Why Dont' Physicians Do What They Say They Ethically Ought to Do?

The Annals of Internal Medicine just published a major study that contrasted physicians' attitudes toward professional norms with their self reports of whether they acted in conformity with these norms. [Campbell EG, Regan S, Gruen RL et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med 2007; 147: 795-802. Link here.]

In brief, the authors developed a survey which asked physicians whether they agreed with various professional norms organized according to the 2002 ABIM/ ACP/ ESIM Physician Charter. They also asked them about whether they acted in conformity with these principles in terms of their recent actions, or in responses to scenarios. Physicians surveyed were primary care practitioners (family medicine, general internal medicine, and pediatrics), cardiologists, anesthesiologists, and general surgeons. The overall response rate was 52%.

In general, large majorities of physicians agreed with the ethical norms. How often they reported acting in agreement with these norms varied. In particular, nearly all physicians reported treating patients honestly (less than 1% reported telling a patient's family member something untrue in the last 3 years, 3% reported withholding information from a patient or a family member.) However, although 96% agreed that "physicians should put the patient's welfare above the physician's financial interests," 24% would refer a patient to an imaging facility in which the physician was an investor, without revealing this conflict of interest.

Some commentators suggested that external pressures may prevent physicians living up to the standards they themselves have endorsed. For example, physicians interviewed in a Washington Post article suggested that the current emphasis on patient satisfaction may conflict with the physician's ethical obligation to avoid wasting resources when a patient demands an unnecessary but not clearly harmful test. The Congressional Quarterly reported quoted the CEO of the Federation of State Medical Boards saying that physicians "were penned in by the American the health care system, fighting giant bureaucracies while fearing legal action if they make a mistake."

However, there was not much more discussion of the sorts of external pressures that might push physicians to forsake their values. Yet readers of Health Care Renewal might be able to come up with more examples.

For example, consider the pressures on young medical school faculty, who are under tremendous pressure from their academic leaders to become "taxpayers," i.e., people who bring in more money from external funding sources than they consume (See this post, in which the Dean of a prominent medical school ranked such "taxpayers" above all other faculty.)

Since government and foundation research support is tight, this leads many faculty to seek research support from pharmaceutical, biotechnology, and device companies. Once they get such support, they may find it hard to turn down offers of consulting positions, speakers' honoraria, advisory board positions and the like from such companies. Spurning such positions may cost them their research support. And their academic superiors often set the example that it is fine to accept such payments. (See this post about the prevalence of such financial arrangements among medical school department chairs.) Under these circumstances, preaching to young faculty about conflicts of interest seems to be just adding insult to injury.

I am most reminded of an article about business ethics we discussed back in July. The theme was that business students understand ethical principles, and know what they ethically ought to do. The problem is that they have trouble actually doing it.

The new article by Campbell et al also suggests that physicians know what they ethically ought to do. They thus don't need new statements of ethical principles, or more instruction about what they ought to do.

Instead, physicians need to focus on the discrepancy between what they know they ought to do and what they actually do.

Some of these discrepancies no doubt arise from their own human failings.

But absent in most of the current discussion is the enormous pressures physicians feel, often from leaders of powerful organizations with strong (usually economic, sometimes political or ideological) vested interests that may conflict with the admirable values embodied in the Physician's Charter.

It's easy to say that individual physicians always ought to do the right thing, regardless of external pressure. Maybe the individual physicians who feel uncomfortable being pressured into doing the wrong thing might get better organized to resist this pressure.

It would be even more helpful if medical and health care leaders could actually support physicians who want to do the right thing. Given that many medical and health care leaders have vested interests that push them in opposite directions, they may not jump at this opportunity.