Moral Courage for Physicians

In our current healthcare environment there exists a discrepancy between the public’s perception of our role and responsibilities and our own perception of what our "job" is. In addition to our clinical duties, there are our moral obligations.

Bioethicists describe two principles that guide the moral obligations of our job: beneficence and nonmaleficence. (Notice I do not say profession, nor vocation. Because, when we peel the layers of ego, imposing technology and social position, ours is just a job, yet a job with moral implications).

I will clarify the relationship between these two principles and moral courage. The principles and the virtues are not only related but inexorably linked as we must have the moral courage to defend the principles and exist consistently with the teleological paradigm of our profession.

Beneficence, simply put, is the idea that we must act, always with the best interest of our patient. In essence, to always act or decide in beneficial ways toward our patients. Non maleficence is the principle of "doing no harm."

Deep disagreements have plagued moral theorists regarding how much is demanded by obligations of beneficence. Some ethical theories insist not only that there are obligations of beneficence, but that these obligations demand severe sacrifice and extreme generosity in the physician’s relationship with his patients. On the other hand, some formulations of utilitarianism, for example, appear to derive obligations to patients on the basis of need or at times societal value, a view of "distributive justice."

It is the latter interpretation that pervades current physician's moral philosophy. It is likely that no society has ever operated on such a demanding principle as the former but, the former premise does seem embraced, at least abstractly by our patients and, according to Thomas Beauchamp, respected Kennedy Institute bioethicist, the mainstream of moral philosophy has been to make not harming and helping both obligations.

Nonmaleficence is easier to morally reconcile as we can always allow the patient to decide whether they accept a potentially harmful treatment which in the end will be "beneficial."

So, does a physician have a moral obligation to always act in the best interest of his patient, i.e., is moral courage to implement the action a requirement? Situations often arise in healthcare where the physician is placed in a moral conflict.

Here's an example: A patient is admitted for pneumonia. She improves yet still requires convalescent care. The patient has no family or social support. The utilization reviewer decrees that the patient had to be discharged. The patient has no means for her care. What is the moral obligation? Obviously, discharge would not be "beneficial" and would lead to either readmission or worse. Keeping the patient in the hospital would incur administrative wrath. Can the physician act according to administrative dictum and still keep her moral obligation?

It is important to note that, currently, physicians are evaluated based on hospital stay, readmissions, compliance, and even attitude. In the future these parameters will be linked to reimbursement for services and continued employment for most physicians, further coercing the physician’s actions. The patient above will perceive - correctly - that discharge will be "harmful." The institution has no moral obligation yet, has the power to coerce, cajole, and influence the physician's decision with the threat either real or perceived of repercussions. The answer is intuitive. However, how often is it put into practice? Increasingly physicians are thrust into environment of regulation and bureaucratic scrutiny all devised under the rubric of the greater patient good. Yet, negative patient outcome or perceived malfeasance always is accountable to the physician regardless of whether the so called "guidelines" are followed or not.

Another example, with a different moral conflict: A patient is well-insured with terminal pancreatic cancer. The patient had advanced directives for limiting futile care yet the family wishes "everything" done. The physician continues to provide futile care for fear of legal repercussions, i.e. lawsuit, inability to reconcile her own mortality, or a more sinister reason: reimbursement! In this case, regulation/system actually protects and supports the withdrawal of futile care but still requires active physician participation yet inconsistently continues to reimburse the physician for obviously futile services. The decision to withdraw futile therapy is often in the best interest of the patient and prevents unnecessary treatment and suffering. Yet, said decision requires the moral courage to act in the face of resistance from not only family but our peers. The physician must follow the patients' wishes and ought have the moral courage to do so.

It is no surprise that patients perceive us as self serving and the government perceives us as roguish. Can a mere mortal span this moral chasm and act in the best interest of his patient and institutions? No, for when moral conflict exists between the best interest of the patient and institution or even our own biases, the patient shall always win. Duality negates the essence of the doctor-patient relationship. I would argue that impartiality is only applicable between individual patients; not between patient and the "system" or patient and others.

Utilitarians would argue in favor of the concept of distributive justice - what is good for the system is priority. Unfortunately, the affected and integral components are the individual human beings. When ostensibly just actions negatively affect the individual under your care, we as physicians have not acted beneficially.

The only question is: How far does our obligation to the individual patient go? I submit a modification of Bernard Gert's 10 rules as a modern moral code for physicians.

1. Do not kill
2. Do not cause pain
3. Do not disable
4. Do not deceive
5. Do not cheat
6. Keep your promises
7. Obey the law
8. Do your duty
9. Defend your patient's rights
10. Treat your patient as you would your family

To follow the above regardless of perceived coercion requires moral courage. Have we as physicians forgotten our raison d'être? Or have we merely lost our moral courage. The ethical literature is replete with articles and examples of moral courage in medicine. However, they are almost invariably applied to nurses and nonphysician providers. Nurses and paramedical personnel whistleblowers are protected and exalted for their "morality" and selfless acts. Yet, physicians are usually the target of whistle blowing.

The latter is exactly how society - including our patients - is coming to perceive us. Our moral paradigm should always be in the best interest of our patient, regardless of personal sacrifice. It is only when we are perceived as such, that we will regain our exalted position in the eyes of our patients.