Application Of Decision-making Theories To Avoid Ethical Dilemmas In Patient-physician Relationships

Patient-physician relationships are tense. The growing concern and desire for advanced care at low costs contributes to the stress among this specific relationship. However, the responsibility to maintain the patient-physician relationship rests with both parties. Ethical concerns that may arise from physicians include concerns regarding fact sharing, shared-decision making, and creating a false sense of security that stems from the lack of patient-specific understanding and listening. Similarly patients may fail to share information or share true information; making trust the most crucial aspect of the relationship. It is important that providers engage patients in the decision making process and patients rely and trust physicians to relay complete information. To best avoid these ethical dilemmas it could be argued that leadership should employ a mix of the decision-making theories.

Applying Classical Decision Theory could prove to be beneficial to this relationship in regards to having full information relating to the problem and also knowing all the alternative solutions. For example, patients desire to be more engaged and it would be beneficial in the shared-decision making process if patients had complete information and understanding regarding their health. Thus, leading to improved care outcomes and higher patient satisfaction. However, if you believe theory could be applied solely, I have some lakefront property on the moon I’d like to sell you. It is unreasonable to assume that individuals whether patient or physician will always make logical, rational decisions such as the classical model suggests. Lee et, al. (1999) suggests that, in regards to this theory, the decision maker is objective and acts in a world of complete certainty in which they have complete information and have considered all possible alternatives and consequences. In healthcare this is unrealistic. When working to avoid ethical dilemma among this relationship it is important that both parties share complete information. However, it is also important to consider the behavioral aspect. Individuals react and are defined by their life experiences and cannot be expected to make decisions in the same manner.

Behavioral Decision Theory highlights the importance of customer’s beliefs and values. In some circumstances patients may lack the medical knowledge to make difficult decisions regarding their health. Thus, the need to engage in open dialogue and lift the burden of decision is great. Quill and Brody (1996) suggest, “Enhancing patient autonomy requires that the physician engage in open dialogue, inform patients about therapeutic possibilities and their odds for success, explore both the patient's values and their own, and then offer recommendations that consider both sets of values and experiences.” It is important for providers to educate patients to minimize ethical dilemmas. While trust is paramount to the relationship overall, implicit in the trust of any relationship is informed consent of both parties. It is unreasonable to expect a patient to give complete control of their health to their physician without the knowledge of what that healthcare may entail or worse its long-term outcomes. This last point has actually had lasting impacts over the years from the more paternalistic practice of medicine years ago, particularly before the advent of evidence-based medicine. It used to be common practice for men over 45 to have a digital prostate exam by their primary care provider with their annual physical every year in order to screen for prostate cancer. A large-scale study in the 2000s however, found that while the practice did increase diagnoses of cancer, it did not improve survival — the cancers it was finding earlier would not have caused premature death at any higher rate, and the care of these tumors was not impacted by their time of diagnosis. Not only that, but for every case or prostate cancer diagnosed, there was a false positive that received further invasive testing and, in a not-insignificant number of cases, was harmed by these tests. However now there is still a large contingent of aging men who expect a prostate exam as part of their routine screening, despite recommendations to the contrary. This can decrease trust in their provider when this is not offered as standard. The prevailing recommendations suggest an in-depth discussion and shared decision-making with patient and provider. This has the capacity to improve patient outcomes and satisfaction while also decreasing costs associated with the dispensation of health care, but only with time spent in patient education and trust-building.

Lastly, the Ethical Decision Model should also be considered. This model has the ability to increase trust and respect among the relationship and suggests that decisions are made in a manner that is consistent with ethical principles. The ETHICAL Decision Model requires three things: commitment; consciousness; and competency. Commitment describes the intention to do the right thing regardless of cost. This can be thought of as equivalent to the physician’s Hippocratic Oath, and underpins the rest of the model. It suggests that the decision to act ethically is independent of personal cost and consequences. The model as a corollary then requires consciousness, the awareness and ability to apply ethics and moral behavior consistently to daily interactions and behavior. Lastly, the ethical model requires competency. Similarly to the other models, the ethical model requires an ability to evaluate information critically with the eye toward the long-term consequences.

The payer-patient relationship, the last of the relationships typically to occur in the visit timeline, after the patient has seen the provider and the provider has billed for services, nonetheless has a high capacity to create ethical dilemmas. This relationship is a zero-sum game wherein the capital for one side is profit, and for the other is their lives. In order for a payer to remain solvent and able to provide payment for services (while maintaining a profit), they by definition must pay less for patient care than they are being paid by patients. This system creates an incentive system for payers to cover fewer services and to cover only healthy people. The decision model most impactful for this relationship would be the classical decision model. While am ethical decision model would be ideal, I think it beggars belief that a for-profit entity would be able to apply the commitment, consistency, and competency that would be required. Realistically, a logical, regimented decision-making model has the highest capacity to minimize ethical dilemmas. More importantly, however, transparency in pricing, coverage, and reasoning would be required. This would also improve dilemmas within the patient-provider relationship, if there was transparency in pricing. Overall, the triad of patient, physician, and payer creates a complex dynamic highly susceptible to corruption and ethical dilemmas. Through a consistent, constructed decision-making model, the process can be consistently improved and optimized for all parties involved.

Resources

1. Lee, D., Newman, P., & Price, R. (1999). Decision making in organisations. Financial Times Management.
2. Quill, T. E., & Brody, H. (1996). Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Annals of internal medicine, 125(9), 763-769.
3. Schröder, F. H., Hugosson, J., Roobol, M. J., Tammela, T. L., Ciatto, S., Nelen, V., ... & Denis, L. J. (2009). Screening and prostate-cancer mortality in a randomized European study. New England Journal of Medicine, 360(13), 1320-1328.