Doctors Say Honesty Is Not Always Best Policy
Most physicians would be willing occasionally to mislead insurers and patients’ families--either to protect their patients’ interests or even, in some instances, to protect themselves, according to a new study.
The study, published today in the Journal of the American Medical Assn., found that more than half of the 211 doctors surveyed would deceive an insurance company to help out a patient, or would let a patient lie to his wife about his diagnosis of venereal disease.
More than a third said they would provide incomplete or misleading information about a mistake that led to a patient’s death--contending, in many cases, that the patient’s family would only be further hurt by knowing of the mistake.
“There is this tension between what’s ethically correct in the abstract and what works in practice,” said Dr. Dennis H. Novack of Brown University, an author of the study. “I think physicians tend to be practical people.”
The anonymous questionnaire, aimed at exploring attitudes toward deception, presented the randomly selected physicians with four quandaries. In a multiple-choice format, they were asked to choose a course of action and identify their reasons.
The physicians were also asked generally about their basic principles. The results:
- Nearly 70% said they would mislead an insurance company to obtain coverage of a routine mammogram for an apparently healthy 52-year-old woman. In the example, the woman’s insurance covered mammography only if there were some sign of cancer.
The physicians said they would tell the insurer the test was needed to “rule out cancer,” rather than simply as routine screening. Justifying the deception, they argued that the insurance rules were unreasonable and their obligation was to their patient.
- More than 60% would permit a man who had caught gonorrhea from a prostitute to deceive his wife rather than jeopardize his marriage: They would allow him to tell her he had a non-specific infection, as long as he would ensure that she be treated.
But the authors noted that the wife might then underestimate the infection, neglect her antibiotics and run the risk of developing pelvic inflammatory disease--a painful consequence of untreated gonorrhea that can in some cases leave a woman infertile.
- More than a third of the doctors surveyed said they would omit telling a mother that her 15-year-old daughter was pregnant. In the hypothetical case, the girl begged for secrecy, saying she would get an abortion in a nearby state not requiring parental consent.
The physicians said they would tell the mother that they had discussed the daughter’s health with her and she could discuss it with her mother. Most justified their evasion on grounds of patient confidentiality. Some simply said it was best for the girl.
- Finally, nearly 40% said they would be willing to mislead the family of a hypothetical 80-year-old patient who had been hospitalized with severe hypertension, and who had then died after receiving a fatal dose of medication from a mislabeled vial.
While more than half the physicians surveyed said they would admit the accident, others would simply stress the risks of strong medication. Some said they would say the patient had been very sick and had died, despite the physician’s best efforts.
“While many argued in their comments that the family would only be further hurt by the knowledge of the mistake, deception clearly offered benefits to the physicians as well,” the researchers noted in the paper.
Asked generally to describe how they felt about deception, 87% of the 109 physicians who answered that question said deception would be acceptable on rare occasions to protect the patient from harm, to circumvent “ridiculous rules” and to protect confidentiality.
Survey’s Value
The researchers--including physicians from the medical schools of Brown, Harvard and the universities of Washington and Pittsburgh--said their exploratory survey, which they believe is unprecedented, could serve as groundwork for developing guidelines, teaching ethics and further research.
“My view of ethics is that in certain cases there are right and wrong answers,” said Dr. Robert Arnold, an assistant professor of medicine at the University of Pittsburgh and a co-author. “In other cases, what counts are not the answers but the reasons.”
While the researchers believe the survey’s anonymity encouraged honest responses, one expert in opinion research said there is a well-documented tendency for people to “over-report good behavior and under-report bad behavior.”
“Having things be entirely anonymous does not entirely ensure frankness,” said Tom Smith of the National Opinion Research Center. “Doctors may be sophisticated enough to know that what they report might reflect upon the profession as a whole.”
