Ethics Forum: Unexpected Ethical Issues in Private Practice, Clinical Research

Although our patients may not request specific medications the way television commercials say they should, they do ask us for things. Sometimes, the things they ask for are hard, or even impossible, because of our medical opinions, our beliefs, our egos and our faith that we, and medicine, will ultimately prevail.

In each of these cases, we were asked to do something we weren’t expecting. To comply was difficult and/or potentially unethical. Each of these situations tested our resolve to do the right thing. These cases create tension between competing priorities, including the basic bioethical tenets of patient autonomy, justice, beneficence and non-maleficence.²

Even when the best choice is clear, we may be tempted to make a different choice, especially given all the unfairness in healthcare delivery. Protocol criteria exclude patients who would benefit from study treatments. Co-pays put biologicals out of reach for many. Other practitioners and our patients may ask the impossible. So sometimes the question is less about what to do and more like, “Wait, what? You want me to do what?”

How should these cases be handled? Good communication, patience and resolve are good starting points. Don’t be afraid to ask a trusted colleague what they would do or look to the published literature for advice.^1,3,4 Once you’ve considered the question carefully, don’t hesitate to draw a line in the sand. Often, the answer to difficult requests we face should be “No, I cannot do that—and here’s why.”

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Donah Zack Crawford, MA, is the director of clinical trials at the Arthritis Group in Philadelphia, a member of the ARHP Programming Committee and a past ARHP representative to the ACR Committee on Ethics and Conflict of Interest.

Jill Johnson, MD, is a staff physician at the Arthritis Group.

Neal K. Moskowitz, MD, PhD, is a staff physician at the Arthritis Group.

James Udell, MD, is director and principle investigator of the Arthritis Group. He is a member of the ACR Communications and Marketing Committee, and immediate past president of The Philadelphia Rheumatism Society.

References

1. The American Medical Association Code of Medical Ethics. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page.
2. Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 7th ed. Oxford University Press, 2012.
3. Antommaria AHM, Bramlage KS. Enrolling research participants in private practice: Conflicts of interest, consistency, therapeutic misconception, and informed consent. AMA J Ethics. 2015 Dec;17(12):1122–1126.
4. Friedman E. The Right Thing: Ten Years of Ethics Columns from Healthcare Forum Journal. San Francisco: Jossey-Bass, 1996.

Editor’s note: If you have questions, comments or a case you’d like to see in Ethics Forum, email us at [email protected].