Doctor—Patient Ethics

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As patients — which, inevitably, all people with diabetes are — we place a certain trust in our doctors to act in our interest. Most of the time, what this means is clear: doing whatever is necessary to treat the issue at hand, helping the patient heal. But as a new survey shows, some situations present ethical dilemmas to doctors, and not all agree on the best course of action.

The survey, commissioned by Medscape and published as its 2012 Ethics Report, touched on a variety of topics — from when to end life-sustaining treatment to whether doctor–patient dating is ever acceptable. While some questions produced widespread agreement, others saw a nearly even split (doctors were also given the choice of “it depends” rather than yes or no on all questions). Many questions dealt with issues related to presenting or withholding information from patients. How a doctor feels about many of these questions could, therefore, be of great interest to his or her patients.

One topic that is likely to ignite strong emotions is whether it is acceptable to direct scarce resources toward a younger rather than an older patient. In the survey, 39% of doctors stated that they would never do this, while 27% declared that in some situations they would. Among the doctors who said they might allocate resources based on age, life expectancy and the fact that in a crisis, split-second decisions must often be made about whom to save were mentioned as reasons. Doctors completely opposed to age-based allocation of resources mentioned that not all younger people live longer or “more valuable” lives, and that human life is precious and always worth helping or saving.

Another controversial topic from the survey is whether a patient who is “non-adherent” or who overuses resources should be dismissed. Perhaps surprisingly, doctors were nearly evenly split on this topic, with 32% answering yes, 33% no, and 35% “it depends.” Doctors who answered yes mentioned that in the case of noncompliance, the doctor and patient are clearly not on the same page, so the relationship cannot be productive. Some doctors on both sides of the question drew a distinction between being unable to comply with treatment instructions and refusing to do so. Many people with diabetes, however, may have a more nuanced view of “compliance,” since sometimes a treatment may demand a degree of attention that blurs the line between being unable and refusing to follow instructions.

Questions related to doctor–patient honesty provoked a wide variety of responses. While 80% of doctors found it unacceptable to downplay the risks of a procedure if they strongly believed it would help a patient, only 48% found it unacceptable to prescribe a placebo (inactive pill) to a patient intent on receiving treatment even when it is not necessary; 34% expressed a willingness to prescribe a placebo. Since placebos have repeatedly been shown to improve outcomes when patients believe they are being (or might be) treated, some doctors apparently believe that honesty might not always be the best policy.

Perhaps not surprisingly, on the topic of receiving free lunches from representatives of pharmaceutical companies, 72% of doctors believed that they could remain unbiased while accepting such lunches, while 20% believed that they could not remain unbiased. Some doctors scoffed at the notion that a sandwich could make them change their prescribing habits, while others noted that if they developed a friendly relationship with a pharma rep, they might feel pressure without even knowing it. This topic has proven to be extremely controversial in places like Massachusetts, where a law prohibiting giving free lunches to doctors while pitching a drug was weakened earlier this year.

Would you be upset to find that your doctor disagreed with you on these questions, or any others in the survey? Do you believe that complete honesty between doctors and patients is desirable, even if it means conveying a pessimistic outlook that may be demoralizing? On the other side, have you ever exaggerated your efforts to comply with a doctor’s instructions? Can doctors receive lunches or gifts while remaining unbiased? Leave a comment below!

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