Monday, January 24, 2011

Physicians Treating Family Members

Randy Cohen, who writes "The Ethicist" column for the New York Times, is my ego ideal for this blog. I admire his down to earth,humorous way of responding to the questions put to him. Yesterday Randy responded to an interesting medical ethics situation:
My elderly aunt became ill and phoned me, a physician, to ask if she should call an ambulance. I surmised that she was severely dehydrated. From my hospital, I took a bag of saline, IV tubing, an IV lock and a needle. An unsuspecting nurse handed me the tape that secures the needle. I gave my aunt these fluids at home, and she soon felt better, as did I: my stealing $50 worth of medical supplies saved the taxpayers more than a thousand dollars for an E.R. visit. Did I do right? E.G., NEW YORK

I love the hint of zany hijinks in the words “an unsuspecting nurse.” I respect your concern for your aunt and admire your ingenuity in curbing costs, but — there is a but — I am wary of your conduct. You were deceitful with your own hospital and imprudent in taking over your aunt’s treatment.

One doctor, the medical director of a large public hospital, e-mailed me to say: “We frown upon treating family members. It’s incredibly difficult to be objective in the best of circumstances.” He added: “The aunt’s bedroom is not the optimal environment for diagnosis or treatment. This physician took many shortcuts and may have done his aunt a great disservice by not performing a complete assessment.” He makes a persuasive case that while your diagnosis was correct, it was not certain to be: your aunt might have had other problems requiring a more drastic response.

Your altruistic pilferage, while thrifty, was ethically dubious, requiring you to betray the trust of your co-workers. The medical director I spoke to suggests a less buccaneering alternative: “If he had asked for the supplies, his hospital would have undoubtedly given them to him.”

The real solution to such problems is to arrange health care so as to avoid so stark a dilemma, perhaps by providing local clinics or health professionals who make home visits, changes unlikely to occur any time soon. Given the current circumstances, I should offer a word in your defense from another doctor, Paul R. Marantz, director of the Center for Public Health Sciences at Albert Einstein College of Medicine, who acknowledged that what you did was stealing, but said in an e-mail that “purloining $50 (more likely $20) worth of medical supplies while saving hundreds (more likely thousands) seems a good choice compared with the more burdensome alternative of a visit to the E.R.” I agree that those who practice medicine in imperfect institutions might — must — sometimes choose imperfect actions, but believe that your supply-room raid still fell short.
Randy's response to E.G. is right on. The question E.G. asked - about the materials he took from his hospital - is easy, but trivial. It's wrong. He should have asked, and the materials probably would have been given. And who hasn't taken pens and the like from their workplace?

The question E.G. should have asked was about treating his own aunt. As the public hospital medical director correctly reported, this is a practice the medical establishment "frowns upon," since family relationships can distort objective judgment and lead to errors in treatment. But given what happens to frail elderly folks who come to emergency rooms, the medical director's claim that "The aunt’s bedroom is not the optimal environment for diagnosis or treatment," is dubious. The home environment often provides clues that are invisible in the emergency room. And the medical director's conclusion - "This physician took many shortcuts and may have done his aunt a great disservice by not performing a complete assessment" is also dubious.

Sometimes a "complete assessment" turns up non-obvious findings that allow for effective treatment. But all-too-often, a full court press emergency room workup leads to finding "incidentalomas" - ostensibly "abnormal" findings that have no clinical meaning. The radiology report may say "I cannot rule out XYZ." Even though there is no reason to have suspected XYZ, finding an incidentaloma may lead to further tests and procedures, all of which can have side effects.

For me, the key ethical question is about care, not cost. A lot of money is wasted by unnecessary emergency room visits, but E.G. shouldn't try to balance the health care budget on the back of his elderly aunt. If saving money was his motive, I'd chastise him.

But if E.G. had experience allowing him to make a probable diagnosis for his aunt, and if he knew her to be a frail person for whom an emergency room visit stood a high chance of being traumatic and a source of avoidable harms, I believe he gave proper balance to the competing values. Treating our family members is, on average, a bad idea. But the rule of thumb isn't an absolute - it can be outweighed by other values, such as protecting his aunt and allowing her to be ministered to in the safest and most congenial manner.

Saving money for the health system wouldn't have been a reason for treating his aunt at home, and it's not the justification for what E.G. did. But from my reading of the story, E.G. did the right thing, though by imperfect means.

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