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Should Doctors Ever Lie on Behalf of Patients?
Warren Kinghorn
JAMA. 1999;282:1674-1675.
Is it ever ethical for a physician to code a patient's diagnosis falsely in a medical record to gain benefits for the patient? The small amount of empirical research available suggests that many physicians do indeed choose to deceive third-party payers. In a decade-old survey, 70% of a sample of clinicians stated that hypothetically, they would write "rule out cancer" to secure funding for screening mammography if the patient's insurance would not otherwise fund it.1 Nearly half the physicians in a more recent survey admitted to exaggerating the severity of patients' conditions to get the care they felt the patient needed.2 In another study, in 1998, 39% of the physician sample admitted to exaggerating the severity of patients' conditions, changing official billing diagnoses, and documenting nonexistent symptoms—all to gain additional benefits for patients.3
Several approaches to such a dilemma have been articulated. One consider the ethics of lying. Sissela Bok champions the "principle of veracity," which emphasizes the intrinsic moral undesirability of a lie because no one likes to be deceived.4 Others worry about the effect lying would have on trust on the patient-physician relationship.5 Still others worry that exaggerated and inaccurate diagnoses may frighten patients and compromise their future clinical care.6
Alternatively, the question may be interpreted as one of distributive justice. The reimbursement boundaries set by third-party payers are a de facto resource allocation mechanism. Much has been written about whether physicians should ever withhold available interventions because of a high cost-to-benefit ratio.7-8 The same reasoning applies to the question of whether physicians should ever transgress reimbursement boundaries to secure benefits not covered by insurance plans.
Entrants in the 1999 John Conley Ethics Essay Contest for Medical Students were asked: "Suppose a potentially useful procedure is available that is not covered by a patient's medical insurance. Under what circumstances, if any, would you consider it appropriate to miscode (and thereby make available) the needed procedure?" Peter Ubel, MD, frames the issue as a question of distributive justice. Then, from opposed perspectives, the winners of this year's contest argue that miscoding is unethical because of its effect on the "medical commons" (Dena Rifkin) and that miscoding is sometimes justifiable based on the role society accords physicians (Greg Webster). On reading these essays, we hope readers will be better equipped to answer this question for themselves.
REFERENCES
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1. Novack DH, Detering BJ, Arnold RM, Forrow L, Ladinsky M, Pezzullo JC. Physicians' attitudes toward using deception to resolve difficult ethical problems. JAMA. 1989;261:2980-2985.
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2. Kaiser Family Foundation. Survey of physicians and nurses. Available at: http://www.kff.org/1999/1503. Accessed September 17, 1999.
3. Wynia M, Cummins D, VanGeest J. Managed care and markets: impact of managed care on providers [abstract]. Association for Health Services Research website. Available at: http://www.ahsr.org/1999/abstracts/cummins.htm. Accessed September 17, 1999.
4. Bok S. Lying: Moral Choice in Public and Private Life. 2nd ed. New York, NY: Vintage Press; 1989.
5. Cain JM. Is deception for reimbursement in obstetrics and gynecology justified? Obstet Gynecol. 1993;82:472-478.
6. Morreim EH. Gaming the system: Dodging the rules, ruling the dodgers. Arch Intern Med. 1991;151:443-447.
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7. Ubel PA, Arnold RM. The unbearable rightness of bedside rationing: physician duties in a climate of cost containment. Arch Intern Med. 1995;155:1837-1842.
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8. Angell M. Cost containment and the physician. JAMA. 1985;254:1203-1207.
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