Medical ethics in the office should not be a private matter

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.

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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  • Patricia Lindholm

    This article raises very pertinent questions that arise daily in office practice.  Recently our clinic integrated with a hospital and I attended an ethics committee meeting in which the issue of clinic ethics was raised and suggested as a topic for study.  I am going to share this list as a starter for the conversation.  

  • Patrick Hisel

    I think everyone has a different perspective, so there cannot be one-size-fits-all answers to ethical questions like these.  The ethical decisions are in a significant respect private, or at least personal.

    Here is how I would answer these questions.  My answers are ethical to me but surely not to everyone:

    1.  Both patients get an appointment.  Payment is expected prior to visit, including past balance.  If the patient will not take care of their bill and the issue is not emergent, the visit is rescheduled.
    2.  Disclose the conversation to the patient unless it hinders delivery of care to the patient.  The obligation is to serve the patient’s best interest, not the spouse’s.
    3.  No.  The doctor must accept the patient.  Abandonment issues arise unless there has been a formal termination of the doctor patient relationship.
    4.  The practice is not unethical.  The physician is a player in the game playing by the rules of the game.  Maybe the game is unethical?  The physician can elect to minimize involvement with reps and use of samples as a personal ethical choice.
    5.  No.  There is no obligation to testify against a colleague.  If the facts are clear, the plaintiff’s attorney will be able to find an expert and shouldn’t depend on a local colleague.  
    6.  Yes.  The cardiologist has a private practice and can accept or not accept whoever he wants.  Likewise, patients can choose to see him or someone else.  
    7.  It is ethical to fill out the forms honestly.

  • Anonymous

    In principle, medical ethics are independent of context.  They serve as an ethical compass for the partnership between physician and patient to navigate through the maze of diagnosis, disease state, treatment and recovery.  A physician who uses his medical knowledge and skills should not be considered ethical if he decides to interact with the patient depending on his insurance coverage.  This would be a violation of the ethical principle of justice that calls for practicing medicine independently from the economic status of the patient.  Furthermore, the real danger in unethical physician behavior is in assigning a monetary value to medical care.  The principle of confidentiality between a physician and his patient is considered sacred.  Incorporating information given to the physician by others might assist the physician to navigate around his questions to the patient without betraying the patient’s trust in him.  In other words, the trust built and maintained in the interaction of physician and patient is sufficient to eradicate any kind of information that is fed to the physician by others.

    It would be unethical for a doctor to decline medical evaluation to a patient who demonstrated with his pat behavior his lack of compliance with medical advice.  It is the job of a physician to unravel why the patient disregards the physician’s advice.  After all, health is a social good.

    It is unclear what the motives are of a physician who freely gives pharmaceutical products as samples to the patient.  The obvious ethical concern is whether the patient is receiving compromised care.

    Finally, the first and most essential ethical obligation of a physician is to his patient and not to the brotherhood of physicians.  Tolerance of medical malpractice by physicians is unethical because it contradicts the ethical principle of, first do no harm to the patient.

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