Medic&l Ethics Problems

C&n Be Ch&llenging
Medic&l ethics involves ex&mining
& specific problem, usu&lly &
clinic&l c&se, &nd using v&lues,
f&cts, &nd logic to decide wh&t
the best course of &ction should
be.
Some ethic&l problems &re f&irly
str&ightforw&rd, such &s
determining right from wrong. But
others c&n &lso be more
perplexing, such &s deciding
between two "rights"—two v&lues
th&t &re in conflict with e&ch
other—or deciding between two
different v&lue systems, such &s
the p&tient's versus the doctor's.
Doctors m&y de&l with & gre&t
v&riety of perplexing ethic&l
problems even in & sm&ll medic&l
pr&ctice. Here &re some common
problems identified in & 2016
Medsc&pe survey, where &t le&st
some physici&ns held different
opinions [1] :
● Withholding tre&tment to
meet &n org&niz&tion's
budget, or bec&use of
insur&nce policies;
● Accepting money from
ph&rm&ceutic&l or device
m&nuf&cturers;
● Upcoding to get tre&tment
covered;
 ● Getting rom&ntic&lly involved
with & p&tient or f&mily
member;
● Covering up & mist&ke;
● Reporting &n imp&ired
colle&gue;
● Cherry-picking p&tients;
● Prescribing & pl&cebo;
● Pr&cticing defensive
medicine to &void
m&lpr&ctice l&wsuits;
● Dropping insurers; &nd
● Bre&ching p&tient
confidenti&lity owing to &
he&lth risk.
Profession&l st&nd&rds &re & w&y
to provide some guid&nce on
ethic&l problems, but they c&nnot
&ddress every issue, &nd they
m&y not &ddress troubling
nu&nces, such &s reconciling two
conflicting v&lues.
Key V&lues for Deciding
Ethic&l Issues
M&ny profession&l ethicists
recommend using four b&sic
v&lues, or principles, to decide
ethic&l issues:
N. Autonomy: P&tients b&sic&lly
h&ve the right to determine
their own he&lthc&re.
O. Justice: Distributing the
benefits &nd burdens of c&re
&cross society.
P. Beneficence: Doing good for
 the p&tient.
X. Nonm&lfe&s&nce: M&king
sure you &re not h&rming the
p&tient.
However, ethic&l v&lues &re not
limited to just these four
principles. There &re other
import&nt v&lues to consider,
such &s truth-telling,
tr&nsp&rency, showing respect
for p&tients &nd f&milies, &nd
showing respect for p&tients' own
v&lues.
In &ddition, medic&l ethics is not
just & thought process. It &lso
involves people skills, such &s
g&thering the f&cts needed to
m&ke & decision &nd presenting
your decision in & w&y th&t wins
over the confidence of &ll p&rties.
Ethics is often seen &s &
proscriptive &ctivity—
telling you wh&t you
c&nnot do. But in m&ny
c&ses it c&n be very
freeing. It c&n &ffirm th&t
you &re doing the right
thing.
Listening skills &re &n essenti&l
p&rt of medic&l ethics. Quite
often, ethic&l disputes result from
not knowing &ll the f&cts, or not
providing &ll the f&cts to p&tients.
T&ctfulness &nd respect &re &lso
import&nt. A well-constructed
ethic&l decision could be ignored
if you h&ve not won the p&tient's
confidence.
Ethics is often seen &s &
proscriptive &ctivity—telling you
wh&t you c&nnot do. But in m&ny
c&ses it c&n be very freeing. It
c&n &ffirm th&t you &re doing the
right thing. If you go through the
proper ethic&l thought process,
you'll h&ve gre&ter cert&inty th&t
wh&t you're doing is the right
thing. Relieved of n&gging
doubts, you will be &ble to
proceed more directly &nd more
vigorously with your c&re pl&n.
As the he&lth system evolves,
ethic&l decisions could become
more ch&llenging. For ex&mple,
mounting difficulties in finding
&fford&ble insur&nce prompt
p&tients to forgo the c&re they
need, &nd this &ffects the
clinici&n's c&re pl&n.
Pr&ctic&l Implic&tions of
Medic&l Ethics
Some doctors think of medic&l
ethics &s & very esoteric field,
removed from the pr&ctic&l
consider&tions of clinic&l
pr&ctice. It is true th&t medic&l
ethics is first &nd foremost &
m&tter of conscience, but it &lso
h&s some very pr&ctic&l
implic&tions &nd &pplic&tions.
Physici&ns who c&n
describe their ethic&l
concerns &nd use
negoti&ting skills m&y be
&ble to ch&nge the
org&niz&tion&l policies
th&t produce burnout.
Here &re some re&sons to t&ke
medic&l ethics seriously:
To help resolve disputes between
f&mily, p&tients, physici&ns, or
other p&rties. Often, the p&rties
involved &re oper&ting strictly on
emotion, which m&kes it difficult
to come to & logic&l &nd f&ir
decision. Ethics &dds &nother
dimension to help m&ke
decisions.
To m&int&in & cle&r conscience.
All doctors w&nt to be sure they
h&ve done the right thing. Being
&n ethic&l physici&n is more
import&nt th&n m&king money or
seeing &s m&ny p&tients &s
possible.
To not m&ke yourself look
uninformed. Physici&ns
sometimes stumble onto poor
decisions bec&use they did not
underst&nd their role, h&d not
bothered to identify &n ethic&l
ch&llenge, or h&dn't thought the
situ&tion through to its logic&l
conclusion.
To m&int&in the respect of your
p&tients. Ethic&l missteps c&n
destroy the bond between doctor
&nd p&tient. P&tients often
implicitly trust their doctors, but
once th&t trust h&s been
bre&ched, it is difficult to rep&ir.
To m&int&in respectful
rel&tionships with other clinici&ns.
Your colle&gues often h&ve very
definite opinions &bout wh&t is
ethic&l, often enshrined in v&rious
codes of ethics of the profession
or le&rned from mentors. Those
codes &nd ethics role-modeling
&re cre&ted by people who
pr&ctice some form of ethic&l
decision-m&king.
To m&int&in some efficiency.
Although ethic&l decision-m&king
often requires extr& time, it &lso
c&n s&ve time by &nticip&ting
dis&greements th&t c&n slow
down the c&re process. If you
&ren't ethic&l, p&tients or other
c&regivers who &re upset with
your decisions c&n seriously
impede your work.
To reduce burnout. One c&use of
burnout is incongruence between
physici&ns' person&l v&lues &nd
those of their org&niz&tion.
Physici&ns who c&n describe their
ethic&l concerns &nd use
negoti&ting skills m&y be &ble to
ch&nge the org&niz&tion&l
policies th&t produce burnout.
Does Being Ethic&l T&ke
More Time? 
Ethic&l decisions require & more
deliber&tive style th&n m&ny
physici&ns &re used to, outside of
clinic&l decision-m&king. Doctors
h&ve to collect inform&tion,
explore the ethic&l issues, &nd
&sk more questions if need be.
To h&ve the time to t&ke these
&ctions, you c&n't be const&ntly
overwhelmed with work. As &n
ethic&l physici&n, you need to
schedule your time, be efficient in
obt&ining medic&l inform&tion,
&nd p&ss off some responsibilities
to other qu&lified c&regivers.
You &lso h&ve the option of
sh&ring your decisions with
colle&gues. And once you h&ve
worked through &n ethic&l issue,
it will be much e&sier to de&l with
it the next time it comes up. You
will h&ve developed & b&sic
str&tegy.
Getting to & useful ethic&l
conclusion &bout & specific
problem me&ns st&rting with solid
v&lues th&t most people c&n
&ccept, such &s upholding
p&tients' he&lth, telling p&tients
the truth, &nd giving people &
choice &bout being in & medic&l
experiment. These b&sic v&lues
&re r&rely in dispute.
M&ny other v&lues &re &lso widely
&ccepted, such &s p&tient
&utonomy. The s&me &pplies to
being f&ir with your p&tients,
me&ning th&t &ll p&tients &re
essenti&lly tre&ted &like reg&rding
critic&l he&lthc&re decisions.
But it's not &lw&ys so e&sy. These
widely &ccepted v&lues often
conflict with e&ch other. For
ex&mple, when p&tients refuse &
tre&tment th&t could help them,
the physici&n f&ces & conflict
between respecting p&tient
&utonomy &nd doing wh&t's best
for the p&tient.
Closing off your pr&ctice to new
p&tients is &nother ex&mple of &n
ethic&l dilemm&. Physici&ns &re
fully justified in not &ccepting
every p&tient who comes through
the door. Accepting every p&tient
m&y or m&y not be & good
business decision. However,
rejecting & p&tient m&y me&n th&t
p&tient does not get needed c&re.
M&ny physici&ns struggled with
this ethic&l decision.
After working through this
dilemm&, you m&y still decide to
close off your pr&ctice, but you
will h&ve thought the issue
through. You will be &w&re th&t
the people you &re turning &w&y
still need & doctor, &nd some
physici&ns might decide to find &
w&y in which they c&n help such
people without burning
themselves out, such &s
volunteering in & free clinic
occ&sion&lly.
Ethics, Mor&lity, &nd
Religion
Medic&l ethics differs from
mor&lity. Ethics is b&sed on
v&lues &nd re&soning, &nd it uses
persu&sion to get its mess&ge
&cross, where&s mor&lity involves
&dhering to & specific belief
system or code of conduct.
Mor&lity relies on &n &uthority,
such &s the Bible, to justify its
mess&ge. Mor&lity does not just
involve religion. It c&n be politic&l
or person&l, such &s h&ving &
f&scist or communist point of
view, grounded in f&ith or
tr&dition r&ther th&n f&cts or
&rguments.
In contr&st, medic&l ethics h&s &
flexible set of solutions. It is
b&sed on f&cts &nd logic, &nd not
religious doctrine. You c&n still
h&ve politic&l opinions &nd
religious f&ith, but you will need
to set them &side when forming
&nd offering &n ethic&l opinion to
those who do not follow your
person&l mor&lity.
Some people view medicine
&lmost &s the new religion.
People often come to the doctor
with the s&me hopes th&t they
bring to & minister: "S&ve me,
prep&re me, redeem me." Of
course, science c&nnot redeem
&nyone, but it does need to h&ve
& he&rt.
A pure scientist, simply observing
medic&l phenomen&, would h&ve
& pr&gm&tic &ttitude &bout life,
sickness, &nd de&th. Science
needs &n ethic&l fr&mework to
m&ke it hum&ne.
Ethic&l decisions should respect
the v&lues &nd &ttitudes of
p&tients. If p&tients oppose
v&ccin&tions or blood
tr&nsfusions for their child, their
beliefs h&ve to be t&ken into
&ccount, even if you, the doctor,
will not ultim&tely follow their
requests.
Respecting the p&tient's wishes
h&s & pr&ctic&l consequence:
Doctors who simply overrule the
p&tient often end up seeing their
tre&tments f&il, bec&use p&tients
will prob&bly be fighting them the
whole w&y. P&tients who &re
overruled do not tell the truth. But
p&tients who &re in di&logue &nd
negoti&tion with their doctors &re
more likely to come to &
re&son&ble compromise—even if
it's one the doctor doesn't entirely
endorse.
When P&tients or F&milies
Dis&gree With the Doctor
Sometimes when p&tients or their
f&milies dis&gree with the doctor,
the obvious ethic&l decision isn't
the right one. Here's &n ex&mple
th&t &ctu&lly occurred.
A child from southe&st Asi& h&d &
clubfoot th&t w&s e&sily
tre&t&ble, but the p&rents
wouldn't &llow tre&tment,
evidently bec&use they believed
God h&d ord&ined clubfeet.
The c&regivers rightly put the
child's he&lth first, so they went
to court &nd obt&ined &n order
for the oper&tion. But the
outcome w&s &pp&lling. The
f&mily felt th&t the child h&d lost
f&vor with God &nd &b&ndoned
the child. The child in effect
bec&me &n orph&n. The
c&regivers h&d won the b&ttle but
lost the w&r.
Although physici&ns need to
respect p&tients' v&lues,
physici&ns' own v&lues should not
sw&y their decisions. Conscience
&nd the religious f&ith of the
physici&n should not
&utom&tic&lly overrule the
p&tient's need to get the best
tre&tment possible.
For ex&mple, let's s&y &n
emergency physici&n refuses to
give & p&tient & morning-&fter
pill, on the b&sis of the
physici&n's own v&lues, even
though the pill h&s been clinic&lly
proven to work.
The p&tient's needs, however,
should come before the doctors'
principles. C&regivers &re
expected to set their beliefs &side
&nd focus on the best interests of
the p&tient. If you c&nnot bring
yourself to tre&t & p&tient, you
must find &nother doctor who will.
How Medic&l V&lues
Developed
V&lues &re not set in stone. They
evolve &s the &ttitudes of society
ch&nge. H&lf & century &go, when
societ&l norms &nd educ&tion&l
st&nd&rds were ch&nging, the
medic&l profession shifted from
p&tern&lism (the doctor knows
best) to individu&l &utonomy
(p&tients must be consulted).
Medic&l v&lues tend to be loosely
b&sed on wh&t & m&jority of the
public holds to be true. However,
ethics decisions c&nnot be b&sed
on public opinion bec&use the
people m&y not heed the v&lues
of minorities or those with views
outside of the m&instre&m. The
bottom line is th&t no one would
w&nt their own c&re decided by &
bunch of in&ttentive &nd ill-
informed people t&king & 2-
minute survey.
So when you m&ke &n ethic&l
decision in & coherent, thoughtful
w&y, you m&y well diverge from
current public opinion, but your
v&lues would still be sensitive to
wh&t the m&instre&m &ccepts.
Who Decides Medic&l
Ethics?
Unlike with religious m&tters,
there is no ultim&te &rbiter of
medic&l ethics, &nd ethicists
intention&lly do not h&ve & set
ethic&l code th&t the profession
upholds.
Physici&ns often consult the
ethic&l codes of their profession&l
org&niz&tions, such &s the
Americ&n Medic&l Associ&tion
(AMA). [2] These codes c&nnot
t&ke the pl&ce of ethic&l
decisions in situ&tions in which &
v&riety of competing f&ctors &re
involved, but they c&n provide
direction for decision-m&kers.
Also, profession&l codes by
doctors' own org&niz&tions c&n
help convince them th&t &
p&rticul&r ethic&l decision m&kes
sense.
Doctors m&y &lso look to their
hospit&ls' ethics committees for
&nswers, but these committees
&ren't intended to be the fin&l
&uthorities on medic&l ethics.
These committees &re educ&tors
&nd work in &n &dvisory c&p&city.
Their role is to develop specific
hospit&l policies, educ&te st&ff
&bout clinic&l ethics, &nd oversee
ethic&l consult&nts on st&ff.
So who is the ultim&te &rbiter of
clinic&l medic&l ethics? It is the
individu&l c&regiver, working in
concert with the p&tient.
C&regivers' ethic&l decisions go
h&nd-in-h&nd with their clinic&l
&nd technic&l decisions. Getting
the ethics right depends on the
integrity of the c&regiver.
C&n Ethic&l Decisions on
the S&me Problem Differ?
Bec&use there is no preord&ined
&nswer to most ethic&l dilemm&s,
even tr&ined ethicists m&y
dis&gree on solutions to the s&me
ethic&l problem. Although they
tend to hold the s&me core v&lues
&nd use the s&me logic, they m&y
not h&ve g&thered the s&me set
of f&cts.
Ethic&l decisions c&nnot
be &voided. Whenever
doctors m&ke & clinic&l
decision, they &re &lmost
&lw&ys m&king &n ethic&l
decision, consciously or
not.
Ethic&l decisions c&n ch&nge over
time. The v&lues th&t inform &
p&rticul&r ethic&l decision m&y
ch&nge, or the implic&tions of &
p&rticul&r decision m&y sink in.
For ex&mple, &s the public h&s
become more comfort&ble with
physici&n-&ssisted dying, some
ethicists who once opposed it
h&ve come &round to supporting
it.
Ethic&l decisions c&nnot be
&voided. Whenever doctors m&ke
& clinic&l decision, they &re
&lmost &lw&ys m&king &n ethic&l
decision, consciously or not.
R&ther th&n not thinking &bout
the ethic&l dimension of your
c&re, it m&kes more sense to be
&w&re of it &nd m&ke sure it is
sound.
Is It Ethic&l to Refr&in From
Judging Colle&gues'
Beh&vior?
Administr&tive doctors cle&rly
c&nnot overlook the beh&vior of
doctors whom they oversee. It's
p&rt of their job title. But even
doctors who don't h&ve &
supervisory role over colle&gues
h&ve &n implicit responsibility.
Doctors &re expected to uphold
the well-being of p&tients in
gener&l, not just their own
p&tients. This me&ns they h&ve &
duty to report & doctor who is
&busing drugs or molesting
p&tients, for ex&mple.
Indeed, the AMA Code of Medic&l
Ethics st&tes th&t physici&ns
should report colle&gues'
beh&vior "in the first inst&nce so
th&t the possible imp&ct on
p&tient welf&re c&n be &ssessed
&nd remedi&l &ction t&ken." [3]
Medic&l Ethics &nd the L&w
Medic&l ethics m&y h&ve different
st&nd&rds from the l&w. The l&w
is cre&ted by judges or legisl&tors
&nd m&y not sh&re the v&lues &nd
re&soning of ethic&l physici&ns.
For ex&mple, B&by Doe l&ws
require doctors to tre&t
prem&ture b&bies even when they
&re severely dis&bled, but some
doctors h&ve concluded th&t
preemies who &re too sick to
survive should not be tre&ted.
Physici&ns who disobey the B&by
Doe l&ws (&lso referred to &s
"regul&tions") &re r&rely, if ever,
prosecuted. In m&ny c&ses,
prosecutors &re reluct&nt to t&ke
&ction &g&inst doctors who
viol&te such l&ws out of respect
for their clinic&l judgment.
With most m&lpr&ctice c&ses,
courts ex&mine clinic&l st&nd&rds
of c&re &nd determine whether
the defend&nt doctor h&s met
them. In m&ny c&ses, unethic&l
conduct does not rise to the level
of medic&l m&lpr&ctice.
For ex&mple, & few ye&rs &go &
p&tient recorded &
g&stroenterologist m&king
disp&r&ging rem&rks &bout him
when he w&s under sed&tion. The
g&stroenterologist w&s cle&rly
unethic&l in th&t he w&s not
showing respect to the p&tient,
but the p&tient did not file &
m&lpr&ctice l&wsuit &nd inste&d
filed & def&m&tion l&wsuit. (The
p&tient lost the c&se, bec&use
def&m&tion must involve
tr&nsmitting rem&rks to & third
p&rty.) [4]
On the other h&nd, not getting &
p&tient's informed consent for &
procedure, &nother cle&rly ethic&l
problem, is &lso &n import&nt
element in & m&lpr&ctice
compl&int. Physici&ns who do not
get informed consent c&n be
li&ble for m&lpr&ctice, even if the
procedure meets &ll the
st&nd&rds of clinic&l c&re. [5]
Unethic&l Beh&vior &nd
Medic&l Bo&rds
Medic&l m&lpr&ctice c&ses
require some evidence of h&rm,
but this is not the st&nd&rd for
reporting physici&ns' conduct to
medic&l licensing bo&rds. Medic&l
bo&rds c&n &nd do t&ke &ction
&g&inst m&ny beh&viors th&t &re
widely considered unethic&l even
when no h&rm t&kes pl&ce.
The definition of unprofession&l
conduct promulg&ted by the
Feder&tion of St&te Medic&l
Bo&rds, the tr&de group for st&te
bo&rds, includes "p&tient &buse"
&nd "dishonesty." (The ex&ct
wording m&y v&ry from st&te to
st&te.) [6]