The difference between right and wrong in medicine

Excerpted from "Doing What Might Be ‘Wrong’: Understanding Internists’ Responses to Professional Challenges," Academic Medicine. April, 2014 — To develop a deeper understanding of the complexity of physicians’ decision making when faced with professional challenges, Dr. Shiphra Ginsburg and a team conducted a secondary analysis of transcripts from focus groups with 40 internists in 2011. Participants responded to scripted professional challenge scenarios, and the authors then analyzed the transcripts for instances in which participants discussed “doing what might be wrong” (i.e., something that goes against their values or others’ expectations). They used the theory of planned behavior (TPB), which posits that intention to act is predicted by attitudes, subjective norms and perceived behavioral control, to understand the findings in a broader context.

The results showed that the theme of “doing what might be wrong” was pervasive, particularly in response to scenarios involving stewardship, non-patients’ requests for advice or care or requests for email access. Participants’ rationales for suggested behaviors included a desire to keep patients happy and be (or appear) helpful.

The study’s authors concluded that physicians often do what might be wrong when they are asked to do something that goes against their values and beliefs, by patients, others or as perceived by their organizations. Actions are often rationalized as being done for the right reasons. The study reported that these findings should inform the development of educational initiatives to support physicians in acting in accordance with their ideals.

Commentary

CMDA Executive Vice President Gene Rudd, MD: “These findings are troubling. Medicine has always had some ‘bad apples,’ physicians who failed to live up to the values of the profession. But now we hear that physicians ‘often’ choose to violate their conscience and do what is wrong when someone else expects them to. Such wholesale capitulation with cultural expectations will undermine all medical ethics.

“I recall a patient asking that I change the due date of her pregnancy on an insurance form to make it more likely she would qualify for coverage. While I wanted to please her, I recall my conscience warning me that it would be wrong. I told her that if I ever lied for her, she could never be sure that I wouldn’t lie to her. I expected her to leave my practice, but in this case, she didn’t. She found the demonstration of integrity more valuable than the potential loss of insurance coverage.

“Maintaining ethics begins with personal integrity. Whatever the ethical value, to be operative, the individual must have the moral courage to adopt it. This study reveals the widespread lack of moral courage required to adhere to convictions. No wonder standards of professionalism promoted over the last decade have failed to change professional behavior.¹ Values, morals or ethics mean nothing and accomplish nothing without disciplined commitment to them. Convictions are nothing more than casual opinions unless acted on.”

¹Kinghorn WA, McEvoy MD, Michel A, Balboni M., Professionalism in modern medicine: does the emperor have any clothes?, Acad Med. 2007 Jan;82(1):40-5.

Resources

Professionalism in Peril – Character Counts by Gene Rudd, MD
Grace Prescriptions – Learning How to Share Your Faith in Practice