"What would you do, Doctor?" New issues in medical ethics

The insurance reimbursement situation, pay for performance,and expensive technology have made it harder than ever to choosethe most appropriate ethical course.

MS. GARFINKEL WEISS is a senior editor for Medical Economics, an Advanstar publication from which this article was adapted. She hasnothing to disclose in regards to affiliations with, or financial interests in, any organization that may have an interest in any part of thisarticle.

There are exceptions but, on the whole, medicine isn't a profession that attracts the amoral. Most people who become a physician do so because they want to help relieve suffering. And, although many physicians "do well while doing good"-that is, earn a satisfactory 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.

Further complicating the ethics picture, physicians face fresh economic challenges, including mounting numbers of patients without health insurance or with limited coverage, declining reimbursements, and pay for performance.

"Family physicians rarely do a wallet biopsy before seeing a patient," says Larry S. Fields, a family physician 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."

So although doctors may be in a profession that values toeing the ethical line, in some circumstances that line is as elusive as fairy dust. The difficulty of acting ethically with confidence is drawn into sharp relief in the vignette "A dilemma over reproductive care: What would you do?" about a plausible (perhaps common for you) ethical dilemma in the care of a young person.

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, MD, 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, three chief ethical issues confront physicians today:

The temptation to "game the system" on behalf of parents and 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 a "double dose" of a pharmaceutical so that 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 parent's or 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 (see "A dilemma over reproductive care: What would you do?")? 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 Dr. Alexander. Some of these finite resources are the physician's own time and energy. But there are also finite material resources, such as kidneys to be transplanted and vaccinations to be given.