George Lundberg, reviewed what he called the Principles of medical ethics in his blog on MedPageToday.com on December 20, 2010. He’s done us a service by bringing this up as the season for reflection is upon us.
The AMA’s Code of Medical ethics as revised in June 2001 is separate from the Hippocratic Oath, which most medical students recite on graduation. The AMA’s Code, which is less widely known, also reads like much of what should be noble in the profession, as it relates to an individual physician-patient encounter.
However, the code is fuzzy when it talks about the patient as paramount. There is nothing in these principles that relates to stewardship of health resources that are not limitless. There are multiple examples where physicians have done what they may have thought were in the patient’s best interest, but actually hurt them. One of the most egregious examples of this was in the 1990s when there was benefit presumed from bone marrow transplant based therapies for women with stage IV breast cancer. Physicians sent women for this therapy believing that it would help prolong their lives. Most often this was based on thinking of the patient as paramount, even if the therapy actually didn’t help most patients who had been studied. Where does the physician’s responsibility for evaluating the mountain of medical literature and for reaching a valid independent conclusion about an individual patient’s likelihood of benefiting from a therapy begin or end. In 2010 there were approximately 4600 journals catalogued in the Medline Database at the National Center for Biotechnology Information (NCBI). What a physician does for an individual patient must clearly be in the best interest of that patient. However, an individual physician’s “clinical judgment” may often be colored by his heuristics and individual biases. We need to work on ways of allowing us to be better informed and generally work in the patient’s as well as society’s best interests. We simply cannot do everything possible for an individual patient without taking into account the incremental benefit of individual diagnostic tests or therapeutic adventures. There multiple examples of where a “it can’t hurt” to do a diagnostic or therapeutic procedure has led to catastrophic outcomes.