You are one of a small number of surgical faculty members who regularly staff resident physicians in caring for patients with otolaryngology-head and neck disorders in an inner city clinic. You believe you are providing care for patients who otherwise would not have the opportunity for care: Many are homeless, unemployed, economically disadvantaged, or otherwise not eligible for health insurance. The patient population is quite diverse, owing to a large immigrant population that has increasingly occupied the inner city over decades. You and your colleagues offer a full range of otolaryngologic medical and surgical care, with the surgical procedures primarily performed at the health system’s main teaching hospital, which is not in the same location as the clinic.
Explore This IssueFebruary 2020
Over the past 50 years that this clinic has been in operation, medical students and resident physicians have been taught a great deal about caring for disadvantaged and impoverished patients, gaining an important appreciation for the challenges of caring for this population, as well as better understanding cultural diversity and managing language barriers. From an ethics perspective, it has provided an opportunity for trainees and faculty to “stoke” the fire of altruism, which hopefully played a role in their choice of medicine as a profession.
Unfortunately, you have just learned that the national healthcare corporation that just purchased your not-for-profit community healthcare system has decided to close the clinic in a “cost-cutting” effort to reduce overhead and improve profit margin. They want to reduce the level of staffing throughout the system and cut any expenses that do not contribute toward a profit. Some of the clinic staff may be relocated to the main hospital facility, but others will simply lose their jobs. Medical students and residents will no longer be exposed to a diverse community of patients in need, who may have no other options for healthcare. To say you are “morally outraged” would be quite an understatement. You secure an appointment to discuss the situation with the executive vice president and chief operating officer of the corporation, and present the historical elements of the clinic’s community service, and the need to continue to care for these patients. They listen, but then inform you that they are “running a big business,” not a charity. They may investigate other options for the patients’ care in the community, but at this time it is not a working priority for them, so you need to “walk away from this issue.” Having provided care at this clinic for most of your academic career, you are frustrated beyond belief.
How would you handle this situation? Read more below.
Physicians are challenged by ethical dilemmas nearly every day of practice. While well-defined ethical principles are available to guide physicians in their approach to clinical ethical dilemmas, it is quite another thing to actually stand up and do the right thing, especially when you are facing a goliath in the form of a healthcare corporation. So, what personal and professional attributes might prepare a physician to consider the ethical options in dilemmas such as this one? Can moral strength and professional courage be learned, or are they inherent traits? How can physicians assess their own moral strengths in order to apply them to their professional obligations in everyday ethical dilemmas?
Physicians experience moral outrage and frustration when they are thwarted in some manner by external forces in their efforts to provide the best possible care for their patients. This frustration can be significant enough in some cases to lead to moral distress, which is considered to be a potential contributor to the development of burnout syndrome. When appropriate ethical decision making and actions cannot be carried out in a patient’s best interests for reasons out of the physician’s direct control, moral courage must come into play. Moral courage is making the ethically correct effort on behalf of one or more patients in the face of institutional, financial, political, or other confining impedances. While businesses and institutions may claim to have ethically moral and prudent policies to guide their corporate decisions, they will not be as patient-centered as will be an individual physician. Achieving a positive “bottom line” does not negate the primary mission of healthcare organizations: patient care.
Principled moral outrage is a very appropriate feeling for the physician under the circumstances described in the fictional clinical scenario above. Moral outrage should beget moral courage. Physicians have a duty to advocate for their patients, and for those individuals who may never have the opportunity to become patients. One may ask, “What are the formative agents that give rise to moral courage as part of a physician’s professional and ethical development?” Indeed, moral courage is a fundamental—and required—attribute of an ethical physician, as are the duties of honesty, integrity, competence, and trust. These attributes should be founded early in the physician’s persona and solidified and refined over the course of a career. The courage to act on behalf of a patient, especially in a difficult and challenging situation, is a responsibility rooted in one’s moral compass, a sense of right and true conduct, and an adherence to our profession’s code of ethics.
There may be times when a physician must place herself or himself in a position of risk by taking a stand against external forces that threaten a patient’s clinical care. Likewise, when a community of patients, especially those who are so disadvantaged that they have no “voice,” is facing a threat to their health and well being, physicians have an obligation to speak for them. Most ethical dilemmas seen in everyday practice can be approached, and usually resolved, by applying the ethical principles of autonomy, beneficence, and non-maleficence to the decision-making process. What we physicians don’t always have the opportunity to advocate for is the principle of social justice, which is the guiding principle in this scenario. One measure of a social construct (society) is how it is concerned with the human rights of its citizens and provides a fair and equitable distribution of its valuable resources and opportunities across economic, educational, cultural, and occupational strata. While it is quite difficult to achieve full parity, a society must endeavor to distribute according to need. Autonomy, beneficence, and non-maleficence are ethical principles typically applied on the individual patient level, where the patient—and often family—have shared decision-making with the physician.
There may be times when a physician must place herself or himself in a position of risk by taking a stand against external forces that threaten a patient’s clinical care.
Medical students and resident physicians must be taught the importance of social justice in healthcare, as it directly relates to their altruism and sense of duty. Teaching moral courage and behavior in the face of making, and carrying out, ethical decisions on behalf of communities of patients may be best approached through a combination of role modeling and scenario discussions. Giving consideration to actions and options in the face of social injustice may seem overwhelming to those training to become physicians, but the need for moral courage in the face of such injustice must be instilled. If moral distress is indeed a contributor to physician burnout, then we have an obligation to our future physicians to prepare them with the best moral and ethical foundations to act appropriately, with strength and commitment, in their advocacy of patients who cannot act on their own.
In addition to closely adhering to the solid ethical principles of our profession, an additional deterrent to moral distress may well be the fostering of a commitment to embracing the highest order of physician virtues in our personal and professional lives. Moral courage to do the right thing evolves over our lifetime, and each successful effort to advocate for our patients will inform and strengthen our next challenge.
This fictional clinical scenario may seem like the proverbial “David vs. Goliath” encounter, but the physician need not fight this alone. She or he can enlist the support of like-minded, ethical physicians who also believe in the importance of this particular clinical site as one of professional growth and development of physicians, and service to a disadvantaged population. A group of strong and respected clinicians with moral courage generated from moral outrage, advocating together for social justice and offering ethical alternative options for caring for these patients with great health needs, may prevail over such a health system Goliath. As professionals, even when we are acting out of moral courage, we still understand that a reasoned approach to a disagreement will more likely lead to resolution or working alternatives than will confrontation or arguing. Advocating for one patient or a population of patients is more likely to succeed when a range of better options are presented and supported with facts and reason. Social justice is an ethical principle for which one should always stand tall and firm.
Dr. Holt is a professor emeritus in the department of otolaryngology-head and neck surgery at the University of Texas Health Science Center in San Antonio.