Oncologists React to Ethical Controversies: Medscape Survey

Roxanne Nelson, RN, BSN

February 04, 2021

More than half (54%) of oncologists surveyed said that physicians should speak out against their workplace if their needs are not being met.

Beceause the survey was conducted during the ongoing COVID-19 pandemic, one of these needs is likely to have been for personal protective equipment.

Respondents said that complaints should be about "real issues as opposed to mindless carping" and that the when concerns are being raised, "doctors should be well advised of all the facts." One oncologist emphasized that the "enemy is the virus."

These responses were collected in the Medscape Oncology Ethics Report 2020. The survey includes responses from 103 oncologists, who made up 2% of the 5130 physicians surveyed in an overall report from Medscape.

One aspect of the pandemic is that it may have influenced views concerning vaccination generally. The majority of oncologists (83%) said that annual flu shots should be mandatory, which is up from 73% in 2018. In addition, the percentage of physicians who previously reported that "it depends" declined by 17%.

One respondent commented: "Our patients may have a significantly higher risk of morbidity and mortality from influenza than we, presumably healthy, physicians do. Therefore, if we are exposed and unvaccinated, we may do significant damage to our own patients by spreading the virus."

Delving Into Controversy

The survey also touched on controversial issues, including physician-assisted dying (PAD). This remains a hot button issue despite the fact that the number of states that allow the practice is gradually increasing. Currently, nine states and the District of Columbia permit physicians to write lethal prescriptions for terminally ill patients, provided they meet stringent criteria. More than half of surveyed oncologists (55%) agreed that PAD should be legal, which is up from 49% in 2018.

Commenting in the Medscape report, Paul Helft, MD, an oncologist and director of the Charles Warrne Fairbanks Center for Medical Ethics at Indiana University, noted that "familiarity breeds comfort," referring to the rising number of regions that allow the practice.

There was less support for PAD for patients with incurable suffering but who were not terminally ill. On this question, oncologists were almost evenly divided. Slightly more were opposed (37% said yes and 40% said no), and 23% stated that "it depends." These numbers show an increase in those in favor compared to 2018, when 23% said yes and 53% said no.

One oncologist posed the question: "Which is better, suffering for a short time or suffering for years?"

Regarding suspicions of drug and alcohol use, nearly all surveyed oncologists (91%) said that they would report a colleague who appeared to be impaired by drugs, alcohol, or illness, but about two thirds (68%) said that they would do so only after first speaking with the person. Only 4% said they would not. Others noted that their decision to report their colleague would depend on the situation — for example, whether the doctor was impaired while at work or in a social setting.

Half of the oncologists surveyed (50%) opposed random testing for drug and alcohol abuse. This is a higher percentage than physicians in general (43%). One third felt that they should be subject to random testing, and 16% felt that circumstances need to be considered.

One respondent noted that "if random substance testing is required, then what about cognitive tests, random vision tests, random hand coordination tests?"

Another controversial topic was in regard to personal relationships with patients. Almost all oncologists (91%) felt that it is unacceptable to become involved in a romantic/sexual relationship with a patient. However, 22% qualified that statement, indicatng that it was okay after the physician had stopped treating the patient 6 months previously.

Business Issues

The pandemic has caused high rates of unemployment, causing many people to lose employer-sponsored health insurance. Most oncologists (79%) said that if their patients had lost employer insurance because of COVID-19 and had to go on Medicaid, they would not limit the number of Medicaid patients. Only 7% said that they would limit it; 3% reported that they had already done so.

Some oncologists acknowledged that these decisions were not theirs to make and that it is up to the administration. They noted that these decisions are often made without the oncologist's knowledge.

Regarding other business-related questions, 80% of oncologists stated that it is not morally acceptable to overstate or upcode a patient's condition when submitting claims or seeking prior authorization. Many condemned the practice and referred to it as "fraud" or said that it was illegal, but the percentage who opposed it decreased from 86% in 2018, and "it depends" responses increased from 7% in 2018 to 12% in the current survey. One oncologist said: "It's never a good idea to lie; however, occasionally, the best interest of the patient must prevail."

Industry Influence Over Prescribing

Regarding the influence that pharmaceutical companies have on prescribing habits, it seems that oncologist think they are less likely to be influenced by pharmaceutical companies than other doctors. Nearly three quarters (72%) of oncologists surveyed agreed that being a paid speaker at pharmaceutial company–sponsored dinners or accepting lunches from pharma reps would not influence prescribing habits. This was a higher percentage than among physicians in general (63%).

This survey result conflicts with evidence from a recent meta-analysis of 36 studies that found that financial payments from the pharmaceutical industry to US physicians were associated with increased prescribing of the paying manufacturer's drug. That meta-analysis also found "a temporal association and dose-response [that] suggest a causal relationship."

"One of the historical oppositions to further reform has been the fact that individual physicians were resistant to the idea that marketing could drive their prescribing practices," commented Aaron S. Kesselheim, MD, JD, MPH, professor of medicine and director of the Program on Regulation, Therapeutics, and Law at Harvard Medical School, Boston, Massachusetts.

"Hopefully, solid systematic reviews like this one can help finally put to rest that idea," Kesselheim told Medscape Medical News at the time.

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