Certain issues in medical ethics tend to grab the headlines, such as removing life support from brain-dead patients or the implications of genetic testing. But medical ethics is much more useful to doctors when dealing with everyday issues, such as delivering bad news or handling disagreements with the patient's family. Here are some common issues and ways to handle them.

When do you tell the patient the truth about bad news, such as needing an artificial hip, having Parkinson disease, or being diagnosed with cancer?

In a 2016 Medscape survey, physicians were asked if they would ever "withhold information from a patient about a terminal diagnosis in an effort to bolster their spirit or attitude." Whereas 21% said it would depend on the situation, 72% said no, and only 7% said yes. ^[1]

The 2016 survey also asked physicians if they would ever "withhold information from a competent patient at the family's request." In that case, 75% said no, 20% said it depends, and only 5% said yes. ^[2]

Not revealing a prognosis harks back to the old days of paternalism, but there is such a thing as being too frank with the patient or family. You can still tell the truth without hurting peoples' feelings with blunt statements such as, "He's going to die soon."

Similarly, saying you want to "remove life support" might cause panic among the patient's family. There are softer ways of saying this, without referring to life support, such as "remove the feeding tube."

Issues Surrounding Medical Futility

Even when it is clear that more medical interventions for a dying patient will be futile, it's not easy to stop a determined family from insisting that life support for the patient must be continued. Some states have futility laws, which authorize doctors to overrule the patient's family, but even in these states doctors are required to go through a lengthy process before life support can be removed.

Not challenging a family that wants to keep the patient alive when the situation is futile seems like an overreaction to the old paternalism. It gives too much credence to the principle of patient autonomy—assuming, of course, that the family correctly interprets what the patient would have wanted.

Many doctors would take a stand against the family when treatment is futile, or at least express their reservations and point of view. A 2016 Medscape survey found that only 22% of physicians would recommend life-sustaining therapy they believed would be futile, whereas 42% would not and 36% said it would depend on the situation. ^[3]

There are ways to avoid stand-offs with the patient's family about futility. When you discuss a major medical procedure with the patient and family, include a discussion on when life support should be stopped. And when you discuss a terminally ill patient's chances, do not leave the family with the impression that the patient could survive.

Offering some modest hopes can be a successful strategy—for example, "Maybe you will see him again tomorrow with the whole family."

It's a good idea to avoid disagreements with the patient's family as much as possible. Disagreements can derail the whole care process. Therefore, it's very important to maintain good relations with family members and treat them with respect and cordiality. Understand that family members are scared and will need to be comforted.

There are some simple steps you can take to avoid disagreements in the long run. When visiting the family, these steps can help create an atmosphere of trust:

1. Sit down when you talk to them, rather than standing up; it puts the conversation and interaction on a more equal level.

2. Ask the family to talk about the patient; they will trust you more if they sense that you have an understanding of the patient as a human being, and you'll learn how they relate to the patient.

3. Admire family members' interest in the patient.

4. Discuss what's happening at each step of the care process. Family members who feel included are more likely to be your allies.

If you do get into a disagreement with the family, try to determine what it's about. It may be that family members are misunderstanding the facts, such as the clinical options that remain for the patients.

It could be that family members simply don't like you, and that may not change. It may be that it's hard for them to relate to you because you are very different from them. In this case, the best solution would be to find another physician, if possible, to replace you—someone more acceptable to the family.

When revealing medical errors, where do you draw the line? In a 2016 Medscape survey, 78% said it was never acceptable to avoid revealing a mistake, but 7% said it was acceptable and 14% said it would depend on the situation. ^[4]

Some errors aren't worth bringing up. When primary care physicians at integrated delivery systems were asked about hypothetical situations of a delayed diagnosis of breast cancer or delayed response to the diagnosis, more than 70% said they would provide only limited or no explanation or apology. ^[5]

Each revelation of a mistake has the potential to reduce the patient's trust in the doctor. There's no reason to bring to the patient's attention mistakes that didn't cause any harm. However, you should be discussing all mistakes, even the minor ones, with clinical colleagues, so that you can learn from them.

Increasingly, patients have insurance with high deductibles; high copays; and narrow networks, in which patients will only be covered for seeing certain providers. Some states are trying to reduce Medicaid coverage, and if some proposed changes do take hold, in the near future patients may arrive in your office with stripped-down policies that don't have the minimum essential coverage mandated by the Affordable Care Act. ^[6]

Unfortunately, this is a systemic problem that can only be fixed through government intervention, but there are some ethical steps that physicians can take. One is deciding not to cherry-pick—meaning, do not only select patients who have good insurance.

Cherry-picking can be particularly harmful to patients with chronic diseases, because they have a particular problem getting essential care. An ethical way of handling this problem—without having to go out of business—would be to selectively accept a limited number of patients with poor coverage, such as a child who has asthma.

Another ethical step physicians can take is to be strong advocates for their patients on such issues as getting prior authorization from insurance companies and dealing with the escalating costs of drugs. You may not always win, but the fight could be worth it.

Physicians have to consider the use of defensive medicine, which involves ordering a procedure that some consider warrantless, with the sole purpose of protecting yourself from a possible malpractice lawsuit. In a 2016 Medscape survey, 68% of physician respondents said they would never do this, 18% said it depends on the situation, and only 13% said they would do it. ^[7]

In this age of high deductibles, defensive medicine can mean that the patient or, often, their insurer is asked to pay more money in return for a questionable increase in quality of care. The threat of a malpractice suit can be all too real, but sometimes an extra test outside the standard of care may be hard to justify.

Taking driver's licenses away from elderly patients who have become demented or partially blind can stir up anger and depression. Americans regard driving as a fundamental right, and without their license they're exposed to isolation and loneliness.

However, if these patients are allowed to drive, they could be a danger not only to other people but also to themselves. At least six states, including California, require that doctors in particular report drivers who might be impaired to the Department of Motor Vehicles (DMV), and 25 more states encourage physicians to report them. ^[8]

It takes some thought to come up with an ethical approach. Rather than simply report such patients to the DMV, bring up your concerns with these patients, get their response, work towards an agreement, and get sign-off from family members. The agreement might stipulate use of other transportation, such as Uber, Lyft, a community van, or a taxi, so that they don't have to be housebound.

Should doctors protect the public from colleagues who are impaired, addicted, or incompetent? Some doctors, while practicing, have been drinking heavily; taking drugs; or exhibiting significant loss of memory, stamina, or motor coordination.

Reporting them is mandated under many state laws and under ethics codes of many professional societies, such as the American College of Surgeons. Surveys of physicians also support reporting. A 2016 Medscape survey asked physicians if they would report a colleague who "occasionally seemed impaired by drugs, alcohol, or illness." Whereas 18% said it would depend, 78% said they would and only 4% said they would not. ^[9]

However, the closer you look, the more reservations doctors have about reporting colleagues. A 2010 survey in JAMA found that only 64% of physicians would always report an impaired colleague. ^[10] Those who would not report cited concerns about what might happen to reported doctors and fears of retribution by them.

Some physicians worry that licensing boards would be too harsh on reported physicians. However, many boards protect these doctors. Often, they allow the doctors to keep their licenses if they agree to go into treatment or practice under observation. In any case, the need to shield the public from harm outweighs the need to shield a physician's reputation.

More doctors now think it's okay to date former patients. In Medscape polling, the percentage of doctors who thought it was never permissible to date patients fell from 83% in 2010 to 70% in 2016, and the percentage who said it was okay if the doctor waited 6 months to a year after no longer treating the patient rose from 12% in 2010 to 21% in 2016. ^[11,12]

However, there are many strong ethical arguments against dating your patients.

Having intimate relations with patients, even when consensual, can exploit the patient's vulnerability and compromise a doctor's ability to make objective judgments about the patient's care. And don't expect much loyalty from a patient-turned-lover if the relationship ends.

Physicians also have to be cognizant of how they approach patients. Obviously, unwanted advances toward patients are never okay, and this injunction has only intensified with the #MeToo movement. To address any confusion, let patients tell you what they want the boundaries to be. Ask them if it's okay to touch them on the arm, and whether they want to be called by their first name or not.