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Authors and Disclosures
Author(s)
Leslie Kane, MA
Leslie Kane, MA, is Editorial Director of Medscape Business of Medicine.
Disclosure: Leslie Kane, MA, has disclosed no relevant financial relationships.
From Medscape Medical Ethics
Exclusive Ethics Survey Results: Doctors Struggle With TougherThan-Ever Dilemmas
Leslie Kane, MA
Posted: 11/11/2010
Introduction
Moral and ethical decisions come with the turf of being a doctor.
Some of those decisions have massive consequences that affect people's lives forever. Other ethical issues,
although not life-and-death, have a huge impact on patient well-being as well as on doctors' careers and their
own sense of integrity.
To find out what doctors would do if faced with those difficult situations, Medscape surveyed physicians'
attitudes about some of the most frequent and wrenching ethical issues of our time. Over 10,000 physicians
responded to the survey, which asked about end-of-life dilemmas; pain treatment; insurance reimbursement;
colleague relations; withholding information from a patient with a terminal disease; patient privacy at the
expense of other people; romantic relationships with patients; and others. The survey was fielded in August September 2010.
Medscape also asked doctors, "What was your toughest ethical dilemma," and received almost 7000
responses -- many of them clearly emotional.
What came through loud and clear is that by and large, doctors tried to do what they believed was right.
However, the better path was not always clear. Some of the questions clearly struck a nerve, and showed how
tough it is to make the right decision -- if there even is a right decision. "Being a virtuous person is not what this
is about," says Kenneth W. Goodman, PhD, Co-Director of the University of Miami's Ethics Programs and
Professor in the University of Miami's Department of Medicine, Miami, Florida. "It's about critical thinking."
Today's doctors face more frequent and more complex bioethical dilemmas than in former times, says Thomas
H. Murray, PhD, President of The Hastings Center, a bioethical research institute in Garrison, New York.
"In medicine, doctors can do far more than they could in the past," says Murray. "They can do interventions that
were unimaginable a few decades ago. Every time you give those kinds of power, they come with difficult
situations and tough ethical choices.
"For example, when we didn't have penicillin, you'd have an old person lying in bed, and there was no decision
to be made. God or Nature decided if they would live or die, and the doctor just kept them comfortable. But the
increased power to intervene now requires that doctors make choices whether to do so or not."
Ethical Dilemmas Have Increased
More ethical dilemmas also occur today because of increased perception and awareness, says Murray.
"Doctors were always making a large number of moral choices, but were not labeling them or seeing them as
such; much of the decisions were unconscious," Murray says. For example, deciding whom to talk to in a
patient's family, or getting informed consent, were previously done on the basis of a doctor's judgment or what
would bring the best results. However, according to Murray, due to legalities and regulations doctors need to
think: "What are my obligations? Who do I talk to?"
Numerous external influences affecting the healthcare profession have also increased the number and nature
of ethical issues, says Murray. Reimbursement and insurance issues now come into play as a result of
government regulations and other factors that set conditions for physicians' practices.
Still, feeling morally challenged by ethical issues is a positive sign, says Murray. "If a physician recognizes that
he or she is having a tough ethical dilemma, it shows that this is a morally conscious individual trying to do the
right thing. The doctor can feel good that they've noticed the issue and it bothered them. It's a good need," says
Murray.
Now and in the coming weeks, Medscape will examine the individual ethics questions and explore doctors'
responses. Some of the nation's leading bioethics experts will weigh in on why doctors answered the way that
they did, and what this means for the future of medicine.
The following pages contain an overview of the questions and answers from Medscape's Exclusive Ethics
Survey.
End-of-Life Care Questions
End-of-life care seemed to pose the biggest quandaries, on the basis of the wide dispersion of answers and the
high percentage of "it depends" responses.
1. Would you ever recommend or give life-sustaining therapy when you judged that it was futile?
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Yes, 23.6%
No, 37.0%
It depends, 39.4%
2. Would you ever consider halting life-sustaining therapy because the family demands it, even if you
believed that it was premature?
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Yes, 16.3%
No, 54.5%
It depends, 29.2%
3. Should physician-assisted suicide be allowed in some cases?
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Yes, 45.8%
No, 40.7%
It depends, 13.5%
Liability and Medical Error Issues
4. Is it acceptable to perform a procedure that isn't medically warranted, for reasons of defensive
medicine?

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Yes, 16.1%
No, 61.3%
It depends, 22.7%
5. Are there times when it's acceptable to cover up or avoid revealing a mistake if that mistake would
not cause harm to the patient?

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Yes, 19.0%
No, 60.1%
It depends, 20.9%
6. Are there times when it's acceptable to cover up or avoid revealing a mistake if that mistake would
potentially or likely harm the patient?
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Yes, 1.6%
No, 94.9%
It depends, 3.5%
Patient Treatment Issues
7. Would you ever prescribe a treatment that's a placebo, simply because the patient wanted
treatment?
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Yes, 23.5%
No, 58.3%
It depends, 18.2%
8. Would you ever undertreat a patient's pain because you're concerned about repercussions or
because you believe that a patient -- even a terminal patient -- might become addicted?

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Yes, 5.6%
No, 84.1%
It depends, 10.3%
9. Would you hide information from a patient about a terminal or preterminal diagnosis in an effort to
bolster their spirit or attitude?

Yes, I soften it and give hope even if there's little chance, 14.6%

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Yes, unless someone is going to die imminently, I don't tell them how bad it is, 1.7%
No, I tell it exactly as I see it, 59.8%
It depends, 23.8%
Insurance Issues
10. Would you feel conflicted about dropping insurers that don't pay well even though some long-time
patients would probably stop seeing you?

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Yes, 57.0%
No, 26.5%
It depends, 16.5%
11. Is it ever acceptable to overstate or falsify a patient's condition when submitting claims or seeking
prior authorization?
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Yes, in order to get a patient the services -- such as drugs, treatment, or hospital coverage, 17.1%
Yes, in order to bring in more revenue, 0.2%
No, 73.2%
It depends, 9.4%
12. Would you ever "fire" a noncompliant patient so that you could improve your pay-for-performance
scores or stop dealing with patients who "overuse" resources on their capitation plans?

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Yes, 9.0%
No, 78.9%
It depends, 12.1%
Physician Relations & Patient Privacy
Physician Relations
13. If a physician-friend or colleague were impaired (alcohol, drugs, illness) or was no longer
competent -- and he or she ignored your warnings to get help -- would you report that person to a
superior or to the state medical board ?

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
Yes, 86.2%
No, 2.3%
It depends, 11.6%
14. Would you refer a patient to a physician simply to return a favor to the doctor, when you didn't think
that that person was the best qualified?

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Yes, 2.4%
No, 92.4%
It depends, 5.2%
Patient Privacy
15. Would you ever discuss patient information in situations that did not fully protect their privacy, ie,
socially or while talking with doctors about subjects not related to the patient?

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Yes, 8.4%
No, 77.4%
It depends, 14.2%
16. Is it ever acceptable to break patient confidentiality if you know that a patient's health status may be
harming others?


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Yes, 53.2%
No, 20.2%
It depends, 26.6%
Other Ethical Issues
17. Would you agree that you should refuse gifts or perks from pharmaceutical companies because
they may influence your medical judgment?



Yes, 46.8%
No, 36.8%
It depends, 16.4%
18. Could you become involved in a romantic/sexual relationship with a patient?




Yes, while that patient is still a patient, 0.8%
Yes, but not until at least 6 months after they stopped being a patient, 11.7%
No, 83.1%
It depends, 4.5%
19. Should it be legal for people to buy organs for transplant, if they would not be able to receive an
organ by waiting their turn through the national database?



Yes, 19.9%
No, 66.5%
It depends, 13.6%
20. Would you perform an abortion in certain situations, even if it were against your own beliefs?

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
Yes, 34.1%
No, 53.5%
It depends, 12.4%
21. What was your biggest ethical dilemma?
The array of answers was mind-boggling, attesting to the complexity of medicine and morality today. Some of
the main categories noted include:
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Reporting an incompetent or impaired colleague
Owning up after making a medical error
Physician/patient confidentiality when one half of a couple is HIV positive and the other half doesn't
know
Prolonging futile care for a dying patient
Denying care to a nonpaying patient
Whether to honor a family's request not to tell a relative that he/she has a terminal illness
Exaggerating a patient's condition to get insurance coverage
Writing a prescription for a family member or friend
For physician-respondent comments, see Physicians' Top 20 Ethical
Dilemmas
Methodology
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Medscape's Ethics Survey email was sent on 8/18/10 to 151,000 US-based Medscape physicians
spanning more than 25 specialties.
The invitation to participate included a sweepstakes to win an iPad.
The promotion period ran from August 18 to September 15, 2010.
The number of respondents was 10,078.
Medscape Medical Ethics © 2010 WebMD, LLC