Medicine as Business May Mean More Ethical Challenges for Physicians

Physicians today are facing more ethical dilemmas as patient decisionsare being based less on beneficence and more on business modelsof success, says Sister Patricia Talone, ethics consultant, MercyHealth Corporation of Southeastern Pennsylvania.

Speaking during the recent Radiation Therapy Oncology Group (RTOG)meeting in New Orleans, Sister Patricia discussed models for ethicaldecision-making, and Father Albert Jenemann emphasized that physiciansmust follow fundamental moral principles when determining patientcare. These principles include beneficence, nonmalificence (notcausing needless harm or injury), and utility (bringing the greatestbenefit with the least harm).

"A patient's care must be just, in that similar cases receivesimilar care," says Father Jenemann, associate professorof philosophy at St. Joseph's University in Philadelphia. Justicecan be interpreted in a number of ways, he says. Some suggestthat those who have a greater need should receive more, whileothers suggest that those who contribute more or exhibit a higherlevel of effort should get more. For example, the more competentperson receives a higher salary. Sister Patricia emphasizes that"need" should be the most important determining factor.This may not be the case when medicine is considered a business,she adds.

Patient autonomy, which includes adequate information and sufficientability to deliberate and make a decision, is another moral principle,says Father Jenemann. Autonomy can be restricted to benefit thepatient and to sacrifice a small benefit in order to bring majorbenefits to others.

The Step-by-Step Way to Ethical Decisions

There is a step-by-step process that physicians can follow tomake appropriate ethical decisions, says Sister Patricia. Ethicaldecisions are best made by a group rather than just one or twopeople, she adds. All medical, social, emotional, religious, andspiritual factors must be gathered regarding the patient. Thefinancial reality of the situation also might be considered.

The patient, if capable of making medical decisions, should bepart of the decision-making process. If the patient is incapableof doing so, a surrogate, such as a family member, must be included.All decision-makers should should deliberate or discuss the optionsand their consequences. "Deliberation works best when thereis a willingness to share experience and listen to others. Thefrequently wrong but never unsure person is not good for the deliberationprocess," says Sister Patricia. After deliberation, a decisioncan be made. Any decisions should be documented, then evaluated.

"Some physicians are reluctant to document their decisionsbecause of a fear that their decisions will later be second-guessed,"says Sister Patricia. Documentation and evaluation help keep anaccount of responses to ethical questions. These responses mayhelp answer future ethical dilemmas or may even indicate the needfor a change in policies and procedures, she says.

"The shift of medicine into a business model can have frighteningconsequences," says Sister Patricia. It is essential thatphysicians remain principled and virtuous.

"Ethical principles are only enacted by persons with character,"she says.