If doing the right thing were easy, we'd be a lot closer to a perfect world.
However, as respondents to Medscape's exclusive ethics survey indicated, the most wrenching situations in which physicians find themselves -- those that involve breaching physician-patient confidentiality, being asked to falsify billing information, overseeing end-of-life care, owning up to mistakes, or reporting an inept colleague -- can be extraordinarily complicated and are rarely without consequences.
For example, one respondent was torn about whether to report a case of domestic violence despite the patient's opposing entreaties. Another was unwilling to reveal a missed bowel perforation that ultimately led to a patient's death. A third wondered what to do about a colleague "who is very friendly, helpful, and well liked, but incompetent."
The survey was fielded during August-September 2010, and included responses from over 10,000 physicians who answered questions about numerous medical ethics issues.
Although the right course of action in many of these circumstances is evident or even mandated by law, following ethical strictures often requires considerable courage and resolve, says Prof. Kenneth W. Goodman, PhD, Director of the Bioethics Program at the University of Miami, Miami, Florida. You should report an incompetent colleague who has injured a patient -- your responsibility is to the patient, and your hospital has policies in place requiring you to speak up -- but doing so may mean derailing the colleague's career, or your own.
If you're the one who has blundered, Goodman continues, it's hard to muster the courage to look someone in the eye and say, "I made a mistake." "People don't like to admit that they have erred," he says, "but ethics solves that problem by indicating, 'You have to man up here.' It's not just physicians who have trouble telling the truth when in a tight spot. Still, that's what professionals do. The ethics is easy; the psychology, alas, is very hard indeed."
Breaching Physician-Patient Confidentiality
Deciding whether to disregard the doctor-patient confidentiality rule is especially difficult for physicians. When a patient reveals information that could have important repercussions for another person, either response -- retaining the information, or passing it along -- can hurt you.
A frequently mentioned incarnation of this quandary -- a patient is HIV positive and his or her spouse is not infected with the virus -- leaves physicians with no "good" choice: Either you violate confidentiality, or you fail to warn an innocent third party.
Indeed, one respondent wondered whether to tell a patient's spouse about the patient's "treatable STD that was acquired through an extramarital affair." Another was unsure about what to do when faced with "an HIV-infected patient who wanted to get married, but did not want to disclose his HIV status to his future spouse." To complicate matters, this patient was lax about following prescribed medication regimens.
Goodman recommends that physicians who are faced with these types of challenges appeal to patients' better nature to get them to do the right thing. "Start with, 'I'm sorry, but we have a problem here. Someone you care about is being exposed to a potentially deadly disease. Privacy is not absolute, especially when an innocent third party is involved. We've passed a tipping point where my duty to warn exceeds my duty to protect confidentiality. I'm going to have to tell your significant other anyway, so you might as well work with me now,'" says Goodman.
In all situations in which you violate confidentiality, you need to carefully document your reasons for doing so. What you shouldn't do is sit on your hands, says Goodman. Many states have "privilege to warn" laws that basically require you to assess the facts of the case and then do the right thing. "In other words, law and ethics are very often in sync. If you're faced with a lawsuit you want to say, 'I did the right thing for these reasons.' That's very powerful risk management," Goodman adds.
Privacy Is a Concern
Privacy issues that involve minors are no less thorny. One doctor was torn about whether to honor the request of a 16-year-old who, after being brought to the ED complaining of nausea, didn't want the doctor to tell her parents that she was pregnant so that she could seek an abortion.
"The parents, who were in the waiting room, pointedly asked me if she was pregnant, and expressed strong religious views about pregnancy termination," the doctor noted. "I had, from the start of the encounter, held the position that the patient-doctor relationship is private, so I was able to keep information vague, but essentially I lied to the parents. I urged the patient to tell them herself, or allow me to tell them, but she was firm about her wishes. According to the laws of my state, the patient had the right to keep that information private. It was just hard with her parents in the ED."
Asking physicians not to reveal important medical information isn't the only instance in which patients try to persuade doctors to bend the truth. Some respondents to the survey wrote about struggling with requests to falsify or exaggerate patients' conditions in order to get insurance coverage for them.
One mentioned, "Leaving out information regarding a pre-existing condition." A physician who lied to an insurance company "in order to obtain medically needed services for a patient" felt justified in doing so because "it seemed that the insurance company was completely motivated by cost."