Ethical Issues in Clinical Medicine
67CHAPTER 11
■ IMPLICATIONS FOR CLINICAL PRACTICE
Individual health care providers can do several things in the clinical
encounter to address racial and ethnic disparities in health care.
Be Aware That Disparities Exist Increasing awareness of racial
and ethnic disparities among health care professionals is an important
first step in addressing disparities in health care. Only with greater
awareness can care providers be attuned to their behavior in clinical
practice and thus monitor that behavior and ensure that all patients
receive the highest quality of care, regardless of race, ethnicity, or
culture.
Practice Culturally Competent Care Previous efforts have
been made to teach clinicians about the attitudes, values, beliefs, and
behaviors of certain cultural groups—the key practice “dos and don’ts”
in caring for “the Hispanic patient” or the “Asian patient,” for example.
In certain situations, learning about a particular local community or
cultural group, with a goal of following the principles of communityoriented primary care, can be helpful; when broadly and uncritically
applied, however, this approach can actually lead to stereotyping and
oversimplification of culture, without respect for its complexity.
Cultural competence has thus evolved from merely learning information and making assumptions about patients on the basis of their
backgrounds to focusing on the development of skills that follow the
principles of patient-centered care. Patient-centeredness encompasses
the qualities of compassion, empathy, and responsiveness to the needs,
values, and expressed preferences of the individual patient. Cultural
competence aims to take things a step further by expanding the repertoire of knowledge and skills classically defined as “patient-centered”
to include those that are especially useful in cross-cultural interactions
(and that, in fact, are vital in all clinical encounters). This repertoire
includes effectively using interpreter services, eliciting the patient’s
understanding of his or her condition, assessing decision-making
preferences and the role of family, determining the patient’s views
about biomedicine versus complementary and alternative medicine,
recognizing sexual and gender issues, and building trust. For example,
while it is important to understand all patients’ beliefs about health, it
may be particularly crucial to understand the health beliefs of patients
who come from a different culture or have a different health care experience. With the individual patient as teacher, the physician can adjust
his or her practice style to meet the patient’s specific needs.
Avoid Stereotyping Several strategies can allow health care providers to counteract, both systemically and individually, the normal
tendency to stereotype. For example, when racially/ethnically/culturally/
socially diverse teams in which each member is given equal power
are assembled and are tasked to achieve a common goal, a sense of
camaraderie develops and prevents the development of stereotypes
based on race/ethnicity, gender, culture, or class. Thus, health care
providers should aim to gain experiences working with and learning
from a diverse set of colleagues. In addition, simply being aware of the
operation of social cognitive factors allows providers to actively check
up on or monitor their behavior. Physicians can constantly reevaluate
to ensure that they are offering the same things, in the same ways, to
all patients. Understanding one’s own susceptibility to stereotyping—
and how disparities may result—is essential in providing equitable,
high-quality care to all patients.
Work to Build Trust Patients’ mistrust of the health care system
and of health care providers impacts multiple facets of the medical
encounter, with effects ranging from decreased patient satisfaction to
delayed care. Although the historic legacy of discrimination can never
be erased, several steps can be taken to build trust with patients and to
address disparities. First, providers must be aware that mistrust exists
and is more prevalent among minority populations, given the history
of discrimination in the United States and other countries. Second,
providers must reassure patients that they come first, that everything
possible will be done to ensure that they always get the best care
available, and that their caregivers will serve as their advocates. Third,
interpersonal skills and communication techniques that demonstrate
honesty, openness, compassion, and respect on the part of the health
care provider are essential tools in dismantling mistrust. Finally,
patients indicate that trust is built when there is shared, participatory
decision-making and the provider makes a concerted effort to understand the patient’s background. When the doctor–patient relationship
is reframed as one of solidarity, the patient’s sense of vulnerability
can be transformed into one of trust. The successful elimination of
disparities requires trust-building interventions and strengthening of
this relationship.
■ CONCLUSION
The issue of racial and ethnic disparities in health care has gained
national prominence, both with the release of the IOM report Unequal
Treatment and with more recent articles that have confirmed their
persistence and explored their root causes. Furthermore, another
influential IOM report, Crossing the Quality Chasm, has highlighted
the importance of equity—i.e., no variations in quality of care due to
personal characteristics, including race and ethnicity—as a central
principle of quality. Current efforts in health care reform and transformation, including a greater focus on value (high-quality care and
cost-control), will sharpen the nation’s focus on the care of populations
who experience low-quality, costly care. Addressing disparities will
become a major focus, and there will be many obvious opportunities
for interventions to eliminate them. Greater attention to addressing the
root causes of disparities will improve the care provided to all patients,
not just those who belong to racial and ethnic minorities.
■ FURTHER READING
Buchmueller TC et al: The ACA’s impact on racial and ethnic disparities in health insurance coverage and access to care. Health Aff
(Millwood) 39:395, 2020.
Carnethon MR et al: Cardiovascular health in African Americans: A
scientific statement from the American Heart Association. Circulation 136:e393, 2017.
Dwyer-lindgren L et al: Inequalities in life expectancy among us
counties, 1980 to 2014: Temporal trends and key drivers. JAMA
Intern Med 177:1003, 2017.
Kreuter MW et al: Addressing social needs in health care settings:
Evidence, challenges and opportunities for public health. Annu Rev
Public Health 42:11, 2021.
Krieger N: Measures of racism, sexism, heterosexism, and gender
binarism for health equity research: from structural injustice to
embodied harm: An ecosocial analysis. Annu Rev Public Health
41:37, 2020.
Medscape: Medscape Lifestyle Report 2016: Bias and burnout. http://
www.medscape.com/features/slideshow/lifestyle/2016/public/overview.
Vyas DA et al: Hidden in plain sight: Reconsidering the use of race
correction in clinical algorithms. N Engl J Med 383:874, 2020.
Williams DR et al: Racism and health: Evidence and needed research.
Annu Rev Public Health 40:105, 2019.
Physicians face novel ethical dilemmas that can be perplexing and
emotionally draining. For example, telemedicine, artificial intelligence,
handheld personal devices, and learning health care systems all hold
the promise of more coordinated and comprehensive care, but also
raise concerns about confidentiality, the doctor–patient relationship,
and responsibility. This chapter presents approaches and principles
that physicians can use to address important vexing ethical issues they
11 Ethical Issues in Clinical
Medicine
Christine Grady, Bernard Lo
68PART 1 The Profession of Medicine
encounter in their work. Physicians make ethical judgments about
clinical situations every day. They should prepare for lifelong learning
about ethical issues so they can respond appropriately. Traditional
professional codes and ethical principles provide instructive guidance
for physicians but need to be interpreted and applied to each situation.
When facing or struggling with a challenging ethical issue, physicians
may need to reevaluate their basic convictions, tolerate uncertainty,
and maintain their integrity while respecting the opinions of others.
Physicians should articulate their concerns and reasoning, discuss and
listen to the views of others involved in the case, and utilize available
resources, including other health care team members, palliative care,
social work, and spiritual care. Moreover, ethics consultation services
or a hospital ethics committee can help to clarify issues and identify
strategies for resolution, including improving communication and
dealing with strong or conflicting emotions. Through these efforts,
physicians can gain deeper insight into the ethical issues they face and
usually reach mutually acceptable resolutions to complex problems.
APPROACHES TO ETHICAL PROBLEMS
Several approaches are useful for resolving ethical issues, including
approaches based on ethical principles, virtue ethics, professional oaths,
and personal values. These various sources of guidance may seem to
conflict in a particular case, leaving the physician in a quandary. In a
diverse society, different individuals may turn to different sources of
moral guidance. In addition, general moral precepts often need to be
interpreted and applied to a particular clinical situation.
■ ETHICAL PRINCIPLES
Ethical principles can serve as general guidelines to help physicians
determine the right thing to do.
Respecting Patients Physicians should always treat patients with
respect, which entails understanding patients’ goals, providing information, communicating effectively, obtaining informed and voluntary
consent, respecting informed refusals, and protecting confidentiality.
Different clinical goals and approaches are often feasible, and interventions can result in both benefit and harm. Individuals differ in how
they value health and medical care and how they weigh the benefits
and risks of medical interventions. Generally, physicians should respect
patients’ values and informed choices. Treating patients with respect is
especially important when patients are responding to experiences of, or
fears about, disrespect and discrimination.
GOALS AND TREATMENT DECISIONS Physicians should provide relevant and accurate information for patients about diagnoses, current
clinical circumstances, expected future course, prognosis, treatment
options, and uncertainties, and discuss patients’ goals of care. Physicians may be tempted to withhold a serious diagnosis, misrepresent it
by using ambiguous terms, or limit discussions of prognosis or risks for
fear that patients will become anxious or depressed. Providing honest
information about clinical situations promotes patients’ autonomy and
trust as well as sound communication with patients and colleagues.
When physicians have to share bad news with patients, they should
adjust the pace of disclosure, offer empathy and hope, provide emotional support, and call on other resources such as spiritual care or
social work to help patients cope. Some patients may choose not to
receive such information or may ask surrogates to make decisions on
their behalf, as is common with serious diagnoses in some traditional
cultures.
SHARED DECISION-MAKING AND OBTAINING INFORMED CONSENT
Physicians should engage their patients in shared decision-making
about their health and their care, whenever appropriate. Physicians
should discuss with patients the nature, risks, and benefits of proposed
care; any alternative; and the likely consequences of each option. Physicians promote shared decision-making by informing and educating
patients, answering their questions, checking that they understand
key issues, making recommendations, and helping them to deliberate.
Medical jargon, needlessly complicated explanations, or the provision
of too much information at once may overwhelm patients. Increasingly, decision aids can assist patients in playing a more active role in
decision-making, improving the accuracy of their perception of risk
and benefit, and helping them feel better informed and clearer about
their values. Informed consent is more than obtaining signatures on
consent forms and involves disclosure of honest and understandable information to promote understanding and choice. Competent,
informed patients may refuse recommended interventions and choose
among reasonable alternatives. In an emergency, treatment can be
given without informed consent if patients cannot give their own
consent and delaying treatment while surrogates are contacted would
jeopardize patients’ lives or health. People are presumed to want such
emergency care unless they have previously indicated otherwise.
Respect for patients does not entitle patients to insist on any care or
treatment that they want. Physicians are not obligated to provide interventions that have no physiologic rationale, that have already failed,
or that are contrary to evidence-based practice recommendations or
good clinical judgment. Public policies and laws also dictate certain
decisions—e.g., allocation of scarce medical resources during a public
health crisis such as the COVID-19 pandemic, use of cadaveric organs
for transplantation, and requests for physician aid in dying.
CARING FOR PATIENTS WHO LACK DECISION-MAKING CAPACITY Some
patients are unable to make informed decisions because of unconsciousness, advanced dementia, delirium, or other medical conditions.
Courts have the legal authority to determine that a patient is legally
incompetent, but in practice, physicians usually determine when
patients lack the capacity to make particular health care decisions and
arrange for authorized surrogates to make decisions, without involving
the courts. Patients with decision-making capacity can express a choice
and appreciate their medical situation; the nature, risks, and benefits of
proposed care; and the consequences of each alternative. Patient choices
should be consistent with their values and not the result of delusions,
hallucinations, or misinformation. Physicians should use available
and validated assessment tools, resources such as psychiatry or ethics
consultation, and clinical judgment to ascertain whether individuals
have the capacity to make decisions for themselves. Patients should not
be assumed to lack capacity if they disagree with recommendations or
refuse treatment. Such decisions should be probed, however, to ensure
the patient is not deciding based on misunderstandings and has the
capacity to make an informed decision. When impairments are fluctuating or reversible, decisions should be postponed if possible until the
patient recovers decision-making capacity.
When a patient lacks decision-making capacity, physicians seek
an appropriate surrogate. Patients may designate a health care proxy
through an advance directive or on a Physician Orders for LifeSustaining Treatment form; such choices should be respected (see
Chap. 12). For patients who lack decision-making capacity and have
not previously designated a health care proxy, family members usually
serve as surrogates. Statutes in most U.S. states delineate a prioritized
list of relatives to make medical decisions. Patients’ values, goals, and
previously expressed preferences guide surrogate decisions. However,
the patient’s current best interests may sometimes justify overriding
earlier preferences if an intervention is likely to provide significant
benefit, previous statements do not fit the situation well, or the patient
gave the surrogate leeway in decisions.
MAINTAINING CONFIDENTIALITY Maintaining confidentiality is
essential to respecting patients’ autonomy and privacy; it encourages
patients to seek treatment and to discuss problems candidly. However,
confidentiality may be overridden to prevent serious harm to third
parties or the patient. Exceptions to confidentiality are justified when
the risk to others is serious and probable, no less restrictive measures
can avert risk, and the adverse effects of overriding confidentiality
are minimized and deemed acceptable by society. For example, laws
require physicians to report cases of tuberculosis, sexually transmitted
infection, elder or child abuse, and domestic violence.
Beneficence or Acting in Patients’ Best Interests The principle of beneficence requires physicians to act for the patient’s benefit.
Patients typically lack medical expertise, and illness may make them
vulnerable. Patients rely on and trust physicians to treat them with
Ethical Issues in Clinical Medicine
69CHAPTER 11
compassion and provide sound recommendations and treatments
aimed to promote their well-being. Physicians encourage such trust
and have a fiduciary duty to act in the best interests of patients, which
should prevail over physicians’ self-interest or the interests of third
parties such as hospitals or insurers. A principle related to beneficence,
“first do no harm,” obliges physicians to prevent unnecessary harm
by recommending interventions that maximize benefit and minimize
harm and forbids physicians from providing known ineffective interventions or acting without due care. Although often cited, this precept
alone provides limited guidance because many beneficial interventions
also pose serious risks.
Physicians increasingly provide care within interdisciplinary teams
and rely on consultation with or referral to specialists. Team members
and consultants contribute different types of expertise to the provision
of comprehensive, high-quality care for patients. Physicians should
collaborate with and respect the contributions of the various interdisciplinary team members and should initiate and participate in regular
communication and planning to avoid diffusion of responsibility and
ensure accountability for quality patient care.
INFLUENCES ON PATIENTS’ BEST INTERESTS Conflicts arise when
patients’ refusal or request of interventions thwarts their own goals for
care, causes serious harm, or conflicts with their best medical interests.
For example, simply accepting a young asthmatic adult’s refusal of
mechanical ventilation for reversible respiratory failure, in the name
of respecting autonomy, is morally constricted. Physicians should elicit
patients’ expectations and concerns, correct their misunderstandings,
and try to persuade them to accept beneficial therapies. If disagreements persist after such efforts, physicians should call on institutional
resources for assistance, but patients’ informed choices and views of
their own best interests should prevail.
Drug prices and out-of-pocket expenses for patients have been escalating in many parts of the world and may compromise care that is in
the patients’ best interests. Physicians should recognize that patients,
especially those with high copayments or inadequate insurance, may
not be able to afford prescribed tests and interventions. Physicians
should strive to prescribe medications that are affordable and acceptable to the patient. Knowing what kind of insurance, if any, the patient
has and whether certain medications are likely to be covered may help
in determining appropriate prescriptions. Available alternatives should
be considered and discussed. Physicians should follow up with patients
who don’t fill prescriptions, don’t take their medications, or skip doses
to explore whether cost and affordability are obstacles. It may be
reasonable for physicians to advocate for coverage of nonformulary
products for sound reasons, such as when the formulary drugs are less
effective or not tolerated or are too costly for the patient to pay for out
of pocket. These should be shared decisions with the patient to the
extent possible.
Organizational policies and workplace conditions may sometimes
conflict with patients’ best interests. Physicians’ focus and dedication to
the well-being and interests of patients may be negatively influenced by
perceived or actual staffing inadequacies, unfair wages, infrastructural
deficiencies or lack of equipment, work-hour limitations, corporate
culture, and threats to personal security in the workplace. Physicians
should work with institutional leaders to ensure that policies and practices support their ability to provide quality care focused on patients’
best interests.
Patients’ interests are served by improvements in overall quality
of care and the increasing use of evidence-based practice guidelines
and performance benchmarking. However, practice guideline recommendations may not serve the interests of each individual patient,
especially when another plan of care may provide substantially greater
benefits. In prioritizing their duty to act in the patient’s best interests,
physicians should be familiar with relevant practice guidelines, be able
to recognize situations that might justify exceptions, and advocate for
reasonable exceptions.
Acting Justly The principle of justice provides guidance to physicians about how to ethically treat patients and make decisions about
allocating important resources, including their own time. Justice in a
general sense means fairness: people should receive what they deserve.
In addition, it is important to act consistently in cases that are similar
in ethically relevant ways, in order to avoid arbitrary, biased, and unfair
decisions. Justice forbids discrimination in health care based on race,
religion, gender, sexual orientation, disability, age, or other personal
characteristics (Chap. 10).
ALLOCATION OF RESOURCES Justice also requires fair allocation of
limited health care resources. Universal access to medically needed
health care remains an unrealized moral aspiration in the United States
and many countries around the world. Patients with no or inadequate
health insurance often cannot afford health care and lack access to
safety-net services. Even among insured patients, insurers may deny
coverage for interventions recommended by their physician. In this
situation, physicians should advocate for patients’ affordable access
to indicated care, try to help patients obtain needed care, and work
with institutions and policies to promote wider access. Doctors might
consider—or patients might request—the use of lies or deception to
obtain such benefits, for example, signing a disability form for a patient
who does not meet disability criteria. Although motivated by a desire to
help the patient, such deception breaches basic ethical guidelines and
undermines physicians’ credibility and trustworthiness.
Allocation of health care resources is unavoidable when resources
are limited. Allocation policies should be fair, transparent, accountable,
responsive to the concerns of those affected, and proportionate to the
situation, including the supply relative to the need. In the 2019–2020
SARS-CoV-2/COVID-19 pandemic, some epicenters anticipated or
faced shortages of staff, protective equipment, hospital and critical care
beds, and ventilators, even after increasing supplies and modifying
usual clinical procedures. Many jurisdictions developed guidelines for
implementing crisis standards of care to allocate limited interventions
and services. Under crisis standards of care, some aspects of conventional care are not possible and interventions may not be provided to
all who might benefit or wish to receive them. Crisis standards of care
aim to promote the good of the community by saving the most lives in
the short term, using evidence-based criteria.
When demand for medications or other interventions exceeds
the supply, allocation should be fair, strive to avoid discrimination,
and mitigate health disparities. First-come, first-served allocation is
not fair, because it disadvantages patients who experience barriers to
accessing care. To avoid discrimination, allocation decisions should
not consider personal social characteristics such as race, gender, or disability, nor consider insurance status or wealth. Allocation policies also
should aspire to reduce health care disparities. U.S. African-American,
Latino-American, and Native-American patients suffered a disproportionate number of COVID-19 cases and deaths, likely due in part to
being employed in jobs that cannot be done remotely or with physical
distancing, crowded housing, lack of health benefits, and poor access
to health care.
Fair and well-considered guidelines help mitigate any emotional
and moral distress that clinicians may experience making difficult
allocation decisions. Authorizing triage officers or committees to make
allocation decisions according to policies determined with public
input allows treating physicians and nurses to dedicate their efforts to
their patients. Ad hoc resource allocation by physicians at the bedside
may be inconsistent, unfair, and ineffective. At the bedside, physicians
should act as patient advocates within constraints set by society, reasonable insurance policies, and evidence-based practice. Many allocation decisions are made at the level of public policy, with physician
and public input. For example, the United Network for Organ Sharing
(www.unos.org) provides criteria for allocating scarce organs.
■ VIRTUE ETHICS
Virtue ethics focuses on physicians’ character and qualities, with the
expectation that doctors will cultivate virtues such as compassion,
trustworthiness, intellectual honesty, humility, and integrity. Proponents argue that, if such characteristics become ingrained, they help
guide physicians in unforeseen situations. Moreover, following ethical
precepts or principles without any of these virtues could lead to uncaring doctor–patient relationships.
70PART 1 The Profession of Medicine
■ PROFESSIONAL OATHS AND CODES
Professional oaths and codes are useful guides for physicians. Most
physicians take oaths during their medical training, and many are
members of professional societies that have professional codes. Physicians pledge to the public and to their patients that they will be guided
by the principles and values in these oaths or codes and commit to the
spirit of the ethical ideals and precepts represented in oaths and professional codes of ethics.
■ PERSONAL VALUES
Personal values, cultural traditions, and religious beliefs are important
sources of personal morality that help physicians address ethical issues
and cope with any moral distress they may experience in practice.
While essential, personal morality alone is a limited ethical guide
in clinical practice. Physicians have role-specific ethical obligations
that go beyond their obligations as good people, including the duties
to obtain informed consent and maintain confidentiality discussed
earlier. Furthermore, in a culturally and religiously diverse world,
physicians should expect that some patients and colleagues will have
personal moral beliefs that differ from their own.
ETHICALLY COMPLEX PROFESSIONAL
ISSUES FOR PHYSICIANS
■ CLAIMS OF CONSCIENCE
Some physicians, based on their personal values, have conscientious
objections to providing, or referring patients for, certain treatments such
as contraception or physician aid in dying. Although physicians should
not be asked to violate deeply held moral beliefs or religious convictions,
patients need medically appropriate, timely care and should always be
treated with respect. Institutions such as clinics and hospitals have a
collective ethical duty to provide care that patients need while making
reasonable attempts to accommodate health care workers’ conscientious objections—for example, when possible by arranging for another
professional to provide the service in question. Patients seeking a
relationship with a doctor or health care institution should be notified
in advance of any conscientious objections to the provision of specific
interventions. Since insurance often constrains patients’ selection of
physicians or health care facilities, switching providers can be burdensome. There are also important limits on claims of conscience. Health
care workers may not insist that patients receive unwanted medical
interventions. They also may not refuse to treat or discriminate against
patients because of their race, ethnicity, disability, genetic information,
or diagnosis. Such discrimination is illegal and violates physicians’
duties to respect patients. Refusal to treat patients for other reasons
such as sexual orientation, gender identity, or other personal characteristics is legally more controversial, yet ethically inappropriate because it
falls short of helping patients in need and respecting them as persons.
■ PHYSICIAN AS GATEKEEPER
In some cases, patients may ask their physicians to facilitate access
to services that the physician has ethical qualms about providing.
For example, a patient might request a prescription for a cognitively
enhancing medication to temporarily augment his cognitive abilities in
order to take an exam or apply for employment. Patients may request
more pain medication than the physician believes is warranted for
the given situation or marijuana to facilitate sleep. Patients may ask
their physician to sign a waiver to avoid vaccines for reasons that
are not included in state exceptions (see Chap. 3). A physician may
feel uncomfortable prescribing attention-deficit/hyperactivity disorder medications to a young child because she is not convinced that
the possible benefit justifies the risks to the child despite the parent’s
request. In these circumstances, the physician should work with the
patient or parent to understand the reasons for their requests, some
of which might be legitimate. In addition to considering possible risks
and benefits to the patient, the physician should consider how meeting
the request might affect other patients, societal values, and public trust
in the medical profession. If the physician determines that fulfilling
the request requires deception, is unfair, jeopardizes her professional
responsibilities, or is inconsistent with the patient’s best medical
interests, the physician should decline and explain the reasons to the
patient.
■ MORAL DISTRESS
Health care providers, including residents, medical students, and
experienced physicians, may experience moral distress when they feel
that ethically appropriate action is hindered by institutional policies
or culture, decision-making hierarchies, limited resources, or other
reasons. Moral distress can lead to anger, anxiety, depression, frustration, fatigue, work dissatisfaction, and burnout. A physician’s health
and well-being can affect how he or she cares for patients. Discussing
complex or unfamiliar clinical situations with colleagues and seeking
assistance with difficult decisions can help alleviate moral distress, as
can a healthy work environment characterized by open communication, mutual respect, and emphasis on the common goal of good
patient care. In addition, physicians should take good care of their own
well-being and be aware of the personal and system factors associated
with stress, burnout, and depression. Health care organizations should
provide a supportive work environment, counseling, and other support
services when needed.
■ OCCUPATIONAL RISKS AND BURDENS
Physicians accept some physical risk in fulfilling their professional
responsibilities, including exposure to infectious agents or toxic
substances, violence in the workplace, and musculoskeletal injury.
Nonetheless, most physicians, nurses, and other hospital staff willingly
care for patients, despite personal risk and fear, grueling hours, and
sometimes inadequate personal protective equipment or information.
During the COVID-19 pandemic, many communities honored clinicians’ dedication to professional ideals, and some medical students who
were relieved from in-person patient care responsibilities volunteered
to support front-line workers in other ways. The burdens of navigating
professional and personal responsibilities fall more heavily on women
health care providers. Health care institutions are responsible for
reducing occupational risk and burden by providing proper information, training and supervision, protective equipment, infrastructure
and workflow modifications, and emotional and psychological support
to physicians. Clinical leaders need to acknowledge fears about personal safety and take steps to mitigate the impact of work on family
responsibilities, moral distress, and burnout.
■ USE OF SOCIAL MEDIA AND PATIENT PORTALS
Increasingly, physicians use social and electronic media to share information and advice with patients and other providers. Social networking
may be especially useful in reaching young or otherwise hard-to-access
patients. Patients increasingly access their physicians’ notes through
patient portals, which aim to transparently share information, promote patient engagement, and increase adherence. Physicians should
be professional and respectful and consider patient confidentiality,
professional boundaries, and therapeutic relationships when posting to
social media or writing notes for the portal. Overall, appropriate use of
these platforms can enhance communication and transparency while
avoiding misunderstandings or harmful consequences for patients,
physicians, or their colleagues. Unprofessional or careless posts that
express frustration or anger over work incidents, disparage patients or
colleagues, use offensive or discriminatory language, or reveal inappropriate personal information about the physician can have negative
consequences. Physicians should separate professional from personal
websites and accounts and follow institutional and professional society
guidelines when communicating with patients.
CONFLICTS OF INTEREST
Acting in patients’ best interests may sometimes conflict with a physician’s self-interest or the interests of third parties such as insurers or
hospitals. From an ethical viewpoint, patients’ interests are paramount.
Transparency, appropriate disclosure, and management of conflicts of
interest are essential to maintain the trust of colleagues and the public.
Disclosure requirements vary for different purposes, and software has
