Physician Ethics

Topic 1 – Post 1

I appreciated the example that you used in your response about a doctor potentially breaking a client’s privacy being a breach of moral responsibility.  As we know, HIPPA has many requirements that require doctors to keep the information confidential, and there are severe penalties if that confidentiality is not maintained, but there is also a serious moral duty for the doctor to do so.  An area that I could see where this could become a serious problem is in the area of psychiatry, where a doctor is helping a patient with mental health issues.  Because psychiatry is so dependent on the ability of the patient to openly share very deep and personal issues, if a doctor were to fail in their moral responsibility to maintain strict confidentiality, it could so severely impact a patient that in the future they may not be able to open up to another mental health professional, thus causing them to fail to get the needed attention. 

You mentioned that the side result from this betrayal could be that the patient may not want to hold up their responsibilities to the physician in such a case.  This is true, because – having experienced a violation of their trust – the patient may no longer feel that the particular doctor cannot be trusted anymore.  They may project these negative feelings across all medical professionals, resulting in their not reaching out to get the care they need.  As we know, when someone is seeing a psychiatrist, generally they have a much higher need for care and treatment, and if they fail to get that care, the results could end up being tragic. 

Another concern that Pozgar (2016) notes is that if a physician were to break a client’s privacy, this could create a situation that could be legally actionable.  As he explains, the right to privacy is even implied as part of the constitutional rights of every individual, so such an action could expose the doctor and the institution that he works for to serious liability.  Another area that he notes that doctors must be careful about is unwarranted intrusions into a patient’s private affairs.  This is a major threat with the emergence of telemedicine. Pozgar (2016) does note that there are some very specific situations where it is not only morally but also legally proper for the privacy relationship to be broken.  He notes such cases as where there is a communicable disease involved, potential elder abuse, potential child abuse, or evidence of gunshot wounds as being cases where such confidentiality could rightly be breached.

Topic 1 – Post 2

I really appreciated your focus on a physician’s responsibility to keep up to date and be committed to their ongoing education as a physician.  You note that physicians can be older and “set in their ways.”  I recall a doctor that I knew who was in his 70s and had been practicing as a pediatrician for over 50 years.  His wife was the office manager.  I asked her how he was going to respond to the new government requirement to institute electronic medical records (EMRs) and she responded that he would retire before he switched to EMRs.  There was another doctor in the practice who was only a few years younger than him, but I noted that his attitude was completely different towards technology, and he almost viewed it as a daily challenge to keep up with the latest technology.

Keeping up to date with current procedures and advances is a moral responsibility because doctors hold their patient’s lives in their hands, quite literally.  If a doctor is treating a patient and exposes them to a dangerous infection, like a Staphylococcus aureus infection because they have not been keeping up on the latest procedures on how to prevent such infections, like chlorhexidine gluconate prep, then they could hold some responsibility for the staph infection and the complications arising therefrom.  I like how you brought into your response specific examples like the use of new “robotic” surgical techniques that are promising and could result in better outcomes for patients.  The point you raised about the dentist performing plastic surgery was a scary example, but a very real one of a breakdown in someone’s moral compass.  I think an analogous situation would be a doctor trying to perform a complicated procedure in a specialty where they do not have the advanced training to perform the task.  

Topic 1 – Post 3

I noted in your response that you highlighted how the patient must be honest in divulging information to the patient.  One example I remember from Pozgar (2016) was the example where he discussed how sometimes doctors may self-refer out clients to testing centers where they have a financial interest for expensive tests, while not revealing that case to the client.  This is both an ethical and moral breakdown on the part of the doctor.  You make another good point in discussing how a physician must make good choices in the patients that they choose to care for (with the exception of emergencies, of course).

This is a situation that can especially be important in the area of psychiatric or mental health care arenas.  Because the therapeutic setting is highly personal, and the ability of the patient and therapist to be able to work together well depends on both of their experiences, it is critical for the therapist to be open and candid in evaluating not only if the patient works well with them, but also if they work well with the patient.  A case could arise where a particular patient triggers emotions or feelings on the part of a clinician that could interfere with their objective and impartial treatment of the individual.  In such a case it would be unethical and immoral for them to continue treating the patient knowing that their ability to do so completely and wholly in the patient’s best interest is compromised.

Topic 2 – Post 1

You are so right in your assertion that premature termination hurts all who are involved in the therapeutic process.  When clients are seeking care for deeply held issues like emotional distress or PTSD, they likely already have deep-seated problems with trust, so when they have opened up to a clinician only to find out that their care is being abruptly terminated, it can have devastating effects on the patient.  As Pozgar (2016) points out, once a physician or therapist enters into a course of treatment with a patient, they have an obligation not to neglect them.  As such, the relationship must end only with “mutual consent” of both parties.  

You note that premature termination of a patient could result in legal action, however that is only true if several elements are present.  As Pozgar (2016) explains, it had to be unreasonable, against the patient’s will, the doctor has to have failed to have arranged for other treatment of the patient, the physician has to have been able to foresee that there could be a potential for harm, and actual harm to the patient has to have occurred.  Absent all of these elements, a case for recovering damages from a doctor due to abandonment may be compromised.

Topic 2 – Post 2

I like how you applied the Hippocratic Oath to the issue of patient abandonment.  The specific section mentioned is “[t]he regimen I adopt shall be for the benefit of my patients according to my ability and judgment, and not for their hurt or for any wrong” (Pozgar, 2016, p. 365).  The case study of Scripps Medical Center, who adopted a policy of terminating treatment of a patient upon receipt of an intent-to-sue letter is an interesting case in point.  Even though they had a legitimate reason to terminate care, if it was determined that another medical care system could not be identified that would be able to give the patient adequate care, or if the patient’s treatment would be jeopardized due to the patient’s current medical state, they would not enforce the policy.  This demonstrates a good understanding of the governing physicians at the Scripps Medical Center of the primacy of their obligation under the Hippocratic Oath and how that responsibility, from a moral perspective, outweighs any potential legal harm that may come to them from continuing to care for the patient.

It is also an important point that you bring up regarding if the patient is the one who breaks the relationship.  The patient’s breaking the relationship with the doctor precludes them from later going back and claiming abandonment, trying to recover financial damages (Pozgar, 2016).  If a doctor were to unilaterally abandon a patient in the midst of treatment, you are very correct in pointing out that serious harm could come to the client, such as relapse, emotional distress, loss of trust, or even (possibly) loss of life.  This is especially the case in mental health care settings.  If a patient was highly emotionally unstable and found themselves suddenly cut off from their clinician, this could cause the patient, who is already in an emotionally unsteady state, to take drastic action such as attempting suicide. 

Topic 2 – Post 3

I really appreciated your thorough and well-thought-out response to this question.  End of life or potentially terminal patients do present some of the strongest moral and ethical challenges to doctors and clinicians.  When patients are potentially near the end of life or have experienced prolonged suffering, then they may dictate that they want to discontinue certain aspects of their treatment.  You are specifically addressing the premature termination of treatment from the patient perspective rather than that of the doctor’s perspective.  

Solomon et al. (1993) note that in cases like these the doctor’s own conscience can come into play.  Oftentimes, doctors and nurses are concerned that considerable resources are being expended on a person who is near death, and they feel it is unethical to prolong suffering in that way.  However, the physician is not the person who has the right to make that determination, especially in that situation.  As you mentioned, as long as the patient is of sound mind and the treatment is no longer benefiting them, then it is acceptable to terminate particular treatments as indicated by the patient.  Pozgar (2016) also notes another potential aspect earlier in the book in the form of Advanced Medical Directives.  After the case with Kathleen Quinlan, the topic of an individuals’ “right to die” became a huge topic (Solomon et al., 1993).  Since then, most states have established policies where patients can determine well in advance of a life-threatening situation what they want to happen.

Even though it may be against a physician’s own preference, they have an obligation to treat the patient in the way that they want to be treated.  You also bring up an important point that there are times when the patient themselves may create a situation that makes it difficult or impossible for the doctor to treat them properly, like being abusive to staff, noncompliant, or uncooperative, causing the doctor to be unable to properly render care in that particular situation.   Even then, the doctor must follow proper procedures, as you outlined, to terminate the relationship in order to protect themselves from a charge of abandonment.

References

Pozgar, G. D. (2016). Legal and ethical issues for health professionals (4th ed.). Jones & Bartlett.

Solomon, M. Z., O’Donnell, L., Jennings, B., Guilfoy, V., Wolf, S. M., Nolan, K., … Donnelley, S. (1993). Decisions near the end of life: Professional views on life-sustaining treatments. American Journal of Public Health, 83(1), 14–23. http://doi.org/10.2105/AJPH.83.1.14