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Ethics in the Emerging Health Care System

Keynote Address, MUSC Faculty Convocation

Robert M. Sade, MD,     August 20, 2014

Thank you for the kind introduction, Dr. Sothmann. As a member of  this faculty for exactly 38 years this month, I feel incredibly honored to have the opportunity to open this academic year by speaking to the faculty I’ve worked with for decades, and, from personal experience, hold in the highest regard. Thank you for allowing me this privilege.

I have to confess that I find it more than a little daunting to talk about the emerging health care system, because, like Yogi Berra, I think it’s difficult to make predictions, especially about the future. Anyone who predicts the form of the emerging health care system is likely to follow in the footsteps of Charles Duell, US Commissioner of Patents, who said, in 1899, "Everything that can be invented has been invented."  And don’t forget Harry Warner, one of the Warner Brothers, who famously said, in 1927, "Who the hell wants to hear actors talk?"

Or Stephen Paget who wrote about my own field, in his book, The Surgery of the Chest, in 1896, "Surgery of the heart has probably reached the limits set by Nature to all surgery. No method, no new discovery, can overcome the natural difficulties that attend a wound of the heart." So much for open heart surgery.

Or, Dr. Lee DeForest, the electronics pioneer, who said, in 1967, "Man will never reach the moon — regardless of all future scientific advances.” Two years later, Neil Armstrong was walking on the moon. So, no predictions from me about the future form of our health care system.

OK, to get to the issue at hand, as our new health care system emerges, whatever its form, what ethical guidelines can help us navigate it?

It’s not news that the health care enterprise is highly complex and has many different components, including clinical professionals, scientists, and administrators. Each of those groups has different purposes and goals, and each works toward achieving those goals guided by ethical principles. Of course, the choices we make have to be within the law, and, in health care, the Affordable Care Act is going to determine the system’s broad outlines.

But it’s important to realize that the law isn’t the only determinant of the shape of the emerging health care system. Regardless of the ACA’s successes and failures, we workers in the trenches of health care will still be responsible for caring for patients, providing facilities that we use to provide that care, and continuing to innovate and discover toward enhancing our ability to prevent and cure disease. Each of us will also help to shape the coming health care system, guided not only by the law, but even more by our respective ethics.

I say “respective ethics” because I believe that there’s not a single health care ethics to help decision making. Rather, I believe that there are different ethical guides for at least three different groups — clinical professionals, research scientists, and university and hospital administrators.

Now, let me be clear. The ethical principles for these three groups are the same — we’re all human beings, and each of is imbued with a human nature that requires certain kinds of responses to daily challenges. But, although the principles are the same, their order of importance is different, because the problems that each group faces are different. Let me back up and explain.

Every day, each of us faces a flood of choices, from whether it’s healthier to use butter versus margarine on our toast for breakfast to whether to recommend medical treatment versus open heart surgery to a patient with coronary artery disease. To navigate those choices successfully, we need certain principles as guides. A partial list of the principles that are important for all of us includes respect for the right of every patient to decide what happens to their own bodies, honesty in all professional interactions, integrity, rationality, keeping promises, work-related competence, compassion for suffering patients, and an attitude of benevolence toward others. The precise order of importance for the various principles, though, is different for the different groups. That’s because their goals and the problems they face are different. I’ll describe what I mean for each of the three groups.

Hospital administrators are basically business people, so their ethical principles are essentially business ethics. To understand the relative importance of principles for administrators, we have to know what’s the goal of the business of maintaining hospitals. The central goal of university hospital administrators is to preserve the university’s long-term existence in the service of its mission. The stated mission of MUSC is “to preserve and optimize human life in South Carolina and beyond.” Given that, what does it take to preserve long-term existence? Well, for patients to be willing to come to our hospital for treatment, they have to trust that the hospital will treat them honestly and fairly, exhibiting what some have called “common decency”.

University administrators have to deal with problems related to the financial balance sheet. They have to keep revenues and expenses in relative balance in order to ensure long-term survival of the institution. Also, they have to create and enforce policies that enable the university to accomplish its mission.

These administrative responsibilities aren’t easy. For example, Emory University and its hospitals lost a huge amount of trust when a scandal erupted 4 years ago. Dr. Charles Nemeroff, chair of the Department of Psychiatry, was revealed to have accepted over $2½ million from drug companies while publishing papers and speaking on behalf of the companies’ products. Clearly, Nemeroff handled his conflict of interest poorly, but it was even worse that the university administration stonewalled the investigation. Administrators had an unambiguous responsibility to oversee such conflicts of interest, they knew about Nemeroff’s conflicts of interest for several years, yet they abdicated that responsibility.class="MsoEndnoteReference" class="MsoEndnoteReference"[1] A number of similar scandals at the university level have taken place in recent years, at Harvard, the University of Pennsylvania, the University of Wisconsin, and UAB, for example.

The administrator’s role requires that their foremost ethical principles have to be … honesty, fairness, and common decency, all to ensure the university’s and the hospital’s continuing existence and long-term flourishing.

The enterprise of science has an entirely different goal: the discovery or creation of new knowledge. Like all human beings, scientists should have … benevolent impulses toward others and compassion for the human predicament. But the ethical principles that’re most important for successful achievement of the goals of science are not beneficence and compassion — they are integrity and honesty. Without absolute honesty and integrity in designing, conducting, and reporting results of their studies, the foundations of science can be undermined and even destroyed.

Right now, those foundations are at risk because of pockets of ethical wrongdoing in the biomedical sciences. A recent study of several thousand early- and mid-career scientists asked whether they personally had engaged in any of 10 seriously unethical practices, including, for example, falsifying or fabricating research data. Fully 33% of the respondents admitted they had engaged in at least one of those 10 behaviors in the previous three years.class="MsoEndnoteReference" class="MsoEndnoteReference"[2] Research misconduct of this magnitude seriously endangers the foundations of science, and, worse than that they pose risks to patients whose doctors and other clinicians will be making patient care decisions based on false information.

The disturbing studies I’ve cited clearly show the paramount importance for scientists to base their day-to-day behavior on the ethical principles of integrity and honesty, regardless of external pressures.

Now I’m going to talk about ethics for the clinical professions, taking medicine as representative of all of them, while recognizing that the ethical principles that guide the professional activities of physicians are in some ways different, but in many more ways, very similar to those of other clinicians.

The foremost professional goal of physicians is to work for the good of the patient.  For the healing relationship to succeed, the first requirement is that patients trust that their physicians are acting in their best interest. There’s good reason for this: successful medical care requires that physicians have access to intimate details of the patient's personal history, as well as intimate access to the body itself in ways that are allowed to no one else, including the patient's minister, lawyer, and even his or her wife or husband. Think here of physical examinations and surgical opening of body cavities in patients who’re anesthetized and completely vulnerable. The fundamental need for those extraordinary intimacies means that patients have to trust that their doctors are acting in the patient's interest rather than the doctor’s.

So for those reasons, the virtues required of physicians as they serve the good of the patient come in two packages: what’s good for the patient from the biological perspective and what’s good for them in terms of their own value systems. First, to serve the patient's biological good, the physician has to have scientific objectivity and has to be competent in both medical knowledge and technical skill. Second, to serve the good of the patient from the patient’s perspective — the physician has to respect the patient's personal values, has to be honest in disclosing the information patients need to make decisions consistent with their own values, and has to have compassion for the patient’s humanity and suffering. To sum it up in a single word, the physician has to be trust-worthy — that is, has to have all of the other qualities I just mentioned to be truly worthy of the patient’s trust.

Yet, there’re problems in the house of medicine. From an ethical perspective, when a medical error occurs and a patient is harmed, the physician’s first responsibility is to the patient and the patient’s right to know what happened.  Yet a survey of 1300 physicians … found that only  half of them, 50%, believed that such an error should be disclosed to the patient, and only 39% believed that the patient should be given an apology.class="MsoEndnoteReference" class="MsoEndnoteReference"[3] As a matter of honesty and personal character, physicians should not withhold information from patients, nor, to point to another problem, should they lie to insurance companies, either to increase their own incomes or to reduce expenses to patients.

Yet, misrepresentation of diagnoses and procedures is commonly supported by physicians. Asked if they would approve of deceiving an insurance company to get coverage of an uncovered service, such deception was supported by 58% of physicians for a coronary bypass operation, 56% for an arterial revascularization, and 70% for routine mammography.  They do this to help patients deal with despicable insurance companies, but observe that the physician and often the hospital often benefit by being paid for their otherwise unpaid services. Also, as a family doctor commented in a New York Times article, “Every time I lie just a little bit, I find it’s easier to lie the next time.”

There are undoubtedly practical reasons for withholding from patients information about medical errors and for lying to insurance companies. But, it can be argued, as I do, that these acts are simply wrong, they’re wrong because they diminish personal character and undermine trust-worthiness.

The ACA contains many penalties for violating the law. But, laws and threats of punishment are blunt instruments. They are far from the best way to reduce ethical misconduct. Doing the right thing depends on developing habits of doing the right actions in the given circumstances, and these habits have to be internalized for right action to be reliable in the long run. We internalize ethical behavior by doing what we know to be the right thing deliberately every time we make a choice.

Albert Einstein said, in 1930, “I never think of the future. It comes, soon enough.” The emerging health care system is coming, soon enough, but its form is hardly predictable. We need to be prepared for whatever emerges, but fortunately, as human beings with a human nature that’s been stable for thousands of years, our responses to the coming challenges can rely on our internalized ethics, if you will, our virtues, to successfully meet the inevitable challenges that lie ahead.

For administrators, this requires consistently acting with fairness and common decency in the service of the institution’s flourishing. For biomedical investigators, it requires exercising impeccable honesty and integrity in the service of science. And for clinicians, it requires being trustworthy in every way, in the service of unswerving, even ferocious dedication to the welfare of our patients. We owe them nothing less.

Thank you.

class="MsoEndnoteReference" class="MsoEndnoteReference"[1]

class="MsoEndnoteReference" class="MsoEndnoteReference"[2] Martinson BC, Anderson MS, de Vries R. Scientists behaving badly. Nature. 2005 Jun 9;435(7043):737-8

class="MsoEndnoteReference" class="MsoEndnoteReference"[3] Loren DJ. Risk Managers, Physicians, and Disclosure of Harmful Medical Errors. The Joint Commission Journal on Quality and Patient Safety. March 2010 Volume 36 Number 3: 102-108


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