Photo Credit: Trifonov_Evgeniy

Ethical conflicts occur when caring for patients, so learning when to prioritize a patient’s needs over training/standard protocol is an important skill.

Working as a physician is no easy feat, especially at times when ethics come into play. Sometimes, doctors must consider whether a specific patient’s needs should trump the physician’s ethical training, even if it means going against what they learned in medical school. For example, when engaged in her residency rotation on a Native American tribal reservation, the tribal elder informed family physician Melissa Lucarelli, MD, that, in their culture, medical conditions might be brought on even by the simple act of speaking about a particular fetal genetic problem or pregnancy complication. Nonetheless, Dr. Lucarelli’s advisors told her to mislead prenatal patients by referring to screening labs as “routine blood tests,” as the US ethical standard requires detailed test explanations to ensure that patients can make informed decisions regarding their care. Dr. Lucarelli’s superiors essentially told her to lie about the purpose of bloodwork, especially bloodwork ordered to determine fetal health, out of concern that patients would jeopardize fetal health by refusing to have blood drawn—a move that completely disregarded Native American ethical beliefs.

Growing divisive social and cultural issues pervading the US as a whole have crept into doctor-patient relationships as well. Everything from the Supreme Court’s overturning of Roe V. Wade to vaccination skepticism has created a climate of nervousness and sometimes fear amongst physicians. While making sure to do right by their patients is a top priority, some physicians nonetheless worry about overly litigious patients and the threat of going to jail. According to assistant professor of bioethics at the Case Western Reserve University (CWRU) School of Medicine in Cleveland, Oliver Schirokauer, MD, PhD, the lack of clear ethical guidelines driving today’s physician-patient relationships can frustrate doctors, as the ethics training that they underwent in medical school may now be contradicted or blurred.

Dr. Schirokauer finds that physicians tend to prioritize patient autonomy. Although doing so might help avoid litigation regarding ethical questions, it also may result in patients not receiving the best possible care and, ultimately, the best possible health outcomes.  In other words, even if a physician knows that a certain avenue may be best for the patient’s health, if the patient is opposed to going down that avenue, prioritizing patient autonomy would mean choosing a different route.

According to the president of The Physicians Foundation, Gary Price, MD, ethics in medical care are particularly complicated regarding end-of-life choices. While decades ago, a patient’s primary care provider (PCP) would have been involved in that patient’s hospitalized care and their end-of-life decisions within the hospital, the fragmented nature of today’s healthcare system has all but eliminated PCPs from involvement in hospitalized patient care. As such, patients often make end-of-life decisions based on the guidance of doctors with whom they have no pre-existing relationship.

Other factors that blur ethical lines in healthcare, adds Dr. Price, are the new state of healthcare ownership and financing. Dr. Price mentions, for instance, conflicts of interest due to the US’s biggest employer of physicians, Optum, being a subsidiary of the same company that owns UnitedHealthcare. This situation allows for an insurer who controls reimbursement and who could, as the physician’s employer, influence decisions made regarding patient care. Sadly, this influence largely comes from financial concern instead of concern for the patient’s best health outcomes.

According to L. Allen Dobson Jr., MD, FAAFP, former chief executive officer (CEO) of Community Care of North Carolina, physicians essentially have the government and the insurance companies in the exam room; the physician-patient relationship is no longer a twosome. Should a physician disagree with either the government or the insurance company’s denial of their medical recommendation, Dr. Dobson notes that doctors can ethically advocate for their patients within the “gray areas” of laws and payer rules. However, Dr. Dobson urges physicians to use solely verifiable facts to back up their case. Should a physician find themselves in an ethical dilemma, Dr. Price suggests discussing it with a colleague, their hospital’s ethics committee, or their hospital’s legal team.