Problems with Medical Ethics: The Elephant

Fifteen years ago, I did part of my first pediatric training in the pediatric clinic of St. Raphael’s Hospital in New Haven. It was a nice hospital, well-known at the time for their excellent cardiac care. It was run by the Sisters of Charity of Saint Elizabeth, an amazingly generous order that really practices charity every day by helping those who need it most. Some of the nurses were in the order. The exceptional physician who ran the pediatric clinic was kind and really smart. I still use his home-made guide to pediatric neurological exams. We got along well.

When Reyna came into the clinic, she didn’t look particularly sick, just in pain. She was clutching her abdomen. She saw one of the medical residents, higher in the feeding chain than a lowly medical student like myself. Abdominal pain is one of the most studied of medical symptoms, especially because it’s so common. One by one, the resident and I ruled out some of the things it could be. The girl was 16. We needed a pregnancy test. Oddly, there was some sort of a problem requisitioning one. In fact, the clinic didn’t have one on hand. Her pain got worse, and she was admitted to the hospital. That night, her pain worsened considerably. Blood tests showed no signs of infection. The head of the clinic told us that a pregnancy test wasn’t needed. Within a couple of days, she needed an enormous amount of intravenous morphine. Eventually, if I recall correctly, she was taken by ambulance to Yale-New Haven Hospital for emergency surgery that fixed—and ended—her ectopic pregnancy. Maybe the doctor in charge knew a lot more than me about pediatrics. But I am still affected by my memory of this girls pain. Where was his ethics committee?

Every hospital I’ve ever entered had an office for chaplains. I think this is a good thing. Not meaning to joke about it, my post about lollipops discussed my rationale for using a partly physiological and partly placebo intervention to make a child feel better. I have described my use of hypnosis to help with an anxiety disorder. I think that if a child, if any patient, will feel better after an intervention of some sort, I’d like to use it if it’s safe. For the devout, the counseling of a religious guide can make an important difference in their quality of life. I respect it and recommend it when appropriate.

There is no bigger elephant in the room in which medical ethicists sit around and sip their lattes than religion. The topic is deeply taboo, and I can’t help but wonder if my email address will be unceremoniously ripped from the bioethics listserv database.

At a major national meeting a few years ago, I went to all the sessions given in ethics. In one, a discussion was promised concerning the ethical issues of contraception counseling and prescribing for teenagers. One side brought up the sobering statistics we all know about teen pregnancy and STDs. The other side argued that since condoms only work 95% of the time, that’s a 5% failure rate. Since that’s not acceptable, the only reasonable counseling for physicians to be doing is to tell teens is that abstinence is the only effective form of contraception.

More than a decade ago, I attended Georgetown University’s Intensive Bioethics Course. It was well-organized and I learned a lot. After the first couple of days of lectures, I asked why every lecture on any topic, with no exceptions, included mentioning what The Pope had said on the subject. It was Georgetown, and I was not naive about who ran the place. But I didn’t think it was an insulting question. I really wanted to know why my patients—atheists, Jews, Hindus, and Wiccans—might be affected by this*. Are religious leaders, whether laypeople or divinely chosen, gifted in unraveling of ethical complexities by their career success?

In what way, exactly, does holding a title of religious training qualify a person to sit at the medical ethics table? Are they guided by their training or constrained by it? Do their opinions apply only to their flock? What about the rest of us?

A rigorous principle of contemporary medical ethics involves disclosure. It might be in a grey area that all the objects in your doctor’s office—the post-it notes, the clipboards, the pens, even the magazines—have the name of a drug or drug company on them, but as long as the doctor discloses all the side income, then it’s OK. (They usually don’t disclose unless required to do so. Next time you’re in the doctors office, look around. How many of these ‘gifts’ can you spot?) Do we ever disclose religious affiliation? Should we? Should doctors disclose this? Should the hospital tell you that their ethics committee which has set the policy for pregnancy testing of unmarried teenagers is made up entirely of clergy handpicked by somebody who has a whole different set of values from you? What would happen if they did? Would parents of 16-year-old girls with abdominal pain bring their daughter there for evaluation? Here’s a scary thought: maybe they would prefer to bring them there.

If there is some basic foundation of ethics based on truths we hold to be self-evident, what exactly is added by expertise in dogma?

The case I described above is a real one. It was a horrible experience for me, the resident, and of course the patient. She did fine. It was one of the most unethical events I have ever witnessed.

*I really asked the question. What was I thinking? Like Peter Riegert walking into the Dexter Lake Club in 1978's Animal House, suddenly, the huge auditorium fell completely silent. The lecturer awkwardly dismissed my question without answering it, and I was too humiliated to insist.

Problems with Medical Ethics: Man in the Mirror

In Perimortal Obsession, I noted that a great deal of the work in medical ethics is focused on unusual near-death situations that, though interesting, have limited relevance to the daily practice of medicine. In my last post about the problems in medical ethics, Recruiting, I tried to point out that experts in ethics who were based at big and important institutions and medical schools really have no contact with the practice of medicine as I and tens of thousands of my primary-care colleagues know it. So it’s understandable that they are either unaware of the issues that face me and my patients or maybe they don’t see the importance.

The work that is currently being done in the field of medical ethics is important and interesting. At some point in each of our lives, it may become sadly crucial as we are forced to make a wrenching decision about a baby, a parent, a loved one…or ourselves.

In this series of posts, a theme that’s been repeated is the field's apparent lack of interest in the ethics of primary care. It’s curious to me that this disparity of focus has somehow developed.

But not nearly as curious as the glaring lack of self-reflection amongst those who have made this their work. Who gets to be on an ethics committee? How are members chosen? Do the people who teach ethics to doctors actually see patients every day?

The tasks of ethics committees in academic environments, besides working on perimortal crises, also often involve the important work of protecting patients who are subjects of medical research. (Disclosure: I sit on an IRB, an Institutional Review Board, whose task is to review and approve protocols for medical research.)

Experts in medical ethics end up knowing quite a lot about new technologies and treatments, end-of-life care, and principles of patient rights. My experience in the work world suggests that people don’t get very far criticizing the company they work for, the industry they’re in, their boss or the top executives. I think this holds true for professional ethicists at big nonprofits also, such as hospitals or medical schools.

For the record, people who go into the field of medical ethics don’t do it for the money. There’s no pharmaceutical industry backing their work, and they don’t earn more by doing more of some kind of procedure. Indeed, some already find themselves walking on eggshells because they gently point out some of the questionable priorities of work being done at their own institutions.

That’s not good enough.

It's the money, stupid.

In one of my Southern California interviews for medical school, I was told to meet a faculty member at his medical office. A prominent kidney specialist (nephrologist), he had a big, busy office. I was greeted warmly by the receptionist, and didn’t have to wait long to see him. He was just a few years older than me, but was in much better shape. He asked what I thought of the stock market. As politely as I could—I was trying to get in, after all—I told him that I wasn’t really involved in the stock market and was really focused on medical school. He seemed a little frustrated when I left about 40 minutes later. He interrogated me nonstop for my opinion of sector rotation, Elliott Wave theory, and insider stock tips. He asked if I knew anything about options. As it happened, I knew a lot about options, and like a fool, I told him that I did know something about them. Politely, I felt him out about his understanding of Arrow-Debreu Theory and the Cox-Ross-Rubinstein model. Every time I tried to bring the conversation back to why I wanted to go to medical school, he steered the other way. In the packed parking lot of his office was a meticulously polished candy-apple-red Ferrari with the license plate ‘beans.’ Maybe I can’t complain too much: I was admitted.

A PubMed search of the word ethics turned up 139,072 published references in medical journals. A search of ethics AND money turned up just 536.

It’s no secret among the general public what the main conflict-of-interest is for many doctors, especially those who use the latest technology, do the most procedures, and, yes, make the most money. So why does it seem like a mystery to those in the ethics field? Nearly 30 years ago, business ethics were an integral part of my business school curriculum. These days it’s part of nearly every course in most top business schools. The business ethics of medical practice were never mentioned, even in passing, in any of my years of medical training. The money of medicine has such a palpable taint that doctors never bring it up with their patients--the billing office does that for them. It is so taboo that it is never discussed in medical school, and those who want to talk about it are openly shunned. Yet the faculty with clout in major institutions are often the ones who bring in the most revenue for their struggling hospitals and clinics.

But though I may have been a reformed, life-changing convert, I went through training with my eyes open and—when I had enough sleep for rational thought—my mouth shut. My years and years of training and experience in finance made some things shocking to me.

It is generally true that doctors who do things to you make a lot more—way, way more—money than doctors who do things for you. In fact, much of the payment system for doctors is largely controlled by procedure-type doctors. Why is this? Do they work harder? Are they smarter? Do they help you more?

In medical school, somehow we got the impression that psychiatrists were among the lower paid. After all, they got paid by the hour, not per procedure. But we were never told that what your psychiatrist probably does with you is heavily influenced by lectures and reviews given by a very small group of department heads of psychiatry departments at major medical schools. Members of this elite club might earn a pretty good, even enviable, living from their faculty positions. But they could earn a million dollars a year from ‘consulting’ and guest lecturing and speaking at educational seminars. Even for Wall Street, that’s real money. Is it ethical for them to take this money from pharmaceutical companies? How about neglecting to disclose this to their institutions (officially, their employers)? Should they have to disclose to patients that the drug they are recommending is one that they are paid a staggering amount of money to promote? Would I, as a patient, really believe that this doctor has my best interest as his only priority? Is there a level of compensation at which a reasonable person would not be expected to remain unbiased?

Studies showed that when doctors owned their own x-ray centers, their patients ended up getting, on average, more x-rays. In some states this is now illegal. But most big hospitals need to support themselves, and so work in partnership with doctors who do procedures in order to stay in business.

The comments and questions I would often receive while in training and occasionally since then, are telling. They went like this. ‘Wasn’t it awful working with all those greedy people on Wall Street?’ No, I replied. Most of the people I worked with were unbelievably smart, creative, and ambitious. Everybody was there to make money—it’s how you were measured. There was no deceit about it. But medicine, I saw, had many people who hid their material ambitions behind their job description. Maybe they were embarrassed by them. Maybe they knew that for them, patient care didn’t always come first. Every patient in America knows. Every doctor in America knows. It's the money.

I would be happy to volunteer to lead this effort, to define and examine the business ethics of medical practice.

The print at top is from my collection and is by Mary Cassatt.