8 Common Dilemmas in Physician Ethics

In everyday practice, physicians face numerous ethical questions, not just the weighty life-and-death ones. Less dramatic questions pop up frequently—from taking gifts to sharing political views.

What’s the correct response according to the code of medical ethics? AMN Healthcare spoke to two experts who weigh in on some of the most frequently asked ethical questions.

8 Common Ethical Questions For Doctors

1. Should physicians accept gifts from patients?

The answer is a big “No,” said Celia B. Fisher, Ph.D., the Marie Ward Doty University Chair in Ethics at Fordham University in Bronx, New York.“Gifts from patients create a blurring of lines between the physician's professional role and a nonprofessional relationship with a patient,” Fisher said. “Reinforcing a patient's perception of a personal relationship can impair the effectiveness of the physician's recommendations for health compliance, and if the physician feels an obligation to the patient based on a gift, can compromise the physician's objectivity.”

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Some people have suggested the value of the gift matters, and many institutions, including Duke University Medical Center in Durham, North Carolina, limit the value of the gifts that can be accepted or require they be shared with others in the clinical area, such as food around holidays, said Philip M. Rosoff, MD, MA, chair of the Duke University Hospital Ethics Committee.

“Anything more valuable is felt to be such that it could cause the physician to treat the patient or her family more deferentially or give preference to his care,” Rosoff explained.

2. Should doctors provide “VIP” care for certain patients?

Different types of VIP care exist, such as a patient paying extra for special treatment, perhaps a better room or food. Concierge medicine is another example of this.

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The other type is when a patient is treated differently because of who he or she is, say, a member of the board of trustees of the institution or a major donor, Rosoff said. No matter what makes them VIPs, physicians and advanced practitioners should not allow patients’ status to cloud their professional judgment or behavior.

“Ironically, while those who are on the receiving end of VIP may relish the prospect of being treated as ‘special’ – and it is reasonable to assume that many ‘VIPs’ have this experience throughout their lives – data has shown that VIP treatment is not so good and may be inferior to that given to the less ‘privileged,’ especially at teaching hospitals,” Rosoff said.

3. Should doctors accept gifts from pharmaceutical company representatives?

Again for physician ethics, the answer is “No,” Fisher said.

“Taking gifts from pharma is a conflict of interest that also compromises objectivity in terms of a potential perceived obligation to prescribe a particular medication against data for other medications and can also give the impression of a conflict of interest that can compromise the patient's trust in the physician,” Fisher said.

The gift-givers goal “is to influence the prescribing and/or purchasing habits of the doctor,” Rosoff added. Academic medical centers often institute bans on pharma or device reps.

“Even minor gifts bestow a sense of obligation on the recipient, even if they may be unaware of it,” Rosoff said. “And, of course, as we get to the bigger dollar items—like trips to sunny climates in the winter or golfing jaunts or luxurious gourmet dinners with expensive wines—then the goal of the companies is much more apparent.”

4. Should physicians “Google” their patients?

“Only if there is a concern regarding the patient's safety or health that the physician believes may not be available through health records or contact with the patient,” Fisher said.

“There is also the problem of entering the information gained from Google into the patient's health record since there is no guarantee that the information from Google is correct,” she continued. “Physicians also need to be aware that based on HIPAA regulations, patients have access to their health records and will appeal or question information that is obtained from an unreliable source.”

5. Should doctors be friends with patients on social media?

“No, for the same reasons as not accepting gifts,” Fisher said. “This creates a dual relationship, blurring the boundary between personal and professional roles, which can compromise physician objectivity and patients’ trust in the professionalism of recommendations.”

6. Should physicians report incompetence in a member of the healthcare team?

It depends, Fisher explained. For instance, if the incompetence has not affected a patient and when informed about the need for training, the other [person] takes appropriate steps to get the training and refrains from treatment for which he or she is not trained, then a formal report may not be necessary according to doctor ethics.

“If the team member is actively placing patients in danger, it must be reported,” Fisher said. “The physician needs to be knowledgeable about hospital procedures for reporting.”

7. Should doctors voice political opinions with patients?

Patients may bring up politics with their physicians.

“The folk wisdom that one should not discuss politics or religion at the dinner table also applies to discussing potentially ‘hot’ topics with patients,” Rosoff said. “Unless there is very good reason to believe that the doctor’s political or religious views would have a positive material impact on the care of a particular patient, there is no justification to announcing that she is a Republican or supports such-and-such a candidate for town council.”

Outside the clinical setting, Rosoff said it is OK for physicians to voice political support.

8. Should physicians terminate non-adherent patients?

“If a patient is not complying with a medical regimen and the physician has made all appropriate efforts to work with the patient to comply, then it is appropriate to let the patient know that further visits are not likely to improve the patient's health,” Fisher said. “There is also a potential problem in charging the insurance company for visits in which it is assumed that treatment will not be effective.”

“However, a patient should not be left without a provider, so the physician must provide the patient with a referral to another provider who may be better suited to helping them adhere,” Fisher concluded.

The American Medical Association’s Code of Medical Ethics includes information about these and other doctor ethics challenges, including social media and political communications.

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