February 1998 Bulletin

"I must do what I can to help my patients. Thatís my ethical obligation."


The managed care environment has put ethics to the test, but physicians must maintain a deeply ingrained moral commitment to the patientsí best interests.

By Laura Pelehach

When Christopher Wills, MD, an Orange, Calif.-based orthopaedic surgeon, began speaking to patients, newspaper reporters - virtually anyone who would listen - about what he perceives to be the immoralities of managed care, he knew he was taking a big gamble. In California, where managed care runs as deep as the San Andreas fault, itís difficult for physicians to survive without a managed care contract. And Dr. Willís outspokenness drew the kind of attention that doesnít necessarily make one popular among managed care companies.

"The way managed care is being run is basically unethical, and Iíve been telling everyone that," says Dr. Wills. "Iíve been telling patients the way the system works, where doctors get kickbacks for not taking care of patients, is wrong. Thatís gotten back to the managed care organization."

Consequently, when the orthopaedic IPA he helped form was fired by its only managed care client, Dr. Wills was not one of the physicians to be rehired on an individual basis. Nor does he expect to be. His practice is still busy, but, by degrees, is becoming less so. He has no idea how many more patients he will lose as a result of his severed connection with the managed care organization. Still, heíll tough it out. "Ethically, emotionally, Iím doing much better by not having this double standard," says Dr. Wills.

For Dr. Wills, the prospect of working in the managed care structure felt as uncomfortable as if he had met a stranger in a dark alley who offered him the privilege of continuing to practice medicine - the patients, income and security - in exchange for "just a few concessions." It just didnít feel right, and Dr. Wills walked away.

His case exemplifies the ethical struggle physicians face daily as they weigh their responsibilities to the patient against the often seemingly conflicting goals of the organizations that employ their services. This month, the Academy issues the third edition of the "Guide to the Ethical Practice of Orthopaedic Surgery," which states: "The basic tenet of these documents is that, within orthopaedic surgery, the orthopaedic surgeon must develop and maintain a deeply ingrained moral commitment to the patientsí best interests."

That commitment is becoming more complex as physicians are confronted by financial incentives for doing less for patients, the temptations to take a "piece of the action" by owning or managing for-profit hospital chains and treatment centers and the competition for managed care contracts with their colleagues.

Ethical questions are becoming more complex. "There used to be a straight line between the doctor and patient," says Gordon Aamoth, MD, chairman of the Academyís Committee on Ethics. "Now thereís a relationship between the patient and doctor, the doctor and insurance company, and the patient and insurance company. Itís a triangular relationship, and triangular relationships usually donít work too well. That relationship is whatís causing some of the ethical issues."

"By and large, medical care is still ethical," says John O. Cletcher, Jr, MD, who also is a member of the Committee on Ethics. "We just have to jump through more hoops. We are trying to reconcile our duty to the patient with our practical responsibilities to the person paying the bill."

Jump through hoops for his patient is precisely what Dr. Martin (not his real name) had to do. Although Dr. Martin, a specialist in adult reconstructive orthopaedic surgery, received approval to perform a total hip and knee replacement on a patient with a severe arthritic condition secondary to a rare congenital deficiency, he did not
receive the insurerís approval for follow-up care. Concerned, he encouraged the patient to return for an outcomes study at no charge. He noted drainage in the patientís knee region, which the patient said his primary care physician was treating with oral antibiotics. Outraged, Dr. Martin informed the primary care physician and the health care administrators that the patient could lose the knee replacement if it were left untreated and the hip could become secondarily infected as well.

Without the insurerís authorization, Dr. Martin encouraged the patient to come to the facilityís emergency room. At this point, the right hip also was draining, and Dr. Martin was forced to remove both prostheses.

Today, payment is in limbo. Dr. Martin asked that the hospitalís collection department suspend the pursuit of payment from the patient.

The ordeal has solidified Dr. Martinís values and the realization that physicians often must take matters into their own hands. "Our ethical responsibilities are changing," he says. "I thought I could trust the process, the government and professional organizations to do the work for me, but I realize that no one can do the work for me. I must do what I can to help my patients. Thatís my ethical obligation."

So, how does a physician hold onto ethical principles in the current health care environment? By taking control and learning how to best operate within the environment, says Peter A. Ubel, MD, assistant professor of medicine and on the faculty of the Center for Bioethics, division of general internal medicine, University of Pennsylvania, Philadelphia. If high costs were what created the current health care situation, itís far better to have physicians, rather than managed care companies controlling them, he says. "There are two ways to address the problem of costs," Dr. Ubel says. "You can tie the physiciansí hands and take their decision-making power away, so that they canít make appropriate medical decisions, or you can untie their hands and let them make decisions, but make those decisions with cost in mind."

Dr. Ubel acknowledges that sometimes compromises must be made. "Our responsibility now is to promote patientís interest while recognizing that sometimes you have to do less than the best. You have to decide how much benefit is worth how much cost. Thereís no magic number. You just have to make the judgment. We are used to making tough decisions all the time in clinical medicine.

"When we are talking about a low-yield diagnostic test that is very costly, thatís when we should back off," says Dr. Ubel. "When you think a certain treatment that has been denied will give certain benefits, thatís when you fight the system and lobby for your patient."

Physicians need to be vocal when they feel a managed care companyís action will harm the patient, says Dr. Ubel. And they need to be willing to take a cut in pay. "The only way physicians can credibly reclaim some of their power in medicine in the service of ethics is to show weíre willing to give up some income. Thatís not going to come easily. I donít know the right amount of money physicians should make. But we might as well face reality and regain control over where medicine goes."

Part of regaining that control, Dr. Cletcher adds, is remembering what being a physician is all about, and shunning the mentality that weakens the relationship between a patient and physician. "We are privileged to practice medicine and to enter the innermost secrets of humans," he says. "We have access to their minds and bodies. That privilege carries enormous responsibility. We need to set ourselves apart from the provider and customer mentality."

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