Who Am I Supposed to Fear and Hate Today?

As physicians, we think a lot about our fiduciary duty to our patients. We may not focus on it consciously, and we usually don't use the term "fiduciary" when we do; but it is always at the heart of how and why we go about the business of taking care of patients. To be a fiduciary, in its simplest form, is simply to work solely for the good of another person, while setting aside one's own needs, and other external influences. In medicine, we often see and practice our role as fiduciaries in their component parts such as being truthful and encouraging patient autonomy in obtaining informed consent for procedures, or weighing the good against the potential harm a therapy or medicine might cause a patient. Do we divide our time fairly between patients when the day's schedule gets overbooked? Was the insurance company's denial of a procedure just, and are we willing to take the time to appeal it? Do we treat the patients we like fundamentally differently from the patients we find problematic? It is an ongoing and imperfect process that calls for us to constantly be re-examining our decisions and considering how we would handle the same situation "next time".

So, where do these principles of medical ethics come from? Very smart people have devoted whole careers to answering this question. But, the short and truthful answer is simply: They come from us. We recognize the basic tenants of medical ethics as familiar concepts which seem immediately "good" and "right" to us. We learned them as children from our parents, in our earliest religious training, and on the playgrounds and sporting fields of our youth. They are who we aspire to be in our better selves.

If that is true, then how are these principles manifested in our own lives? What is our fiduciary responsibility to each other? I read the news each morning and I find scant trace of it. In the pervasive surround sound audio of the media, our collective voices have become a shrill cacophony of self-interest, anger and blame; of one group condemning another. Politicians, liberals, the rich, Chinese, Christians, gays, Palestinians, straights, Republicans, Jews, terrorists, Hindus, feminists, Arabs, environmentalists, Israelis, the poor, Russians, conservatives, whites, Muslims, business leaders, blacks, Mexicans, Wall Street, Democrats, evangelicals, anarchists, Mormons, police,....the lists seems never ending. And I am left wondering, "Who am I supposed to fear and hate today?"

In medicine, we make ethical decisions by first doing our very best to determine the facts of the case, and then by applying those fiduciary principles to find and to do good for the patient. As you might imagine, neither step is always clear or easy, and we are often far from perfect in our efforts. But it is a process we believe in, and that we try in ways both great and small to practice every day for the benefit of our patients. When I take off my white coat, put my stethoscope away and head home at the end of the day, shouldn't I apply the same principals to my neighbor? Wouldn't it be good and wise if we took the same steps with each other? To paraphrase the Bible "Am I my brother's fiduciary?"

What do you think?