Guest post by Jon Tilburt and Baruch Brody

Editor’s note: this post introduces a recent paper by the authors now in press at the Journal of Medical Ethics: “Doubly distributing special obligations: what professional practice can learn from parenting“

Gaps between our ideals and our behavior are common. Sometimes what we say we believe and what we actually practice differ because we fail to live up to what we actually believe. Doctors who are disingenuous, selfish, corrupt, or duplicitous in their actions must own their failures to live up to their said ideals. Other times we use oversimplified language to describe a said ideal because the wording feels right even when that language is not strictly speaking accurate and never has been completely true in lived reality.

According to a traditional ethic of medicine, part of what makes medicine a profession is that doctors sign up for a greater level of service and self-effacing care to some people, namely our patients.  Taking care of my patients is my particular job.  If I consider someone my patient, that means something about what I owe them in terms of time, attention, and care.  I will stay late for my patient; I don’t have special obligations to all of the patients who show up at my institution or who live in my community; I have special obligations to my patients.

But the structure of medical practice is changing.  In the US, Accountable Care Organizations (ACOs) and Medical Homes are asking healthcare organizations and their groups of providers to manage populations of patients, and pilots are underway to test the feasibility of paying for group care with so called “bundled payment” for all the care a population needs.  In times like these, one might wonder “Is the idea of special obligations obsolete?” Is it feasible or ethically correct to say that individual physicians should and do have greater obligations to specific individual patients?  Or should we abandon that arcane idea altogether and opt for a more generic public health ethic. Such an ethic might assert nobly that the whole army of a healthcare workforce is generally devoted to the health of the whole population they serve more or less equally. Maybe special obligations are obsolete for modern medicine.

We suspect that the medical professions’ singular and absolute said ideals about “special obligations” always functionally made space for the inherently plural and distributed nature of those obligations in the lived reality of practice without questioning how the said ideal was formulated. It has always been the case that physicians who are practicing, practice with multiple patients with limited time, emotional and intellectual resources.

The needs of individual patients assigned to a given doctor may and often do conflict.  Under those circumstances, physicians must prioritize. Responsibilities to “my patients” are responsibilities to “my patients“ regardless of whether a physician is a busy primary care doctor at Kaiser or a concierge dermatologist in Manhattan. Physicians’ special obligations are and probably always have been applied to groups, are thus plural, and by necessity are distributed.  Physicians talk like they are singularly devoted to the needs and care of individual patients because in one sense they are, usually by serially dealing with the patient in front of them until there is an emergency, a vacation, a bar mitzvah, a conference, a t-ball game, etc. Exceptions don’t disprove the rule, but they bring a tempered realism to what those obligations actually mean in the lived reality. That’s why we thought the lived reality of special obligations deserved more specific attention. We call this examination an account of “doubly distributed” special obligations because these duties and devotion that come with the role are distributed in two senses: across multiple caregivers and across multiple care recipients. As we explore in the paper, that double distribution is not so uncommon and plays out in other life circumstances that can be illustrative for physician special obligations.

Talking through some intuitions about the obligations of parents as we do in the paper helps illustrate how the said obligations jibe with the lived reality of a finite human being. What about other roles and goals parents have? What about multiple children? What about multiple parents? What about empowering kids to help solve their own problems? Are wants different than needs? How does the context in which you carry out your obligations influence what doing a “good job” looks like? We work through these and apply our answers about parenting back to clinical practice.

Discharging special obligations frequently happens in the context of competing care needs of equally deserving children and patients who a parent or physician would respectively claim as “my children” or “my patient.”  And we seem to have managed to juggle all of that without throwing out the idea of special obligations. We probably also fail to live up to the ideal much more than we would like to realize, but that fact doesn’t negate the possibility or appropriateness of the ideal or it being distributed yet still being truly special.

So now that population health, ACO’s and physician group responsibility appear the new norm for the indefinite future, physicians must adapt again, practically and ethically. But special obligations are still possible in such a changing healthcare environment. The trick will be making them a reality in the distributed reality of modern healthcare.

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For more, see the authors’ paper, now in press at the Journal of Medical Ethics: “Doubly distributing special obligations: what professional practice can learn from parenting“