I've been (not) workin' on the railroad

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.