Bending ethical norms to serve patients' interests

A survey among rheumatologists finds many face moral dilemmas when trying to do what's best for their patients in the current health care environment.

The study, titled "Bending' Ethical Norms to Serve Patients' Interests: Tensions in Medical Professionalism," will be presented at the American College of Rheumatology/ Association of Rheumatology Health Professionals Annual Meeting on October 28 in San Diego.

The complete study was published in the October issue of the journal Arthritis and Rheumatism.

Rheumatic diseases, such as rheumatoid arthritis and lupus, are a common cause of disability. Affecting all sectors of the population, they diminish quality of life and have a significant social impact. Despite the benefits of early treatment and effective therapies, access to rheumatologic services may be difficult, involving long wait times, even difficulties finding providers, according to C. Ronald MacKenzie, MD, a rheumatologist at Hospital for Special Surgery in New York City and lead author of the study.

"When people receive a diagnosis, the cost of effective treatment may render it unaffordable for many," says Dr. MacKenzie, who is also chair of the American College of Rheumatology (ACR) Ethics and Conflicts of Interest Committee. "While an optimal or fair system would mitigate these impediments to care, our survey of ACR members suggests that this is often not the case. In fact, physicians report they frequently find themselves in situations of ethical conflict in an effort to best serve their patients."

To conduct the survey, 14 closed-ended and two open-ended questions were sent electronically to 5,500 members of the American College of Rheumatology in the United States.

"We found that a pressing ethical issue for many rheumatologists is their perceived need to 'bend' ethical norms and compromise ethical principles in order to provide the care their patients need,'' Dr. MacKenzie noted.

In the survey, physicians reported ways in which they see themselves as 'bending' ethical standards and presented justifications for doing so.

Examples included 'embellishment' of symptoms to help patients obtain prior authorization from insurance companies; stretching the truth to obtain needed drugs and testing for patients; and providing patients with certain diagnoses to obtain coverage for needed medications or physical therapy.

"The delivery of medical care takes place in a particular social context, and when this context includes conditions that are unfair, healthcare practitioners may be forced to struggle with ethical conflicts, making trade-offs that may go unrecognized or are not adequately discussed,"

Dr. MacKenzie said. "An awareness of this problem and its consequences is the first step in finding solutions to the challenges that physicians face."