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Old Yesterday, 10:21 AM   #1
xjx388
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Medicine, ethics and law: What are doctors supposed to do?

I think this is a timely subject to discuss but it originally sprung out of the “Donald Trump is dangerously mentally ill” thread. I posed the argument: “Ethics requires doctors/clinicians to follow the law.” I think that’s pretty obvious and uncontroversial.

A good example of this is what’s going on now with many doctors writing scrips for chloroquine, etc/azithromycin for themselves/family/friends/ patients -not because they have an autoimmune disorder or a positive Covid-19 diagnosis, but “just in case.” This has caused a shortage. I think that’s unethical and now many States have started clamping down on this with new emergency rules prohibiting the practice. Doctors/Pharmacists should comply with the law even if they don’t agree with it.

The counter argument has been, in a nutshell, that a doctor can “override” laws that they find unethical/harmful and that doctors should use individual clinical judgement to make ethical decisions against a law/ethical rule they see as unjust. Others can correct me if I’ve misstated the basic position.

Abortion is cited as an example: if abortion was made illegal today, it would be ethical for docs to keep on doing them because the law itself would be unethical.

I think doctors overriding the law is dangerous and that ethics requires them to comply with the law, even against their own clinical judgement. In the case of a total abortion ban, they would be putting patients and their licenses at risk: patients would have a harder time getting safe abortions and treatments for complications that arise; doctors would be less likely to send patients with complications to hospitals because they don’t want to risk their licenses. If they lose their licenses, we have a doctor shortage problem. I am NOT arguing that such a law is good. I am arguing that the medical community’s duty is to follow the law and fight/lobby against unjust laws that affect patient care.

So what say you? What is a clinician’s duty in regards to ethics and the law.
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Old Yesterday, 01:54 PM   #2
Skeptic Ginger
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We are allowed to prescribe "off label" so there is not law against that. It does not require 'overriding' any laws to prescribe off label. Many meds used in pediatrics are prescribed off-label because drug companies don't do a lot of clinical trials on kids. It's off-label or no med options.

Is this thread about unethical laws or just your general feelings about what things doctors do that are and are not ethical?

I find your position there on abortion to be all over the place.
Quote:
Abortion is cited as an example: if abortion was made illegal today, it would be ethical for docs to keep on doing them because the law itself would be unethical.
So let the 12 yr old carry and deliver the child conceived by incest until the law is changed?

How about a law requiring one wait until the fetal heartbeat stops when a pregnant woman needs an emergency abortion and the fetus has no chance of survival anyway? Is that law ethical, risk the life of the mother even when fetal demise is imminent?

Are needless laws ethical when they are no more than a thinly disguised means of blocking the Constitutional right to an abortion? The latest version is claiming an abortion is an elective surgery and therefore banned at this time. Consider also few of those abortions are done in hospitals.
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Old Today, 02:08 AM   #3
Roboramma
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It seems pretty simple to me: in a society whose laws are ethical, following the law is ethical.
In a society whose laws are unethical, following the law is unethical.

For most of us, for most laws that affect doctor's decisions, they are ethical, so a good baseline is to follow the law.

When faced with an unethical law, other practical considerations will come in to play, like how acting out of accordance with the law will affect both the doctor and the patient. This is a second order consideration, but won't necessarily result in a conclusion that following the law is the best course of action.
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Old Today, 07:48 AM   #4
xjx388
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Originally Posted by Skeptic Ginger View Post
We are allowed to prescribe "off label" so there is not law against that. It does not require 'overriding' any laws to prescribe off label. Many meds used in pediatrics are prescribed off-label because drug companies don't do a lot of clinical trials on kids. It's off-label or no med options.
Maybe Washington isn’t a state that has issued an emergency rule. I did find this: https://wmc.wa.gov/news/wmc%C2%A0statement-chloroquine:

Quote:
We want providers and pharmacists to act with their best discretion to ensure patients continue to receive appropriate treatment in time of shortages. However, we discourage inappropriate prescribing of this medication for prophylaxis, which may restrict access for patients that really need appropriate therapy such as those patients in our state with lupus, rheumatoid arthritis, and malaria diagnoses.
Other States have taken stricter action. This brings up an important part of my overall position. Professional ethics imposes a higher duty than the law does. Ethics requires following the law AND it requires exercising ethical professional judgement outside of the law. To wit: Prescribing a drug off-label may not be illegal; but, ethically, it may be inappropriate. Colleagues prescribing chloroquine to each other prophylacticly may not be illegal, but it’s certainly unethical when 1)There’s a shortage and 2) There’s no good evidence that the drug is even effective for prophylaxis or treatment.

Even in normal times, off-label prescribing requires the clinician to consider the weight of the evidence, the known risks and expected benefits as well as other concerns like cost, availability, etc. Prescribing HCG for weight-loss may not be illegal, but it’s certainly unethical.

Quote:
Is this thread about unethical laws or just your general feelings about what things doctors do that are and are not ethical?
Its right there in the title: the intersection of the law, ethics and what doctors should or should not do.

Quote:
I find your position there on abortion to be all over the place.

So let the 12 yr old carry and deliver the child conceived by incest until the law is changed?

How about a law requiring one wait until the fetal heartbeat stops when a pregnant woman needs an emergency abortion and the fetus has no chance of survival anyway? Is that law ethical, risk the life of the mother even when fetal demise is imminent?

Are needless laws ethical when they are no more than a thinly disguised means of blocking the Constitutional right to an abortion? The latest version is claiming an abortion is an elective surgery and therefore banned at this time. Consider also few of those abortions are done in hospitals.
They may not be ethical laws; no argument there. Ethical practice still requires following the law. Now, I understand there are laws that could be passed that would be egregiously out of line. It’s happened and we have a mechanism for fighting them: SCOTUS. Those laws don’t pass Constitutional muster. Is there a specific, actual law in force right now you have an issue with? Because I don’t see an actual law like the one you describe. I’d like to stick with the real-world doctors are operating in now as opposed to hypothetical scenarios we could imagine. Even the Covid related abortion bans you talked about have been blocked.
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Old Today, 08:00 AM   #5
xjx388
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Originally Posted by Roboramma View Post
It seems pretty simple to me: in a society whose laws are ethical, following the law is ethical.
In a society whose laws are unethical, following the law is unethical.

For most of us, for most laws that affect doctor's decisions, they are ethical, so a good baseline is to follow the law.

When faced with an unethical law, other practical considerations will come in to play, like how acting out of accordance with the law will affect both the doctor and the patient. This is a second order consideration, but won't necessarily result in a conclusion that following the law is the best course of action.
Fair enough . . . however, who decides a law is unethical? Is that a decision that an individual clinician gets to make?
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Old Today, 08:17 AM   #6
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We live in a society.

Nobody can tell anyone else what's right and what's wrong. Each individual gets to decide that for themselves.

But we live in a society. Obviously we're going to have a collective agreement on what's tolerable and what's not. You can - and do! - have your own ethical standard, but there's also the standard you have to meet to avoid negative consequences from the people who share in the same society.

So. Every doctor, like everyone else, should follow their own ethical standard regardless of what the law says.

But we live in a society. We have a collective agreement on the baseline ethical standards and boundaries appropriate for doctors. If you want to be a doctor in our society, without consequences arising from violations of our collective ethics, you must meet our ethical standard.

If you want to live in our society. If you want to enjoy its benefits. If you want all the protections we offer, against those who would ignore our ethics to profit from your misfortune. Then you have to comport with our ethics. Not because we can tell you what your ethics are. But because we live in a society. In a sense, society is the part of the Venn diagram where most people's ethics overlap.

If you want to be a good doctor - an ethical doctor - it's not just about hewing to your own personal standard of right and wrong. It's about practicing medicine at that ethical intersection where society happens.

Therefore, in most cases, an ethical doctor is a doctor who practices medicine according to the collective ethical standards of their society. A doctor who practices medicine in violation of those standards may be true to his own ethics, but he's violating the ethics of the society he serves, which is itself unethical.

And even if it isn't unethical in the doctor's own eyes, it still invites (and justifies) negative consequences from the society he serves.

Because we live in a society.
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Old Today, 08:23 AM   #7
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Originally Posted by xjx388 View Post
Fair enough . . . however, who decides a law is unethical? Is that a decision that an individual clinician gets to make?
Yes and no.

The individual clinician is the only person who can decide for that person what's ethical and what isn't.

However, society still gets to decide that there should be consequences for clinicians that apply their personal ethics in violation of the collective ethics.

The question for the clinician isn't "do I get to decide for myself whether this is right or wrong?" The question is, "am I okay with the consequences for violating society's collective sense of right and wrong?" and, "is it right for me to try to practice medicine according to a sense of right and wrong I don't believe in?"
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Old Today, 09:41 AM   #8
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Aren't there state & organizational (associations) ethic boards in every state that make these determinations? I'm not sure under what authority they are empowered or how they can enact their decisions.
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Old Today, 11:45 AM   #9
xjx388
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Originally Posted by theprestige View Post
Yes and no.

The individual clinician is the only person who can decide for that person what's ethical and what isn't.

However, society still gets to decide that there should be consequences for clinicians that apply their personal ethics in violation of the collective ethics.

The question for the clinician isn't "do I get to decide for myself whether this is right or wrong?" The question is, "am I okay with the consequences for violating society's collective sense of right and wrong?" and, "is it right for me to try to practice medicine according to a sense of right and wrong I don't believe in?"
Sure, I can agree with that.

It kind of jibes with my overall feeling about it: If a clinician will not practice according to the law and ethical codes applicable to their profession, they shouldn't be practicing at all. Ultimately, our society has decided that medical professionals are subject to several authorities: The legislature (through Occupation Codes and State Medical Boards) and the professional organizations that train and certify them (AMA, specialty societies and boards). When you choose to be a medical professional, you are subjecting yourself to society's restraints on your actions.

Off-label prescribing, abortion, etc are all well covered in the law and in the ethical codes. We can't allow clinicians to operate with open disregard for those things just on their own judgement.
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Old Today, 12:50 PM   #10
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Originally Posted by xjx388 View Post
Sure, I can agree with that.

It kind of jibes with my overall feeling about it: If a clinician will not practice according to the law and ethical codes applicable to their profession, they shouldn't be practicing at all. Ultimately, our society has decided that medical professionals are subject to several authorities: The legislature (through Occupation Codes and State Medical Boards) and the professional organizations that train and certify them (AMA, specialty societies and boards). When you choose to be a medical professional, you are subjecting yourself to society's restraints on your actions.

Off-label prescribing, abortion, etc are all well covered in the law and in the ethical codes. We can't allow clinicians to operate with open disregard for those things just on their own judgement.
This is an ancient question about any regulated profession.

Here's the thing: laws vary by region and over time. This alone should be evidence that there's no objectively 'true' set of ethics. So knowing that, I think it follows that there's no true set of medical ethics either. Unethical behavior is like pornography: can't really define it, but we know it when we see it.

Here's an example coming from the other direction. In some regions, a GP is forbidden by law to discuss safe healthy options for contraception, not to mention abortion. According to some posters above, a GP who breaks the law and helps his patient be informed about her options in violation of the law is "unethical" and "should not be practicing medicine." I disagree.

An example from history is healthcare staff who secretly broke Jim Crow segregation laws by treating black patients with the same quality of care as white patients, even though the law mandated the correct procedure would be to risk killing the patient by turning them away at the door. Again, I'm not sure these doctors were unethical or unfit to practice medicine.

So, I get it, there's room for debate, just like with any discussion about morals and ethics and professions. A lot of regions deliberately shoehorn in an ethical clause that gives MDs some scope for refusing to do activities that they consider morally objectionable. The debate is whether this conflicts with other higher goals such as patient informed consent and autonomy. For example similar to above, but in reverse: a Catholic GP deciding not to tell a teenaged patient about safe contraception options and leaving her in the dark.
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Old Today, 01:23 PM   #11
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Originally Posted by blutoski View Post
Here's an example coming from the other direction. In some regions, a GP is forbidden by law to discuss safe healthy options for contraception, not to mention abortion. According to some posters above, a GP who breaks the law and helps his patient be informed about her options in violation of the law is "unethical" and "should not be practicing medicine." I disagree.
Heh. I disagree with your disagreement. We live in a society. We agree that healthcare should be licensed, and that licensing involves adhering to the guidelines of the licensing authority. Your personal ethics may allow you to claim the authority and privileges of the license even though you don't actually adhere to its guidelines. But I think you'll have a hard time convincing the society that licensed you that you're behaving ethically, and that they should continue to give you license to practice medicine.

But it's an ethical quandry that can only be solved on an individual basis. On the one hand, you're lying to the society that licensed you. On the other hand, obtaining the license through fraud allows you to practice medicine and do a lot of good without a lot of persecution for practicing without a license.

Which is the most ethical course of action? Society will tell you what they require, to recognize you as an ethical practicioner. You will tell yourself something different. Only you can decide which is the most ethical course for you to take.

However, your personal ethics decisions do not trump society's privilege to impose negative consequences on you if you break with society's ethical standards.

I can respect a doctor that would rather go to jail, than practice medicine according to society's ethics. I can't respect a doctor who says they should't go to jail because they were being true to their personal ethics.
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Old Today, 01:39 PM   #12
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Originally Posted by theprestige View Post
Heh. I disagree with your disagreement. We live in a society. We agree that healthcare should be licensed, and that licensing involves adhering to the guidelines of the licensing authority. Your personal ethics may allow you to claim the authority and privileges of the license even though you don't actually adhere to its guidelines. But I think you'll have a hard time convincing the society that licensed you that you're behaving ethically, and that they should continue to give you license to practice medicine.

But it's an ethical quandry that can only be solved on an individual basis. On the one hand, you're lying to the society that licensed you. On the other hand, obtaining the license through fraud allows you to practice medicine and do a lot of good without a lot of persecution for practicing without a license.

Which is the most ethical course of action? Society will tell you what they require, to recognize you as an ethical practicioner. You will tell yourself something different. Only you can decide which is the most ethical course for you to take.

However, your personal ethics decisions do not trump society's privilege to impose negative consequences on you if you break with society's ethical standards.

I can respect a doctor that would rather go to jail, than practice medicine according to society's ethics. I can't respect a doctor who says they should't go to jail because they were being true to their personal ethics.
And this is why there's entire courses on is-the-law-the-definition-of-ethical?

Bring on the Heinz dilemmaWP !

(sounds like you're at Level 2)
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Old Today, 04:00 PM   #13
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What that really illustrates is that law and ethics are always products of the societies that make them. As societies evolve, so do their laws and ethics.

Even in the Jim Crow era, white doctors had discretion to treat black patients if they chose to. They werenít breaking the law, just exercising their choice. Iím sure that many of them were socially ostracized and lost white patients because of their choice. But this is a reflection of the society of the time and not the actual laws of the time.
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Old Today, 04:14 PM   #14
theprestige
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Originally Posted by blutoski View Post
And this is why there's entire courses on is-the-law-the-definition-of-ethical?

Bring on the Heinz dilemmaWP !

(sounds like you're at Level 2)
Were you intending more discussion, or are you pigeonholing me to signal you're done here?
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Old Today, 06:45 PM   #15
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Originally Posted by xjx388 View Post
What that really illustrates is that law and ethics are always products of the societies that make them. As societies evolve, so do their laws and ethics.

Even in the Jim Crow era, white doctors had discretion to treat black patients if they chose to. They werenít breaking the law, just exercising their choice. Iím sure that many of them were socially ostracized and lost white patients because of their choice. But this is a reflection of the society of the time and not the actual laws of the time.
If the laws had been such that they were prohibited from treating black patients, should they have simply made the decision to either practice medicine and follow the law, or not practice medicine at all?

I think as a society we can make the choice that when we find doctors practicing medicine not in accordance with the ethical standards decided on by society, we don't allow them to practice medicine anymore. That makes sense: that's how society can go about deciding upon and enforcing an ethical standard, and it's very clear that we need to do both of those things.

As an individual each person will have an ethical standard, and there's no reason, as an individual, to presume a priori that the standards of society are superior to one's own standards. I would suggest that there is a certain degree of wisdom to society and that considerable weight should be put on the proposition that the standards of society exist as they do for a reason and if you don't agree with them, you may be in the wrong. But at least in some cases one can go through that analysis and still come out of it thinking that in this particular case society is wrong. In that case it's time to do a cost/benefit analysis of going against society's ethical precepts. The outcome may be "I should stop being a doctor in this society given that I can't conform to the ethics prescribed", it may be "I should engage in civil disobedience and make clear my willingness to oppose these precepts", or it may be "I should covertly engage in this behavior that society's ethical standards don't allow."

All of those are possible given the right society and set of ethics.
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