Clinical Ethics in a Generalist's Practice

Often, ethics discussions center on ethical decisions that are made in tertiary care environments. Medical personnel discuss the future of premature babies, the risks and benefits of dangerous procedures, and the boundaries between life and death in the ICU. These cases in tertiary care settings have become models for the ethical decisions that physicians make when they learn to distribute scarce resources and make difficult decisions about patient care. Yet, the majority of Americans seek medical care on a daily basis from providers in ambulatory and office settings, and bring with them numerous ethical decisions to be made by their generalist physicians. The ethical decisions made by generalist physicians can be more subtle than those in tertiary care settings, and they often are non life-threatening. Yet they are equally as important and we, as future generalists, will have to make many of these types of decisions throughout our careers.

• What is the cost effectiveness of your treatment plans?
• How do you counsel teens on birth control issues?
• How do you work with patients who refuse care?
• How do you help patients make difficult decisions about medical procedures?

Why do we need to learn to make ethical decisions?
Medical ethics is not as easy - nor possibly as complex - as it may seem. For many medical students, medical ethics has been discussed so frequently in the media and in the medical community that many students believe it is impossible to master, so they throw up their hands, give up, and say that they will turn to common sense, their morals, and if necessary, legal precedent. And what is wrong with that solution, you ask?

• Well, in many medical situations, common sense points to many correct solutions. The difficulty is that it is necessary to weigh each of these solutions against the other and evaluate which path must be enacted. The process takes consultation with other physicians and knowledge about medical ethics.
• While religious ethics and morals can be a strong foundation for personal decision-making, we live in a society whose members hold a wide variety of religious beliefs. Therefore, in decision-making involving other people it is best to turn to ethical decision-making rather than personal religious beliefs.
• In terms of legal precedent, the law is often lenient and allows for a variety of interpretations. In some situations, such as with abortion, members of the legal profession disagree with some members of society as to whether the law is ethically correct. [Brody H, Tomlinson T. Ethics in Primary Care: Setting Aside Common Misunderstandings. Primary Care 13(2), June 1986: 225-239.]

How do medical students learn to make ethical decisions?
Ethical decision making, it seems, is the art of medicine, passed down from one generation of physicians to the next. It is something we begin to understand in discussions during first and second year, and then grasp more concretely during our clinical and residency years. There are some guidelines which can be used:

• Take an excellent history: Listen to your patient's story and learn about their personal life values and plans.
• Involve the patient in the decision-making if possible. Often with a brief outline of the pros and cons of a situation, patients can make educated choices about treatment options and other medical decisions. If after laying out the best treatments a patient refuses, investigate the reasons for the refusal and explore the consequences.
• Develop a strong foundation of basic values: do no harm, promote the health and quality of life of your patients, be truthful and trustworthy, be honest in your academic and research endeavors, do not perpetrate abuse, understand the values of the major groups in the population you serve.
• Learn to classify the type of ethical dilemma you are facing and call on your past experience with similar problems: Treatment refusal, cost of care, capacity to choose medical treatment, informed consent.
• Consider all of the factors which play a role. These factors can be strictly ethical, such as the consequences of an action, the moral rights owed to other individuals, and the duties incumbent upon one as a moral agent, in addition to societal factors such as the legal rights of patients and medical politics.
• In the office use time to your advantage and as a therapeutic tool. Often the issue doesn't need to be solved all at once. Schedule another appointment.

What organizations discuss medical ethics?
There are number of organizations nationwide which focus on medical ethics, ethical research, and medical school curricula. These organizations hold annual meetings and can be excellent resources for students interested in pursuing medical ethics as a whole, or specific issues in ethics faced by generalist physicians. Students interested in summer or rotational opportunities should call these groups.

American College of Physicians

(215)351-2400

[publishes the ACP ethics manual, and educational case studies]

 

Society for Teachers of Preventive Medicine

(816)333-9700

Society for Health and Human Values

(703) 556-9222

[organization advancing teaching and scholarship in humanities (including ethics) related to health care]

 

American Society for Law, Medicine, and Ethics

(617)437-7596

[multidisciplinary organization providing debate, scholarship and critical thought for professionals at the junction of law, health care, policy, and ethics]

 

Institute for the Medical Humanities

(409)772-2378

[teaching, research, and consultation on ethical, social, historical, and legal dimensions of health care]

 

American Association of Bioethics

(801)581-4673

[promotes exchange of philosophical ideas, research, discussion and teaching of Bioethics]

 

Bioethicists for Universal Health Care

(612)347-8794

[organization examining the interrelation of medical ethics and politics]

 

Society for Bioethics Consultation

(202)877-6211

Potential Poster Copy

• 30% of patients seen in a medical office present an Ethical Problem.
• Percentage of patients in a medical office presenting an ethical problem for the physician, as demonstrated in a 1988 study: 30%Types of ethical problems presented in an office, in order of frequency:
• costs of care
• psychological factors that influence preferences
• competence and capacity to choose
• refusal of treatment
• informed consent
• confidentiality

[Connelly JE, DalleMura S. Ethical problems in the Medical Office. JAMA 1988; 260: 812-815.] Clinical Ethics Cases

Summer & Rotational Opportunities
In addition, medical students interested in spending a summer or a rotation examining issues of medical ethics can utilize three resources that list graduate programs in ethics. The listings often have opportunities for medical students interested in shorter term commitments also.

• The Hastings Center (914) 762-8500
• The Kennedy Institute of Ethics (202) 687-8089
• Univ of Minnesota Center for Biomedical Ethics (612) 625-4917

Students interested in opportunities in their own medical school can contact medical ethicists on an affiliated hospital's Ethics Committee. If there is no Ethics Committee, write a letter directly to the President of the Hospital, explaining their interest and asking for suggestions of physicians who are involved in ethics.

The cases which follow represent the most common ethical problems faced by generalist physicians. Discussion of these cases now will help us, as medical students, prepare for similar cases we will see in outpatient environments. These cases were drawn from Promoting Medical Students Ethical Development; A Resource Guide prepared by Janet Bickel, AAMC. 1993.; LaPuma J, Schiedermayer DL. Outpatient Clinical Ethics. Journal of General Internal Medicine. Vol. 4, 1989. p. 413-419.; and Connelly, JE, DalleMura, S, Ethical Problems in the Medical Office, JAMA 1988; 260: 812-815.

An 89 year-old woman with dementia requests a physician's statement (for automobile insurance purposes) that testifies to her mental competence. Would you give it to her?

A 78 year-old woman constantly worries about her health. She comes to the office with symptoms that suggest the possibility of stomach cancer. The physician prescribes medications and orders diagnostic tests without telling the patient about the possible diagnosis. Would you have done the same thing?

A 65 year-old patient at your migrant health clinic wants to go for a hip replacement. You are on a limited budget and know that the money could go towards preventive care for the community, as well as improving your patient's mobility and ability to work for her family.

An 82 year-old woman refuses to complete screening for colon cancer because she believes "finding blood is fatal". Do you comply?

A 43 year-old patient discloses that her husband, also a patient, is an alcoholic. She requests that he not be told of her conversation with the physician. Do you comply?

The majority of the patients in your community clinic cannot afford to purchase medications. You believe it is inappropriate to accept gifts or samples from pharmaceutical representatives, but you understand that it benefits your patients. Should you accept samples?

A patient with a bipolar disorder cannot pay for repeated determinations of her serum lithium level. Do you change your treatment of this patient?

A 51 year-old woman's insurance will not cover screening mammography. One of her friends was just diagnosed with breast cancer, and she is very concerned that she has breast cancer; she is not eating or sleeping well. Should you falsify your report to the insurance company so that she can be covered for a mammography?

You receive the test results for a 27 year-old attorney who has a mildly atypical pap smear. Should you deviate from your normal behavior and refer her to a gynecologist?

The parents of a 16 year-old boy, who is failing in school and is often truant, ask his physician to drug-test him, "for our sakes". Do you agree?

Your uncle has chronic angina pectoris and has just had a bout over the weekend. He asks you for a prescription for medication. Should you give it to him, or tell him that he needs to go get an EKG? (you know that is difficult for him to pay for both the EKG and prescription)

A 50-year old patient is a chronic smoker and presents with a chronic cough. His pulmonary function tests are normal, yet you decide to tell him that the tests show slightly abnormal pulmonary functioning and indicate moderate emphysema. Do the ends justify the means?

You are your sister's physician. She has just tested positive for syphilis and asks you not to report the case. It is your legal obligation to report a positive serologic test for syphilis to the authorities. Do you report?

A 14 year-old female presents to your out-patient service in an Ob-Gyn clerkship. Her presenting problem is identified as a need for contraception. She announces that she has recently become sexually active with her boyfriend, a senior in high school; she has heard about the pill and would like you to get her started on oral contraception. What are the possible options in this situation, and which is best? How would your behavior change if your were the physician instead of the medical student?

In your family medicine clerkship a pilot with Northwest Airlines presents with urinary tract infection. His culture comes back positive for gonorrhea. He is extremely remorseful in explaining that on a weekend layover in Hong Kong, he had been seduced by a woman in a bar and had unprotected sex. He admits to having had sex with his wife upon returning home, and before he was symptomatic. His wife is in the waiting room; she has come to the doctor's office complaining of a sore throat and will be your next patient. The pilot requests that you treat her symptoms with antibiotics, giving her a sufficient dosage to insure that if she is infected with gonorrhea, that she will be effectively treated. He also asks that you keep his sexual information confidential.

You are the primary care provider for Mr. Ritter, a likable 33 year-old factory worker who is covered by his company's health insurance policy. Recently he has had some acute anxiety attacks brought on by severe crises in his personal life. You have treated him with some anti-anxiety medication and with frequent, lengthy sessions of office counseling. Today, Mr. Ritter states happily that he has had no symptoms in some time and feels the need for medication and counseling has passed. He is, however, concerned about the bills for his many office visits, pointing out that his insurance does not reimburse for psychotherapy or counseling. He requests that you fill out his insurance papers, substituting some organic diagnosis for his real problem. Otherwise, he will be stuck with the bill, causing hardship to himself and his family. What will you write on his insurance form? If you tell the truth, how will you address the patient's concerns? What circumstances, if any, justify falsifying a report?

You see an 11 year-old in the office with a sore throat, fever, headache, and abdominal pain. Your rapid test for strep is positive. The mother tells you from past experience that they've had extreme difficulty completing a course of oral penicillin. The mother asks you to administer intramuscular penicillin instead. The child beocmes hysterical and threatens to bite anyone who comes near her. What do you do?

Articles and Books of Interest to Students

1. English DC, ed. "Bioethics: clinical guide for medical students." Norton Company, NY 1994.
2. Simpson K. The development of a clinical ethics consultation service in a community hospital. J Clinical Ethics 1992; Vol. 3(2): 124-130.
3. Orr R, Moss R. The family physicians and ethics at the bedside. J Am Board of Family Practice, 1993. Vol. 6(1): 49-54.
4. la Puma, J, Schiedermayer DL. "Ethics consultation: A practical guide". Jones and Bartlet Publishers, 1994.
5. Christie RJ, Hoffmaster CB. "Ethical issues in family medicine". Oxford University Press, NY, 1986.
6. Smith HL. Medical ethics in the primary care setting. Social Science and Medicine. 1987; 25(6):705-709.
7. la Puma J, Schniedermayer DL. Outpatient clinical ethics. J Gen Intern Med, 1989; 4(Sept/Oct): 413-420.
8. Christianson CE. Ethical issues in family-centered primarycare. Counseling and Values, 1985;30(1):62-73.
9. Purtilo R, Sorell J. The ethical dilemmas of a rural physician. Hasting Center Report, 1986 (August) 24-28.