D.B. presents to the orthopaedic surgeon's office with a knee injury. He
informs the surgeon that he injured the knee at work. The physical examination
is consistent with a torn medial meniscus. The surgeon requests a magnetic
resonance imaging study and tells the patient that, depending on the results
of the scan, arthroscopic surgery may be necessary. D.B. then explains that he
no longer has health insurance, but, by saying that the injury occurred at
work, his treatment will be covered by Workers' Compensation insurance. On
further questioning, it seems unlikely that the injury did occur on the job.
D.B. asks the surgeon to report the injury as work-related; otherwise, he will
have to pay for the surgery himself and he cannot afford the expense.
All of us are well aware of our ethical commitment to act for the good of
our patients. But how far does the scope of that dictum extend? The case above
raises the question of whether doctors should be concerned only with patients'
health and medical well-being or whether they should also take an interest in
other things that are of importance and value to their patients. Although in
most circumstances it may seem very clear that doctors are not obligated to
improve the financial situation of their patients, in some circumstances the
extent of the physician's responsibility is not so obvious.
The health-insurance structure in the United States leaves approximately
40,000,000 patients and their doctors facing difficult dilemmas about what
they will sacrifice to be able to obtain or provide needed medical treatment.
In the case above, the doctor and the patient confront the question of whether
truth, health, or money should be relinquished. In this particular case, and
in other similar situations that we often face in our practices, several
considerations should be taken into account.
As physicians, we are obligated to assess the patient, diagnose his or her
injury, and recommend and provide appropriate treatment. That is, essentially,
the substance of the physician's responsibility as it has been recognized
throughout history. Honesty plays a crucial role in the fulfillment of that
responsibility at a variety of levels: (1) The doctor-patient relationship, at
its very essence, relies on honest communication. We expect patients to be
honest when providing their history to us. In turn, they expect us to be
honest in evaluating their problem, recommending treatment options, and
implementing a treatment plan. The honest exchange of information is the
foundation of patient autonomy. (2) The relationship between physicians
depends on honest reporting of patient information, the day-to-day transfer of
patient-care responsibilities, the sharing of patient-care responsibilities,
and the dissemination of information through education and scientific
reporting. When colleagues are unable to rely on the word of a fellow
physician, the power of medicine is eviscerated. (3) The relationship of
medicine with society depends on an honest disclosure of information about
professional competence, the nature of professional practice, safety and
hazards, and costs. Lying or misleading undermines the veracity of the
individual physician and casts doubt on the trustworthiness of the profession
as a whole. Moreover, when physicians cannot be trusted to tell the truth in
their reports to insurance carriers or other social agents, reliance on their
word is undermined.
We therefore always have at least two very serious reasons for concluding
that we should not lie; these reasons are that dishonesty is generally wrong
and that a doctor's dishonesty undermines the trustworthiness of medicine. So,
why would physicians consider misrepresenting patient information at all, when
doing so, even to expedite medical care, constitutes fraud and deception? They
would do so because many physicians believe that they are, in fact, acting in
the patient's best interest. As physicians, we are supposed to be patient
advocates. By misrepresenting patient information, we assist patients in
receiving treatment that would otherwise be denied. Physicians often see their
deception as justified because it corrects an apparently unjust system of
health-care distribution. It may seem as if describing D.B.'s injury as
work-related would be the right thing to do if the patient is otherwise unable
to obtain magnetic resonance imaging and subsequent surgery.
Physician collaboration in the deception that allows patients to receive
medical care that would otherwise be denied can occur in a variety of
circumstances. For example, certain medications, such as the cyclooxygenase-2
inhibitors, may not be covered by healthcare plans unless a specific diagnosis
or comorbidity is identified. Is the physician justified in modifying the
diagnosis to cover the required medication? Should this be done for all
patients, for those with financial difficulties, or only for those who would
have to forgo appropriate treatment without the deception?
As the situations that invite deception become less pressing, the
justification for lying loses its force. Physicians are often required to
supply information regarding home-care services, visiting nurses,
physical-therapy protocols, and other social benefits. We are often asked to
write letters of medical necessity regarding private-duty nurses or other
specialized forms of care. Physicians are even asked to write letters so
patients can avoid the financial consequences of modifying gym memberships,
changing airline reservations, or missing days of work. In such cases, is
inaccuracy ever justified? To what extent are physicians obligated, if at all,
to assist their patients in achieving these goals? Do these types of
deceptions count as "providing good medical care"?
There are a variety of medical situations that require honest reporting by
physicians. Physician assurance of a patient's general health allows others to
fulfill their special responsibilities. For example, a physician clearing a
student athlete for team sports assists the school coach who must safeguard
the student's health. Physician assurance of a patient's ability to perform at
a particular standard, such as having adequate vision for driving, can provide
for an important social good, namely, protection from visually impaired
drivers. Physician reporting of infectious disease can protect public health.
Physician compliance with programs and policies for the allocation of health
resources can allow health-care institutions to function efficiently and
provide medical services.
These are tremendously important benefits that can be achieved only through
the honesty of physicians. Fraudulent reporting not only undermines the public
trust, but it also necessitates the creation of expensive oversight mechanisms
and drives up medical costs. Thus, bending the rules for one patient can do
far more harm than good for everyone who would otherwise benefit from
physician trustworthiness.
Physicians must closely examine their motives for consenting to
misrepresent patient information. Furthermore, obtaining approval for medical
services or surgical procedures can certainly be financially advantageous to
the physician. A physician may be concerned that his or her patient will seek
care elsewhere with a more "cooperative" doctor. Likewise, a
physician may find that saying "no" to a patient is uncomfortable
and awkward, and that it is easier to comply with the patient's request.
However, none of these selfserving reasons warrants fraud.
D.B.'s situation raises all of these issues. Although it may be easier and
perhaps more financially advantageous for the doctor to go along with D.B.'s
request, those considerations do not constitute an adequate justification for
deception. Lying will undermine a patient's confidence in that physician.
Patients are more likely to think that a physician who lies, even for that
patient's benefit, will be more likely to lie in other situations. Thus, the
physician-patient relationship is severely compromised. Additionally,
dishonesty on the part of a physician erodes society's trust in the medical
profession as a whole. Doctors must therefore avoid dishonesty.
Finally, the Workers' Compensation system does provide important benefits
to patients with work-related injuries. It is therefore important to avoid
actions that would tend to undermine this system or others like it by
diverting resources away from such programs that provide appropriate patient
benefits.
Yet, D.B. does have a medical need that requires attention. If it is
unlikely that D.B. will be able to receive treatment without third-party
payment, it is important that the doctor try to help to achieve that important
goal. In this case, the doctor can simply report the medical findings and
recommendations for treatment to the insurance carrier. 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.