Physicians' ResponsibilityTo Whose Trust: Patients vs Society

Matthew K. Wynia, MD, MPH, FACP, Director, The Institute for Ethics American Medical Association, a physician ethicist, posted today comments to a bioethics listserv which really covers a number of issues which I have written to this blog (doctors conflict of inteest, patient trust in physicians, what should be written in patients' charts) and including the last post here regarding the issue of physicians attending the prisoners at Guantanamo Bay. His comments are reproduced below with his permission. Of course, Matt writes for himself and is not necessarily representing the views of AMA in this posting. I would be interested to read what my visitors think about his views. ..Maurice.


Physicians – and all professionals – have an inherent dual role in society. We care primarily for our individual patients, and we promise that we will put their interests first. And because we do so, they confide in us, stand naked in front of us, allow us to touch and even cut them and, in sum, they trust us with their lives.

At the same time, we promise the community as a whole that we will use our skills and knowledge also to protect social goods and values. We will not take bribes to prescribe controlled substances – even when our patients want them. We will not write inappropriate work or school excuses, instead try to help our patients re-integrate into the community. To protect the public, we report into the public health system when a patient has a contagious disease, etc. Because of these promises, we are given a state-sanctioned license that allows us to touch and cut, and provides us with a number of unique social privileges (such as control over the use of narcotics, and sick days).

In brief, physicians earn patients’ trust by promising to look out for their best interests, but we earn the social right to do so by promising society that we will, as a group, take seriously our civic roles. This balancing act is not easy, but it is core to the effective functioning of medical professionalism in society.

Often, our obligations to the community (the state, if you will) and to individual patients are in perfect concert. But sometimes they are not. In some such cases, we must stand up to our patients’ demands, and refuse (for example) to ‘fudge’ information on a form that might allow a patient to get a handicapped parking permit, or social security benefits. This isn’t always easy, given the personal relations we have with patients and our well-known promise to always put their interests first, but it is part of maintaining our professional integrity. In other cases, we should stand up to the community or state and stand by our patients. Such was the case in the event of managed care ‘gag clauses’, for example, which would have prevented physicians from discussing medically appropriate but uncovered services with their patients. The profession said that even though such contracts might be legal, they were unethical and should not be adhered to. That’s also part of maintaining professional integrity.

The question of whether or not to put information in the medical record because to do so might harm one’s patients is actually an old one – but not one to which an easy answer is obvious. A number of doctors do, in fact, keep ‘shadow records’ or they just don’t write some information into the record and rely instead on memory But there are a lot of problems – both ethical and practical – associated with this practice. Legally, the record is supposed to be complete, and a doctor can be held accountable for inaccurate or incomplete record keeping in a variety of ways. On the other hand, ethically, it would be wrong to write down information if you were convinced that doing so would end up harming your patient.

In this specific instance, newer military policies have made increasingly clear that interrogators – inlcuding any health professionals involved (eg, psychologists) – are not supposed to have access to detainee medical records. And if any non-treating personnel do access detainee records, this event must be documented and justified in writing. The hope is that under these new rules abuses will not recur and it is now safe for military health professionals to record full information in detainee records… but it is very hard to know what the actual practices are, or were, since no independent investigation has yet occurred.

As a side note, I think there will need to be a full and independent investigation into medical practices at GTMO and elsewhere before military medicine can fully restore its credibility in this regard. I believe that many military medical personnel would welcome such an oppourtunity to clear the air. But it’s unlikely to happen under the current administration, which is sad. The military medical personnel I’ve come to know over the last few years are by and large some of the most integrity-oriented people I’ve ever met, and they would be extremely well-served by an independent, open review. But they are also very well aware of the importance of civilian control over the military, and the civilians in charge of the military today appear to have something to be afraid of in ordering an independent review of the medical policies and practices they’ve tried to implement at GTMO and in Iraq, Afrghanistan and other unnamed detention sites around the world.
Matt