In a February 2013 issue of the AMA journal on ethics (“The Physician as Hospital Employee”) the following ethical case is presented and then discussed.
A doctor who used to be in an independent practice is now employed at a hospital. All the doctors, including her, received an email from the CEO that contained a spreadsheet of all the monthly ordering costs per physician. In the email the CEO discussed the need for all the doctors to do what he or she could to cut costs; the idea, presumably, was that a public document with such data would move them in that direction. The doctor, who had a high monthly cost, was outraged by the implication that monetary decisions should trump good judgment. She was about to write an angry letter back to the CEO when she stopped and considered her new role as an employee, as “she was one of many salaried physicians on staff—did she want to come off as a difficult employee? Did she have the clout to refuse to comply?”
According to the first group of commentators, “The fundamental ethical issue is whether a physician can advocate for the patient if he or she is also expected to think about the personal and societal financial implications of treatment decisions.” The commentators then proceed to do an ethical analysis weighing patient care against societal obligations and decide it makes sense for the hospital to try to control cost, but that this (practically) form of shaming and communication might have been a bit sloppy.
One commentator suggests that the doctor take her concern to the quality care committee who should them develop a plan of action.
As a union of employed physicians we would challenge two of the underlying assumptions that both commentators seem to make. First, they assume that the ethical unit is the individual doctor. Second, and following from the first, they assume that the range of actions available to the doctor are limited to individual actions. From our perspective both premises are wrong.
The email in question was sent to all the doctors at the hospital and it is unclear why the doctors should not respond to the CEO as a group. They could easily meet, discuss the issue and have a unified response. They could write a polite and professional letter, sign a petition, go to CEO’s office and demand a change or they can decide that the CEO’s strategy is a fair one and accept it.
The point is they can do this as a group of doctors not as individuals. In short there is a solution to the doctors’ lack of clout- take collective action and form a union.
But while one could argue the political pros and cons of collective action as such, it is also important to phrase it as an ethical question: Do doctors have an ethical obligation on the institutional level on behalf of their patients and profession to take collective action? Do the doctors in the hospital discussed in the article have an ethical obligation to respond to the CEO’s email as a collective group?
It is this analysis of the institutional level that is often missing in discussions of medical ethics. Dr. Thomas Huddle, for example, argues for a strong distinction between the professional and the political: “The recent claim that political advocacy must also be a professional norm is a category mistake. Political advocacy, if it is a virtue, is a civic virtue rather than a professional one. If we owe society civic virtues, as perhaps we do, we owe them as citizens rather than as professionals.” What are doctors at a hospital to do with ethical conversations limited to categories of the professional and the civic?
Salaried physicians on the institutional level are assessing how decisions on the hospital level will affect their patients. Is the fight for proper staffing at a hospital or clinic a political or professional fight? Is it a political or professional decision for doctors at an underfunded facility to lobby or speak out for more funds? On the institutional level the political/professional distinction breaks down.
Perhaps it is true that on the level of the profession as a whole the ethical questions of a physician’s responsibility are not so clear. But for the salaried doctor that level of abstraction misses the urgency of the daily struggle in the hospital or clinic.
Sara Dobson et al seem to have a feel for the urgency of the issue when they state that the “main barrier to productive conversations about the place of health advocacy appears to be a lack of clarity around what a physician should do as a health advocate and how this should manifest in daily practice.”
Dobson et al make a distinction between agents and activists in which the “agent acts on a patient’s behalf to secure access to social services, facilities, and support” while the “activist campaigns to bring about institutional, social, economic, or political change.” They suggest that this distinction will help clarify the ethical obligation of the doctor insofar as one can now have the language to argue that a doctor should be an agent or an activist. It is a useful distinction.
To return to our example, we believe the doctor and her colleagues should consider organizing a union for ethical reasons. There needs to be a collective institutional response from physicians to hospital policies that impact patients and doctors. If doctors are serious about their ethical responsibility –as agents or activists- they need to seriously think about how to both organize that response and make sure it is successful on behalf of their patients.