Excerpt from the program on Thursday, March 28, 2013

ROBERT M. PEARL, M.D., Executive Director and CEO, The Permanente Medical Group

VICTORIA SWEET, M.D., Laguna Honda Hospital; Associate Clinical Professor of Medicine, UCSF; Author, God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine

JOSH ADLER, M.D., Chief Medical Officer, UCSF Medical Center and UCSF Benioff Children’s Hospital

LISA ALIFERIS, KQED Health Editor – Moderator

LISA ALIFERIS: We’ve arrived at a singular juncture in American medicine with the biggest expansion in health care in this country in 50 years speeding toward us courtesy of the Affordable Care Act. At the same time, American medicine is rife with challenges. At the most basic level, when compared against other developed countries, America is at or near the bottom for lifespan, infant mortality and deaths from non-communicable diseases. Explain what you think is meant by ethics in medicine, and name one or two of the most pressing challenges you see in medical ethics.

JOSH ADLER: I’d like to begin by framing [my response] around some age-old medical-ethical principles and the fact that the current state challenges some of those and broadens them. The first is the principle of “do no harm,” which is an age-old principle in the care of patients and really refers to not proceeding with a treatment unless it’s likely to help, because if it’s not likely to help we certainly wouldn’t want to do anything wrong. But since 1999, when the Institute of Medicine published its seminal work on patient safety, we know that in fact a large amount of harm can come to patients in the conduct of care that is actually supposed to be beneficial. So the challenge to us ethically is being able to, [first], minimize harm, which I think American medicine is proceeding on – we have a very long way to go, but we’ve certainly made progress. But assuming we can’t eliminate all harm, we have to consider the potential harm and benefit that will accrue with any particular intervention a patient may undergo. That’s really a new wrinkle to this age-old principle.

The second is a principle of justice, which originally had at its core being fair, that all patients should be treated fairly and in many ways this had to do with equity, that people would be treated the same no matter where they come from, whether they could pay, or what their social makeup. But in the state we’re in in the United States and in the world around the cost of health care, there’s a new wrinkle to justice and it has to do with the appropriate stewardship of a limited resource to a population and how that intersects with the care of an individual patient. This is a critically important principle because we don’t have unlimited resources, and whether those are dollars or doctors or nurses or technicians or hospital beds, we have to come up with the best possible distribution of those resources so we do the greatest good for the greatest number.

VICTORIA SWEET: Since I’m a historian as well as a doctor, I had to look up the etymology of ethics, which is Greek ethika and originally comes from the word ethos, which in Greek means character or disposition. I take that to mean that we get ethics from our innate character – what’s easiest for us to do, what feels right. Ethics come out of what feels right to do. So it implies a natural human goodness, a kind of altruism, an innate inclination to be ethical, to do the right thing. In medicine a lot of work has gone into classifying ethical principles. For instance, there’s the principle of beneficence, of providing benefit to the patient, doing good. Then there’s the principle of autonomy, that is, the patients’ right to decide. One of the things for me that is so difficult about ethics in medicine is that, in so many places – end-of-life care, confidentiality and privacy, even diagnoses and treatment – these ethical principles are in conflict. So it’s not usually a clear situation of evil versus good, but of good versus good.

This leads me to the second part of this question, which is what I think is the most pressing challenge today, not only for me as a doctor but for everyone involved in the health care system, though I can only talk here as a doctor. [The challenge is] the conflict implicit in these suddenly new roles that I as a doctor have, which is to not only be a doctor to my patient, but to be this thing called a “steward” of the nation’s health-care resources, as one recent economist put it in a New England Journal [of Medicine] article and, in addition, to be a loyal health-care employee of my employer. I can’t begin to tell you how stressful these three, often opposing, ethical imperatives often are for a doctor.

My fundamental Hippocratic duty is to enter the house of the sick only for the benefit of the sick; it’s a person-to-person contract. For instance, if I determine that my patient is best served by having an expensive test or medication, that is what I’m ethically supposed too provide, but these days I’m also expected to be a careful steward of society’s health-care resources, which should mean that before I order that expensive test, I take into account not just what is best for my patient, but what is best for the health-care system as a whole, the nation’s budget, our public health. So what do I do if my patient is old or disabled or one of the “bad boys” or “bad girls” I had so many of at Laguna Honda [Hospital] – not a gainfully employed, contributing member of society, and not ever likely to be one? Should I order that expensive test? Wouldn’t that money be better spent on public health measures to raise America’s standing against the measures of lifespan, infant mortality and death from non-communicable diseases?

In addition, there’s my new ethical duty toward my employer, a hospital or health-care company, who if it’s one of the new accountable care organizations in the Obamacare Act, stands to lose quite a bit of money if I order that expensive test. I have the obligation of helping it continue as a going concern.  What do I, as an ethical doctor, do?

ROBERT PEARL: As I think about ethics, my perspective is that it’s a set of rules that allows us to do the right thing and that they’re built upon a moral framework, but they serve best as a compass, particularly, as Victoria [SWEET] said, when there are competing points of view and not a single right answer. Ethics are essential in times of change, and that’s what’s happening today.

You asked about two potentially crucial issues, not just for physicians, but also for the entire society. The first one that comes to my mind is, how are we as a nation, how are we as care deliverers going to respond to the forces out of Washington, D.C., out of business and individuals to lower the cost of health care? There are some who believe that the solutions must involve two-tier systems, rationing or cutbacks; it is my belief that ethically those aren’t the right answers. The right solutions from an ethical perspective will require that we restructure American health care, that we move from a system of rewarding volume to one that focuses on outcomes; that we start to value prevention as the best means, not only of making patients healthy, but of being able to reduce the cost; that we focus on patients’ safety, make sure we get it right the first time. These changes will fundamentally alter how physicians practice and how patients receive care, but I think, from an ethical perspective, they’re the right answer to a very complex question that faces us today.

The second area is that of the pernicious relationship between the for-profit drug and device companies and doctors. We at Kaiser Permanente have come down very strong on it from the ethical perspective that it’s simply inappropriate and wrong. It violates the fundamental principles any time a physician does it or even has the perception that he or she might be putting his or her personal finances ahead of the greater good of the particular patient. I think that’s an ethical stand that we have to take as an entire nation. 

ALIFERIS: I’d like to go directly into the Affordable Care Act and some of the conflicts that have come up. [There’s] the debate we’ve seen around requirements that contraceptives be covered, the morning after pill, and especially about abortion. [What are] the ethics around doctors and health-care providers of all kinds bumping into a patient request that is outside of their own personal ethics?

SWEET: The example would be a patient who asks me to give them something that they can kill themselves with. Now, I’m not particularly against euthanasia, as long as somebody else does it. I’m not against passing a law [allowing] it, but I wouldn’t do it. So I would just say no. In that case it’s illegal, but even if it were legal I would still say no. I believe that my patients need to know that I’m an ethical person from the inside out and that I start with myself and doing what’s ethical for me and mine and you are part of me and therefore I wouldn’t do something I consider not ethical. So even though I’m personally in favor of a woman’s right to abortion, I have no problem with that, if somebody else feels as strongly as I do about other things, then I think they have [the right to refuse to do it.]

ADLER: My view is that coverage decisions should be based on science, so not covering contraceptives goes against scientific evidence that proves that this is a valuable medical therapy. I think to your point about should an individual doctor be required to provide a service that they personally believe is unethical, the answer is no. You can’t ask individuals to do something that they think is unethical. But I do think that we have a responsibility to then help that patient find someone who will. That is our own internal policy [at the UCSF Medical Center].

PEARL: Thirty-four million uninsured is unethical, and we have to start with that. From my personal belief, it’s a basic right. We know it defines not only health, but happiness, life, a lot of other positive aspects that are fundamental to who we are both as people and as American citizens. So I want to start with the fact that the bill solved an ethical problem, which is providing coverage to 34 million more people.

There’s still a second ethical issue, which is that it didn’t address the issue of affordability which is going to become the next problem that we’re going to take on. As individual physicians we shouldn’t be violating our ethics, and yet at the same time we have to make sure that we don’t abandon our patients. So part of our job is to make sure we’re able to provide for them those things that may go against our individual [beliefs]. You have to separate, though, ethics and legal, and that’s where the challenge often is. It’s complex. Patients deserve to be able to get those things they want that will be able to increase their health and we as a society, as individual physicians, have a moral and ethical obligation to do the best we can.