Think Today's Ethical Issues Are Tough? Just Wait
Slomski, Anita J., Medical Economics
Bioethicist Arthur L. Caplan is one of the most-quoted people in health care. Reporters call him because he's opinionated, colorful, and controversial--qualities that irk his more pensive, less public peers. In 1993 alone, Caplan gave 36 public lectures, wrote 17 articles, and edited two books; his curriculum vitae runs 51 pages at the moment. His high visibility and forthright positions have caught the attention of policy-makers and earned him a spot on President Clinton's health-reform task force.
For the past seven years, Caplan, 44, has been director of the Center for Biomedical Ethics a the University of Minnesota. Next month, he moves to the University of Pennsylvania in Philadelphia to head the school's Center of Bioethics. He'll hold teaching appointments in the departments of genetics, medicine, and philosophy.
Caplan, who has a Ph.D. in the philosophy of science, never intended to become a bioethicist. But while still a graduate student, he jumped at an opportunity to earn $750 teaching an ethics class to medical students. Although most of them dropped the class--he knew nothing about medicine--Caplan found he loved the subject. He enrolled in Columbia University College of Physicians and Surgeons for one year as a special student, and launched a career for himself.
Midwest Editor Anita J. Slomski recently sat with Caplan to discuss the tough ethical challenges today's doctors face.
Q You've said that many physicians find medical ethics "hopelessly opaque and irrelevant." Why is that?
A A couple of reasons. Ethical issues are gray zones, and doctors, like everyone else, don't like ambiguity. They prefer to pay attention to blood-gas levels, which are concrete, rather than talk about patient autonomy or paternalism. Also, most experienced physicians think they know what to do and don't want to be second-guessed. And then there's the problem of legal liability. In ethics, you often challenge the law, and that makes doctors nervous.
Q Is there a way to make physicians more comfortable about consulting ethicists?
A It helps that some doctors are now becoming bioethicists. Also, mainstream medical and scientific journals are publishing articles on ethics, which enhances our credibility.
But although I want doctors to be comfortable with bioethicists, there should always be some friction between the two, so that issues get raised. Doctors and nurses will continue to get advice from one another, because there aren't enough bioethicists and philosophers to be at every bedside. Moreover, it isn't appropriate for ethicists to intrude into the doctor-patient relationship; their role is to be consultants.
Q As health reform progresses, what new ethical dilemmas will doctors face?
A The main challenge at the bedside is compromised advocacy. Under fixed budgets--which is what managed competition is, no matter how you look at it--it will be a lot harder to be a zealous advocate for your patient. Doctors won't be able to say yes to marginal treatment or to unproven procedures because they'll be thinking about budgets. And the patient will be wondering whether the doctor is cutting corners to save money.
Q We already ration care in this country based on a parent's ability to pay and for scarce resources such as donor organs and rehabilitation services. How far are we from widespread rationing?
A If we get reform that attacks the inefficient aspects of health care, we can hold off general rationing for 10 years. For example, we can get significant returns by having fewer than 1,500 payers. And we can buy time by weeding out futile and harmful care. It's not rationing to prevent people from getting treatments that don't work or are dangerous. You don't lose a benefit when doctors stop doing the procedures they do only to please risk managers, satisfy lawyers, or increase their own incomes. Cesarean sections are one example. Another is pediatric office visits for kids with colds, which are totally useless but are paid for all the time. …