To the Editor:

Until the last paragraph of their scenario regarding "Lying for the Patient's Good", the authors make a clear case why a doctor should not lie. But in the last paragraph this is all swept aside with the justification that the patient needs elective treatment that would be difficult for him to receive otherwise.

Apparently the key phrase is –"it seems unlikely that the injury did occur on the job". The "unlikely" seems to imply a reasonable shadow of remaining doubt about the injury onset facts.

If indeed true doubt about the event surrounding the injury remained, then the doctor’s decision to further evaluate and treat the patient’s injury as work-related is justified. But, it seems very likely that a careful history by a competent orthopedic surgeon would remove this doubt. And, it is very likely that at some point the orthopedic surgeon is going to have to declare whether or not in his opinion the injury is or is not work-related.

This article seems to this reader to be another example of situation ethics. My point in writing is to draw further attention to the very real issues raised by the authors and to raise serious doubt about their conclusion.

Sincerely,

Marc Asher, M.D.

University Distinguished Professor MAA/to

To the Editor:

In their short essay “Lying for the Patient’s Good,” Capozzi and Rhodes present the case of a man with a torn medial meniscus who initially reports that he injured the knee at work. However, on further questioning, it seems unlikely that the injury occurred on the job. The patient then explains that he has no health insurance, and explicitly asks the physician to report the injury as work-related so that Workers’ Compensation will cover the cost of treatment.

Capozzi and Rhodes review the reasons that patients ask physicians to deceive third parties for the patient’s good, and they argue cogently that the overall harms of deception generally outweigh the benefits in such situations. But their conclusion is puzzling. In the last paragraph, the authors note that the hypothetical patient “does have a medical need that requires attention,” and they make the following recommendation to the hypothetical physician: “In this case … with regard to an account of where and when the injury occurred, the physician can state, ‘According to the patient …,’ thus providing an honest report of the description of the injury as presented by the patient.”

Most readers, I believe, will infer that the authors are recommending the language “According to the patient, this injury occurred at work.” (Surely the authors are not recommending “According to the patient, the injury occurred at work in one version of his story, but outside of work in another version”). But if the patient indeed stated initially that the injury was work-related and then changed his story, the statement “According to the patient, the injury occurred at work” would not represent an honest report. The language “according to the patient” does not negate the deception if the physician intentionally omits part of the story.

The language “according to the patient” is particularly appropriate when patients with subjective symptoms (e.g., pain, chronic fatigue) ask physicians for medical statements that will help them secure benefits such as disability payments or leave from work. In such cases, a physician frequently has no independent objective basis upon which to judge the patient’s functional capacity. In contrast, the patient described by Capozzi and Rhodes has provided an inconsistent narrative about a specific point in the medical history. To ignore the inconsistency is to collaborate in the deception. The physician should find another way to secure medical care for this patient.

We agree with Dr. Levin’s letter and his approach to patients who have falsified their medical information. We hope, however, that our closing paragraph did not convey the impression that lying for the patient’s good is acceptable if the lie is caged in evasive terminology. That was not at all our intention. Our point was that if it is clear that the patient’s injury did or did not occur in the workplace (or other insurable area) then the physician’s report should indicate that information. If, however, the exact mechanism, location, or circumstances regarding the patient's injury are unclear, then the physician should simply report the information as it was relayed by the patient. Our primary goal as physicians is the care of our patients, not policing the veracity of the patient’s history.

To the Editor:

Dr's Capozzi and Rhodes (Ethics in Practice, Lying for the Patient's Good) are to be commended for their excellent synopsis of why it is wrong to lie solely for the patient's good. Unfortunately, their ultimate recommendation to report the patients history as "according to the patient...." violates all of the principles which they elucidated.

I suspect many of us have encountered patients who have reported a history and then advised us "off the record, this is what really happened". In this instance, the reason for the deception was to commit insurance fraud. The patient made it clear to the treating physican what their intentions were. Once the physician received this information they would be participating in the "lie" by submitting a claim to the workers compensation carrier. This would clearly be in violation of the ethical guidelines for which are bound to in our pratices as physicians.

When I have been faced with this situation, I notify the patient that I will not submit a claim to their workers compensation carrier. This is not synonymous with denying the patient necessary medical care. Depending on the urgency of the situation the patient could be immediately hospitalized, referred for social service counseling, supplying the care free of charge, and/or work out payment plans which are feasible for the patient.

We all recognize that health care expenses in this country are exorbitant and that too many Americans remain uninsured(Approximately 40 million). Clearly, our health care system is in need of a major overhaul. Ultimately, all patients should be treated with any and all interventions which the treating physician deems necessary, even if it is clear that the individuals will never be able to pay for the services. Lying will not help reform the broken down system and, as Dr. Capozzi and Rhodes report, "undermines the veracity of the individual physician and casts doubt on the trustworthiness of the profession as a whole".

To the editor:

I read “Lying for the Patient’s Good” with interest and agreed with the general ethical principles discussed. However, I felt the solution to the ethical dilemma facing the orthopedic surgeon in this case was self- serving and ultimately dishonest. This solution (describing the patient’s “official” version of the history while knowing it to be untrue in order to ensure payment for services) would make the physician an accomplice in a fraudulent activity. In addition to lying by omission of well-known pertinent information, the physician is cheating a system that is already notorious for abuses and excessive costs. In addition to being wrong on ethical grounds, a physician’s participation in this type of activity further erodes society’s trust in our profession.

The very few times I have been placed in this difficult situation I have told the patient that I cannot provide care under these circumstances. I give the patient two options: Continue with me under more honorable conditions or have the visit record voided. No fee is charged for the visit if the patient chooses the latter option. Although this approach may still not be fully unassailable from an ethical viewpoint, it excludes me from wrongdoing and allows the patient to pursue treatment in a manner consistent with his or her own ethical standards.