REVIEWED BY WILLIAM J. BAZAN
The Loyal Physician: Roycean Ethics and the Practice of Medicine
Griffin Trotter
Vanderbilt University Press, Nashville, TN, 1997, 312 pp., $29.95
This highly intellectual and challenging book asks this central question: With the healthcare community under siege and critics in ample supply, are physicians and other providers becoming as morally and spiritually bankrupt as these critics charge?
Trotter challenges healthcare providers, especially physicians, to reconnect with a higher calling based on a consistent loyalty to humanitarian ideals, not grounded in the imperatives of a confused moral relativism. As a guide through the moral minefield created by the tensions between this loyalty and a moral relativism brought on by cost-effectiveness and the demand for technical flawlessness, the author explores the philosophy of Josiah Royce and applies his thought to the practice of medicine.
Trotter intellectually challenges the reader to reflect on such issues as the fractured tradition of medicine, which can lead to ethical incompetency, and a moral idealism based on a renewed sense of loyalty to humanitarian ideals. Quoting liberally from Royce, Trotter defines loyalty as "the willing and practical and thoroughgoing devotion of a person to a cause." Royce connects loyalty to love, specifically to love of the community. The ideals that define the community are the cause to which the loyalist is faithful. A person's true loyalty is characterized and motivated by true choice, not chosen by default or because someone expects something from him or her.
Are physicians today grounded in loyalty and fidelity to the well-being of the communities in which they serve? The author discusses this question in the chapter on the physician-patient relationship, and makes two important points: (1) the community of physician and patient, conceived purely as a dyad and not part of a larger whole, engenders a morally corrupt cause incompatible with true loyalty; and (2) as a dyad, the community eventually will become unstable. The entrepreneurial practice of medicine in this dyadic relationship must be replaced with a triadic social structure. That is, the physician and patient are members of a "greater medical community" (i.e., a concerned public) and thus have primary loyalty to the larger whole.
Both physician and patient must understand that their clinical relationship is part of the larger community and its continued health. The loyal physician views economic realities, community health, and other issues through the lenses of a triadic social structure.
In the final chapter, Trotter summarizes his thesis: "The physician, by virtue of his esteemed social role, as well as his helpful presence during periods of sickness and vulnerability, has a unique opportunity to inspire loyalty in others. Often he fails. Sometimes it is the patient who must be the moral teacher . . . . But part of the task of medicine is to work at lifting the burden of moral or spiritual emptiness, which contributes as much to physical suffering and destitution as any microbe or autoimmune catastrophe" (p. 240).
Medicine, with its traditions and practitioners, must first attend to its own spiritual lethargy. This is the challenge that Trotter leaves with the reader.
Trotter deserves credit for addressing the critical question: What do physicians stand for? Where are their loyalties grounded? What is the future of medicine if nothing changes in the moral climate of medical practice? Any person serious about exploring and rethinking the future of medical practice should read this book. It is not a "how to" text, but a philosophical, ethics-oriented work that contributes immensely to the national dialogue on the future of U.S. healthcare — and where the people want it to go.
Reviewed by William J. Bazan, Vice President, Metro Milwaukee, Wisconsin Hospital Association, Milwaukee