September 20, 2020
Gwen Y. Reyes-Amurao, M.D.
Ethics is a branch of knowledge that deals with moral principles that govern a person’s behavior or conduct. For physicians though, ethics can be far more complicated than what was described. According to the National Institute of Health, medical ethics deals with the right choices of conduct considering all circumstances. Furthermore, it deals with the distinction between what is considered right or wrong when it comes to physician obligations in relation to the patient. In short, ethical concerns mainly arise from a doctor-patient relationship, with the prerequisite that the outcome should always be for the good of the patient.
A physician’s practice is based on the principle of providing good patient care and preventing harm. Because patients and cases vary, every situation entails a different ethical approach. This can lead to some ethical dilemmas. Here are some common ethical issues physicians and the healthcare industry in general, currently face.
Because of the increasing number of patients or consults and the limited clinic hours, doctors are often pressured to keep consultations brief in order to see as many patients as possible. Sadly, this often leads to compromised patient care, making it more difficult to reach an accurate diagnosis that can lead to undesirable health outcomes. At present, the standard time of allotment per patient is between 10 to 12 minutes, which seems not nearly enough time to perform a thorough physical examination and extract relevant medical history in order to make an excellent diagnosis.
How to Deal With It
Effective time management seems to be the simplest answer to such a dilemma. However, when a patient comes to consult, the amount of time it would take for him to completely divulge or report all complaints is out of the hands of the physician. Extracting the right information related to the illness may take some time. The doctor sometimes addresses this issue by asking leading questions, cutting off the patient or cutting corners on patient care.
Dr. Clarence Braddock’s study published in the Journal of General Internal Medicine, mentions the importance of hearing out all the patient’s complaints and how not letting them do so may mean missing out on the most important one. He suggests asking the patient to list down all his complaints, running through all of them, and asking him to prioritize which ones need to be dealt with first.
Although being ethical may entail spending more time with a patient, the relationship built and the type of management or care provided that the patient receives will always be beneficial for both the patient and the physician.
Inappropriate Drug Dispensing
Closely related to brief consultations leading to compromised patient care is the ethical issue that involves over- and sometimes under-dosage of medications. When patients are all lined up, reaching for the prescription pad seems to be the fastest option instead of paying attention to a patient’s complaint. This is especially true in patients who come in presenting with pain. Described as a band-aid solution, doctors may have a tendency to simply give pain medication even without thoroughly assessing the patient and finding out the underlying cause of the pain. This often leads to recurrent or chronic pain which soon affects the functionality of a patient and ends up doing more harm than good.
The issue of under dosage is often seen in pediatric patients where computation of dose is essential in the administration of the exact amount adequate for the child’s weight, and not merely on how the child appears. Antimicrobials or antibiotics are especially sensitive to dose and may lead to resistance when not administered properly.
How to Deal With It
Again, taking time to listen to the patient and determining the underlying problem of each complaint can help address this issue. A doctor must also resist the urge of prescribing or giving medications as soon as the patient comes in for consultation. Sometimes, merely listening to the patient can already provide relief and not require any type of medication. Doctors also often encounter patients who demand to take medication, especially antibiotics even when not indicated. In this case, it is important to emphasize who the patient and the doctor is, and how physicians always choose what’s best for their patients clinically.
Conflicts of Interest
Pharmaceutical companies often target physicians when it comes to dispensing drugs or medications they carry. Unfortunately, most of the doctors are still influenced by which companies can give them the most freebies and business trips for them to prescribe the medications from such companies. In a report published in the Journal of Obstetrics and Gynecology, it was noted that even small gifts produce in their recipients a disproportionately powerful willingness to reciprocate in some manner. Even something as simple as a pen or ref magnet can already pose a strong influence when it comes to deciding which type or brand of medication should be prescribed to the patient. More than anything, efficacy and cost-effectiveness should still be the cornerstone of any treatment regimen, with or without gifts in tow.
How to Deal With It
Recently, the Council of Medical Specialty Societies published a Code of Ethics which was meant to address such a dilemma, seeking to limit the influence of for-profit enterprises. Although clinicians are encouraged to shy away from such practices, in the end, the ethical and moral decisions lie entirely on the physician and how he chooses based on the need of the patient and not his own.
Restrictions in Patient Referrals
This ethical dilemma often arises within the hospital setting. Patient referrals are most of the time, automatic and limited to specialists within the organization, which can sometimes entail the highest cost, but not always the highest quality of care. In the Philippine setting, health cards or Health Maintenance organizations’ (HMOs) currently dictate which doctors will be seen by patients despite a proper decking referral system. In these cases, preferred doctors are assigned patients more often compared to those who are less preferred. Although a physicians’ roster is available for patients to choose from, HMOs’ may sometimes direct or lead the patients into choosing those closely associated with them, thus leading to more patients and more professional fees to be collected for the preferred physicians.
How to Deal With It
Computerized referral systems seem to benefit physicians by making sure that all referrals are made and done equally and removes the likelihood of having preferred physicians as default. If a doctor observes such a bias in his practice, it would be best to report to the HMO Coordinator or the HMO or healthcare provider since these do have consequences for those involved.
Science and technology have invaded the medical field in more ways than one. Although generally beneficial for patients, especially those found in far-flung areas, the advent of online and electronic communication with patients is slowly substituting real, personal consults with physicians. Because of issues involving increasing fuel prices and horrible traffic filling up the streets, telehealth or telemedicine is now becoming a widely-accepted form of receiving and giving medical attention. The issue of depersonalization or loss of a personal, caring touch from a physician, especially in sensitive medical conditions, threatens the quality of health care in the end.
According to the American College of Physicians, a doctor-patient relationship should and can be established through some guidelines that deal with real time audio and/or visual technology. Some recommendations include:
Telemedicine is not applicable in all specialties though. Based on a 2015 Cochrane study entitled Interactive Telemedicine: Effects on Professional Practice and Healthcare Outcomes, results were the same for telehealth and office visits for heart failure, mental health, substance abuse and dermatology. While a more recent study showed better outcomes than just office visits for patients with chronic conditions like hypertension and other respiratory conditions.
How to Deal With It
According to the British Columbia Medical Journal, both the patient and the doctor must be aware of the implications of consulting through Telehealth or Telemedicine. Its emergence does not necessarily mean a decline in clinical practice especially when the physician is aware of how to deal with privacy issues or concerns while exploring this option in his field. In fact, this mode of practice has even increased delivery of medical care especially in areas too far to reach physically but are accessible through the internet. Currently, there are protocols and guidelines being used when it comes to telemedicine intervention. Since this concept is still relatively new here in our country, it is still best to advise the patients to come in for actual health consultation for follow-up care later on.
The Age of Genetic Testing
The National Institute of Health defines genetic testing as a type of medical test that identifies changes in chromosomes, genes, and proteins. This is often used to confirm or rule out a suspected genetic condition especially when there is a high chance of developing it through genetic lineage. Several methods that are currently being used include:
The ethical dilemma when it comes to genetic testing lies not in the test itself, but more on how to relay information once the tests come out positive for a particular genetic disorder, more so if no known cure has been associated with it.
How to Deal With It
In any physician practice, it is always best to be well-informed and updated when it comes to advances in technology and healthcare. It is important to do thorough history taking especially when it comes to determining the family history of certain genetic disorders or conditions to determine which type of test is suitable for those involved.
It must be understood that genetic testing is purely voluntary and getting adequate information from a geneticist or genetic counsellor may be needed in order to fully understand the pros and cons, limitations, and risks of such a test. Referring to a geneticist or genetics specialist for proper counselling or further management is important once a genetic disorder is detected.
The Hippocratic Oath
The basic objective of the medical profession is to give service to everyone with full respect for the dignity of his profession and mankind. In the end, physicians should always act on what is good and avoid doing harm, and bear in mind the well-being of their patients, the protection of public health, and the betterment of the medical profession. Once these are the primary considerations, ethical issues are kept to a minimum and both the patient and the physician win.
Braddock CH 3rd, Snyder L. The doctor will see you shortly: the ethical significance of time for the patient-physician relationship. Journal of General Internal Medicine 2005;20:1057-1062.