My toughest choice

By Leslie Kane
Senior Editor

Hundreds of physicians volunteered to tell us about the biggest ethical dilemma they ever faced. Their stories range from the kinds of wrenching end-of-life decisions that have confounded philosophers to more mundane matters, such as whether to provide free medical care to relatives and friends.

Most dilemmas respondents shared fell into five areas: end-of-life care, managed care pressures, blowing the whistle on another physician, doctor-patient confidentiality, and abortion—the same areas we asked specific questions about.

But numerous dilemmas defy categorization. For example, one physician wrestles with his sexual attraction to a patient, another doctor tells about being asked to perform sperm retrieval from a brain dead patient. A third is distressed because he can't give a blood transfusion to a Jehovah's Witness, who might bleed to death, while another worries about the temptation to provide a lower level of care to indigent patients.

Here are survey respondents' personal stories. The kind of experiences you just can't quantify.

The eternal ethical challenge

End-of-life dilemmas cut both ways. Benjamin J. Levinson, an internist from Columbia, SC, had problems dealing with a patient's family who wanted to let their loved one die. The 60-year-old patient was in respiratory failure due to a lung infection. Levinson was convinced the man could survive.

"I continued with aggressive care, although the family questioned what I was doing," he says. "I had to tell them that I could not stop care until it was clear to me that the patient would not make it. It was very awkward to go against a family's wishes, but I don't believe they fully understood his medical problems. And I worried that they might have had ulterior motives. Eventually, the patient recovered."

On the other hand, some physicians worry about the high cost of aggressive treatments that might briefly prolong a patient's lifespan, but not its quality. One physician worries about "continued aggressive treatment in a medically devastated child who has no hope for any quality of life." Another doctor laments "the high cost of expensive procedures, medicines, and hospital care at the end of a patient's life, when there is great doubt of any benefit."

A cardiologist from Hayward, CA, says, "We know that invasive cardiac treatments may solve one aspect of a patient's multiple problems, but it doesn't change the big picture. Sometimes elderly folks cannot fully comprehend the treatments and risks involved. In some cases, the patient's child wants to convince the patient and me that the patient should receive all the treatments available, regardless of outcome."

Conversely, Matt Anderson, an ob/gyn from West Burlington, IA, recalls a patient whose family refused to pay for needed surgery. "Her daughter told me that there was no way I was operating on her mother because it would be fruitless, and it would use up all her money—meaning the daughter's inheritance," says Anderson.

Policing others: never easy

Turning a blind eye to the actions of colleagues who've messed up makes some physicians extremely uncomfortable. Doctors want to protect patients, but know that confronting or reporting an errant physician can bring legal or employment trouble for themselves.

One small-town doctor was disturbed by an older physician in the community. "His skills were out of date and dangerous. Trying to rectify the situation led the older physician to accuse me of antitrust violations."

Another physician remained silent when his colleague botched an operation. It nags at his conscience. "I assisted one of my partners in the resuscitation of a 3-year-old surgical patient and discovered that he had severed the esophagus. By the time I corrected the situation, it was too late, and the child died. Everyone was puzzled by the cause of the child's demise, and I did nothing to bring the true cause to light."

For some physicians, it's concern over a lawsuit that prevents them from taking action. One doctor who supervised residents tells of feeling guilty for "not failing an incompetent female colleague for fear of an unfounded sexual harassment claim."

Another physician knew that an associate had engaged in misconduct, but worried that taking action could bring retaliation: "He is known to sexually harass female employees and patients. The administration doesn't seem to care, as long as he meets his quota. He also dates co-workers and patients, although he's married. If I reported him, he could counter with a libel suit."

When doctors do turn in a colleague, they often feel tormented, even when it's the right ethical choice. One New York psychiatrist found it difficult when he reported a pharmacist who had been a personal friend. "I learned that he had kept refilling a one-week antibiotic prescription for a patient in a nursing home. He refilled it 25 times, and he billed the family each week."

To tell or not to tell

Confidentiality issues bother many physicians. Some are troubled by keeping information secret, knowing that it could harm an innocent party. Others have an especially tough time with matters of teenage sexuality, or venereal disease in an allegedly faithful spouse.

Charles Shaefer Jr., an internist from Augusta, GA, was torn about "protecting the confidentiality of an HIV positive patient from his family, and from the surgical team planning elective back surgery. Eventually, the patient allowed us to inform the surgeon."

Another doctor was conflicted over "not telling the mother about the pregnancy of her 14-year-old daughter, who wanted an abortion." A third told us he feels plagued over "not informing a patient's husband that he isn't the father of the child his wife is carrying."

Then there was the doctor who watched helplessly as a teenage patient's life unraveled. Because she'd lied about her sexual activity, the doctor had given her an MMR vaccine, not realizing that she was pregnant. "We told her mother together," the doctor recalls. "The mother threw her daughter out onto the street. I could not reveal to her father [who was divorced from the mother] what was going on with his homeless, pregnant daughter who'd been given a vaccine that could cause deformities to her unborn child."

However, some doctors broke confidentiality despite potential legal ramifications. One felt compelled to "inform another doctor about the poor care given to an infant who was failing to thrive. That doctor was then able to hospitalize the infant."

Like many physicians in our survey, Michael Tschoepe, an ophthalmologist from New Braunfels, TX, reported an older patient's failing vision to his state driver license division. "I know the patient will hate me for causing him to lose his license, especially since he won't accept that his vision has declined. I've lost patients after I've told them that I had to report them. I feel bad for the patient on a human level, but I have to report him for the greater good of society."

Abortion and conscience

Abortion causes pain on many fronts. Some doctors flatly refuse to perform the procedure; others who are against abortion do perform them when required, but struggle with their consciences.

"I was forced to do a hysterectomy on a uterus with a viable 23-week pregnancy, knowing it would kill the baby, but was necessary to treat the mother," admits one. Another faced an ethical dilemma over "whether to assist with an abortion for a young heroin addict when I was a medical student. I did, but I never felt good about it." One doctor had trouble "giving a morning-after pill to a patient whose father raped her."

Some talked about their conflicts when they've seen a fetus so damaged that the baby would live in a vegetative state. For one ob/gyn, the difficulty wasn't making his own decision, but "allowing patients to decide whether to abort their fetuses when the fetuses have defects that are incompatible with life."

Other doctors won't participate in anything that promotes sex outside of a husband-wife relationship: "I hold strict standards—no sex, no birth control, no Viagra outside of marriage," states one.

Managed care: how to be fair

The difficulties of treating patients within managed care guidelines was a constant thorn to many doctors. John O. Cletcher Jr., an orthopedic surgeon from Colorado, says his dilemma is "trying to get my patients the care they need without bankrupting them."

Another physician struggles with "how I can reasonably amplify or exaggerate my patients' condition to the HMO, to get medically necessary treatment." And a third agonizes over "having to say No to tests or procedures because the insurance won't pay for it."

One doctor briefly practiced in a managed care clinic and felt that he was prevented from providing proper treatment. "I resigned after three months."

A Massachusetts internist is conflicted over "being squashed between customers who want everything for nothing, increased government vigilantism, and insurers who only want to please the money payers." Another doctor bemoans "wanting to continue practicing medicine when the reimbursement is going down, and the overhead is going up."

"Care of the poor is an issue," says a Buffalo, NY, ob/gyn. "Patients on Medicaid often request or demand expensive elective treatments, like for infertility. There's an obvious conflict between patient desire, financial realities, and my own mixed feelings."

Another physician feels some guilt at having to turn away poor patients "even though I would get paid little or nothing. I am too overworked with little time for myself." But another physician doesn't mind: "Why should we care for people who can't afford to pay? Other professions don't have to."

Relatives and difficult patients

It's not just the poor who create payment problems. One doctor is concerned about "charging friends and other doctors for visits. As a solo doc, I need to, yet I think they expect that I won't."

Difficult patients also create ethical problems. "I wonder when to get rid of patients I don't like, or who don't pay, or are obnoxious," says one reader. Another worries "when patients are so noncompliant that care is compromised. I never know if I should just fire them so I'm not involved with poor care, or if I should hang in there and keep trying."

Some of the most heart-rending dilemmas are caused by relatives. Louis J. Cole, a GP from Odessa, TX, had a rich elderly patient whose children believed that her second husband had married her for her money. "The adult children thought he was drugging her, and wanted to get her away from him," recalls Cole. "They didn't feel she was competent to handle her affairs, so they demanded her medical records in order to have her declared incompetent. However, she had never been declared legally incompetent, and the husband didn't want to release her medical records.

"I wanted to help, but I couldn't turn over the medical records without a court order," he says. "I made a lot of enemies in that family, but there was nothing I could do."

The conflict between doctors' individual values, and those of patients, their families, or the health care system, weigh on physicians—often for years after the incident occurred. But such ethical issues remain a key part of dealing with patients.

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Leslie Kane. My toughest choice. Medical Economics 2002;19:122.