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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
The number of patient-care decisions that physicians must make daily can be overwhelming. Sometimes these decisions require a doctor to follow a law or code of medical ethics. Sometimes they demand a physician's good judgment and common sense. Almost always, these decisions will exact a mental toll.
Medscape asked US physicians how they would react to some ethically challenging scenarios affecting patient treatment. More than 4100 doctors revealed how they would react and described their reasons.
(Note: Some chart data in this presentation do not add up to 100% owing to rounding.)
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
Going public about issues with a physician's hospital or healthcare organization became a major issue during the COVID-19 pandemic, as some medical professionals struggled to get enough PPE and made it known. Prominent cases of hospitals firing nurses and doctors who complained over social media may influence physicians' willingness, Arthur L. Caplan, PhD, a New York University professor of bioethics and Medscape blogger, believes.
"I also think some doctors would say, 'Speak out to who?'" he adds. Many doctors will aggressively push for resources through the internal chain of command "but don't think talking to the media is ethical or appropriate."
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
It's legal in 11 jurisdictions for doctors to help a terminally ill patient with dying on the basis of state law, ballot initiative, or court ruling. Hawaii, Washington State, Oregon, California, Colorado, New Mexico, Montana, Maine, Vermont, New Jersey, and the District of Columbia give physicians this ability. Would you prefer that your state be added to that list?
Since our 2010 report, the share of physicians who answer this question "yes" has risen somewhat from 46%, and "no" responses have declined from 40% (Note: From 2010 to 2022, the question shifted from physician-assisted suicide "in some situations" to "in all 50 states.")
The support may arise partly from doctors who practice in states that have passed laws and partly from growing support nationwide, says Eric Mathison, PhD, MA, a clinical ethicist at the University of Toronto.
"The public and physicians are getting more comfortable with" physician-assisted dying, he says. "Physicians are seeing it used in practice and hearing from other physicians who are participating."
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
As an ethical matter, your duty is clear. Physicians have admitted that being so forthcoming may create legal and career difficulties for themselves, but most feel that they owe it to the patient. For decades, medical societies including the American Medical Association and the American College of Physicians, have endorsed disclosing to patients and their families any error that could jeopardize the patient's health.
"Disclosure of close calls should also be made," Mathison says. "From a health law context, being up front with the patient is standard practice."
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
How do you help patients who have years to live but want to die because of incurable suffering? What about helping a patient with incurable suffering but years to live die? As opposed to physician-assisted dying for terminally ill patients, no US state recognizes the legal right to help end the lives of patients in terrible, unending pain. However, Belgium, the Netherlands, and Luxembourg do under certain conditions. Could you as a physician get behind that idea?
In our 2018 report, the share of US physicians answering "yes" to this question was 27%, whereas "no" comprised 45% of answers.
It's not easy for many doctors to get behind this idea, says Caplan. They may fear being asked to help someone with mental health problems to die, notes Caplan. Plus, "they're becoming a little less convinced that physicians can't help control physical pain," notwithstanding the opioid addiction crisis.
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
Attitudes toward this have changed since we first asked the question in 2010. In 2010, only 6% "yes" responses were given; physicians seemed more cautious and more willing to undertreat.
Two years ago, however, when Medscape asked about undertreatment of a non-terminally ill patient over fears of the authorities or of triggering addition, responses were much the same as now.
"For sure, a big part of it is a response to the opioid crisis and physicians being more careful about prescriptions," Mathison says.
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
Over time, physicians have become less inclined to answer "no" to this question and more likely to equivocate with "it depends." In our 2010 report, those percentages were 55% and 29%, respectively. What does that mean?
"Doctors have learned to be wary about the ability of families to correctly guess what the patient wants," Caplan warns. "A lot of doctors have become skeptical and distrustful about whether family members are looking out for their own financial interests.
"The other problem is, families are getting more complicated. You might have eight people at the bedside, thanks to two divorces in the family. Who's family and who's not? You're not always sure who to listen to."
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
It's common for family members to want to do anything and everything possible to save their loved one. Responses to this question are about the same as in Medscape's 2020 report, but over time, doctors have become increasingly willing to go along with family wishes. Meanwhile, family members more often participate in care decisions than they did a decade ago.
"What's tricky about these cases is that people interpret 'futility' differently," Mathison notes. "Some physicians will see futility even if there is some chance of success or if the treatment will increase the patient's life. But if the family has evidence that the patient wanted to prolong life, then it is ethical to consider those requests."
As for whether a doctor thinks a hospital's resources might be used needlessly, "in general, those decisions should not be made at the patient's bedside." Such discussions are best left to healthcare organizations rather than physicians, he says.
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
Over the past 12 years, the share of physicians who would report a physician colleague or friend who occasionally seems impaired at work (either outright or after talking with the fellow doctor first) has stayed pretty stable.
"Our obligation is to do no harm to patients, and the professional standards and integrity of the profession is at stake," one survey respondent says.
"A colleague who recognizes the problem and after private discussion enters a treatment program is often better served than by the often excessively harsh management by the state medical board," another physician says.
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
The underlying issue is whether you as a physician have a responsibility to patients and their health that is so special, random testing for substance abuse is justified for you but not others. Caplan thinks that physicians face enough responsibility to patients to warrant such testing randomly but infrequently.
"Doctors may feel like they're being treated unprofessionally, like drug addicts, or question the accuracy of testing," he notes. But he tilts instead toward "the moral fight to protect patient safety and trying to drive down malpractice costs."
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
Of note, somewhat fewer respondents get behind annual flu shots for doctors with patient contact than was reported last year (when 72% answered yes). At the same time, the Centers for Disease Control and Prevention says adult flu vaccinations are up 35%.
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
In 2021, US Surgeon General Vivek Murthy called on all Americans to speak out against health misinformation during the COVID-19 pandemic and beyond as "a moral and civic imperative." When it comes to physicians, is such an "imperative" also an ethical duty?
Mathison doesn't believe that it should be mandatory for physicians. "That's certainly something they should consider," if physicians are comfortable with messaging through the mainstream or social media, "but saying it is an ethical duty is too strong. Some physicians are just not suited to that role."
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
Doctors feel more strongly that they have an obligation to treat COVID patients than they expressed in our 2020 report, when 47% of them answered "yes." It should be noted that earlier report included responses given before vaccines were generally available.
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
The range of treatments that physicians generally consider to be "unwarranted" is shrinking, Caplan believes. "Some doctors are expanding their knowledge of what is medically warranted and having a broader definition…makes you feel like you are not using defensive medicine," he says.
"I do think there is some over testing of patients, for example. But doctors aren't saying they do it because they don't want to be sued. They do it because there is a medical risk and they don't want to miss" a problematic condition.
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
Nearly 4 in 5 doctors think they should consider a patient's out-of-pocket cost before recommending a drug. Not only that, but also a discussion with a patient about prescription costs should be standard operating procedure, Mathison believes.
"Physicians need to be careful about making judgments" about whether a higher-priced medication is worth it to their patients, he says. "It depends on how much the individual cares.
"The physician needs to ask about the patient's priorities and take them into consideration in the conversation, along with the doctor's own recommendations."
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
Comparing responses here with those in the previous slide, physicians clearly feel less obligated to consider the impact on a health insurer than on their patient in recommending a medication.
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
Response rates on this question are similar to Medscape's 2020 report. But Caplan thinks that many doctors are deceiving themselves.
"We know from business school case studies that even little gifts like calendars and flashlights work," says Caplan. "Humans get a sense of debt when they receive gifts. Physicians are no exception. If you get a meal or an invitation to do a talk for a small fee, you may still say this is nothing to me," but subconscious favoritism can still result.
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
Doctors feel more strongly about reporting a colleague whom they see bullying or sexually harassing another clinician than they do when they hear racist remarks. They were asked whether they would "always or usually" report in these scenarios.
"If we ignore bad behavior such as this by our colleagues, then we are hurting our profession," one physician said about bullying and sexual harassment.
"I would first discuss with the physician and point out the racist remarks, with the hope that he/she will realize how inappropriate they are," another respondent said.
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
About 8 years ago, there was a flurry of national discussion about implementing a "presumed organ donor" law, under which people would have to actively opt out of being an organ donor. However, the bills petered out without support.
In this country, someone must expressly opt in to an organ donation registry. But multiple Western countries — England and the Netherlands among them — have shifted to "presumed consent," ie, opt out.
US doctors' responses to this question are about the same as they were in our 2020 report.
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
In the Medscape Physicians Behaving Badly Report 2022, doctors said that inappropriate comments about themselves, colleagues, politics, etc. was the leading source of boorish social media behavior that they saw from physicians. Here, nearly 7 in 10 physicians said it is unethical for a doctor to act rudely, offensively, or unprofessionally on social media, even if their practice isn't mentioned.
"Unethical, unprofessional behavior is not acceptable at any time. Period," one respondent asserted.
"'Professional' is not a 9-to-5 descriptor," another physician said.
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
Many physicians have refused to take Medicaid patients owing to the low reimbursement rates. In Medscape's Physician Compensation Report 2022, 3% of physicians said that they will stop treating current Medicaid patients and another 4% won't take new Medicaid patients. Putting aside problematic reimbursement rates and the hassle of government regulations, more than half of respondents think that physicians should be ethically obligated to do so.
"All of us benefitted in our education and residency from public funding. We owe those who cannot afford our care," one respondent argued.
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
Caplan believes that it is appropriate for medical associations to exclude Russian physicians in order to exert any political and economic pressure they can on the Moscow government. But nearly two thirds of physicians disagree with that stance. "Membership in a professional association with a strong code of ethics, regardless of the international reputation of the country in which one practices, is essential for sustaining the ethical practices of the vocation," one doctor argued.
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
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Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Jon McKenna | November 2, 2022 | Contributor Information
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