aim of gaining a better understanding of the historical construction of altruism and what lies at the intersection of medicine and society.

Evaluating the CMA’s Code of Ethics, a greater amount of altruistic content can be found in its earliest versions which stem back to 1868.

Taking into account the effect that systemic societal changes and historical events have had on medicine, Dr. Haddara notes that some of the more ‘heroic’ altruistic content, such as ‘treating patients in times of epidemic regardless of risk to own life,’ disappeared from the Code of Ethics shortly after major events such as the Great Depression and the introduction of Medicare in Canada.

Notably, however, Dr. Haddara says that the 1970 version of the Code of Ethics presents a radical shift from the historical content and introduced non-altruistic ideals.

In the earliest versions of the Code of Ethics physicians were asked to ‘respond to the call of the sick at all times,’ but by 1970, it was amended to say, ‘except in an emergency, [a physician has] the right to refuse to accept a patient’ and includes that they ‘may withdraw from [their] responsibility for the care of any patient provided that [they give] the patient adequate notice of [their] intention.’

With the emergence of universal health care and an influx of new patients to treat, these non-altruistic ideals and emergence of self-driven language presented in the 1970 Code of Ethics appear to be tied to the notion of setting realistic expectations for physicians to adhere to in their professional conduct.

This inclusion of more self-driven language continues into the 2004 Code of Ethics, another major revision, where physicians are directed to ‘protect and enhance [their] own health and wellbeing by identifying those stress factors in [their] professional and personal lives’ and should adjust their practise accordingly.

“We found that many of the altruistic statements were removed very early on from the Code of Ethics. We’re speculating that the changes to the Code of Ethics have nothing to do with medicine, but in fact, have everything to do with societal changes,” said Dr. Haddara. “When you look at the historical framework of the Codes of Ethics that have been very different content-wise, so for example the 1938 and 1970 Codes, they both came in the aftermath of things like the Great Depression, Medicare, the Civil Rights Movement, the Vietnam War, Communism, and so on.”

Dr. Haddara wonders if these progressive changes, along with the new set of pressure and structural inequalities today’s medical students and physicians face has contributed to the idea that altruism is dwindling in medicine.

Income inequality is a factor he says is particularly exploited by the tuition bills medical students are burdened with. Though wealth distribution is not necessarily a new societal issue, the gap between the social classes has been growing in the last few decades. This begs the question, with expanding costs to medical training, is medical school fundamentally inaccessible for those who lack privilege and opportunity?

Gender, race and ethnicity are also added hurdles some must overcome in their journey to medicine. Closing these gaps and making medical education more accessible is, however, not such an ‘open and closed’ solution.

Though Dr. Haddara doesn’t have a definitive answer as to how altruism can be reinvigorated into the field of medicine, he believes that preparing medical students, who will eventually be physicians, to deal with both the pressures faced in and outside of the hospital doors are necessary.

“I have a belief that medical education cannot exist in isolation from societal values,” Dr. Haddara said. “If we want medical students and physicians who are going to perform well in society, because that is eventually where they will be performing, then it’s not just a matter of how well they do in medical school with medical school pressures or routine pressures – it’s about how well they do with societal pressures.”