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

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Is physician decision-making as ethical as we think?

A patient's accusation made this doctor re-examine whether he really takes the moral high ground

From the November 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

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

No one likes to be under suspicion, particularly not an innocent man. So when one of my own patients recently leveled an accusation at me, I entered a plea of "not guilty"—with an explanation.

It all began when a patient came to the office to review biopsy results from a recent colonoscopy. Fortunately, the lesion was benign, and I advised him to get the procedure repeated in three years, in accordance with published clinical guidelines and sound medical practice. As our meeting was drawing to a close, it became obvious that he had one more question to ask. I have known many patients who withhold their true concerns until they are walking out the door ("Did I mention I was having chest pains?"), so I remained attentive.

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The patient, whom I had known well for several years, appeared uneasy, and I presumed he wanted to discuss a new symptom or an ill family member. He prefaced his inquiry by telling me that his question was not entirely his own, but resulted from a recent family discussion. In a measured voice, he asked me if my recommendation to examine him again in three years was influenced by his insurance company. He questioned whether a yearly surveillance examination wasn't more appropriate.

Now we were both uneasy. He knew that this was no ordinary question. When a car mechanic tells me I need to replace a part, I don't ask if he is trying to meet the boss's quota. I will, however, ask questions in order to understand the "diagnosis and proposed treatment." If not satisfied, I may arrange for a second opinion. My patient, however, chose not to ask me about the medical rationale of my recommendation; his question indicated a presumption that my advice was tainted.

As the discussion progressed, it became clear that he was directing his hostility and cynicism primarily toward the insurance industry. However, he was also placing my own integrity under suspicion. I was baffled that this soft-spoken man, who had been my patient for years, could think that I was so easily corruptible. If someone who knew me so well could suspect that I was acting as an insurance company lackey, then what might new patients think?


Am I a hypocrite by claiming to practice ethical medicine while I allow insurance companies to tailor my referrals and prescriptions?

I told the patient that despite external pressures, my advice remained true to my oath to "let my way be lit by truth alone." Physicians, I explained, must offer their best advice regardless of the insurance plan's constraints. For example, a patient with no insurance is entitled to the same medical advice as a corporate CEO. Although cost issues and other restrictions may limit patients' choices, they are still entitled to know their full range of options. Physicians should not serve as information filters.

I contrasted this idealized example with a doctor who consults the insurance company handbook first and then formulates a treatment plan. In this instance, I pointed out, the physician has allowed a bureaucrat to make and influence medical decisions. Unfortunately, this has become the modus operandi of many of today's beleaguered physicians.

My patient, however, had a valid point. In the current health care environment, it is not possible to establish clear and inviolable ethical boundaries. When I select a specialist for a patient, I first look at the patient's list of approved physicians instead of immediately suggesting the best available specialist. If a patient needs to be hospitalized, then I must know which hospitals are in the insurance company's network. And when a pharmacy calls me because my choice of a medicine is not on the patient's formulary, I casually prescribe another medication. Am I a hypocrite by claiming to practice ethical medicine while I allow insurance companies to tailor my referrals and prescriptions?

Though I claim a high ethical standard, I often feel as if I'm paddling upstream. How long can I hold out? What if my patient's insurance company only covered colonoscopies every five years? Would this "guide" me in the same way that the insurance company's formulary influences the medications I prescribe?

Although my patient received the colonoscopy, he showed me the light. He made me reflect on whether I am truly as ethical as I think. He helped me to realize that despite my best efforts, I am no saint.

What physician can prevail every time against the Hydra of managed care edicts, insurance company pressures and financial conflicts of interests? While we physicians struggle for ethical breathing room, we must disclose and discuss these issues with our patients, not just pretend that they don't exist.

Am I guilty? I'll let my patients judge me. Thanks to one gentle accuser, I already have an appeal scheduled in three years.

Dr. Kirsch is a practicing gastroenterologist and freelance writer in Highland Heights, Ohio.

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