Question

Why is there moral tension in the concept of the physician scientist?

Answer 1

The place of the physician in Western society has changed remarkably over the last century. The physician has been transformed from a respected and trusted healer of the sick to just another “healthcare provider,” viewed with some suspicion by the government, the insurance industry, hospital administration, and patients alike. The twentieth century was replete with shocking moral and ethical failures perpetrated by physicians, leading to loss of patient trust and markedly increased oversight and control of the patient-physician relationship by governments, for-profit entities, self-appointed watchdogs, and the like. Implicit in most of these failures is a deep-seated confusion between the role of the physician as healer and the more modern role of the physician as scientist.

One useful tool we can use to appraise the differences between the scientist and the healer is to consider the ends or goals that each has in view. The physician, in the Hippocratic tradition of Western medicine, is a healer of the sick. The physician uses a body of knowledge, acquired during a long period of apprenticeship and study, to benefit individual patients under his care. The goal of the Hippocratic physician is the health and welfare of the physician’s individual patient. As is clear from the Hippocratic code, and from later ethical statements such as those of John Gregory in the 1770s, the welfare of the patient should take precedence over all other considerations.

In contradistinction to the ancient role of the physician as healer, the physician-scientist serves the ends of science. In Aristotle’s view, science is a path to immutable, infallible knowledge—to Truth. Though the means employed have differed, this older perception of science changed little through the centuries, extending down to Ernst Mach in the 19 century and the logical positivists in the 20 century—until recently. Now, most scientists, and nearly all philosophers of science, have abandoned the Aristotelian goal of science. The less grandiose view, which I will take for the purposes of this essay, is that science has two basic ends: to explain, and to make accurate predictions.

Physicians need to consider more carefully their changed relationship with their patients when they are conducting clinical research. While Miller et al. have discussed the moral conflict that arises between the investigator as clinician and the investigator as scientist, they fail to note that physicians have already begun to think and act outside of the Hippocratic ideal as soon as they begin to consider themselves as investigators. If we have the privilege of teaching medical students or residents, we must strive to teach the importance of the healing paradigm, and must train young physicians to understand clearly when one is operating outside of that paradigm. A good physician-scientist may be able to serve two masters—but cannot serve them both at the same time.

It was not until the Declaration of Helsinki in 1964 that the differences between medical research, which may or may not benefit a patient, and patient care were formally recognized by research institutions, long after the damage to patient trust and the physician’s profession had been done. Worse, simple observation suggests that most physicians still do not appreciate the fundamental difference between our two roles, but blur them together under the “doing good” rubric. For example, most patients entering a clinical trial, despite a rigorous, mandated process of informed consent, retain markedly exaggerated notions that the research being conducted will be of direct benefit to them. In large part, this reflects the great psychological difficulty both physicians and patients have in extracting themselves from the customary therapeutic or healing model of their relationship.