To plateau and profit or release and replace is an ethical dilemma we clinicians will face sometime during our career. In work situations in which oversight ranges from limited to excessive, we navigate our practices, businesses and/or positions between the poles of profit and loss, moral and legal. Our professional journey may become treacherous when our livelihoods are at stake.
The consequences range from guilt to burnout to imprisonment. The question is: What do we do when the patient's clinical progress becomes stagnant, yet they will freely continue to receive treatment?
Superficially, the answer is obvious, but the “devil is in the details” in the business of medical care. Flourishing or failing office, insurer reimbursement rate, patient's countenance and behavior, employment status, and clinical autonomy are some factors which may impact such a decision.
Temptation resides in continuing to treat a patient whose insurer pays many times what their average patient's insurer pays. The temptation is magnified by a failing clinic with staff salaries to pay. A highly profitable practice would barely notice the loss of the same patient.
Professional oaths and codes of conduct are little more than printed paper aesthetically framed and mounted to a wall when unenforced and breaches are unrecognized. The patient who accepts their plight and enjoys the rapport of the clinic personnel may feel unconcerned about wasted medical resources. The employer who benefits from payment almost seems complicit in violating these sacred pacts.
The ethical dilemma arises when attempting to reconcile conflicting roles and responsibilities. The clinician has a fiduciary responsibility toward the patient, but the employee also acts on behalf of their employer to ensure their employment. The business owner has a responsibility toward their employees and stakeholders. Altruism, propriety and profit vie for dominance.
Which shall prevail: “the good of the one” – the patient – or “the good of the many” – all who benefit from the fee-for-service model of health care? To quote “South Park”'s Eric Cartman: “If you cheat and fail, you're a cheater. If you cheat and succeed, you're savvy.”
Deciding whether to plateau and profit or release and replace may result in ethical distress which may have dire consequences as it insidiously progresses to eventually culminate in ethical burnout. Ethical burnout is the emotional, mental and professional exhaustion due to prolonged struggle with ethical dilemmas. Symptoms include depersonalization, moral apathy, emotional exhaustion, boundary violations and lack of professionalism. This can end a career.
Before attempting to resolve an ethical dilemma, it behooves the clinician to contemplate the situation to confirm if an ethical dilemma exists:
- Maybe the patient has another condition worthy of treatment.
- Maybe the employed clinician can refer to a fellow clinician of the same specialty at the same location.
- Reclassifying the treatment strategy from curative to palliative or preventive is a possible option.
- Performing a detailed assessment to determine if the patient is untruthful regarding their subjective ailments is another option.
- Comparing the rate of new patients to exiting patients may reveal that releasing this patient will have an insignificant impact on the practice.
When making ethical decisions, there are three basic approaches one may adopt. The utilitarian approach is pragmatic- focusing on consequences- the more benefit the more right. The deontological approach focuses on abiding by the rules regardless of consequence – profit be damned!
A virtuous approach considers the moral character of those involved making a decision and development toward moral excellence – how can this decision cultivate may character? The virtuous approach is unbound by standardized rules.
One may refer to Maslow's Hierarchy of Needs as part of introspection regarding their motivations. The five motivations of behavior are: physiological needs, safety, love and belonging, esteem, and self-actualization. The basic premise is that when one level is fulfilled, then one may advance to the next. In practice, they may overlap and vacillate from one to another.
For example, the ability to earn an income allows one to satisfy their physiological needs of food and shelter, but abiding by the rules of the profession regardless of the working conditions ensures that one remain in the profession. How does one currently rank the importance of each when considering whether to plateau and profit or release and replace?
Consider and rank the consequences. There are immediate and persistent, internal and external, microscale and macroscale consequences which may accumulate over time. One's decision may produce the least discomfort at the moment, but produce dire consequences in the future; or immediate and severe discomfort, but garner a positive reputation and respect. The decision may impact the atmosphere of the practice, the severity of legal consequences, one's lifestyle, and self-esteem.
Prepare to honestly explain and justify the reasons for the decision and accept consequences of the decision. Eventually, one may account for the decision to plateau and profit or release and replace. An employer, the patient, colleague, lawyer, and especially the one who will suffer most from the decision may questions one's motivations and loyalties. This may feel very uncomfortable because one's values, faults and fears are expressed.
Explain to the boss / yourself that fear of arrest is greater than loss of employment. Explain to the employee that morals are more important than their livelihood. Explain to the court of law that although the patient is unharmed, the business can't afford to lose the patient's payments. Explain to the patient that although they are happy to continue to receive treatment they have achieved maximum benefit of care. Look into the mirror and explain that others more or less important than yourself.
This ethical dilemma may serve as a positive experience for the clinician. The ethical dilemma can serve as an opportunity for self discovery, personal growth and changes in work environment instead of destructive distress. It forces the clinician to evaluate and prioritize what they hold dear; to assert and defend it to others and themselves. The clinician should not feel very surprised that with time and experience, they respond to the same ethical dilemma differently.
