To deem itself civilized, a society must protect thepersonal integrity of its citizens. Without suchprotection, the integrity of the society itself un-

ravels as more and more effort goes into protecting indi-viduals against the chicanery of their fellow citizens. Per-haps this is why Plato called integrity “the goodness of theordinary citizen.”

If integrity is the characteristic value for the ordinarycitizen, then it’s even more important for those whose so-cial roles are defined primarily in terms of personaltrust—doctors, lawyers, ministers, and teachers. Ordi-nary citizens cannot be healed—or provided with advo-cacy, spiritual counsel, or learning—without trust inthese helping professions. (Unfortunately, history re-counts how some physicians in every age have failed inthe trustworthiness integral to medicine.) When suchprofessions lack integrity, those who need their serviceswill seek to protect themselves by assuring greater indi-vidual or public control over their relationships withthese professions.

For a variety of reasons, this is what is happening inmedicine in today’s complex societies—especially nowthat medicine’s power to alter human life is unprecedent-ed. The result is that the center of gravity for individualdecisions has shifted sharply away from the physician tothe patient. That power shift has been reinforced in law

(witness the burgeoning of malpractice lawsuits and in-surance) and public policy as well. However, one mayrightly ask: Is the good of the patient better served whenhe takes charge and directs his own care, or does the ero-sion of trust in the physician’s integrity put the patient indanger of being morally abandoned by the physician?

I contend that autonomy gives patients the moralright to reject care and protects their human dignity, butthat patient autonomy need not interfere with the in-tegrity of the physician—unless that right is expanded insuch a way that patients can demand and even direct thedetails of clinical care. But if autonomy is understood as aright to demand care, it not only violates the integrity ofthe physician, it also endangers the care of the patient.For the benefit of both patient and doctor, patient auton-omy must be understood in such a way that it can coex-ist with physician integrity.

The Nature of Integrity

Classically, personal integrity has been understood as aperson’s commitment to live a moral life. The

woman or man of integrity is honest, reliable, and with-out hypocrisy. He will admit mistakes, be remorseful, andaccept the guilt that follows wrongdoing. The person ofintegrity fulfills the obligations of his private and his pro-fessional life, which are consistent with each other. He orshe follows his conscience reliably and predictably. Thispursuit is intrinsic to the person’s identity. To violate it isto violate that person’s humanity.

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Physician IntegrityWhy It Is Inviolable

EDMUND D. PELLEGRINO

Try to become not a man of success, but try rather to become a man of value.

—Albert Einstein

Edmund D. Pellegrino, MD, MACP, is professor emeritus ofmedicine and medical ethics at the Center for Clinical Bioethicsat Georgetown University Medical Center. He also serves aschairman of the President’s Council on Bioethics.

In the patient-physician relation-ship, both parties are entitled to pro-tection of their personal integrity.However, the values, beliefs, andnorms that comprise integrity maywell be very different—and presentdifferent challenges—for doctor andpatient. The physician needs to con-tend with an increasingly pluralisticsociety that can create pressure tocompel him or her to accommodatepatients’ differing religious, cultural,or personal beliefs. Also, the specialnature of the patient-physician rela-tionship (which derives from the factthat being sick and being healed arepredicaments of special vulnerabili-ty), the growth of personal freedomof choice, the systematization of pa-tient care, and the trend toward legalresolution of moral conflicts promiseto increase the demand for personaland/or public control of the physi-cian’s clinical decisions. All these fac-tors encourage erosion of the physi-cian’s personal integrity.

On the patient side, the sick or in-jured person—in a state of distress,pain, and suffering—is compelled toseek out and depend on the physicianwho professes to know how to help.The sick person and his family areasked to make choices among thera-pies, choose when life support maybe discontinued, and decide how vig-orously the terminally ill patient shallbe treated. Throughout all this, thepatient and family must trust thephysician—or more likely a team ofphysicians, nurses, social workers,chaplains, etc.—each offering aslightly different rendition of thechoices. Often, the physician andother caregivers are of differentminds, and none may know what thebest choice is. This uncertainty leadsto lack of trust and may prompt thepatient and family to go in despera-tion from Internet site to Internetsite, and to nontraditional healers ormarginal practitioners, in search ofanswers and of someone they thinkthey can trust. Because, in the end,someone must be trusted.

The Empowerment ofAutonomy

Vulnerable patients have alwaysworried about whether their

physicians possessed the competencethey claimed and could be trusted touse it wisely and well. Until recently,however, they had little power tochallenge the authority and some-times authoritarianism of their physi-cians. Today, we live in a time of self-assertion. Autonomy, the most quot-ed principle of bioethics, empowerspatients to challenge physicians’knowledge and judgment. Patientsnow have the moral and legal rightsto be informed and to give or with-hold consent. Increasingly, patientsand surrogates understand autonomyas empowering them to demand thecare they want. Autonomy has ex-panded to the point that it conflictswith the physician’s moral or profes-sional judgments.

The effect on the physician-pa-tient relationship has been profound

and complex. On the one hand, ithas made that relationship moreopen, more adult, more transparent,and more attentive to the patient’svalues and wishes. Some of the edgehas been taken off physician arro-gance and self-assurance, and the pa-tient’s dignity as a person is better re-spected. These benefits have, howev-er, been accompanied by trends thatare dangerous to the patient and un-just to the integrity of physicians. Forone thing, many physicians feel theyare required to satisfy patient or fam-ily demands or be guilty of “paternal-ism”—the original moral sin of mod-ern bioethics.

To avoid paternalism, some physi-cians and ethicists argue that physi-cians should be morally neutral.

Without sanctioning obvious harm,they should yield to patients whochoose a less effective treatment, or atreatment of no proven use, or evenone that violates the physician’s be-liefs about what is right and good.Furthermore, some physicians believethat in the name of patient autonomythey must protect all confidenceseven when others may be harmed—for example, not reporting the inca-pacitated driver who is a public dan-ger, or not revealing HIV infection tosexual partners. Others may take it asan act of beneficence to exaggeratethe severity of disease or disability toincrease the patient’s insurance cover-age.

More subtle—but perhaps moreimportant—is the physician’s grow-ing reluctance to urge the course thathe or she believes is preferable for thispatient. Despite protestations thatthey know what is best for them-selves, patients do make wrong choic-es. For the physician to suggest other-wise is to fail to respect the trust he

has promised. Refusing to “bias” thepatient’s choice by revealing one’sown choices—and perhaps persuad-ing the patient to change his mind isnot a true violation of autonomy.Rather, not to do so violates the prin-ciples of beneficence and trust.Beneficence does not equal “paternal-ism,” which relies on deception,treating the patient as a child, or co-ercing a choice and is itself malefi-cent. To cooperate in a wrong choiceis complicity with what is wrong, andleaving the patient to decide difficultissues about which the physicianhimself may be uncertain is complic-ity in harm. Rather, what the patientneeds is a physician who protects themoral right of patients to reject anyor all treatment after the options have

19Connecting American Values with Health Reform

Is the good of the patient better served when he takes

charge and directs his own care, or does the erosion of trust

in the physician’s integrity put the patient in danger?

been frankly disclosed, and who willnot use deception or ill-placed em-phases to change the patient’s mind.

Overriding Physician Integrity

The desire for autonomy and un-hindered freedom of choice has

led to law and policy that override thephysician’s objections to certain pro-cedures, including abortion, assistedsuicide, euthanasia, some methods ofassisted reproduction, and embryonicstem cell research and therapy. Thisis not the place to argue the ethical is-sues of these practices. However, re-fusing to participate in them is essen-tial to the moral and professional in-tegrity of many physicians. Manipu-

lating law and policy to make provid-ing them mandatory by threateningloss of license or specialty certifica-tion is an assault on the very personof the objecting physician.

The trajectory of efforts to compelhealth professionals to provide carethey find objectionable is toward re-laxation or abolition of conscientiousobjection privileges. At this writing,there are organized attempts in thecourts to block a new federal regula-tion that protects health workers whorefuse to provide objectionable care.The ultimate goal seems to be toeliminate legal protections of consci-entious objection entirely.

Policy Implications

As we approach another round ofhealth care reform, the medical

profession and the public must to-gether find the balance that preservesboth patient autonomy and physicianintegrity, for the benefit of both pa-tients and physicians. Given how es-sential trust is in medical and healthcare encounters, we cannot trustphysicians who shun responsibility,and we do not want patients aban-doned in the midst of critical healthand medical care decisions. For amorally viable relationship in a dem-ocratic society, both autonomy andintegrity must be sacrosanct.

20 The Hastings Center