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J Thorac Cardiovasc Surg 2002;123:403-405
© 2002 The American Association for Thoracic Surgery
Editorials |
From the Division of Cardiothoracic Surgery and the Institute of Human Values in Health Care, Medical University of South Carolina, Charleston, SC.
Received for publication Oct 23, 2001; accepted for publication Oct 31, 2001. Address for reprints: Robert M. Sade, MD, Department of Surgery, 96 Jonathan Lucas St, Suite 409, Box 250612, Charleston, SC 29425 (E-mail: sader{at}musc.edu).
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But times are changing. In the past several decades, the business side of medicine, which has always been present, has risen to a new prominence among the concerns of surgeons. In part, this has been related to environmental change: efforts to control costs through managed care have resulted in substantially lower incomes, and younger surgeons now start their practices with high levels of indebtedness. Both factors provide incentives for surgeons to seek additional sources of income. Another impetus toward increased focus on business is the development of new surgical technologies. As technologies have become more sophisticated, the potential for profiting from them has grown substantially; often, millions of dollars will be made from new inventions and techniques. For many surgeons, business ethics has overtaken, and in some cases, supplanted professional ethics.
I do not speak pejoratively of business ethics. I have little patience with those who reduce business ethics to caveat emptor and then easily knock down that straw man to demonstrate the superiority of professional ethics. In my view, we should respect business ethics in its best expression, much as we view our own professional ethics as an aspirational ideal.
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Business has a central goal, a characteristic that distinguishes it from charities, governments, country clubs, and all other human activities: to maximize the value of the business to the owners over the long term by trading goods and services. Achieving that goal requires businessmen to act in certain ways, most importantly with honesty and promise keeping, for such actions generate the confidence in future transactions that is the foundation of future growth and value of a business. Businessmen act ethically when they maximize long-term value for owners under conditions of ordinary decency, including honesty and keeping promises. 2
Companies work to maximize profits, and this incentive has led directly to the creation of new technologies, which in turn have led to improvements in health, to better quality of life, and to longer life spans in capitalist countries. Not only is the profit motive admirable, it has been demonstrated over and over to be a powerful force for good. It leads to advances that benefit everyone. Compare, for example, standards of living, quality of life, and longevity in 1901 with those in 2001, at every socioeconomic level. Most of those gains have been due to human ingenuity at work in free markets, with money as the incentive for innovation.
Is there some reason why surgeons should act differently from businessmen? The principle of optimizing profits is proper for business, for good reason, but it is not appropriate for physicians. Our ethics—the way we ought to behave in our professional lives—are driven by an imperative that arises from the nature of what we do. The goal of medicine is not to maximize profits, but to serve the patient's interests. Good physicians differ from other professionals in one critically important way: our need to efface self-interest to serve primarily the patient's interests. 3
There is an important, fundamental reason for this special requirement of physicians. To achieve our professional goal, the good of the patient, we need access to information about the patient that he may be unwilling to give to anyone else. People may share certain confidences with their attorneys, with their accountants, or with their ministers. But none of these confidences are as widely ranging and deeply personal as those that must be shared with their physicians. This unparalleled need for intimate knowledge of patients is magnified in the case of surgeons. We need not only historical and current information about the patients, but also access to the interior of their bodies at a time when they are completely helpless, under anesthesia. The intimacy of the information about the patient needed by the surgeon in combination with the extraordinary vulnerability of the body at the time of surgery demands the highest attainable level of trust by the patient in the physician. This requirement for intimacy at many levels makes fidelity to the patient's interests the paramount ethical guide for physicians. Patients will provide their surgeons with all of the critical information needed for appropriate care and will allow access to the interiors of their bodies only if they can fully trust that the surgeon will always act in the patient's interest. This overarching trust lies at the heart of the healing relationship and is the core of our professionalism. 1
Surgeons can benefit personally from the development of new surgical technologies in several ways: for example, by owning a company or its stock, by accepting gifts that are intended to influence the use of new products, and by accepting paid vacations, sometimes on the pretext of "doing research." Each of these may deflect physicians' focus from their patients' interests to their own and therefore represent potential conflicts of interest. Conflicts of interest are ubiquitous and unavoidable. For example, we make our living by charging fees for what we do, and we could make medical decisions on the basis of maximizing income rather than serving the interests of patients. Such conflicts are not necessarily wrong in themselves; the potential for harm comes from how we resolve them, and for physicians, they must always be resolved in the patient's favor. 4
Therefore, it could be argued, when we have an opportunity to benefit personally from development of new products, it would seem that we stand on firm ethical ground if we simply do not allow those benefits to influence our obligations to our patients. The fatal flaw in this view is the human capacity for self-deception. We easily convince ourselves that, although we have conflicts of interest, we will always resolve them in favor of our patients. We justify ownership of device companies, in whole or in part, by claiming that potential profits have not and will not affect the patient-care decisions we make. This is largely self-delusion; patient care often is affected by biases induced by connections with industry. We accept substantial gifts from industry, convincing ourselves they have no influence on patient-care decisions, even though there is a good deal of evidence to the contrary. 5 We tell ourselves that continuing medical education activities sponsored by companies have no influence on patient-care decisions we make when, in fact, much evidence suggests that such influence is pervasive. 6,7 Many of us adjust diagnoses or procedure codes for insurance billing purposes, telling ourselves that we are doing it only for the patient's benefit; clearly, though, we also benefit ourselves by assuring collection of our fees. 8,9 Several spectacular recent cases linking physicians' ownership of stock with harms to patients as research subjects have made national front page news: for example, deaths associated with Protocol 126 at the Fred Hutchinson Cancer Institute, 10 a gene transfer experiment gone awry at the University of Pennsylvania, 11 and premature deployment of the HeartPort technique for cardiac surgery. 12 The physicians in those cases did not mean to cause harm, but inappropriate profit motive played a role in doing just that. We must recognize the human capacity for self-deception and accept that none of us is immune from its insidious expression.
There is no doubt that conflicts of interest are pervasive in our personal as well as our professional lives. Nevertheless, doing our best for our patients requires that they trust us absolutely to act always in their best interest. To maintain the highest level of trust, we must avoid even the appearance of acting primarily in self-interest, because the appearance alone is enough to undermine the trust that is so central to achieving the professional goals of the surgeon. Specific ethical guidelines that address conflicts of interest can be found in the work of the American Medical Association's Council on Ethical and Judicial Affairs. 13
We have many unavoidable conflicts of interest with respect to our patients, such as charging fees and honoring conflicting family obligations. But we violate the trust of our patients when we generate new conflicts unnecessarily, for personal gain. They can take many forms: accepting gifts or trips from companies; participating in joint ventures with health care organizations; signing draconian managed care incentive contracts; using new devices prematurely; or owning stock in device companies whose products we use. Such violations of trust can lead to many kinds of harms. In the short term they can sully our reputations and those of our organizations, interrupt referral lines, or lead to the emotional pain and expense of lawsuits. The long-term harm to professionalism, however, is much more damaging, and the best way to prevent it is to avoid business entanglements entirely. That is the surest way to protect our most critical yet fragile asset: our professional integrity.
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This article has been cited by other articles:
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  M. F. McKneally Beyond disclosure: Managing conflicts of interest to strengthen trust in our profession J. Thorac. Cardiovasc. Surg., February 1, 2007; 133(2): 300 - 302. [Full Text] [PDF]
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