Sunday, January 23, 2011

Why Medical Ethics Should Matter to Patients

Medical ethics has properly gained a foothold in the public square. There is a national conversation about euthanasia, stem cell research, fertilization and embryo implantation techniques, end-of-life care, prenatal diagnosis of serious diseases, defining death to facilitate organ donation, cloning and financial conflicts of interest. Nearly every day, we read (or click) on a headline highlighting one of these or similar ethical controversies. These great issues hover over us.

We physicians face ethical dilemmas every day in the mundane world of our medical practices. They won’t appear in your newspapers or pop up on your smart phones, but they are real and they are important. Here is a sampling from the everyday ethical smorgasbord that your doctor faces. How would you act under the following scenarios?

  • A physician has one appointment slot remaining on his schedule. Two patients have called requesting this same day appointment. The first patient who called has no insurance and owes the practice money. The second patient has medical insurance coverage. Neither patient is seriously ill. Who should get the appointment?
  • Two hours before a doctor is to see a patient, her husband calls to relate private information that he fears the patient will not share with the physician. Should the physician disclose this conversation to the patient? What is the risk if she discovers at a later time that a confidential conversation occurred?
  • A patient has been non-compliant with medical care. He has missed appointments and does not take his medication reliably. The physician is contacted by a local emergency room after the patient arrives there for a medical evaluation. Can the doctor ethically decline to treat this patient who has repeatedly rejected the physician’s advice?
  • Many physicians dispense medication samples to their patients. Is this practice ethical in that it raises drug prices for everyone since drug companies must fund these giveaways?
  • An attorney contacts a physician to testify against a fellow doctor who is accused of committing medical malpractice. The physician and the accused doctor both work in a small community hospital. The facts suggest that a medically negligent act has occurred. Is the physician ethically obligated to testify against his colleague?
  • A cardiologist decides not to accept smokers in his practice as he views this behavior as a direct attack on his medical treatment and strategy. All smokers in his practice are notified that if they do not quit within 6 months that they will need to select another physician. The cardiologist states he will actively counsel and treat all smokers on the available options for nicotine addiction. Can this physician ethically dismiss smokers from his practice who can’t or won’t quit?
  • A patient asks a doctor to fill out a temporarily disability form for back pain present for 2 weeks prior to the office visit. During this time, the patient did not seek any medical care. Is it ethical for the doctor to sign off on this request?
While none of the examples above will make the front page of your morning newspapers, they are newsworthy. They are under the radar, but need to be exposed. While the public square is crowed with the monumental ethical controversies of the day, we need to reserve a small corner there for everyday ethics.  Ethics in the office should not be a private matter.


  1. I had a detailed response and then it got lost when I accidentally clicked a link.

    In short, ethics are plastic over the span of time, defined by the predominant belief of our society at that time. They are also different from society to society in the same time. People in the past are ridiculed for having been unethical, which isn't really fair given the ethics of the time in which they lived.

    I am struck by ethics 'experts' who claim to have a monopoly on truth, as they have no more right to it that anyone else. They may be able to define the language under which we will debate, but have no more right to the answer than any man or woman.

    As for the questions, I have my own answers, which have the value of one human.

    A) schedules are plastic, like ethics. See them both.

    B) There is no doctor patient confidentiality between the doctor and the patient's wife. That said, a wise person would find a way to get this information from the patient without revealing anything. Perhaps watch a little "Lie to Me" and find out how its done.

    C) Nope. Have to care for the patient unless there is an appropriate covering doctor or formal firing process has gone on.

    D) Not unethical. The cost of providing samples is one of a zillion costs the drug manufacturer has in producing drugs. Its it unethical to pay the chemist at Pfizer? The Janitor? Their salaries increase the cost of providing drugs to patients too

    E) It is neither ethical nor unethical. No one has an ethical requirement to testify against another, unless subpoenaed by the court. It is the plaintiff attorney's job to make the case, not the physician in the third party.

    F) I don't know. I want to say that a physician is a private contractor, and unless under other contract with a third party, can see whoever he or she likes, just like any other businessman. The question to me is motivation. Does this physician have such an ego that he can't handle the fact that maybe somebody wouldn't follow his advice? Patients are not beholden to their physician. They pay (or a third party pays) for the physician's best advice. The doctor works for the patient, not the other way around. So I guess _unethical_ then.

    G) If the physician believes that the patient was disabled, yes its fine - but he can't write down things that he cannot verify to be true. It is not ethical to fabricate a story to please the patient. Forget ethics, its fraud.

  2. Nick, outstanding response! No wonder you were the winner of my Grand Rounds!

  3. I heartily agree with Dr. Fogelson's assessment of medical/bioethicists who hold themselves out as the sole qualified voice to answer these sorts of questions, or even the "bigger" questions.

    What I find disturbing about the bioethics establishment is the way in which its mainstream seems to be lined up squarely against any meaningful notion of patient autonomy, or treating non-physicians as somehow entitled to information about and control over their own health.

    I actually just posted something to this effect yesterday, taking the lens of public-choice theory to professional medical and bioethicists. Quis custodiet ipsos custodes?

  4. People tend to view philosophy (of which ethics is a part) as strictly academic rather than practical. However, it is very practical for physicians and others to think very hard about what their personal philosophies are in order to cope with situations that develop. Once one has developed a code of ethics and thought about what situations may develop that require ethical decisions, making those decisions when it is time is a whole lot easier.

  5. Snaps to Dr. Fogelson for actually tackling these ethical questions with answers. I was left pondering some of them. Great post, Dr. Kirsch.

  6. Michael,

    Love your work. Would love to feature you on THCB. Alas, no contact info? Drop me an email or skype me if you'd like to chat. John Irvine, Executive Editor THCB. el.irvine at gmail dot com. skype - skypejib

  7. As a patient I have seen a decline in patient care. I find it hard to believe that physicians actually dispense drugs so freely, without thought. For example, not everyone's high cholestrol is caused by the same thing. While some may have it from being overweight, another might have it because of an inflammatory response from an infectious disease that doctors never treat. Doctors also compartamentalize the body. I know someone who had visual problems and a blue toe. Why can't physicians see a relationship between the two? Instead, they sent the patient to a podiatrist and eye doctor. Years ago (25 years ago to be exact) doctors treated in most cases on the basis of symptoms and cured people. There were never these extensive tests. They knew immediately whether something was intestinally caused or whether there were other factors, just from the symptoms. And they hardly ever prescribed pharmaceutical drugs. As a patient I think this is happening because there are too many doctors. The more doctors, less profit, and more compartamentalization of the body so all doctors profit. Pharmaceuticals are given too readily. All you physicians ought to be watching Dr. Oz who, because he's no longer practicing among you, can speak about actual healing. Don't get me wrong. I am not entirely against pharmaceuticals; but they should be prescribed for seriously ill patients only, like someone who has a cholesterol reading of 400 or something like that. Dr. Oz' remedies for lowering cholesterol actually work. Since watching his show I only eat at home now and I lowered my cholesterol dramatically.

  8. Excellent points re compartmentalization of medical care. Soon, we'll have medical specialists such as a retinologist, for the left eye only!