Physicians' Ethics Change With Societal Trends

Batya Swift Yasgur, MA, LSW

November 23, 2020

The past decade has seen dramatic technologic and social changes that challenge physicians to confront new ethical issues or reexamine their approach to older ones.

In 2010, Medscape conducted its first ethics survey to explore physicians' reactions to key ethical questions. This year, Medscape surveyed over 5000 US physicians, asking similar questions to see how their perspectives and values might have changed over the decade.

Although the core issues of many ethical dilemmas are the same, medical advancements and social forces have shaped how physicians relate to them, said Samuel Packer, MD, professor at the Donald and Barbara Zucker School of Medicine, Hofstra/Northwell, Long Island, New York.

Which Society Trends Affect Doctors' Values?

"One of the major trends that has increased in the last 10 years is the growth of individualism and autonomy in American culture," says John Evans, PhD, Tata Chancellor's Chair in Social Sciences and associate dean of social sciences, University of California, San Diego.

"Americans feel they should be in charge of everything, which impacts medicine, because they're more likely to regard doctors as providers of a service, with patients as 'customers,' " said Evans, who is also co-director of the Institute for Practical Ethics. This cultural trend was reflected in responses to several survey questions.

For example, Medscape asked physicians whether they would ever prescribe a "placebo-type treatment" to a patient who doesn't require treatment but is adamant about receiving something. In 2020, 34% of physicians said they would — up from 24% in 2010.

The concern over having a dissatisfied patient has grown in the past decade, partially in response to the increasing use of internet reviews. A negative review can adversely affect a physician's practice in terms of attracting and retaining patients and can affect the physician's standing in his or her institution, said Packer. "Each healthcare system wants to be rated in the top 10 in the country" — a trend that has continued to rise during the past decade and has led to greater pressure for physicians to please patients.

An emergency medicine respondent acknowledged occasionally recommending unnecessary over-the-counter medications because "hospital systems are pushing patient satisfaction scores. When patients are unhappy because they felt they didn't get what they needed, physicians are penalized, often financially."

Rating physicians is an extension of the "patient as customer" model, similar to rating customer service staff at a hotel or airline, said Evans.

End-of-Life Issues Touch Physicians Deeply

End-of-life issues are among the most complex and important ethical conundrums in medicine. Medscape's surveys showed noteworthy changes during the past decade in responses to some of these critical decisions.

Respondents were asked, "Would you withdraw a patient from life support at a family's request if you thought the patient had a chance to survive?" In 2010, a little more than half of respondents (55%) answered "no," whereas in 2020, only 34% said they would not accede to the family.

Some respondents remained opposed. "Our job is to save lives and not agree to take a life if I think the patient can survive," said an anesthesiologist.

However, more respondents thought that the decision was nuanced ― the response, "It depends," rose from 29% in 2010 to 48% in 2020. Many felt that in the absence of an advance directive from the patient, the decision depended on whether the family was acting in the patient's best interest in light of what the patient would have wanted.

But the family's suffering should also be taken into account, according to a psychiatrist respondent. "The question is the patient's quality of life and the burden on the family. I expect that almost always the family will be very eager to discuss risks and benefits, and once they are educated, empowering the family to choose is very important."

You Are the Captain of the Ship

Far more 2020 respondents than 2010 respondents said they would provide life-sustaining therapy at a family's request, even if they considered it futile (23.6% vs 44%).

Some respondents suggested they might continue treatment for a limited time to allow relatives to say their good-byes or to allow the family to come to terms with the situation. A neurosurgeon wrote, "This often requires multiple difficult family conferences involving clinicians, spiritual mentors, and social services to bring the family as much as possible to a clear understanding of their own motives for continued futile care."

Still, some respondents said it is their role to do whatever the family wants. In the words of an ob/gyn, "If the family requests all to be done to sustain, then, as a physician, I must carry out their request."

Evans said the increased willingness to listen to family members in these life-and-death scenarios might reflect the values of self-determination and individual choice — in this case, the choices and the wishes of the family. It may also be a product of the increased pressure to avoid dissatisfied "customers."

However, it's important to keep in mind that respect for a family's wishes does not mean caving in to every demand, says Kenneth Goodman, PhD, professor, University of Miami, and director of the Institute for Bioethics and Health Policy.

"One should withdraw or extend life support at a family's request only if that family is signaling what the patient would want. Ultimately, the attending physician is 'captain of the ship' whose first responsibility is to the patient," said Goodman, who is also co-director of the University Ethics Programs.

Is It Ethical to Help Patients Die?

When it comes to end-of-life decisions, focusing on patient autonomy and self-determination can lead to greater respect for a patient's right to make decisions about his or her life — and death, said Packer.

A growing movement in the United States, Canada, and the Netherlands is acknowledging these rights. Eight states and Washington, DC, have some form of physician aid-in-dying laws. Public opinion increasingly supports the rights of patients to determine the circumstances of their death in the event of life-threatening illness or other extenuating circumstances.

These changed attitudes are reflected in the responses of Medscape's respondents to the question of whether physician-assisted suicide or physician-assisted dying should be made legal for terminally ill patients. In 2010, fewer than half (45%) of respondents said it should, whereas in 2020, the percentage was 55%.

Many respondents were adamant: "I am not God, so it is not my duty to kill people or help them kill themselves," said a family physician. An emergency medicine physician stated, "Murder is murder."

However, other respondents said they would honor the patient's request. A family medicine physician wrote, "I would adhere to the patient's request if it was clear that it was a terminal illness causing pain and suffering." Said a psychiatrist, "Relieving suffering takes many forms. Giving patients control over their life is important to preserve the dignity of each patient, and assisted dying for terminally ill patients should be legal."

What's in a Name?

In 2020, Medscape asked, "Should physician-assisted dying be made legal for nonterminally ill patients with incurable suffering?" More respondents said "yes" in 2020 than in 2018.

"Because of our increasingly sophisticated technological capacities, we are keeping people alive in ridiculous circumstances," Packer said. "For example, there are patients who are 100 years old and can't walk or engage in any meaningful activity and have no quality of life, or patients in intractable pain who are turning to their doctors for help."

Respondents who said "yes" emphasized the values of self-determination and autonomy when grappling with the decision — a trend that echoes the growing cultural emphasis on these values, according to Evans.

Packer said that using a name such as "physician aid in dying" or "physician-assisted dying" rather than the older term 'physician-assisted suicide' has had an impact, "since suicide is more of a hot-button word." The gentler terminology might reflect a softening of societal attitudes regarding the importance of quality of life that might, in turn, inform the changing attitudes of physicians to facilitating a patient's request for death.

Are Romantic Relationships With Patients Always Off Limits?

Medscape asked physicians whether it was acceptable to become romantically or sexually involved with a patient. Compared to 2010, in 2020, many more respondents were comfortable with having a relationship with a former patient after 6 months had elapsed. In 2020, 2% said they were comfortable having a romance with a current patient; 26% were comfortable being romantic with a person who had stopped being a patient 6 months earlier, but 62% said flat-out 'no' to the concept. In 2010, 83% said "no" to the idea of dating a patient; fewer than 1% agreed that dating a current patient was acceptable, and 12% said it was okay after 6 months

Some respondents felt strongly that romantic or sexual involvement is always off limits, even months or years after the physician is no longer treating the patient. "Once a patient, always a patient," wrote a psychiatrist.

On the other hand, many respondents thought being a "patient" was not a lifelong status. An orthopedic surgeon wrote, "After 6 months, they are no longer your patient." Several respondents said involvement was okay if the physician stopped treating the patient and referred the patient to another provider. Others recommended a longer wait time.

"Although most doctors have traditionally kept their personal and professional lives separate, they are no longer as bothered by bending of boundaries and have found a zone of acceptability in the 6-month waiting period," Goodman said.

Packer added that the "greater relaxation of sexual standards and boundaries in general" might have had a bearing on survey responses because "doctors are part of those changing societal norms."

Evans suggested that the rise of individualism and autonomy partially accounts for the changing attitudes toward physician-patient (or former patient) relationships. "Being prohibited from having a relationship with a patient or former patient is increasingly being seen as an infringement on civil liberties and autonomy, which is a major theme these days."

Many respondents distinguished between the type, duration, and context of treatment the patient received. "If there were some single encounter such as an ER visit for a minor ailment, it would be okay, but it would not be appropriate for an established patient," wrote an emergency medicine physician.

Evans agreed. "Perhaps a doctor who repaired a broken toe in the ER 6 months ago can date the patient. This isn't the same as an ob/gyn or psychiatrist, for example. It's a matter of balance. You have to draw the line someplace, and it should be drawn in a reasonable place."

Pain Management Is a Balancing Act

As the opioid epidemic has ravaged the United States, attitudes toward pain management have changed. There has been move away from opioid therapies and a search for alternative ways to treat pain. In addition, there has been increased scrutiny by the US Drug Enforcement Administration (DEA) regarding the prescribing of opioid pain medication. These trends have had enormous ramifications in how physicians approach pain management, Evans said.

These concerns were reflected in changes from 2010 to 2020 in physicians' responses to the question, "Would you ever undertreat a patient's pain for fear of their potential addiction or fear of DEA scrutiny?"

Although some respondents continued to state firmly that it is unethical to undertreat pain, the percentage of respondents who said they would undertreat pain increased during the period 2010 to 2020 (from 6% to 18%), and the number of respondents who would not undertreat pain dropped by 21 percentage points.

A psychiatrist respondent summarized the dilemma, calling pain management a "balancing act that probably leaves some patients undermedicated due to the physician's fears."

Some participants were afraid of losing their license if they prescribed opioids. A physiatrist reported having been "harassed by the medical board." Others were less worried about legal repercussions than they were about the possibility that the patient might become addicted.

"Don't make this decision in isolation," says Packer. "One of the important trends of the last decades is the increasing emphasis on multidisciplinary collaboration — especially in situations such as this, where you need to determine whether you are indeed undertreating the pain, whether there are alternatives to opioids for pain relief in this patient, and what precautions to take if the patient requires opioids."

Can Truth Be Embellished?

Most physicians have had the experience of fighting with insurance companies to get tests or procedures approved. But is it ethical to overstate or "upcode" the patient's condition when submitting claims or seeking prior authorization?

More physicians said "yes" in 2010, compared to 2020 (17% vs 8%). Participants who responded "yes" justified their view by saying it's in the best interest of the patient. A psychiatrist wrote, "Health insurance companies are for-profit businesses and often predatory, without regard for patient care or life, so all bets are off when stuck in a sociopathic system."

On the other hand, many respondents stated that it is "immoral and illegal" to lie under any circumstances. A family medicine doctor wrote, "It is sorely tempting to do this. Patients have asked me to do so, and I explain that it is fraud."

Some participants distinguished between "upcoding" and "overstating." In the words of a psychiatrist, "overstating when trying to obtain authorization for a required procedure can be done to oversimplify the situation for an unqualified or uneducated gatekeeper and is sometimes necessary, but intentionally upcoding is fraud."

Goodman acknowledged that many physicians are in a "tight spot because they are concerned for the well-being of patients who may need tests or procedures that are not approved by their insurance companies."

Moreover, insurance companies are becoming stingier, and the process of obtaining preauthorization has become more complicated, demanding more time from the physician or other office staff.

Nevertheless, Goodman said, the fact that "our medical system today is a flaming failure does not justify engaging in deception, and physicians are not responsible for taking up the slack in a broken healthcare system."

Beyond ethical concerns, a practical reality may be at play, he added. The ever-increasing use of electronic health records (EHRs) might have contributed to the reduction in overstating and upcoding, because EHRs have made it more difficult to "fudge" or embellish a patient's medical condition than it might have been in the past.

Divided Loyalties?

One very challenging situation for a physician is becoming aware that a colleague may be impaired and that the impairment may affect patient care.

In 2010, Medscape asked physicians whether they would report a physician friend or colleague who was impaired by drugs, alcohol, or illness if he or she ignored a warning to get help. A large number (86%) said they would, and almost no respondents (2.3%) said they wouldn't; 11.6% said it depends.

In 2020, the question was phrased differently, so the comparison is not apples to apples, but there was still a trend. In 2020, respondents were given the option of saying they would speak to the person before reporting them. Only 28% said unequivocally that they would report a physician friend or colleague who seemed occasionally impaired by drugs, alcohol, or illness; 59% said they would but would speak with the physician first. Two percent said they wouldn't, and 10% said it depends.

One reason for the increased wariness over reporting another physician may be that today's physicians are more aware of the potential career-ending actions of medical boards and the damage they can cause. "The consequence of reporting is ending the career of the person and potentially taking on all their workload," wrote a pediatrician.

Packer suggested that the change might be due to "cultural reasons, because over the last 20 or 30 years, once you go to the administration, the game is over. You are on temporary suspension. You can work, but only under surveillance." Moreover, as patients increasingly turn to the internet for information about their physicians, a suspension of privileges can more easily become known, and "once that knowledge is out, it cannot be taken back."

The best thing to do, according to Packer, is to talk directly to the colleague, with formal reporting as a last resort. Indeed, a large number of 2020 respondents said they would do just that. "I owe my colleague the professional and personal courtesy to tell them that they need help, and I'm concerned enough to see that they get it," said a pathologist. Concern about potentially ending another physician's career was accompanied by a sense of vulnerability over one's own career. One respondent described going to the hospital administration twice about impaired colleagues and being regarded as the "bad guy," receiving "negative attention and snubs for years." A family medicine physician expressed fear that there would be retaliation if she stepped forward.

On the other hand, Packer said, "Fellow physicians and nurses frequently share the same concerns about the impaired physician as you do and may be grateful that you had the courage to take action."

Don't Make Decisions on Your Own

Numerous respondents stated that, when faced with ethical dilemmas — especially end-of-life issues — they would request an ethics consult or, at the very least, talk to a colleague.

Their responses reflect an accelerating trend, Packer said. "Our ethics committee is doing more and more consults as time goes on. In the 1980s, when hospitals were mandated to start having ethics committees, we did perhaps three consults in the first year. Now, we do four or five hundred consults annually. Ethics courses are also being offered in medical schools."

Goodman added, "Taking counsel with ethicists is no reflection on a physician's competence. On the contrary, turning to ethics committees will help a physician make better decisions and will also take some of the burden off his or her shoulders."

Batya Swift Yasgur is a freelance writer based in Teaneck, New Jersey.

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