Painful Ethical Choices in 2020 vs 2010: How Has Thinking Changed?

Marcia Frellick

November 17, 2020

Much has changed in the 10 years since Medscape's first survey on what physicians would do when faced with painful choices in patient care.

A new report, Ethics 2020: Life, Death, and Painful Dilemmas, shows that physicians' value judgments have shifted in many respects, sometimes as a result of increased regulations and fears of litigation.

End-of-Life Decisions

Several of the questions in the survey revolved around end-of-life decisions, and in some cases, the differences seen in just a decade were striking. One example concerned life support decisions in the context of a family's choices.

Question: Should you withdraw a patient from life support at a family's request if you thought the patient had a chance to survive?

Answer % 2020 % 2010
Yes 18 16
No 34 55
It depends 48 29

 

Age also seemed to play a role in the 2020 answers to that question: Physicians younger than 45 were more likely (28%) to answer "yes" (that they would withdraw life support in that instance) than were those 45 and older (16%).

A critical care physician said, "If the family appears to have an underlying motivation that may not be in the patient's best interest, I might be inclined to pursue a legal decision prior to withdrawing support."

A cardiologist had a more pointed response to the question: "To me, that would be murder."

Another example of how perspectives have changed over the past 10 years concerns whether physician-aided dying should be legal for terminally ill patients. The practice is now mandated by law in eight states and the District of Columbia, and it is mandated by court ruling in two additional states.

In 2010, 41% said "no." That number dropped to 28% in 2020.

On legalization, a psychiatrist said, "Yes, when there is truly no hope and the quality of remaining life is too poor. We show more compassion to our sick animals than we do to our human population."

Conversely, a neurologist answered, "No, I see younger physicians already becoming comfortable with the idea of deciding ASAP whether there is a reasonable chance of survival and then pressing for the right code status. This change would make things worse."

Assisted Death and Incurable Suffering

Far fewer physicians supported physician-assisted death for those who had years to live but faced incurable suffering: 37% said "yes," 34% said "no," and 29% said "it depends."

However, support was significantly higher than it was just 2 years ago, in 2018, when only 27% supported the concept, the report authors note.

"The shift reflects movements by many states to legalize assisted dying for the terminally ill," Arthur Caplan, PhD, director of the Division of Medical Ethics, NYU Langone Health, said in the report. "Legalization has not been abused, so some doctors are more willing to press further beyond terminal illness as a trigger to suffering."

Conversely, many more physicians (44% vs 24% a decade ago) said they would provide life-sustaining therapy if the family requested it, even if the physician thought it was futile.

"Concerns over a malpractice lawsuit and potential negative patient/family online reviews are factors that play into this change," the survey authors write.

Shared decision making also increased in the past decade.

Would You Undertreat Pain?

Primary care physicians fear the consequences of what they consider adequate pain management more than specialists do (24% vs 17%), the survey authors note.

Ten years ago, Medscape asked physicians whether they would undertreat a patient's pain because of fear of repercussions or the patient's becoming addicted; 84% said "no," and 6% said "yes." The rest said "it depends."

In 2020, the question was asked slightly differently: "Would you undertreat a patient's pain for fear of addiction or Drug Enforcement Administration or medical board scrutiny?" This year, three times as many said "yes" (18%); 63% said "no."

"Respondents this year talked about investigations and reprimands by medical boards, and how much they wanted to avoid that," the authors of the survey wrote.

Should Physicians Be Required to Treat COVID Patients?

Some questions were new this year, including one on whether physicians should be required to treat COVID-19 patients. Fewer than half (47%) answered "yes," 24% said "no," and 29% answered "it depends."

Doctors' answers to this question differed slightly by gender: 50% of men and 43% of women said "yes." In their responses, many physicians said consideration should be given to risk factors, such as age, underlying conditions, risk of family members, and availability of personal protective equipment (PPE).

Another pandemic-related question asked whether physicians felt they should correct physicians who post misinformation about the pandemic on social media. Half (50%) said "yes," 19% said "no," and 31% said "it depends."

Speaking Out Against the Workplace

This year, many physicians have felt betrayed when they didn't have adequate PPE during the pandemic.

Asked, "Is it right to speak out against your hospital or workplace when they don't give you what you need?," 53% of physicians said "yes," 8% said "no," and 40% said "it depends."

A cardiologist made the value judgment this way: "Speaking out just because you had an argument with your boss is inappropriate. Bringing to the public repeated failures to correct situations that have been brought through the proper channels is necessary to incite change."

Random Drug Testing for Physicians?

Another question on the survey asked whether physicians should be subjected to random drug testing for alcohol and drug abuse. About one third (34%) said yes, 43% said no, and 23% said "it depends." A study found that between 10% and 15% of physicians have abused a substance at some point in their career.

The subject continues to hit a nerve in medicine.

A family physician wrote, "This should not be done unless a particular physician had a problem with drug or alcohol abuse and shows signs of impairment."

An internist took a different view, saying, "Military service men and women, police, firefighters, airline pilots, and other professions that have responsibilities affecting people's lives are subject to testing; why not physicians?"

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune and Nurse.com and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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