Ethical conflicts: Making care decisions when the right choice isn't clear

Ethical conflicts are rising in number: ©Stock.adobe.com

Although it happened more than 20 years ago, family physician Melissa Lucarelli, M.D., remembers being told when starting her residency rotation on a Native American tribal reservation to call prenatal labs “routine blood tests,” and not name the conditions for which the labs were screening. That was especially true if the tests had anything to do with the health of the fetus.

“According to the tribal elder at my orientation, simply speaking to the patient about potential fetal genetic problems or pregnancy complications was believed to make those conditions more likely,” she recalls. “This was very different from my earlier residency clinic, where the ethical standard was to explain all tests in detail so that the patient could make more informed decisions about their prenatal care.”

Ethical battlegrounds are growing

Lucarelli’s experience epitomizes, in a small way, a problem with which doctors have grappled for as long as medicine has existed as a profession: what to do when their ethical training conflicts with the circumstances or needs of a particular situation or patient. That question has taken on new urgency in recent years due to several converging trends. First has been the growing role of third-party payers in medical decision-making, in the form of deciding which treatments and medications they will pay for.

Second has been the encroachment of divisive social and cultural issues into the doctor-patient relationship. Following the Supreme Court’s 2022 decision overturning Roe v. Wade, states have been curtailing or outlawing abortions. Meanwhile, the movement to restrict gender-affirming care for children and adolescents has been gaining momentum. Even vaccinations, once administered routinely, have become politically charged since the arrival of COVID-19.

Today it is no longer enough for doctors to ask themselves, “Is what I’m doing right for this patient?”They must also ask, “Can the patient afford it?” or “Will the patient stop coming to see me?” — and even “Could I go to jail for it?”

No clear-cut answers

Fortunately, the ethical quandaries most primary care doctors encounter in day-to-day practice do not come with the threat of jail time. But that does not make them any less vexing, because they frequently depend on particular circumstances and lack definitive answers.

“Most ethical questions don’t have yes-no answers, because they arise from situations that have a lot of complexity,” says Oliver Schirokauer, M.D., Ph.D., assistant professor of bioethics at the Case Western Reserve University (CWRU) School of Medicine in Cleveland. “I’ve learned in this work that one should stay away from absolutes. One has to look at the full range of one’s obligations and try to integrate them into … an ethically supportable position.”

Such uncertainty can be frustrating to doctors, he adds, because their medical training “reinforces the belief that there are answers, and they are accustomed to being rewarded for getting the answers. Then they enter practice and find that things are no longer so certain. It takes thoughtfulness and self-awareness to carefully consider one’s personal values, as well as those that are communally held, to land on firm ground.”

For the majority of physicians, that grounding comes from the ethics training they receive in medical school, much of which is built on the values spelled out in “Principles of Biomedical Ethics” by Tom L. Beauchamp and James F. Childress: respect for autonomy, nonmaleficence, beneficence and justice.

“Most doctors have some exposure to that framework,” Schirokauer says. “We [at CWRU] emphasize that they are meant to provide guidance as to what considerations might be important in a specific situation. But they rarely provide a definitive answer.”

Patient autonomy vs. paternalism

Although no one principle is considered most important in Beauchamp’s and Childress’ presentation, Schirokauer says that in practice most doctors tend to give priority to patient autonomy. “There are concerns about paternalistic behavior where a doctor might say, ‘My obligation is to do what I know is best for this patient and it doesn’t really matter what the patient thinks about it,’ ” he explains. “That attitude is frowned upon, and for good reason.”

Gary Price, M.D., a plastic surgeon and president of The Physicians Foundation, uses that patient-centric approach to guide his thinking when confronted with ethical questions. But he acknowledges it comes with caveats.

“When approaching ethical decisions about patients, my primary guiding force is what’s best for the patient,” he says. “But that has to be modified by issues about patient autonomy and their ability to decide for themselves. And of course, communicating with the patient about these things assumes a trusting relationship, which requires development over time.”

“When you’ve got [older] people who are approaching the end and have a diminished quality of life and there are no more reasonable treatments, the question is, who has that conversation with the patient and their family?” says L. Allen Dobson Jr., M.D., FAAFP, former chief executive officer of Community Care of North Carolina and Medical Economics editor-in-chief.“It’s best done by the primary care doctor who knew them before they reached the acute phase, which is often when ethical decisions need to be made.”

The impact of fragmented care

But such relationships are getting harder to achieve and maintain as patient care becomes more fragmented, Price says, complicating the ethical decision-making process. He cites the example of end-of-life care decisions.

“Thirty years ago, a PCP [primary care provider] was usually involved with a hospitalized patient’s care, and if they had a long-standing relationship with a patient and their family, they’d be a critical part of any end-of-life decision in the hospital. But our care delivery system has largely taken them out of the care of hospitalized patients, so they’re no longer involved in those decisions.”

The ethical landscape is further muddied by the changing nature of health care financing and ownership, Price says. He points to the potential conflicts of interest created by Optum, a subsidiary of the same company that owns insurer UnitedHealthcare, being the nation’s largest employer of doctors.

“Now we not only have the insurer controlling the reimbursement, [but we also] have the potential for the insurer as the doctor’s employer to play a role in decision-making about the patient from their interest, which of course is mostly financial,” he says. “That creates an issue where the physician’s obligation to whoever’s writing their paycheck may conflict with their fundamental obligation to do what’s right for the patient.”

Moreover, doctors must contend with the flood of misinformation patients encounter on social media or through their own online research.

“I think most physicians now run into patients who are convinced they’re experts, thanks to Dr. Google,” Price says. “It’s already difficult and time-consuming to explain complex illnesses and their treatment. But when you first have to get the patient past all the misconceptions they find online or in the media, it puts tremendous pressure on that limited time you have with them.” That, in turn, increases the temptation for the doctor to press ahead with a course of treatment without getting complete buy-in from the patient, he adds.

Government encroachment

As if all that were not enough, today’s doctors also must ensure they do not run afoul of state laws regulating decisions on matters involving abortion and treatment of sexual dysphoria. “It’s interesting how intrusive some state legislatures have gotten into the practice of medicine lately,” Dobson says. “The thing that’s tough for physicians now is that you have both the government and insurance companies in the exam room with you and the patient. So how do you handle it when you feel something is the right course of action and the insurance company or the government says no? How do you do what’s right for the patient?”

He adds that most laws and payer rules contain “gray areas” where doctors can advocate for their patients without crossing ethical lines. The key, he says, is to stay within the bounds of verifiable facts.

“If you say a patient has diabetes with these complications, can you back it up? In other words, you can’t lie or just make stuff up. But you can make sure you maximally present the patient’s condition or reasons why they need a medication if you feel that’s what the patient needs.”

To Lucarelli, patient advocacy is a fundamental part of a physician’s job. “Patients look to me not just for my medical expertise to guide them through their clinical situation, but their health maintenance or the finances of getting health care. But all that advocacy, trying to do what’s best for the patient, involves ethical decisions.”

She cites prior authorizations for imaging procedures, which insurers often make difficult to obtain. “For an MRI, what are the magic words I need to provide so that they understand it’s medically necessary? You’re usually dealing with bots and computers on the other end. So I’m not lying—I’m just emphasizing the things that are going to get the tests for the patients when they need them,” she says.

But Lucarelli draws the line at doing something that could potentially harm the patient and/or land her in legal trouble. She recalls refusing a patient’s request to prescribe that a medication be taken twice daily rather than the once-daily recommended dose so the patient could get twice the number of pills for the same copay.

The reason, she explains, is that a future doctor might see the instruction and administer the medication incorrectly. “So as an ethical principle I’m not going to write a prescription in a way I know the patient’s not supposed to be taking.

“As a physician, my commitment is to try and be beneficent, to not hurt anyone and respect the patient’s autonomy,” she adds. “But it’s not ethical care if you’re doing what the patient wants but it’s illegal or going to harm them.”

The value of consultation

When confronted with an especially thorny issue, experts say it is often helpful for doctors to talk it through with someone else, such as a colleague or even a trusted medical school professor. In addition, most hospital systems today have ethics committees and legal teams their physicians can consult.

“They can provide valuable advice when a physician feels they may not be seeing all the angles from which to consider a problem,” Price says. “But having said that, I think most physicians clearly want to do the right thing for their patients, but that can become challenging when there are conflicting interests from all the insurers, the government and the hospital systems themselves. The idea of the physician’s primary responsibility being to the patient is getting muddled, and that concerns me a lot.”