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Right and Wrong in Medicine: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023
| Contributor Information
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Right and Wrong in Medicine: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
The number of patient-care decisions that oncologists must make daily can be overwhelming. Sometimes these decisions require an oncologist to follow a law or code of medical ethics. Sometimes they demand an oncologist's good judgment and common sense. Almost always, these decisions will exact a mental toll.
Meanwhile, relationships with patients can become quite tricky. Sometimes a patient's desires and the oncologist's view of right or wrong may not align. Other times, money issues — on either the patient's or the oncologist's part — may require a difficult decision. And sometimes there's no right or wrong, just a choice about the best option.
Medscape asked US physicians how they would react to some ethically challenging scenarios affecting patient treatment and to others involving patient interactions, both professional and personal. More than 4100 doctors revealed how they would react and described their reasons. This report focuses on responses from oncologists.
(Note: Some chart data in this presentation do not add up to 100% because of rounding.)
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Right and Wrong in Medicine: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
Going public about issues with an oncologist'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 oncologists' 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 whom?'" he adds. Many oncologists 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: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
In our 2020 report, 83% of oncologists said yes, physicians should have to get an annual flu shot if they see patients. Another 11% of them felt the opposite, and 6% said "it depends." 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: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
Compare what oncologists said here with the 10% of physicians overall who acknowledged that they failed at least once in these situations and 86% who reported that they never did. Thomas May, PhD, a bioethicist at Washington State University, says both male and female physicians strongly support reporting of abuse cases.
"It reflects the tremendous strides society has made in recognizing the impact of abuse and the need for required-reporting policies, because victims are often, if not usually, reticent to come forward," he says. "Required reporting is necessary and in the patient's interests."
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Right and Wrong in Medicine: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | 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 oncologists prefer that their state be on that list?
Compare this report's results with 55% of oncologists who said "yes" to making physician-assisted dying legal in our 2020 report, 34% "no," and 12% "it depends." (Note: from 2010 to 2022, the question shifted from physician-assisted suicide or dying "in some situations" to "in all states.") Support may arise partly from oncologists who practice in states that have passed laws and partly from growing support nationwide, says Eric Mathison, PhD, 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: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
Compare these results for oncologists with those for physicians generally (33% answered this question "yes," 34% "no," and 34% "it depends").
How do we help patients who have years to live but want to die because of incurable suffering? 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?
It's not easy for many doctors to get on board, says Caplan. They may fear being asked to help someone with mental health problems to die, he says. Plus, doctors are "becoming a little less convinced that they can't help control physical pain," notwithstanding the opioid addiction crisis.
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Right and Wrong in Medicine: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
In matters of ethics, your duty is clear. Oncologists 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 like 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: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
Compare these responses with those expressed in our 2020 report, when 4% of oncologists answered "yes" to this question, 69% said "no," 22% said dating would be okay at least 6 months after the patient relationship ended, and 6% said "it depends."
"Such a relationship is inappropriate while the professional relationship is active and even for some time afterward," says bioethicist May. "There's a professional dynamic that needs to be maintained, a sense of objectivity. Plus, the physician is in a power relationship to the patient where there's a sense of gratefulness or vulnerability that makes the patient unable to say no to a personal relationship.
"I'm not sure 6 months after they stop being your patient is long enough. I'd think something like 2 years as a minimum. If I were your oncologist and helped save your life, it may never be appropriate."
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Right and Wrong in Medicine: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
Male oncologists answering this question were about as open as male physicians in general (26% vs 30%) to doctors dating patients once six months has passed after treatment, but likelier (65% vs 54%) to disapprove of any doctor-patient romantic relationship.
Female oncologists were somewhat more likely than female physicians overall (28% vs 23%) to say it was okay to date six months after seeing a person as a patient, and somewhat less likely (59% vs 66%) to disapprove of any romantic relationships between physicians and patients.
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Right and Wrong in Medicine: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
In our 2020 report, about 9 in 10 oncologists said they would report a physician colleague or friend who occasionally seems impaired at work (either outright or after talking with the fellow doctor first). This year, 88% of physicians overall said the same.
"Our obligation is to do no harm to patients, and the professional standards and integrity of the profession are at stake," one survey respondent said.
"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 said.
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Right and Wrong in Medicine: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
Compare oncologists' opinions with how physicians in general answered this question (73% of whom said "yes" and 21% "it depends" to whether they would "always or usually" report a doctor for sexual harassment or bullying of other clinicians).
"If we ignore bad behavior such as this by our colleagues, then we are hurting our profession," one physician commented.
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Right and Wrong in Medicine: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
Again here, it is interesting to show how oncologists' opinions size up against the way physicians generally answered this question (51% of doctors overall said "yes" and 32% "it depends" to whether they would "always or usually" report a doctor for making racist remarks).
A comparison to data from the previous slide shows that doctors overall feel more strongly about reporting a colleague whom they see bullying or sexually harassing another clinician than they do when hearing racist remarks.
"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," one respondent said.
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Right and Wrong in Medicine: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
In comparison with oncologists, 34% of physicians overall answered "yes" in this situation, 45% answered "no," and 21% said "it depends." The underlying issue is whether you as a physician and oncologist 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: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
As in our 2020 report, 8% of oncologists said it was morally acceptable to do this when submitting claims or seeking prior authorization. But in that last report, 80% said it was not and 12% answered "it depends."
Many doctors are willing to stretch coding policies to the limit to support patients and their finances, Caplan says. "That's acceptable advocacy. But most doctors will not say they are willing to commit fraud."
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Right and Wrong in Medicine: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
In our 2020 report, 72% of oncologists felt that yes, they could accept meals and speaking engagements without it creating any issue for them, while 22% answered the question "no" and 7% said "it depends." 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 result.
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Right and Wrong in Medicine: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
Compare these results with our 2020 report, when 11% of oncologists said "yes," 79% answered "no," and 10% said "it depends."
As many physicians have noted, patients with comorbidities often require frequent and complex treatment, which makes treatment more expensive. Still, not many physicians are willing to cast aside patients with multiple diseases or conditions. Most prefer to keep working toward a treatment plan.
"That's the right choice. You should try to help people deal with their health ailments," Caplan says. "Look, a lot of doctors struggle with comorbidities themselves. I don't like [the idea of] weeding out but I think it goes on, often in boutique practices that are responding to other patients who pay for speed."
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Right and Wrong in Medicine: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
Attitudes toward patient confidentiality have changed somewhat in the past decade. In our 2020 report, 54% of physicians generally said it's okay to breach confidentiality while 32% answered "it depends." In our 2012 report, comparable statistics were 63% and 23%, respectively. It's worth noting that communicable diseases vary in severity, Caplan says.
"I teach that if you know someone faces a direct risk from catching a deadly disease, and you know who that person is, then you have a duty to warn," he says. "The disease has to be serious for [breaching confidentiality] to be morally defensible, and your disclosure has to be actionable. Telling your mother won't achieve a lot" in protecting someone's health.
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Right and Wrong in Medicine: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
Many physicians have refused to take Medicaid patients owing to the low reimbursement rates. Among doctors generally, 53% answered "yes" to this question, 34% said "no," and 12% said "it depends." And in Medscape's Physician Compensation Report 2022, 3% of physicians said that they will stop treating some or all current Medicaid patients.
Putting aside problematic reimbursement rates and the hassle of government regulations, should oncologists feel 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: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | 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 such as oncologists, 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: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
Among physicians generally, 14% answered "yes" to this question, 69% said "no," and 17% said "it depends."
In Medscape's Physicians Behaving Badly Report 2022, doctors said that inappropriate comments about themselves, colleagues, politics, etc. were the leading source of boorish social media behavior that they saw from physicians. But is boorish necessarily unethical?
"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: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
May thinks most doctors are fine with the idea that society expects active charity work based on their profession, but some balk at mandated volunteer hours.
"Most physicians see helping fellow man as an important reason for their career path," he notes. "On the other hand … we're seeing a healthcare workforce shortage and burnout at levels we haven't seen in decades. The idea of their providing even more of their time and labor can be daunting."
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Right and Wrong in Medicine: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
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Right and Wrong in Medicine: Oncologists Confront Difficult Decisions
Mary Lyn Koval | February 3, 2023 | Contributor Information
Right and Wrong in Medicine: Life, Death, and Wrenching Choices
Physicians reveal how they would respond to difficult decisions and scenarios involving medical care and personal treatment of patients, sharing both their insight and turmoil.Medscape Features Slideshows, Nov 2022
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Mary Lyn Koval
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Disclosure: Mary Lyn Koval has disclosed no relevant financial relationships.
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