Insights from Adam Smith on the Erosion of Sympathy in Medicine
June 23, 2021
According to a recent American Medical Association survey of changes in physician practice arrangements, the US medical profession has just passed a tipping point. 2020 marked the first year in which less than half of physicians caring for patients worked in private practice. This represents not only a continuation but an acceleration in two trends: 1) instead of owning their practices, more physicians are becoming employees of medical practices and hospitals, and 2) physician practice patterns and compensation are increasingly shaped by the policies and strategies of ever-larger organizations, including large regional and national health systems and publicly traded corporations.
Critics of these trends point to strong evidence that they make physicians less responsive to their patients’ needs, undermine the satisfaction of both patients and physicians, and drive-up healthcare costs. But at stake are deeper matters on which perhaps no thinker can shed more light than the Scottish moral philosopher Adam Smith (1723-1790). Smith’s most fundamental insights on this sea change in the context of medical practice derive not from his well-known economics but his incisive theory of human nature. Looking at patients, physicians, and physician employers through Smith’s eyes reveals infrequently recognized dangers that portend ill not only for medicine but for society itself, for which professions such as medicine serve as a bellwether.
Those who do not know Smith well often regard him as the author of the Wealth of Nations and a proponent of capitalism who believed that self-interest is the motive force in human affairs, and that its pursuit leads, through the operation of an invisible hand, to the enrichment of all. But Smith himself makes clear that he thinks otherwise, writing in The Theory of Moral Sentiments that:
How selfish soever man may be supposed, there are evidently some principles in his nature, which interest him in the fortunes of others, and render their happiness necessary to him though he derives nothing from it, except the pleasure of seeing it.
Human beings are, in other words, sympathetic, and not just in the sense that we take sorrow in others’ misfortunes. We are influenced by and share in the psychological states of others, happiness as well as sorrow. Seeing another’s circumstances, we naturally imagine how we would feel in a similar state.
And this sympathy goes both ways. Just as we experience another’s joy or sorrow, so others feel ours. A physician can feel sympathy for a patient’s pain or fear at the prospect of a life-threatening diagnosis, but I have also been repeatedly impressed by the capacity of patients – even those in comparatively desperate circumstances – to express sympathy for their physician. More than one patient has said to me, “Doctor, I can imagine how difficult this must be for you,” and sometimes it turns out that the patient comforts the physician as much or more than the reverse. It is only natural that physicians should see themselves in our patients, for every physician is also a human being who inevitably falls ill and dies, and that patients should see themselves in their physicians.
Smith makes clear, however, that this capacity for sympathy is limited. It is limited by the psychological distance that separates one person from another. Smith imagines a person learning of a natural catastrophe on the other side of the earth, resulting in great loss of life in China. Everyone, he says, would experience sorrow and reflect on the precariousness of life and the vanity of many of man’s labors, but after doing so he would pursue his business or pleasure, his repose or his diversion, “with the same ease and tranquility as if no such accident had happened.” By contrast, he says, the same man who would “snore with the most profound security over the ruin of a hundred million of his brethren” would not sleep a wink if he knew he were to lose his little finger the next day.
Smith’s words could be construed as an indictment of human nature on grounds of hypocrisy and perhaps even cause for cynicism and misanthropy. But this is not Smith’s intent. Instead, he is simply saying that our capacity for sympathy is limited by our knowledge, experience, and imagination. News of an earthquake in China would probably generate different degrees of concern among a person who had never traveled, a person who had visited China once, and a person who had spent years or even decades there, living with and working to enhance the life circumstances of some portion of the Chinese people. The human capacity for sympathy and benevolence is powerfully shaped by life experience and the degree to which the moral imagination has been deepened and enriched.
This portion of Smith’s account of human nature offers important insights into what might be at stake in the transition from physician as solo practitioner or partner in a small group practice to physician as employee of a much larger hospital, health system, or even publicly traded corporation. First, a physician’s capacity to sympathize with patients, both in sorrow and rejoicing, depends on the degree to which the physician feels closely situated to the patient. If the patient is literally the only person physicians see, because they are entirely focused on the patient-physician relationship, then the capacity for compassion is likely to be enhanced. When physicians think about a particular case, they are seeing only the patient for whom they are caring and to whom they are answerable.
But suppose numerous intermediaries are interposed between patient and physician, all vying for the physician’s attention. Suppose, for example, that the physician must attend to corporate policies and procedures, coding and billing rules, regulatory compliance measures, and a host of strategies and tactics designed less to serve the interests of any particular patient than to ensure that the employer remains in business, expands its market share, generates ever greater excesses of revenues over expenses, and provides attractive compensation and benefits packages to its executive team. In such circumstances, physicians are likely to be distracted, their attention to the patient diluted by concerns that do not emanate from or redound to the benefit of the patient they are caring for.
Such factors tend to make the practice of medicine more impersonal. During a patient-physician encounter, the patient is naturally focused on the problem at hand, such as back pain or a headache. The physician, on the other hand, cannot concentrate solely on the same problem, which from a medical point of view may include such essential activities as clarifying the problem, situating it within the context of the patient’s medical history, performing a physical examination, and perhaps ordering laboratory or radiology tests. Situated in large organizations and tethered by the business interests of employers, physicians must also consider a range of other concerns, such as ensuring that the encounter does not violate prescribed time limits and that it exceeds revenue generation targets.
To a lesser extent today than when I first entered medicine, physicians from time to time elect to spend what could be considered an inordinate amount of time with a patient. What appears at first to be a simple complaint sometimes turns out to be far more complex, as when a patient who complains of headache turns out to be experiencing psychological turmoil over a situation at work or home. In some cases, what the patient needs most is not a diagnostic test, a prescription, or a procedure, but someone to talk to, and physicians can provide much-needed care simply by taking the time to listen. In some cases, such as mental illness, substance use, and abuse of one kind or another, such conversations can be literally lifesaving, helping to rescue the patient from dangerous circumstances.
I know of numerous physicians who shared not only their time and compassion but even their wealth and their homes with patients. The first such instance I ever witnessed was a surgeon who, moved by the fact that a patient could not afford both to fill a prescription and pay for a taxi ride home, handed the patient a $20 bill. In another instance, an emergency room patient with advanced cancer who was about to be discharged literally had nowhere to go, so the physician and her family cared for the patient in their own home over the final weeks of her life. I am not suggesting that such gestures are everyday occurrences, but for the physicians involved, the chance to make a difference in the lives of their patients – to practice the virtue of generosity – turned out to be one of their most memorable contributions.
When I first entered medicine, it was common for physicians to designate the care of some patients “professional courtesy.” This meant that, based strictly on physicians’ discretion, they could designate that no fee would be charged to the patient or medical insurance. The most common reason for doing so, in my experience, was the patient’s inability to pay, and most of the physicians I knew provided such care on an at least occasional basis. Today this capacity has been largely lost. It is no longer up to the physician whether a fee is generated – government and institutional policies strictly regulate the physician’s discretion in such matters. To a substantial degree, we no longer trust physicians to discern when such generosity is appropriate, in part because the revenue belongs to the employer.
It has become common for relationships between patients and physicians to be disrupted by forces entirely outside their discretion. Insurance networks change, requiring patients to seek new physicians and physicians to relinquish the care of patients. Because our private health insurance system is so employer based, workers who change jobs often must seek new physicians. And as physician practices are subsumed by hospitals and health systems, their capacity to choose the patients for whom they wish to care is often constrained. As a result, patient-physician relationships tend to be more fleeting and superficial, making it more difficult for physicians to know their patients and what a particular injury or illness might mean to them.
A related problem is the burden of bureaucracy. As medical practices, hospitals, and health systems grow in size, it becomes increasingly difficult and eventually impossible for them to operate on the basis of personal relationships. The larger an organization grows, the less likely it becomes that everyone knows everyone else. As a result, practices once grounded in personal relationships and trust must shift to policies and procedures. Professional and personal discretion tends to be replaced by compliance, based on the positions of each employee in the organization chart, their job descriptions, and policy manuals. Physicians in such situations tend to be treated less as persons than as functionaries in a bureaucratic network.
Physicians who become the employees of increasingly large organizations become enmeshed in increasingly impersonal matrices, and this inevitably shapes how they see and relate to patients. Organizational policies that tend to treat patients as revenue-generation opportunities, safety risks, regulatory compliance mandates, or potential malpractice litigants make it more and more difficult for physicians to respond to patients as suffering human beings in need of care. Whatever their virtues, bureaucracies are inherently depersonalizing organizational forms, and when they loom larger and larger in the physician’s field of view, they undermine the profession’s ability to respond appropriately to the special needs of each patient.
To put it in Smith’s terms, the gap separating patient and physician is growing. As the culture of medicine shifts to an increasingly bureaucratized form with an increasingly depersonalized conception of the patient-physician relationship, physicians’ moral imaginations and capacities for sympathy are undergoing worsening erosion. Most physicians genuinely want to care well for their patients, partly because they want to see their patients flourish, and partly because their own professional self-conception is at stake. They want to be good doctors, and each day practicing medicine is more fulfilling to physicians who believe they are meeting this mark. To go to work each day knowing that circumstances are conspiring to prevent such care places a heavy burden on professional conscience.
To begin to remedy this situation, we would do well to heed another observation from Smith’s psychology, which explains how it is possible to begin shrinking the gap between patients and physicians and restore the sympathy and benevolence with which they see one another. Smith writes that, after himself, each man feels the pleasures and pains:
Of his own family, and those who usually live in the same house with him, his parents, his children, his brothers and sisters are naturally the objects of his warmest affections. . . . He is more habituated to sympathize with them: he knows better how everything is likely to affect them, and his sympathy with them is more precise and determinate than it can be with the greater part of other people. It approaches nearer, in short, to what he feels for himself.
But Smith hastens to point out that such sympathy is not confined to relatives:
The necessity of conveniency of mutual accommodation very frequently produces a friendship not unlike that which takes place among those who are born to live in the same family. Colleagues in office, partners in trade, call one another brothers, and frequently feel towards one another as if they really were so. Even the trifling circumstances of living in the same neighborhood has some effect of the same kind.
What physicians and the profession of medicine need to begin to rebuild sympathy and benevolence in the care of patients is a transition from the bureaucratic, impersonal healthcare of “Big Med” to a neighborly model of the patient-physician relationship. Physicians need to see patients not as mere healthcare consumers but as neighbors between whom, in at least some cases, genuine friendships may arise. Likewise, patients need to see physicians not as mere healthcare providers but as neighbors for whom they might feel sympathy. The patient-physician relationship is not a tool by which healthcare organizations generate revenue. To the contrary, healthcare organizations need to be seen as tools serving the patient-physician relationship.
If a tool ceases to serve the purpose for which it was created, it should be repaired or replaced. When the organizational forms and policies of large healthcare organizations begin to interfere with the capacity of physicians to care for their patients, it is time to reexamine the tool. In the current setting, patients and physicians seem to have become the tools of their tools, and the quality of their relationship is being sacrificed in pursuit of other goals extrinsic to the practice of medicine. Too often, the decision makers involved are bureaucrats – hospital and health system administrators, public and private payers, and regulators who lack recent experience caring for patients and in many cases have never done so. Smith points the way to a better medicine, and we would do well to take it.