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


When ethics collide in your practice's parking lot

From the February ACP-ASIM Observer, copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

By Michael Kirsch, FACP

A thoughtful physician I know was recently vexed by an ethical dilemma. It did not involve stem cell research, an end-of-life issue or a managed care conflict of interest. In fact, the event didn't occur in a medical setting at all. The doctor witnessed a patient's ethical lapse as she drove into her office parking lot.

She watched her patient pull into the parking lot and hit a parked car. The driver then nonchalantly backed the car out and parked elsewhere. The patient and his wife saw that their doctor had witnessed what occurred.

The three individuals then entered the office. Presumably, all three of them knew the right thing to do. Yet the driver had no intention of making proper restitution to the car's owner.

The doctor was quite distressed about this ethical violation and struggled to ascertain her responsibility. True, she was only a witness, but by remaining silent, did she become an accomplice? Should she confront the patient? Is she under any obligation to interfere when the issue is a nonmedical matter?

See no evil?

The doctor quietly debated her options and decided to remain silent. Afterwards, I questioned her about her "see-no-evil" approach. What if the damaged car had belonged to another patient or to one of the staff? What if it had been her own car? What would she have done if the owner appeared and directly asked who had hit the car?

She explained that the man and his wife were elderly immigrants on Medicaid who had been her patients for many years. They did not speak English. The physician, who speaks their native language, feared that if the relationship was severed, they would become lost in our vast, unfamiliar health care system. Would this outcome be worth forcing a just solution? The doctor exercised her right to remain silent. The car owner, I suspect, would have preferred a more vocal approach.

This seemingly simple event demonstrates ethical complexity. Many choices were available, but none of them were entirely satisfying. Did this doctor do the right thing? She is confident that she did. What would we have done in her place, knowing that it is much easier to offer a righteous response from a safe distance?

Everyday ethics

An ethical decision is often not an easy choice, but is the result of weighing competing rights and interests against each other. There will be winners and losers. Ethical decisions create casualties.

We are obligated to provide our patients with ethical advice, but is this responsibility restricted to medical matters? Undoubtedly, many of our patients have engaged in unethical conduct in their personal and professional affairs. Because we are unaware of these activities, they don't affect the doctor-patient relationship. In this case, however, the patient knew that his doctor had witnessed what occurred.

If we fail to speak out when our patients know that we should, how firm is our own ethical commitment? If one of our patients was shoplifting and knew that we had witnessed the theft, should we look aside? If we remain silent when our patients know we are aware of their misdeeds, does their respect for our integrity diminish? Does our own self-respect suffer as well?

The parking lot can be a true ethical laboratory. We physicians can be study subjects in these experiments, not just spectators. From time to time, our own cars hit other vehicles when we park. When this occurs, what do we do?

Who is the truly ethical physician among us? Is it the doctor who spreads the gospel of informed consent? Is it the physician who vociferously denounces medical fraud and abuse?

Perhaps the most ethical of us all is the quiet doctor who leaves an explanatory note on the windshield of a car he has just grazed—even though no one is watching.

Dr. Kirsch is a gastroenterologist and freelance author. He writes frequently on medical ethics and the doctor-patient relationship.


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