“Can you be an effective physician without also being an ethical physician?” That’s the question students in the inaugural class of the Elson S. Floyd College of Medicine at Washington State University faced for the first time on day two of classes. They’ll revisit it regularly as they make their way towards the MD degree and entry into a profession that has, many bioethicists and physicians believe, an ethic built right into it. To say that there is an ethic internal to medicine is to say that certain kinds of moral responsibilities are built right into what it means to be a part of the profession and to be doing what society expects of its physicians. We need not import ethics from elsewhere. It is native to the land of medicine.
“But what does it mean to be effective as a physician?” some students wonder as the discussion gets going. Indeed, many students explicitly answered the question, throughout the application process and in their personal professions during the August white coat ceremony: The fundamental aim of medicine is to help people. Put more formally, the goal is to promote the (health-related) well-being of one’s patients. So how does ethics help physicians to do that? The discussion on day two focused on conflicts of interest. Later ethics sessions will be devoted to discussing, among many other topics, informed consent and medical confidentiality. Each of these illustrates the connection between ethics and effectiveness.
Consider conflicts of interest. If a prominent medical group receives a very large donation from a major soft drink maker for the purpose of developing educational materials, ostensibly to help patients make good nutritional choices, we might wonder what’s in it for the soft drink maker. But we would also have to wonder if the money changing hands would affect the claims and language of the medical group writing the educational materials. If a physician owns a financial stake in an imaging center, we might wonder whether her judgment that a patient needs a medical scan is affected by the profit she makes each time someone comes through that center. Is that scan really necessary? Is it truly in the best interests of the patient?
At the heart of medicine is a relationship between physicians and their patients. Some describe this relationship as being a covenant, as opposed to a contract. Covenants are defined not by mutual self-interest but by shared goods. And the shared good of the physician-patient relationship is the patient’s well-being. That’s not to say that physicians shouldn’t be paid to do their work. But any financial consideration that affects their clinical judgment does put the covenant between physician and patient in jeopardy. We could quite reasonably wonder if the physician would make the same judgment in the absence of that financial incentive. So, a physician committed to making sure his or her clinical judgments represent a best effort to promote the patient’s well-being would want to avoid a conflict of interest that might compromise that judgment. (Medicine rarely happens by algorithm; doctors must make judgments—decisions under conditions of some uncertainty—all the time on behalf of patients.) An effective physician will thus avoid any conflicts of interest that might affect clinical judgment. And in doing so, he will be—at least in that respect—an ethical physician.
Another aspect of the physician-patient relationship that illustrates the “ethics and effectiveness” connection would be informed consent. Students at the ESFCOM will receive excellent training in many areas—basic biomedical science, clinical training, professionalism, leadership, and more—but what they won’t receive is an expert knowledge of the “next” patient who comes through the door of their practice. Generally, the patient knows her life better than anyone else. So when the question arises, “Which among the medically appropriate interventions we might do for this patient will best allow us to promote her well-being?,” providers have to look to the patient for help in figuring that out. That usually happens in the context of a conversation between physician and patient in which the physician seeks to provide sufficient understanding of the options and to allow the patient to voluntarily decide which option is most consistent with her understanding of her well-being. Many patients will choose the option with the highest odds of success. But not all. Other considerations might inform a patient’s decision to opt for a treatment with, say, lower odds of success but fewer side effects. And of course some patients will opt for no further treatment, or at least none that attempts to cure or overcome a disease. In each of these cases, the physician seeking to use her training to best promote a given patient’s well-being will need to gain that patient’s informed consent in order to know which treatment will do that. It is, with a few exceptions, an ethical responsibility of physicians to gain the informed consent of their patients to provide treatment. And it turns out that gaining informed consent will also allow the physician to best promote each patient’s well-being. So, again, ethics and effectiveness are linked.
As a final example, consider the ethical responsibility physicians have to protect the medical confidentiality of their patients. Laws such as HIPAA (the Health Insurance Portability and Accountability Act of 1996) require the protection of personal health information. But long before HIPAA, ethical doctors understood the importance of not betraying the trust of their patients. Patients must sometime disclose very sensitive information to their physicians. They might discuss with their doctors things they don’t discuss with anyone else. And indeed just about every patient comes to the doctor with needs and vulnerabilities that create a power differential between them. The doctor has knowledge, credentials, and social recognition; the patient may not understand his condition or symptoms and feel like he is in a position of weakness. The doctor observes but the patient is the subject of observation. Under these circumstances patients are understandably eager to be able to trust that their physicians will not take advantage of the imbalance. They will want to know that their doctors will treat them, with all their vulnerabilities and embarrassing symptoms, with respect and consideration. Sharing “war stories” at the bar after work or posting pictures to social media about the gruesome cases she saw that day does not express such respect and consideration, particularly if the identities of patients can be figured out from the details.
Should physicians care if their patients trust them? Yes, if they want to be effective in caring for those patients. A patient who does not trust his doctor will be less likely to share the most embarrassing details, or may not come in to see the doctor at all. In both cases, the doctor cannot effectively treat the patient. Imagine the young teen who swears she is not sexually active and nearly dies from the complications of an ectopic pregnancy before doctors figure out that she is pregnant. Her hesitancy to trust the physician could come at the cost of her life. Thus, when doctors take their ethical responsibility to protect medical confidentiality very seriously, they present themselves to their patients as trustworthy. Trustworthiness is just one of many moral virtues that increases the chances that the physician will also be effective in clinical settings.
So can a physician be effective without also being ethical? In at least some respects such as those discussed above, it seems clear that the answer has to be no. Of course, sometimes students like to point to fictional doctors who seem to be good (at being doctors) precisely because they are bad (at ethics). House, M.D. comes up a lot in these conversations. Dr. House does skirt the institutional rules and laws sometimes. But we shouldn’t equate ethics with all rules and laws. An institution might be flawed; a law might be unethical. Most people can quickly think of historical examples of each. In some cases, the ethical physician is the one who challenges a policy that compromises his ability to provide the best care to his patients. And because contemporary physicians will practice medicine in the context of a host of institutional arrangements with many competing interests, they will likely have to protect their patients on some occasions from the bureaucracy that threatens to compromise patient well-being. The rest of us will look to our physicians for leadership, both as individuals and as members of a profession, that protects us from harm and promotes our well-being as patients. We will look for our doctors to be ethical, so they can also be effective.
William Kabasenche is clinical associate professor of philosophy in the School of Politics, Philosophy, and Public Affairs, and the health systems education director for ethics in the Elson S. Floyd College of Medicine at Washington State University.