MEDICINE - PHYSICIANS 20 TOP ETHICAL CONCERNS - DILEMMAS

Physicians' Top Ethical Dilemmas Would you fight with a family that wanted to withdraw care from a viable patient? Would you follow the family's directive to continue treatment if you thought it was futile? Would you date a patient? More than 24,000 physicians told Medscape, WebMD's physician web site, how they feel about this and other ethical dilemmas.

1. Physicians' Comments: Yes: I have seen a patient recover after a prolonged comatose state post cardiac resuscitation which went on for 30 minutes. His therapy was thought to be futile. It gives time for family members to arrive and to say goodbye before their loved one dies. Therapy may extend the patient's life/time to achieve his or her goals before death. Sometimes it's what the family needs to see before they can let go. No: If it's not medically indicated, I would strongly encourage the family to withdraw treatment. Not if the outcome is blatantly obvious. I would help the family determine if they are making their decisions based on what's best for the patient as opposed to themselves.

2. Physicians' Comments: Yes: I believe the one with the longer life expectancy should be given more consideration. We do that nationally with rationing organ transplants. Crisis situations require one to offer resources based on the chances of surviving. No: There is no guarantee the younger person will live longer or be "more valuable," as if we could make that determination. I would oppose depriving senior citizens of health care in order to divert public monies to unspecified medical services to younger patients. If both were my patients, I would choose an older patient contributing to society over a young psychopathic, mass murderer, for example. A human life is priceless; age has nothing to do with it.

3. Physicians' Comments: Yes: If it's to prevent malpractice, it's necessary! You only know if it was "unnecessary" after the results are known. Medicine is not an exact science. We all fear "missing" something and then having that exploited by lawyers later. The lawyer down the street wants my lunch. No: "Defensive medicine" is an excuse for ignorance of the mechanics of professional liability -- of our duties and risks. It is wasteful and unnecessary. Litigation risk is an embarrassing alibi. If physicians wanted to minimize risk they would exercise their best judgment and thoroughly document it.

4. Physicians' Comments: Yes: Do not take away hope -- miracles do occur. Only God knows that the event will be terminal. I think breaking a patient's spirit of hope will hasten their demise. "Completely truthful" can be a synonym for "gratuitously cruel." We don't know everything. No: Withholding information important to patient's capacity to choose treatment or otherwise manage his/her life is wrong. One can present the truth about the diagnoses and prognosis in a hopeful caring way. If death is impending, they should have the dignity they deserve to make end of life decision and prepare. I have never "hidden" information from a patient. However, one can never underestimate the power of hope within a human being.

5. Physicians' Comments: Yes: If there's absolutely no adverse effect, why undermine the patient's confidence in my competence by discussing every minor mistake? No need to reveal trivial issues: A prescribing error that the pharmacist picked up is obviously not a big deal. I don't feel that "coming clean" is a winning proposition, so with no harm at all, there is no upside. Innocuous errors are unnecessary fodder for plaintiff attorneys and anxious patients. No: I need to be honest at all costs. That is the foundation of a physician patient relationship. Something like giving the wrong drug -- even if no harm results -- is worth reporting for continued quality improvement. Tell the truth always, no excuses. All of my patients have been appreciative of my honesty.

6. Physicians' Comments: Yes: With a terminal patient, 'suicide' is a misnomer; the only choice is about how rather than if they will soon die from their illness. My sister died of ALS and there is no hope. She suffered, her children suffered and I as a physician found it very difficult to stand by when she couldn't even swallow or breathe without assistance and was in severe pain with no end in sight. Patients with a terminal illness lying in misery without cure should be allowed to control their fate instead of suffering through 3 months with hospice attempting to control symptoms. No: The proper term is physician-assisted homicide. NEVER!!! We swore an OATH to do no harm. We are healers, not murderers or accomplices to murder.

7. Physicians' Comments: Yes: My responsibility is to the patient, not the family. If the patient wanted to keep going then that would take precedence over the family's wishes. If I felt a patient had a reasonable chance to recover, I would get an ethics committee opinion or ask the family to find another physician if they wish to terminate care. I wouldn't go against their wishes, but I'd explain fully that I believed the patient had a chance to recover. I did that, once with a young healthy female who overdosed and was on a ventilator. Her 18-year-old son wanted to stop all treatments. No: Not if they have a signed durable power of attorney document. But I will work hard to tell them all the facts and get other appropriate specialists involved so we can build consensus. If family members are legal guardians, I follow their wishes.

8. Physicians' Comments: Yes: If a match made in heaven happens to show up in the office, so be it. You would have to end the patient relationship immediately. If there were a mutual desire to become romantically involved and if the relationship's foundation is love. If it's a single ER visit? Date the doc next month. I'm married to one of my patients for more than 30 years. No: This is creepy and beyond unethical. A patient is vulnerable, it is too difficult to be objective and could place patient at risk. Keep that line large and bright!! Patients can always claim sexual abuse and you are guilty with judge or jury, since it's your word against the patient's.

9. Physicians' Comments: Yes: When I lose money seeing patients and I can't pay my staff, I have little choice. Patients leave us all the time for the same reason. Most of the time I would continue seeing a patient, but there is a practical reality of not being able to stay in business. I would still see them at reduced rates that they could afford. No: I just don't accept new patients in those bad insurance plans, but never fire my ongoing patients. If for some odd reason the insurer does not approve of my fees, I just write them off. It is a privilege to be able to help some fellow human being. I have an obligation to take care of those patients.

10. Physicians' Comments: Yes: We are placed in a terrible situation. I have one patient who is dying because of insurance denials claiming a needed test was experimental. I have other patients who have suffered terribly due to insurance cook book protocols. The rules of the hospital and insurance companies are not always set up for looking out for patient's welfare. To accentuate the negative symptoms, absolutely yes if the purpose is to get the patient needed services. If the insurance company is harming the patient, our duty is to the patient first. No: Anyone who says yes to this should lose their license. This is a form of stealing. There are so many ways to increase one's fee by altering the billing information.

11. Physicians' Comments: Yes: If the individual is still actively in practice and I strongly believe the colleague to be impaired, I would report on the basis of patient safety. Impaired physicians can cause patients harm and even death. Been there, done that. I found out that colleague had been impaired for much longer, and more seriously, than I had ever guessed. I would certainly talk with them first though and give them a chance to correct the situation. No: I should but probably wouldn't. I would make a narrow interpretation of whether it is my duty or not. Only if I could stay completely anonymous.

12. Physicians' Comments: Yes: The physician has no business making a value judgment on what kind of quality of life is good or bad. Did the blind-deaf-mute Helen Keller have a terrible quality of life? Many parents have described the blessing of having a terminal child even for a short period of time, or despite the adjustments their life had to undergo. It's the parents' decision, based on family meetings with my best assessment given to them. No: I would not provide intensive care to a newborn with a known fatal disorder. Having a terrible quality of life is worse than death. I think this is cruel to do to the infant as well as the parents. It is the height of insanity to provide this care in these circumstances. There are too many children who are abandoned by their parents with trachs [a surgical opening in the windpipe] & on chronic ventilation.

13. Physicians' Comments: Yes: Too much information doesn't usually help to make a truly informed decision but it often makes deciders depressed no matter what they choose. I would prefer to be completely frank, but not all my patients have either the education or the intellectual capability to understand everything we tell them. If you took the time to describe the risk of taking aspirin, no one would ever take one and for some it might be life-saving. No: Is it informed consent if the risks are not described? People deserve to be trusted with the truth and we have no business deciding for them what they can know or not know. This will almost certainly come back to haunt you. Good information about the risk vs. benefit is the way to "get" consent. I think if benefits outweigh risks, I should be able to communicate that.

14. Physicians' Comments: Yes: I have actively intervened to get some patients to change physicians when they are innocently trusting a doctor who is dangerous. I'd tell the patient that that doctor was not someone I could recommend and I'd give them a list of other more competent people. "Do no harm" includes PROTECTING patients from harm. I'd tell the patient that I would not let the physician work on myself or any of my family members. No: It is not my place to override hospital credentialing practices. I probably wouldn't say the physician was substandard unless I believed there was a high likelihood that they could hurt the patient. Everyone has varying skill. If the physician is board certified is all that matters. I might recommend a second opinion. Sometimes you pretty much can't do it because you would kick up a hornet's nest.

15. Physicians' Comments: Yes: Placebos can be very powerful treatments; they have a high degree of success in most double blind studies. If in my judgment the patient will leave my care and search out another physician to "treat" (i.e.: medicate), I might prescribe a medication which will do no harm but has no therapeutic value to the patient. You are treating his psychological makeup and this can be helpful and make him feel better. No: I would not prescribe the medication if I felt that it was not needed, regardless of whether the patient was adamant. Don't let the tail wag the dog. I flatly refuse to prescribe, you can find another physician. If a patient has a condition which does not require treatment in my opinion, I am NOT gonna treat them.

16. Physicians' Comments: Yes: If the other person is also my patient, then I have a duty to that patient as well! If the patient does not appear willing to be honest with their partners who can be at risk, I would inform the CDC according to guidelines in the interest of public safety. Only if they refuse to act responsibly and disclose it to others and let them have the opportunity to protect themselves. I would seek legal advice beforehand. No: I would discuss with the patient his/her options and the right thing to do, and request to be allowed to speak with the family or people at risk. I would be inclined to protect as many as I could.

17. Physicians' Comments: Yes: A dedicated lunch offers a chance to ask questions and actually ruminate on how the product might work for your patients. The alternative is doing what we do -- a bit of reading and trying it out patient after patient. I am outraged at the notion that a lunch or a pen or a book could be felt to be inducement for me to prescribe certain drugs. If you accept lunches from ALL reps, that levels the playing field and you make your own choices. I find it insulting that it is assumed physicians will change their prescribing habits for a tuna fish sandwich. No: I want to believe I can be, but the evidence says I'm kidding myself. No, I think we kid ourselves that we are unbiased, but our preferences are just under the surface. No, if I had a couple of lunches with a rep and we developed a friendly relationship, I would feel pressure even if the rep wasn't actively exerting pressure.

18. Physicians' Comments: Yes: My duty is to assure as much as possible that my patients are safe. In some cases I'm afraid reporting would cause more damage than not. I've had experience of reporting and the investigation was not complete or the kids were placed in worse places. I would need more than a "suspicion" to report. The agencies that investigate these complaints have a lot to be desired and do not follow the same evidence-based rigors that the medical profession does. No: Once you've seen the devastation of child or domestic abuse, you become more "ready" to report these problems when they arise. Being conflicted is common -- failing to report is inexcusable. Any suspicion should always be reported, the burden of proof lies with the investigating agencies and other parties involved. I hate to create a problem for a family but I also would hate to miss an incident of sexual abuse. It's best to err on the side of safety.

19. Physicians' Comments: Yes: We usually under-treat pain because we can't measure it and we don't always trust our patients. Becoming addicted to narcotics is a worse outcome than feeling some pain. Controlled pain is a better alternative. I fear the prosecutor more than I fear the patient complaints. No: This should not be necessary with multimodal pain control. Any patient with pain severe enough to need addictive medication should be provided sufficient analgesia to maintain a reasonable quality of life, even if the price is addiction. It would be unethical to intentionally undertreat at a given point in time for a perceived risk in the future.

20. Physicians' Comments: Reporting a family to social services when the parents became incapable of treating their 40-year-old daughter with Down's syndrome and having her removed from the home. Delivering babies when Mom wasn't sure who the Father was and the husband was present. Doing ICU care on a quadriplegic, who could only blink an eye to indicate answers/respond to questions. Sending patients to nursing homes when they do not want up go there. They prefer their homes. Whether to treat a patient to the point that he could be found sane and thus executed. Withdrawing care from a young female who was critically ill but perhaps may have still be kept alive but with brain damage after she suffered septic shock.

Overstating conditions to insurance companies remains the most difficult. I don't want to commit fraud but in each case the patient has benefited greatly with the correct treatment. End of life decisions in the face of medical futility. Recognizing the deficiencies of another physician. Not initiating dialysis in a patient with end of life medical issues. Patients wanting futile care for themselves. Continuing futile care when the family demands it for a terminally ill or brain dead patient. Underage patient whose life threatening illness is easily treatable but guardians refuse to consent to treatment. To abort or not a severely compromised fetus. End stage liver disease patient is currently almost too sick to come out alive from the transplant but will surely die without one. However, the organ might save someone easily that is not as critically ill. Having to operate to save the life of a criminal who had harmed several people.