Influence, interactions, and ethical dilemmas

A wealthy patient who was nearing Medicare age fretted that he'd get “second-class” treatment once his insurance changed. Tom Bledsoe, MD, FACP, reassured the man that he'd remain his doctor and that insurance wouldn't affect any care decisions. But soon afterward, the general internist faced an ethical dilemma when four bottles of wine arrived at his office.

Upon further checking, Dr. Bledsoe realized that the wine retailed for $50 to $70 per bottle, pricier than a small gift basket or a box of chocolates that could be easily shared among office staff or donated elsewhere. Should he keep the wine or not?

Dr. Bledsoe, the Immediate Past Chair of ACP's Ethics, Professionalism, and Human Rights Committee, detailed this dilemma via email among several other personal experiences. If he refused the wine, would the patient be hurt or offended? If he accepted, would he be influenced in some way to provide “special” care? In the end, Dr. Bledsoe said he took time at the man's next visit to thank him for his thoughtful gift but also to explain that it was unnecessary and that his treatment wasn't at all at risk.

Dr. Bledsoe recounted that he's “still a bit conflicted” about this particular situation.

Physicians have been confronted with such ethical dilemmas since the dawn of medical practice, whether it's navigating inappropriate gifts, so-called VIP relationships, or the complexities of end-of-life decisions. But advances in technology, genetics, and evolving financial reimbursement models continue to create new conundrums or add layers or twists to age-old debates. ACP's most recent update of its Ethics Manual, which was published in January in Annals of Internal Medicine, provides physicians with new and expanded guidance on topics ranging from telemedicine to the changing practice environment to social media and online professionalism.

“The practice of medicine has changed a lot, and the world of medical delivery has changed a lot,” said Dr. Bledsoe, who is also a clinical associate professor of medicine at the Warren Alpert Medical School of Brown University in Providence, R.I. “Those changes have brought up new tensions. How does a thoughtful, ethical, professional physician in practice respond to these tensions?”

To some extent, ethical dilemmas for physicians are intractable, although the specifics of the scenarios might shift over the generations, said Matthew Wynia, MD, MPH, FACP, who directs the Center for Bioethics and Humanities at the University of Colorado. “There is something about the nature of being a healer in a social environment that creates ethical dilemmas,” said Dr. Wynia, who published a related piece in 2013 in the American Journal of Bioethics.

For instance, in Plato's time, there was no such thing as mass shooters, but physicians still would have encountered patients expressing violent thoughts, Dr. Wynia said. These days, though, the risks are undoubtedly greater when a physician treats a similar patient, someone who confesses to mass shooting fantasies but says he won't act on them.

“That's a new problem, but it's also an old problem,” Dr. Wynia said. “It's the problem of patient confidentiality versus public safety.”

Evolving ethical dilemmas

While the doctor-patient relationship is to a large degree focused on the individual, the individual's needs may come into conflict with public safety, finances, or other interests, creating a potential push-pull in the relationship, Dr. Wynia said. “Can the individual really trust you to look out for their best interests?” he asked. “Or are you looking out for the interests of the larger community or for a corporation?

For instance, the ABIM Foundation's Choosing Wisely campaign to discourage low-quality care represents “a more explicit acknowledgment that physicians do have a responsibility towards the sustainability of the health system,” Dr. Wynia said. “And that can come into tension, if not outright conflict, with the needs or perceived needs of individual patients.”

Carrie Horwitch, MD, MACP, described one such scenario when a woman with low back pain came to her office after visiting a chiropractor. The chiropractor had recommended an X-ray but said that insurance wouldn't cover it if the chiropractor ordered it.

The patient was upset and insistent about the X-ray, but Dr. Horwitch's physical exam didn't point to any clinical need. She devoted some time to explaining why other steps were preferable, such as physical therapy. “It was not appropriate to do the X-rays simply because she asked for them,” said Dr. Horwitch, who is a past Chair of the ACP Ethics, Professionalism, and Human Rights Committee and an internist and key clinical faculty at Virginia Mason Medical Center in Seattle.

Increasingly, though, ethical dilemmas are becoming further complicated by societal or medical advances, whether that's in the area of genetics or technology or social media, said Dr. Wynia and other bioethics experts.

Even before social media, physicians had to consider their interactions with the surrounding community, such as whether writing an op-ed for the local paper would lead to political conflict in the exam room, Dr. Bledsoe said. But the social media world is creating new scenarios. He cited a piece that a Brown medical student recently wrote for Slate, raising concerns about the ethics of medical students serving as influencers on Instagram.

“They actually can make a pretty penny out of that apparently,” Dr. Bledsoe said. But cashing in on their medical status and feigning a medical expertise they don't yet possess are both ethically problematic, he said.

Another modern ethical permutation: The quality metrics that practices increasingly are being asked to meet, often with financial incentives attached, are raising practice dilemmas, Dr. Bledsoe said. In his practice, as each measurement period ends, he'll receive a list of outliers who haven't yet met their blood pressure targets. Some patients on that list will likely improve the overall metric if they're called in for one more visit and a blood pressure check, he said.

Should Dr. Bledsoe inconvenience those “easy” patients with an additional visit or instead invest that time on sicker, more complex patients, benefiting those most in need but likely not in time to improve the current metric? To head off that dilemma, Dr. Bledsoe said his practice group has worked hard to help patients achieve blood pressure and other screening goals throughout the year, in order to avoid a mad scramble at year's end.

In other scenarios, the logistics of modern-day documentation—specifically involving the sometimes unwieldy design of the electronic health record—can encourage some doctors to take worrisome shortcuts, Dr. Horwitch said. To speed up the documentation process, they might be tempted to cut and paste a prior medical note into the chart without giving the physician who wrote it credit, which is “ethically problematic,” she said, “because they are taking credit for a history or a physical exam that wasn't their own.”

Clear-cut violations

Medicine isn't immune from outright breaches of ethics, violations such as the repeated sexual abuse committed by USA Gymnastics national team doctor Larry Nassar, who was convicted last year. An analysis published in January 2019 by the American Journal of Bioethics, which looked at a total of 280 cases involving sexual abuse, criminal prescription of opioids, and unnecessary surgeries, identified a number of strong patterns. Nearly all of the cases, 97%, involved repeated instances of wrongdoing, overwhelmingly with male perpetrators (95%). Other patterns included nonacademic settings (95%), limited oversight (89%), and a selfish motive such as financial gain or sex (90%).

“I don't think we can prevent all of these, but I do think we could get better at preventing repeat cases,” said James DuBois, PhD, director of the bioethics research center at Washington University School of Medicine in St. Louis and the study's lead author.

Excessive opioid prescribing was particularly likely to occur at very small or solo practices where there was frequently no oversight, Dr. DuBois said. “I think that simply having peers around or even trainees, medical students or residents, provides a certain level of informal oversight that can be very effective,” he said.

The many years of abuse inflicted by Larry Nassar represent one of the most egregious illustrations of the weaknesses in the existing reporting systems, Dr. DuBois said. In his 2019 analysis, he pointed out that the cases of misconduct reported in the National Practitioners Data Bank were described only in vague terms if at all.

And there are signs of inconsistent actions by state medical boards. One study that Dr. DuBois cited, published in 2017 by BMJ Quality & Safety, found that the average rates of state medical board disciplinary actions over a four-year period ranged fourfold across the states, from 2.13 actions to 7.93 actions per 1,000 physicians.

Any discussion about more effective prevention also shouldn't shy away from medicine's gendered culture and the fact that a preponderance of incidents involved male perpetrators, said Alyssa Burgart, MD, who wrote an editorial that accompanied Dr. DuBois' January 2019 analysis. In it, Dr. Burgart cited studies showing patterns of gender inequities ranging from a higher rate of men in medical leadership to a disproportionate number of male first authors on journal articles.

While publication in peer-reviewed journals might simply appear to be just another data point, such kudos contribute to the recognition escalator involved in promotion to medical leadership, said Dr. Burgart, an assistant clinical professor of anesthesiology at Stanford University School of Medicine in California. If more women were in leadership positions, they would be better positioned to speak up when there are discussions involving ethical dilemmas and potential violations, she said.

“It takes moral courage to point those things out,” Dr. Burgart said, and even more so if the physician raising the concern sits lower on the medical hierarchy.

Speaking up

To better protect patients, Dr. DuBois believes that reporting needs to be strengthened, along the lines of a confidential database that follows physicians from medical school throughout their careers. The sorts of violations he studied, he noted, are at the outer extreme of physician misconduct. But identifying them sooner requires physicians to step forward with their concerns, he said.

“Do something rather than nothing,” Dr. DuBois said. Some institutions have policies regarding whom to speak with, he said, and if not, sometimes a confidential compliance hotline number is an option.

But sometimes it's not clear whether a physician's worries about a colleague are valid, Dr. Wynia said. For instance, is a surgeon still operating at an age when his or her skills might have begun to erode?

Depending on the severity of the suspected infraction, it might be best to start by talking to the doctor involved first, Dr. Wynia said. If that goes nowhere, or isn't feasible, then the concerned physician could consult with other colleagues, whether it's the medical staff at the hospital, partners in private practice, or a professionalism committee at a hospital or clinic—people who know the individual involved and the circumstances the best. If those conversations prove to be unsatisfying, then additional steps should be taken, such as reporting to the state medical board, he said.

The updated ACP Ethics Manual includes a six-step decision-making approach to ethical dilemmas that may help physicians, Dr. Bledsoe said. Along with assessing the participants and the principles involved to better assess the dilemma, the six-step guide advises that physicians conduct a preventive review to determine how a similar situation could be prevented in the future.

“It's certainly easier with a lot of ethical dilemmas to just move on and pretend that it didn't happen or isn't happening or it's not my problem,” Dr. Bledsoe said. “But to be a strong profession, part of the definition is self-regulation.”