healthmedicinet

James Whitaker/Getty Images

Hard Cases

Dr. Abigail Zuger on the everyday ethical issues doctors face.

Soon, medical practice will be practically perfect.

Or so one can only assume from the quantities of flow sheets, protocols and guidelines being churned out these days, all intended to transform health care into an instrument as sleek and reliable as a new transcontinental jet, floating through cloudless blue skies from Point Sick to Point Well.

Meanwhile, though, the actual enterprise lurches along like a noisy, crowded bus bumping through back alleys to the local flea market, a place where negotiation rules and even the simplest transaction can stall in a tangle of missed cues and crossed expectations.

The confusions that plague today’s medical care have so little to do with the vision of tomorrow’s smooth operation that no one pays them much mind. Yet they are likely to persist — little cracks in that big jet’s runway, particulate matter in its fuel — and we ignore them at our peril. Hence this new column, a monthly inspection of some of the irregularities on the road.

To start, here is one that comes up all too often. As a primary care provider, I am continually asked to write notes to sick patients’ employers. Invariably, the conversation runs as follows:

Me: “You have a cold. You’ll be fine by Monday.”

Patient (sniffling, coughing, miserable): “Could you make it Wednesday? I have a bunch of errands to do.”

What should I write? On the long stretch between honesty and fraud, where do I pitch my tent?

Whether you should lie often depends on whom you’re lying to, the experts say.

Doctors and patients are never supposed to lie directly to each other. (No surprise there. What is surprising is that this expectation is a fairly modern development. Even a few decades ago, honesty on the doctor’s part, at least when it came to divulging the details of a bad illness, was generally considered unnecessarily cruel. In some countries it is still good medicine to gloss over the bad parts.)

Of course, rare indeed is the examining room where complete mutual honesty prevails. We all withhold, maneuver, and swallow various impolitic thoughts. And then, when a third party enters the picture, all bets are off.

Sometimes the third point in the triangle is a patient’s friend or relative, sometimes an employer. Often it’s the medical insurer, toward whom both patients and doctors are individually bound by strong legal and ethical ties.

In theory, complete honesty suffuses relationships with insurers, too. But surveys have repeatedly confirmed that many doctors habitually tell insurers blatant lies on behalf of their patients — and feel perfectly fine, even righteous, about doing so.

In a recent issue of The American Journal of Bioethics, a half-dozen ethicists chewed over the question of whether a decision to play Robin Hood with the medical insurer is actually ethical. Say that the patient’s health — or even life — is at stake: The insurer, for example, is refusing to pay for an essential test or medication unless the doctor writes down a bogus diagnosis the patient does not have. The experts came down firmly and eloquently on both sides of the issue.

Nicolas Tavaglione and Dr. Samia A. Hurst, both at the Institute for Biomedical Ethics at Geneva University Medical School in Switzerland, argued that lying for a patient under such circumstances was not only ethically permissible but mandatory. Helping a patient takes precedence over all other considerations, they wrote. Telling the truth would be “honoring an ideal principle in a nonideal world.”

Other ethicists protested, pointing out that too many doctors playing Robin Hood would make insurers tighten purse strings further. Dr. Thomas S. Huddle, of the medical school at the University of Alabama, Birmingham, wrote that all lies, even those told for a good cause, imperil the moral fabric of medicine. Dr. Robert M. Sade, of the Medical University of South Carolina, feared instead for the moral fabric of the doctor, pointing out that every lie “reinforces the habit of lying,” which then becomes easier and easier until the “morally disengaged” doctor is capable of really bad behavior.

None of this helps much as I contemplate the unhappy victim of severe nasal congestion who will be better by Saturday and well by Monday, but who needs a microscopic white lie from me to take care of some personal matters until Wednesday.

Of course I write the note. If lying big to a big corporation provokes this kind of debate, who would ever care about such a little tiny lie, quickly forgotten, barely a blip in the day? And Dr. Sade is absolutely correct: The more of these notes I write, the less they bother me.

I am, however, not yet completely morally bankrupt, and I do maintain a mental tally of falsehoods committed to paper and cannot help noticing when obvious patterns emerge. Some patients manage to get an awful lot of errands done in the course of their respiratory infections.

These folks eventually discover that Robin Hood has left the office. In her chair sits the sheriff of Nottingham, who points out that many more missed days of work are probably going to cause them considerable trouble, and sends them back to work bright and early Monday morning.