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The insurance reimbursement situation, pay for performance, and expensive technology have made it harder than ever to choose the most appropriate ethical course.
There are exceptions-Josef Mengele, for one-but on the whole, medicine isn't a profession that attracts the amoral. Most people who become physicians do so because they want to help relieve suffering. And while many physicians "do well while doing good"-that is, earn a nice income while helping sick people get better-that doesn't negate the fact that doctors generally put in long hours, work in a high-stress environment, and strive to provide excellent patient care in an ethical manner.
The last of these, some say, has gotten increasingly complex over time, what with scientific advances that have raised new end-of-life, reproductive, and alternative therapy issues. "For instance, in the past we couldn't keep people alive by artificial means," says Houston psychiatrist Priscilla Ray, chair of the AMA's Council on Ethical and Judicial Affairs. "That's no longer true, so we need to decide when to use life-support equipment, and for how long."
Further complicating the ethics picture, physicians face fresh economic challenges, including mounting numbers of patients with no insurance or limited coverage, declining reimbursements, and pay for performance. "Family physicians rarely do a wallet biopsy before seeing a patient," says Larry S. Fields, an FP in Ashland, KY, and president of the American Academy of Family Physicians. "But if you're not getting paid, it's a lose-lose situation for you and the patient."
This article, the first of a series on medical ethics, concludes with vignettes on common ethical dilemmas, and asks you to indicate-via fax or on our website-what you would do in those situations. Follow-up articles will feature tallies of your choices, your comments, remarks from bioethicists, and sketches of additional "what would you do" ethical quandaries.
The bioethical challenges of today's physicians
"The hallmark of an ethical dilemma is a tension between competing principles and competing needs," says internist G. Caleb Alexander, who teaches at the MacLean Center for Clinical Medical Ethics at The University of Chicago, and has done considerable research on bioethics. According to Alexander, the chief ethical issues that physicians are faced with today are:
The temptation to "game the system" on behalf of patients. Nowadays, because many people are uninsured or underinsured, physicians often are asked to deceive third-party payers so that patients can get needed therapy or medication. The most common means of doing this are exaggerating the severity of a patient's condition to avoid early hospital discharge; prescribing "double doses" of pharmaceuticals, so the patient gets twice as much for one copay; and changing the patient's diagnosis or overstating findings to secure coverage for a treatment or service.
Determining what to do when a patient's judgments, beliefs, and preferences differ from yours. What happens if, say, a patient requests an abortion or the morning-after pill, and you're opposed to both? Or a desperately ill patient wants a referral for an alternative treatment with unproven or even untested efficacy?
The need to consider costs and available resources when making choices about care. Physicians must balance the near limitless needs of patients with finite resources, says Alexander. Some of these finite resources are the physician's own time and energy. But there are also finite material resources, like kidneys to be transplanted and vaccinations to be given.
"As physicians we ration constantly, despite the fact that we view the term 'rationing' with disdain," Alexander continues. "We ration tests. We may send someone for a CT scan, even though an MRI is a much better test for discerning small abnormalities. We even ration our time; many patients who we see for 15 minutes would do better with longer appointments. We ration treatments, often because clinical recommendations have implications for patients' economic well-being as well as their medical well-being."