I love medical ethics, and I am fortunate to be able to spend a substantial portion of my professional life working within this growing field. I recently demonstrated that when medical students engage in debates involving bioethics, it improves their tolerance for ambiguity. Medical school, and the years leading up to it, focus mostly on multiple-choice tests – with one correct answer. Licensing exams do the same. The young physician is given the belief that there is one correct answer for everything – only to find out that is not true in real life. Every patient brings a unique twist, and we must include so many variables in what were once considered simple decisions. Being able to work with ambiguity and pave the way to the best answer for that patient in that situation is what medicine is all about. The uncertainty challenges us to dig deeper, to engage the patient in each decision, and to be open to new possibilities. It makes every day exciting.
Medicine today is a daily ethical challenge. The many issues surrounding death, capacity, treatments that are not indicated, genetics, and the unique issues surrounding the daily new treatments and tests continue to take the front stage. I suggest that it is the daily, less flamboyant issues that we should focus on. What do we say to the patient who comes to us wanting a handicapped sticker when we do not feel they qualify? What do we say when a patient asks for a test that is not needed in our professional judgment? How do we deal with a patient demanding an antibiotic for what we know is a viral sinus issue because they always get one, and it always “makes them better”? How do we deal with the parent who asks for a note for their child who missed school last week when we never saw them or knew of the issue? Every physician reading this could add to this list of the daily dilemmas such as this that come up.
There is one simple answer to all of these – frank honesty. So simple. Yet, this rock of ethics is under fire. Every patient gets numerous texts and emails reminding them of their visit with you. A presidential visit is less heralded. I have been ill recently and have been on the other side. Before I get in my car after a visit, I am getting patient satisfaction surveys! I suggest that these are possibly eroding our ability to just tell a truth that someone does not want to hear. If we deny their request, they can give us a low rating. Yes, we need to couch the answer with an explanation and even tell them we “cannot lie,” but they still leave unsatisfied and now have a tool to lash out. If we take enough time to convince them, we are late for our next patient – another opportunity to select the lower rating on the survey! As most physicians are now employed, these negative responses have repercussions. We have to work hard every day to continue to be honest with our patients and to ourselves in the face of this new world of medicine.
The slippery slope is an ethical model in which a person or society slowly becomes more likely to pursue an action they would not have before after experiencing the outcome of the action. If we say yes to the antibiotic and get a great patient satisfaction rating, and the patient is better (as they would have been regardless), the next time we might bend a bit further … until we break. We must embrace honesty and keep our moral compass steady. There is so much that lies in the balance – even the integrity of our profession. We can get great patient satisfaction outcomes by treating each patient with respect, and that requires us to be honest with them. It is not easy at times, but none of us chose this path because it was easy.
John F. McGeehan is an internal medicine physician.