On the horns of an ethical dilemma

November 1, 2009

In this editorial, explore a discussion of meeting presentations on subjects rarely addressed by physicians in public.

"All I'm saying is let's take the example of something like diabetes, one of-a disease that's skyrocketing, partly because of obesity, partly because it's not treated as effectively as it could be. Right now if we paid a family-if a family-care physician works with his or her patient to help them lose weight, modify diet, monitors whether they're taking their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that's $30,000, $40,000, $50,000-immediately the surgeon is reimbursed. Well, why not make sure that we're also reimbursing the care that prevents the amputation, right? That will save us money."-President Obama

"My doctor gave me 6 months to live, but when I couldn't pay the bill he gave me 6 more months."-Walter Matthau

1. The optimal qualities of ophthalmology residents: What is the appropriate balance of intelligence, ethics, altruism, and ego?

2. Teaching ethics to ophthalmology residents: Can it be done?

3. President Obama's $30,000 foot amputation: Is physician decision-making driven by financial return or the best interest of the patient?

The attendees possessed a range of opinions. Although I know that all of them were ethical and unusually intelligent physicians, it was not always clear how to determine readily if a young trainee is destined to become an ethical physician.

Thus, while all agreed that a premium should be placed on selecting ophthalmology residents who possess the ethical standards and that this quality exceeds the importance of intelligence, it also was not immediately obvious how best to make this determination. Rarely, in my experience, do recommendation letters about candidates for residency or faculty positions comment on the ethics of the applicant.

Can ethics be taught?

Some people (I call them the nihilists) believe that a medical student or physician is either ethical or not, but that a person who is unethical cannot be taught to become ethical. Others believe that what we call medical ethics is a system for discussing an issue in a manner that ensures that the key issues will be considered.

Probably we all agree that residency training programs should be graduating trainees to join our communities who will practice in an ethical manner and reflect well on the profession of ophthalmology. But do we agree on how to make sure that is happening and how to grade the ethics of our residents the way we grade their knowledge of the causes of an afferent pupillary defect or their surgical ability?

Lastly, everyone was interested in our president's tendency to opine that physician decision-making (at least when it comes to leg amputations and tonsillectomies) is heavily or at least partly influenced by the amount of reimbursement involved, rather than purely by the desire to best help the patient.

I think the angry responses to the president's assertion that surgeons get $30,000 per amputation when, in fact, the correct amount is only about $750, miss the point. To me, the issue is not about the amount of money involved.

Instead, the bottom line is that there seems to be the real conviction among the public and our politicians that American physicians and surgeons are not solely motivated by the welfare of our patients.