By Debra Wood, RN, contributor Feb 26, 2018
As medicine has become more complex, physicians’ ethics are often put to the test as they wrestle with challenges such as access to care, end-of-life expenses, genomics and other issues.
“Situations that cause people to feel a sense of uncertainty or distress is a basic way of describing an ethically challenging situation, one where you are not sure how to do the right thing—or can’t do the right thing,” said Nancy Berlinger, a research scholar at The Hastings Center in Garrison, N.Y.
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Ethics in Medicine: Key Challenges Facing Physicians
Access to care: The Haves and the Have Nots
“The top ethical challenges that physicians and medicine face would be access to care and the ability to pay for it, and the failure to offer the undeniable benefits of modern medicine to all who could be helped by it in the U.S,” said Philip M. Rosoff, MD, MA, professor of pediatrics and medicine at the Trent Center for Bioethics, Humanities and History of Medicine and chair of the Duke University Hospital Ethics Committee in Durham, N.C.
One of the principles in the Code of Medical Ethics, adopted by the American Medical Association (AMA), is that physicians should support access to medical care for all people. Yet, doctors face the daily realities of uninsured and underinsured patients, along with changing health system guidelines and financial constraints.
Access to care will likely become an even greater concern as Congress and the Trump administration try to dismantle the Affordable Care Act (ACA), which dramatically improved access and improved the quality of care, said Gerard Magill, PhD, Vernon F. Gallagher Chair and professor at the Center for Healthcare Ethics at Duquesne University in Pittsburgh, Penn.
The tax reform bill, passed in late 2017 eliminated the tax penalty for people who did not purchase health insurance. The nonpartisan Congressional Budget Office predicts 4 million fewer people will have coverage in 2019 and 13 million fewer by 2027. The Centers for Medicare and Medicaid Services estimates 37.7 million people will be uninsured by 2026, as a result of the elimination of the individual mandate.
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Health insurance premiums are expected to rise because of the legislation as even more people will drop coverage, Magill explained.
Magill explained that for the physician it’s frustrating when he or she has to explain that even though a patient has a serious illness, they are not insured.
Access to care is also a top medical ethics issue for nurse practitioners (NPs) and physician assistants (PAs), especially in community health settings.
“For many NPs, the inequities that are present in society and amplified in health care create difficult ethical conflicts around allocation of scarce resources, including their own expertise and attention, securing access to even basic levels of health services for their patients, and assuring that the people they care for understand the trade-offs they are making in their health care decisions,” said Cynda Hylton Rushton, PhD, RN, FAAN, the Anne and George Bunting Professor of Clinical Ethics, professor of nursing and pediatrics at Johns Hopkins University in Baltimore.
End-of-life care expenditures
Doctors often struggle with the question, “How much should be done to extend the life of a terminal patient?” They also wrestle with what can be done, based on ability to pay for end-of-life care.
The expenditure of so much effort and money in the last six months of life for people with terminal conditions rather than focusing on quality of life and palliative care have become physician ethics issues, Rosoff said.
Celia B. Fisher, PhD, the Marie Ward Doty University Chair in Ethics, professor of psychology, and director of the Center for Ethics Education at Fordham University in Bronx, N.Y., said, “What has been going on and will increasingly go on are issues of insurance coverage and what will be the responsibilities of physicians to be responding to cost concerns of loved ones, whose loved ones may or may not have left a DNR [(Do Not Resuscitate order)].”
How physicians ethically navigate economic challenges patients face is a medical ethics dilemma, said Fisher, who explained that patients may seek assisted suicide to avoid the costs of end-of-life care.
Genetic testing and care decisions
Integrating genomics and genetics into practice also creates ethical challenges for physicians.
“As genomics and gene testing is becoming so popular, both in terms of medical professionals and consumer access, physicians are increasingly going to be faced with questions regarding genetic risk for certain diseases,” Fisher said. “Some of it may be based on misinformation which is created by consumer genetic testing companies; some may come from things publicized, or genetic testing in the hospital.”
Fisher explained that genetic testing deals with probabilities, not yes or no definitive answers.
“Physicians have difficulty understanding the probability of risk, and providing adequate feedback to patients.” Fisher said.
Find more information on genetic testing and clinical care from the AMA.
Technology and other challenges in medical ethics
“The burgeoning technology can outstrip our ethical sensibilities as attempts to balance the benefits and burdens associated with them,” Rushton said. “Clinicians regularly struggle with ‘because we can’—should we use technology, especially when the consequences are uncertain?”
Additionally, Rosoff said that the increasing fragmentation of care, the intrusion of the Internet, and misinformation in the doctor-patient relationship creates ethics in medicine issues.
Treating patients with chronic illnesses can also be ethically challenging, because there is no definitive care, Berlinger said.
Team care models can add complexities, as well, as physicians and advanced practitioners may face many of the same types of ethical challenges, yet experience differences based on roles. And Berlinger said that patients can sense when team members do not agree.
“The team should reach consensus before a family meeting,” she recommended.
Find more information:
Code of Medical Ethics – American Medical Association
The Hastings Center – Bioethics Research
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