Mark Hoofnagle has a MD and PhD in physiology from the University of Virginia, and is now a general surgery resident. His interest in denialism concerns the use of denialist tactics to confuse public understanding of scientific knowledge.
This story is disturbing for a host of reasons, but there's a medical ethics issue hiding in here.
Apparently, if you work for the Long Island Railroad, you can retire at 50, then claim disability for a job you no longer have, and collect both a disability check and a pension. I shit you not. But it gets better. According to the Times, "Virtually every career employee -- as many as 97 percent in one recent year -- applies for and gets disability payments soon after retirement...."
I strongly encourage you to read the whole article, but let's focus on a particular point.
Dr. Melhorn, who has studied disabilities, said the numbers alone were a cause for concern, "in particular if there seems to be a limited number of physicians who are providing this disability impairment." [...] L.I.R.R. employees favor certain doctors, and their disability applications are sometimes so similar as to be almost interchangeable, said one Long Island resident who has seen dozens of those applications. That person said that M.R.I.'s merely document physiological changes that commonly affect people over the age of 50. (empasis mine)
In my practice, I often have to fill out temporary disability forms. It's pretty standard---when a patient has a knee replacement or a heart attack their work requires them to file certain papers.
There is a separate subset of patients who believe themselves to be completely disabled, and want me to fill out forms from the state to help them get disability payments. Very few of my patients are so disabled as to be unable to work at all, ever. But many of them think they are. Who wouldn't want to collect a check for doing nothing? I usually tell them that if I answer the questions on the form truthfully, they are unlikely to ever get disability. I let them decide at that point whether they really want me filling them out (which may, of course, be passing the buck, and ducking a responsibility, but since the state can assign doctors for disability exams, I don't feel I'm shirking).
Past studies and surveys have shown that doctors are willing to lie for their patients. What does that mean?
When forced to make difficult ethical choices, most physicians indicated some willingness to engage in forms of deception. They appear to justify their decisions in terms of the consequences and to place a higher value on their patients' welfare and keeping patients' confidences than truth telling for its own sake. (JAMA Vol. 261 No. 20, May 26, 1989).
Unfortunately, the things they lie about don't always benefit the patient. For example, in the 1989 study, many doctors were willing to lie to the wife of a patient with gonorrhea. The intentions were good, but overly paternalistic, and ultimately could put the life of the patient's spouse in danger.
In a study done 10 years later, when HMOs were at the height of their powers, many physicians were willing to lie to insurance companies to obtain necessary procedures for their patients, but not for cosmetic procedures (Archives Int Med Vol. 159 No. 19, October 25, 1999).
So, there does seem to be a pattern of physicians being willing to lie for what they perceive to be the good of their patients. This is not entirely at odds with our professional ethics.
Not entirely.
As we've discussed before, there are a few guiding principles in medical ethics: beneficence, non-maleficence, autonomy (to which I would add "vs. paternalism"), and somewhat more recently recognized, (social) justice, dignity, and truthfulness. Doctors have many responsibilities to their patients but none of them include helping them commit fraud, as seems possible in the LIRR case.
There are many reasons one might consider lying for a patient, the least offensive being to obtain a an essential, time-sensitive service. However, lying always has unpredictable secondary effects. If you falsify medical documents so that your patient's spouse doesn't know about the gonorrhea, she could end up quite ill. If you lie about a needed procedure, the patient could end up with a bill for the entire amount when the insurance company discovers the "error" (and even if there is no legal repercussion, the patient may be dropped from the plan).
In the case of disability payments, if I certify someone who isn't truly disabled, I may have (but probably not) helped them in some way, but I have taken finite resources out of the hands of my other patients who might legitimately need them. More than likely, I'm not really doing my patient any favors by encouraging them to pretend to be disabled. But I would be actively harming them to report them to authorities, so saying "no" to their request is probably enough.
As medical instruments go, lying isn't a scalpel but a blunderbuss---it's effects are unpredictable and difficult to control.
None of the principles of medical ethics requires lying for a patient. There is almost always another way. The best option is to design a health care system that doesn't encourage lying, but I'm not holding my breath. There will always be a temptation to lie, either as an easy fix to a difficult problem, or as a route to fraudulent income. Your best bet is to but up the best fight for your patient while being as truthful as possible. If you remember that your patient's needs come first, and that lying may have unintended consequences for them, you should be just fine.
Medicine & Health
Comments
OT, but Denialism Related:
NIH cuts off studies on antivax chelation therapies. There are more apropos links within, but I give you my source of first instance.
Posted by: The Chemist | September 22, 2008 6:57 PM
As a 25 year veteran of railroading, I can tell you that the Long Island Railroad is the extreme exception. I, personally, have nothing that I would consider a disability but I have had friends with back problems and severe injuries that play hell getting any disability benefits of any kind from either the railroad I worked for OR the RRB.
Just my anecdotal experience.
Posted by: Oldfart | September 23, 2008 7:25 AM
What do you do about someone who is genuinely (medically) disabled, if not unemployable (although considering that where I live, even if you're looking for work and you're disabled but able to work, you've only got a 60% chance or so of finding anything at all), where "not unemployable" means they're likely going to be out of work for years before they find the magic confluence of a) a job they're physically capable of doing, b) a job they're qualified to do, and c) an employer willing to hire a disabled person for a and b simultaneously? Wouldn't it be better to give the person a fair shot at going on disability, just so they don't starve while they're looking for the elusive "suitable employment"?
Posted by: Interrobang | September 23, 2008 3:49 PM
It is a professional responsibility to accurately portray a patient's condition, diagnosis and prognosis. You may find yourself in disagreement with other practicioners, but yours is the authority that the state and businesses rely upon to manage a near crippling economic burden of disability, worker's compensation and other costs related to workplace injuries and illnesses.
People need to understand that many of these disabilities are often very technical and related to their original job (unable to lift more tha 20 lbs with right arm, etc.) Diability fraud is rampant in the United States and this costs EVERYONE money.
Doc, write 'em as you see 'em. Let the patient decide on how to proceed.
Posted by: Citizen Deux | September 24, 2008 2:16 PM
There are some circumstances where lying is the ethical course of action. Those circumstances reflect (as far as I can tell) living in a society which is itself unethical.
I was in a discussion in a fathers' group about our children lying (our children were ~5 at the time). Everyone wanted their children to be completely honest all the time. I said that I wanted my children to be able to lie when it was appropriate, such as if the Gestapo came to the door and asked "are there any Jews here?"
If medical procedures or conditions were criminalized and became subject to mandatory reporting, I could imagine circumstances where it would be ethical for a doctor to lie about his/her patient’s condition. For example if being gay was criminalized, and doctors were required to report the sexual orientation status of their patients, I think it would be completely ethical for the doctor to lie about it to protect the patient.
Posted by: daedalus2u | September 24, 2008 3:25 PM