American College of Physicians: Internal Medicine — Doctors for Adults ®

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Is there an ethical doctor in the house?

Let's talk about everyday moral dilemmas in practice—not just dramatic headline-grabbing issues

From the October 1997 ACP Observer, copyright © 1997 by the American College of Physicians.

By Michael Kirsch, FACP

  • Previously published ethics case studies are available online.
  • For additional ethics resources, visit the College's Center for Ethics and Professionalism

When I was a medical student in the 1980s, ethics was an afterthought in our curriculum. Medical ethics and humanism were given the same serious attention as nutrition and acupuncture. By its absence, we learned that ethics was like the vestigial appendix; you could easily get along without it. While we memorized textbooks of arcane medical knowledge, much of which is irrelevant to clinical practice, we received inadequate ethical instruction, knowledge that affects the care of every patient. How often do we really rely on our gross anatomy training?

Today, however, medical ethics has captured the public's attention. Newspapers and television regularly discuss fetal tissue research, genetic engineering, organ transplant eligibility and surrogate motherhood. Jack Kevorkian, MD, has brought the uncomfortable subject of euthanasia into our living rooms. President Clinton's nominee for surgeon general, Henry Foster, MD, was questioned during Senate confirmation hearings about his medical ethical history, particularly his sterilization of mentally retarded women.

These grandiose moral controversies have overshadowed the ethical issues that doctors face in everyday practice. There is important fine print beyond the bold ethical headlines. Although these workaday ethics may not have the sensationalism of "pull-the-plug" crises, they affect the care of every patient. Consider the following experiences from my own community practice.

To work or not to work

What should we do when patients falsely claim they are too sick to work? Do we risk estranging the patient and refuse the request? By acquiescing, do we condone and actually collude in the dishonest scheme? Clearly, the right action is to deny the improper request, but we have all done otherwise on occasion.

When 'reps' call

Every day, smartly-tailored, silver-tongued salespeople welcome themselves into our offices without invitation. These peripatetic pharmaceutical representatives persuade, cajole and even occasionally beg us to prescribe their products. Although most of these "reps" are knowledgeable and professional, their role creates an ethical dilemma.

They invite us and our spouses out to fancy dinners for "educational seminars." Until recently, they gave us free vacations to Florida with "educational grants" or cold hard cash just for listening to a lecture by a hired speaker. They provide us with expensive medical books and journals and drug samples for personal use. One resourceful rep of ill repute brought me a bottle of sparkling wine on my birthday! They work hard to cultivate feelings of allegiance and obligation, the fuel that keeps the prescription motor running.

I have watched reps "rearrange" our drug sample cabinet, placing their wares in front while relocating the competition out of sight—and hopefully out of mind. Drug-labeled pens, pads, coffee mugs, calendars, letter openers and penlights are standard issue in most of our offices. As a gastroenterologist, I expect to discover any day that our toilet paper has been embossed with a drug company's logo.

Is dispensing drug samples fair to pharmacies and the public who ultimately underwrite the subsidy through higher drug prices? Should we be wary of providing our patients with medical pamphlets that have been prepared by drug companies? We physicians deny that we are influenced by the drug industry's subliminal and overt messages, but I doubt that savvy pharmaceutical conglomerates would waste millions of dollars every year on marketing strategies that don't work.

The futile care dilemma

Should we consent to or offer futile care? Although most examples of futile care focus on dramatic life-or-death scenarios that take place in intensive care units, doctors and patients face smaller but similar challenges in the office.

Many of us have the darnedest time telling symptomatic patients that no additional tests or medicines are necessary. Are we afraid that declaring a medical moratorium is admitting failure? Do we prescribe more tests and treatment to avoid the harder work of listening and counseling, the real medicine that many of these patients need? How often have we prescribed antibiotics for viral upper respiratory infections just to satisfy a patient's demand for treatment? Why do we order so many X-rays on patients with back pain? Do patients with longstanding irritable bowel syndrome really need one more barium enema?

Pressure from HMOs

Managed care has facilitated the emergence of a whole new genre of unethical activity. Doctors, under pressure from their organizations and peers, now have a financial incentive to minimize the medical care provided.

Novel compensation formulas have created new conflicts of interests for physicians. It is almost surreal to witness yesterday's physicians of plenty now suddenly reluctant to prescribe drugs, hesitant to order tests and anxious to get their patients out of the hospital. I know doctors who have reserved appointments on their office schedules exclusively for fee-for-service patients who, unlike prepaid patients, bring new money into their practices. Some of managed care's more abusive practices have attracted legal scrutiny. In Florida, several HMOs have been investigated for allegedly recruiting Medicaid patients under false pretenses to boost enrollment, and recently enacted federal regulations prevent HMOs from stifling physicians with "gag" clauses.

When patients push the limits

Patients can also upset the ethical equilibrium. They miss appointments without canceling, which can prevent the truly sick from being seen. One ill patient I did not know phoned me at night when I was on call and threatened to sue me if I did not authorize an emergency room visit. Another asked me to write his mother's prescription under a different family member's name who had better prescription drug coverage. We must establish firm ethical barriers against patients who threaten our integrity.

Before learning to read, we memorized the alphabet. Yet we have largely ignored the medical ethics of routine medical care, pondering instead the deep ethical dimensions of life and death issues. We expect to construct our ethical house starting with the roof. I believe that we would be better equipped to resolve the larger moral questions after we have confronted the ethical aspects of everyday medical practice.

Dr. Kirsch practices gastroenterology in a multispecialty group in Highland Heights, Ohio.

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