Gaming the System and Following The AMA Principles of Medical Ethics: What is Ethical?

In order to understand the professional dilemma faced by a physician we should first look at the AMA Principles of Medical Ethics (2001)

Preamble:
The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.
I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.
II. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.
III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.
IV. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.
V. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.
VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.
VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.
VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
IX. A physician shall support access to medical care for all people.

How can a physician resolve upholding the standards of professionalism including avoiding engaging in fraud and deception (Principle II) and at the same time “while caring for a patient, regard responsibility to the patient as paramount” (Principle VIII)? Physicians have argued that when a patient needs a test or treatment and the insurance company obstructs then “gaming the system” is deserved in order to do the best for the patient. One could respond, why not respect the law and follow Principle III by trying to change the system. Well, what about that patient that needs attention now? It is a difficult dilemma and as you can see by the study in AJOB noted in my last posting both physicians and patients appear to be motivated to engage in gaming.

Another ethical concern which places a professinal conflict between Principle VIII and the Principles of VII and IX is related to the suggestion that because of the need for cost containment and sheparding of scarce resources there should be encouragement of bedside rationing. I’ll put up a resource discussion on that topic later. ..Maurice.