Hi blueheron,
Thank you for letting me answer this quite sticky yet extraordinarily
interesting question.
As this question has evolved somewhat since your initial posting, my
plan in answering will consist of addressing your initial questions
while also discussing the general ways these
patient/physician/hospital relationships are viewed from an ethical
standpoint. Although it is clear there are many other ways to address
this problem, such as from a legal standpoint, or from a practical
standpoint as taxmama discussed, you seem firmly interested in the
moral obligations of the groups here and I trust you will use this
information as you see fit. Hopefully you can use this information at
your discretion to bring about a positive change at your institution
but at the same time avoid a negative impact on your career. I
provide a number of excerpts to show particular points, however most
of the documents linked to should be very helpful for providing more
depth to the questions at hand, and I suggest reading them in full.
First, all of the discussed obligations fall into two categories:
legal obligations and moral obligations. Legal obligations arise from
your status as either a member of society, a contracted employee of
the hospital, or are a feature of some other status in the common
?legal? sense. Your inquiry seems to be separate from these
obligations, simply about your moral obligations. These obligations
arise from your status as a physician who has some responsibility to
patients, as well as some responsibility to the greater care
institution, your hospital, however obligations to your hospital for
the most part tend to be legal obligations as an employee. We will
discuss both. An important thing to consider is the force behind both
of these classes of obligations. Because you are a citizen, you are
legally obliged to do some things, such as pay taxes for example. But
why are you obliged to act in an ethical manner towards your patients?
Goodwill and other facets of human nature aside, this obligation is a
result of your status as a professional physician:
?Professionals have a fiduciary duty toward those they serve. This
means that professionals have a particularly stringent duty to assure
that their decisions and actions serve the welfare of their patients
or clients, even at some cost to themselves. Professions have codes of
ethics which specify the obligations arising from this fiduciary duty.
Ethical problems often occur when there appears to be a conflict
between these obligations or between fiduciary duties and personal
goals.?
[ http://eduserv.hscer.washington.edu/bioethics/topics/profes.html ]
This ?code of ethics? can be defined many ways, form the ancient
ideals of the Hippocratic oath, to what is now usually considered a
standard code of ethics, one that is devised by a recognized and
respected group of physicians and ethicists, for example, those found
at: [http://dir.yahoo.com/Health/Medicine/Organizations/Professional/Medical_Associations_and_Societies/
]
So, it your status as a physician that provides the moral force as to
why you must act in an ethical manner regarding your patients.
Oftentimes today, this moral obligation is seen as secondary to legal
obligations, however the medical community does attempt to make sure
this does not happen between patients and doctors, as we will see.
Medicine always has, and continues to strive towards howling itself to
a standard of morality far higher than a business or other group of
people. Now we can address your first questions:
?A physician is bound to do his/her best for every patient? Is the
hospital treating the patient??
Yes, a physician is bound by his professional honor, as describe
above, to give the best care possible with the resources available.
According to the American Board of Internal Medicine, physicians are
obliged to practice in an altruistic manner, which they describe as,
?Altruism: A physician is obligated to attend to the best interest of
patients, rather than self-interest.?
[ http://eduserv.hscer.washington.edu/bioethics/topics/profes.html#ques3 ]
The American Medical Association has a similar standpoint on this question:
?A physician shall, while caring for a patient, regard responsibility
to the patient as paramount.?
The American Medical Association, ?Principles of Medical Ethics?
[ http://www.ama-assn.org/ama/pub/category/2512.html ]
?The relationship between patient and physician is based on trust and
gives rise to physicians? ethical obligations to place patients?
welfare above their own self-interest and above obligations to other
groups, and to advocate for their patients? welfare.?
The American Medical Association, ?The Physician-Patient Relationship?
[ http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/E-10.015.HTM&&s_t=&st_p=&nth=1&prev_pol=policyfiles/HnE/E-9.132.HTM&nxt_pol=policyfiles/HnE/E-10.01.HTM&
]
While today there are many questions similar to yours in which patient
welfare is traded off for economic reasons either in the local place
of care or on the scale of a large HMO, from an ethical perspective
the patient is always the physician?s first priority, as well as the
first priority of the hospital or any organization responsible for
patient care. The reasons for this are many, but a well-articulated
and supported view is this:
??.physicians are required to do everything that they believe may
benefit each patient without regard to costs or other societal
considerations. In caring for an individual patient, the doctor must
act solely as that patient?s advocate, against the apparent interests
of society as a whole, if necessary. An analogy can be drawn with the
role of a lawyer defending a client against a criminal charge. The
attorney is obligated to use all ethical means to defend the client,
regardless of the cost of prolonged legal proceedings or even of the
possibility that a guilty person may be acquitted through skillful
advocacy. Similarly, in the practice of medicine, physicians are
obligated to do all that they can for their patients without regard to
any costs to society. Society benefits if it expects it?s medical
practitioners to follow this principle. As Fried has eloquently
argued, in any decent, advanced society there are rights in health
care, in that ?one is entitled to be treated decently, humanely,
personally, and honestly in the course of medical care. In such a
just society, the physician who withholds care that is in his power to
give because he judges it wasteful to provide it to a particular
person breaks faith with his patient.? A similar position has been
stated by Hiatt: ?A physician or other provider must do all that is
permitted on behalf of his patient?the patient and the physician want
no less, and society should settle for no less.? A just society must
have a group of professionals whose sole responsibility as health-care
practitioners is to their patients as individuals.?
[ Excerpted from ?The Doctor?s Master?, Norman Levinsky, New England
Journal of Medicine 311, no. 24, Dec. 13, 1984: 1573-1575. ]
I copied the previous excerpt from a hard copy of mine, but if you can
get a copy of the entire document [listed at:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6438510
] I highly suggest you read it.
In any case, the conclusion from all of these perspectives is that a
physician?s foremost moral responsibility is to provide the best care
possible for his patient. It is the physician who is treating the
patient, not the hospital, HMO, nor any larger institution, and
although the physician probably has obligations towards these groups
as well as the patient, the patient is the first priority and this is
a fact that is a simple product of his status as a physician.
With this in mind, the ideal situation is that the physician in
treating the patient makes all decisions regarding patient care (under
the regular guidelines of working towards the patient?s goals, of
course), including which implants to use. Again, the hospital is not
treating the patient, the physician is, and only he is aware of both
the best medical practices and the patient?s unique conditions and
treatment requirements. Therefore, only the physician should be
making that decision, in full cooperation with the patient, of course.
In your situation for practical/non-ideal purposes, the hospital is
already in this contract situation. Yes, it could be said that they
have a conflict of interests because they have interests to provide
the best possible care for the patients but they do clearly have the
interest to save money by entering into this contract. However, from
an ethical standpoint, their interest to provide the best possible
care for the patient is again of utmost importance, even for the
hospital. This is similar to, but somewhat different, from the
physician?s obligations, and is described by similar yet different
guidelines by provided by different groups. For example, the
following Code of Ethics is the general policy of the American College
of Healthcare Executives and is a guideline for ethical conduct from a
top-down perspective (if we consider the moral actions of the
individual physician with the individual patient to be ?bottom-up?).
?The purpose of the Code of Ethics of the American College of
Healthcare Executives is to serve as a standard of conduct for
affiliates. It contains standards of ethical behavior for healthcare
executives in their professional relationships. These relationships
include colleagues, patients or others served; members of the
healthcare executive?s organization and other organizations, the
community, and society as a whole.
The Code of Ethics also incorporates standards of ethical
behavior governing personal behavior, particularly when that conduct
directly relates to the role and identity of the healthcare executive.
The fundamental objectives of the healthcare management profession are
to maintain or enhance the overall quality of life, dignity, and
well-being of every individual needing healthcare service; and to
create a more equitable, accessible, effective, and efficient
healthcare system.
Healthcare executives have an obligation to act in ways that will
merit the trust, confidence, and respect of healthcare professionals
and the general public. Therefore, healthcare executives should lead
lives that embody an exemplary system of values and ethics.
In fulfilling their commitments and obligations to patients or
others served, healthcare executives function as moral advocates and
models. Since every management decision affects the health and
well-being of both individuals and communities, healthcare executives
must carefully evaluate the possible outcomes of their decisions. In
organizations that deliver healthcare services, they must work to
safeguard and foster the rights, interests, and prerogatives of
patients or others served.?
American College of Healthcare Executives, ?Code of Ethics?
[ http://www.ache.org/ABT_ACHE/code.cfm#report ]
It is fair to say that your hospital is supposed to be following some
set of ethical guidelines devised either by their own committee or
some other respected one; guidelines that are fairly similar to these.
Excerpted from the full Code, ?Demonstrate zero tolerance for any
abuse of power that compromises patients or others served;? The
situation at hand could possibly be considered an abuse of power,
except for the fact that they may not be aware that their contract has
resulted in a level of care that is below what it should be. You must
decide if this is the case, and to what degree the hospital is aware
of the discrepancy of level of care.
You state that the hospital explicitly told you that you must use
their implants or you cannot operate. This violates two principles,
but has an important initial condition. If the hospital either has no
reason to believe that the new implants are inferior (perhaps they do
not trust your thoughts on the matter, or they have some outside
source of approval for them), or if the hospital is simply unaware of
any difference between them (although this is unlikely, because it
seems that you have already raised the issue), then they cannot be
blamed. However, if these are not true, and the hospital is
reasonably aware of a true inferiority of one implant, then it has
violated its ethical guidelines as a care institution, best described
by the following:
?Health care institutions are responsible for providing each patient
with care that is both appropriate and necessary for the patient's
condition. Development and maintenance of organized programs for
utilization review and quality improvement and of procedures to verify
the credentials of physicians and other health professionals are basic
to this obligation.?
and
?Health care institutions should ensure that the health care
professionals and organizations with which they are formally or
informally affiliated have appropriate credentials and/or
accreditation and participate in organized programs to assess and
assure continuous improvement in quality of care.?
From: American Hospital Association, ?Ethical Conduct for Health Care Institutions?
[ http://www.hospitalconnect.com/aha/resource_center/resource/resource_ethics.html
]
The hospital should have some obligation to ensure that not only are
the best possible procedures implemented and the physicians are aware
of those procedure, but that this knowledge is continually being
reviewed and updated. You asked about, ?the availability of new
technology?, and it seems as though the hospital has a responsibility
to constantly be reviewing new technology, and if there is good reason
to believe it is better than the old, to implement it if possible.
Your situation, in which the technology has been apparently
downgraded, is likely in violation of these moral goals/obligations of
the hospital.
In support of this:
?Physicians in administrative and other non-clinical roles must put
the needs of patients first. At least since the time of Hippocrates,
physicians have cultivated the trust of their patients by placing
patient welfare before all other concerns. The ethical obligations of
physicians are not suspended when a physician assumes a position that
does not directly involve patient care. (I, VII) Issued June 1994
based on the report "Ethical Guidelines for Medical Consultants,"
adopted December 1992; Updated June 1998. ?
American Medical Association, ?Ethical Guidelines for Physicians in
Management Positions and Other Non-Clinical Roles?
[ http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/E-8.02.HTM&&s_t=&st_p=&nth=1&prev_pol=policyfiles/HnE/E-7.05.HTM&nxt_pol=policyfiles/HnE/E-8.01.HTM&
]
In this way, the hospital supervisors should have the some moral
obligations as physicians, and a contract with an equipment
manufacturer inhibiting that could be considered unethical.
Additionally, they have possibly violated your moral obligations as a
physician to provide the best care possible for your patient, as
previously discussed. I would view this as true, and a wrong on the
part of the hospital. However, it could be argued that, because your
obligation is to provide the best care possible, it could be viewed
that at your hospital, providing better care (ie. with the other
implant) is not an option for you, so it is not possible per se.
However, it is their responsibility to hold patient welfare paramount
to all other obligations, so this situation should not have arisen in
the first place.
The patient most certainly SHOULD have the right to expect that the
surgeon will use the implants that he/she feels are the best. An
important part of this, however, goes back to the nature of the
physician/patient relationship itself. A patient should not be simply
assuming that the physician will take the best course of action and
should be left alone entirely (this is called medical paternalism, and
has been strongly declining in ethical regard since the 1950?s),
rather the patient and physician should be coming to a mutual
understanding regarding treatment options, the pros and cons of such
options, as well as an ultimate decision about treatment. This is a
fundamental implementation of the ideals of true informed consent.
In the context of this situation, this means informing the patient of
your concerns about this particular implant. Of course there are
possible repercussions of this, for example, a patient is frightened
of possible problems because of an inferior implant, writes to the
hospital, and you are blamed somehow, with what wrong, though, I do
not know. Still, from a moral standpoint, a patient has every right
to expect full disclosure from the physician regarding treatment
options and concerns. If you are legally unable to use different
implants (as part of your legal/contractual constraints to the
hospital and its policies) then that is a separate issue, but at the
very least you should feel ethically obliged and otherwise free to
discuss these concerns with the patient.
The conclusion from all of this is that both you as a physician and
the hospital as well have obligations to the patient to provide the
best possible care as a priority over other interests such as money.
The patient should be able to trust that these obligations are being
fulfilled, and by entering into this contract the hospital, is failing
and harming the patients. I should note that all of the other
benefits you mentioned, such as research grants and company sponsored
education, for our purposes can all be reduced to a financial interest
on the part of the hospital. They are things that are gained that
would otherwise be merely more expensive, and yet are gained at the
sacrifice of patient welfare.
Of course this is all assuming that the new implants are, in fact,
inferior, an this is something you must take into deep consideration,
and look at from the hospital?s point of view as well. It is possible
that, although you do not prefer them in surgery, they are still FDA
(or otherwise) approved, and the hospital would then have good reason
to assert that they are fulfilling their obligations to the patients.
If this were the case, then they could feel free in entering a
contract that would simply save them money. That they fulfilled their
obligations would certainly be true in a legal sense, and quite
possibly true in an ethical sense, however how much extra thought went
into review of the implant, such as feedback from surgeons as
yourself, and how much oversight is done to really ensure that they
are the best possible devices is an important consideration. As
mentioned earlier, health care at its heart is not a business, it is a
profession, and the obligation to provide the best care surpasses that
to make money. If the hospital is relying on an appropriate outside
means of approval for the devices, they certainly could be said to
have met their basic responsibilities towards patients, even if they
have not, perhaps, taken the best possible measures. However, they
would not be living up to the goals and moral ideals of the practice
of medicine, which I believe is the most important thing to you and
the patients, and is only being degraded by the larger institution of
managed care.
Ethics in matters such as these is a constant struggle between what is
right and wrong in theory and what can actually be implemented in the
real world, two considerations you are stuck right in the middle of.
The fact that you brought this dilemma up in the first place speaks
volumes about your consideration for your patients, and shows true
professionalism in that you are not settling for a mediocre standard,
but rather are doing everything possible to enhance patient welfare.
I hope this has provided you with the relevant theoretical foundations
for considerations that must be made in your situation. I have not
discussed the many legal questions that this situation poses, but
hopefully you can bring about some change for the benefit of the
patients while still fulfilling those legal obligations to the
hospital. Good luck!
Additional resources:
American Medical Association Code of Ethics
[ http://www.ama-assn.org/apps/pf_new/pf_online?category=CEJA&assn=AMA&f_n=mSearch&s_t=&st_p=&nth=1&
]
Topics in Medical Ethics:
Managed Care
[ http://eduserv.hscer.washington.edu/bioethics/topics/manag.html ]
Physician-Patient Relationship
[ http://eduserv.hscer.washington.edu/bioethics/topics/physpt.html ]
Professionalism
[ http://eduserv.hscer.washington.edu/bioethics/topics/profes.html ]
Although I trust this information will be more than satisfactory, if
you require a clarification, feel free to request one, especially
before rating this answer. Thank you for bringing your question to us
at Google Answers!
Sincerely,
Andrewxmp
Search strategy and sources cited:
Google: Physician obligation patient
[ ://www.google.com/search?hl=en&lr=&ie=UTF-8&q=physician+obligation+to+patient
]
Google: medicine fiduciary duty
[ ://www.google.com/search?hl=en&ie=UTF-8&q=medicine+fiduciary+duty+&btnG=Google+Search
]
Google: medical ethics physician responsibilities institution care hospital
[ ://www.google.com/search?hl=en&ie=UTF-8&q=medical+ethics+physician+responsibilities+institution+care+hospital]
?Declaration of Professional Responsibility; Medicine?s Social
Contract with Humanity?
[ http://www.ama-assn.org/ama/upload/mm/369/decofprofessional.pdf ]
?Ethics in medicine: Pofessionalism?
[ http://eduserv.hscer.washington.edu/bioethics/topics/profes.html#ques3 ]
?The Doctor?s Master?. Levinsky, Norman. New England Journal of
Medicine 311, no. 24, Dec. 13, 1984: 1573-1575.
Ethical Issues in Modern Medicine. B. Steinbock, J. Arras, A.J.
London,. 2003, McGraw-Hill, New York. |
