Extract
In their short essay "Lying for the Patient's Good"
(2004;86:187-8), 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 being 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 patients' good, and they argue cogently that the
overall harms of deception generally outweigh the benefits in such situations.
However, 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."
In their short essay "Lying for the Patient's Good"
(2004;86:187-8), 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 being 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 patients' good, and they argue cogently that the
overall harms of deception generally outweigh the benefits in such situations.
However, 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 to 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.
I read "Lying for the Patient's Good"
(2004;86:187-8) with interest
and agreed with the general ethical principles discussed. However, I thought
that the solution to the ethical dilemma facing the orthopaedic 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.
On very few occasions that 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: (1) continue with me under more honorable
conditions or (2) have the visit record voided. No fee is charged for the
visit if the patient chooses the latter option. Although this approach still
may 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.
Drs. Capozzi and Rhodes are to be commended for their excellent synopsis of
why it is wrong to lie solely for the patient's good
(2004;86:187-8). Unfortunately,
their ultimate recommendation to report the patient's history as
"according to the patient..." violates all of the principles that
they elucidated.
I suspect that 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 physician what his
intentions were. Once the physician received this information, he or she would
have been participating in the "lie" by submitting a claim to the
Workers' Compensation carrier. This clearly would be in violation of the
ethical guidelines to which we are bound as physicians.
When I am faced with this situation, I notify the patient that I will not
submit a claim to his or her Workers' Compensation carrier. This is not
synonymous with denying the patient necessary medical care. Depending on the
urgency of the situation, the options would be (1) to immediately hospitalize
the patient, (2) to refer the patient for social service counseling, (3) to
supply the care free of charge, and/or (4) to work out payment plans that are
feasible for the patient.
We all recognize that health-care expenses in this country are exorbitant
and that too many Americans (approximately 40 million) remain uninsured.
Clearly, our health-care system is in need of a major overhaul. Ultimately,
all patients should be treated with any and all interventions that 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 to reform the
broken-down system and, as Drs. Capozzi and Rhodes report, "undermines
the veracity of the individual physician and casts doubt on the
trustworthiness of the profession as a whole."
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 to care for our patients, not to
police the veracity of the patient's history.