Lantern of Diogenes: is "honest physician" a 21st century oxymoron?

Concern about unethical physicians is nothing new. Fee splitting, legal drug dealers bribing doctors to prescribe their products, and sweetheart deals between doctors and hospitals are as old as the hills.

However, new to the scene are higher stakes, lower physician fees and a prevailing national ethic that encourages greed, corruption and conflict of interest. For physicians, the temptation to be unethical is greater and the slippery slope is smoother than ever before.

Furthermore, physicians and non-physician executives alike would have to be saints to ignore personal enrichment possibilities inherent in today's profit-oriented U.S. health care system. Does all this mean that even physicians are no longer to be trusted?

Socrates, Plato, and Aristotle lived in Athens, Greece in about 400 B.C. These men, the Big Three of Western ethical thought, believed that living the good life in the moral sense requires a sense of virtue, the ability to think critically about choices in difficult situations and the personal moral values to do what's right.

That is a brilliantly simple idea. However, as with everything else, the devil is in the details. Lesser-known Greek philosophers immediately split into several sects with different ideas about the meaning of virtue. Indeed, the debate over particulars continues to this day.

Antisthenes (c. 445-365 B.C.), like Plato, a student of Socrates, founded a minor Socratic school of thought known as the Cynics. (1) The Cynics found virtue in self-righteousness.

Diogenes is the best-known Cynic because his eccentric ways attracted attention. For one thing, he spent most of his days living in a barrel just outside the city-state of Corinth. Diogenes believed that people were fair and just only to the extent necessary to obey rules and laws. He reasoned that there is no such thing as genuine honesty and integrity.

Membership upon the medical staff shall be restricted to physicians and
surgeons who are ... worthy in character and in matters of professional
ethics;... the practice of division of fees, under any guise whatever,
is prohibited.
Minimum Standard for Hospitals
American College of Surgeons
1919

Diogenes flamboyantly made his point by carrying a lighted lantern around town in broad daylight. Curious people would ask, "Why do you need that lantern?" Diogenes would reply, "I am looking for an honest man."

We cannot summarily dismiss Diogenes' suggestion as the raving of a lunatic. In ancient times and ever since, many people who think they act ethically are, in fact, only law-abiding. Obsession with money reduces the pool of truly ethical people even further.

"Under the blazing sun of money, all other values shine palely, and the hero is the honcho with the condo and the limo and lots and lots of dough." (2)

On the TV show, Dallas, someone asked ruthless tycoon J.R. Ewing, "What's the secret of your success?" "There's no secret," replies J.R. "Heck, once you give up integrity, everything else is a piece o' cake."

Keys to hiring ethical people

The ACPE ethical behavior survey seeks to quantify the degree to which unethical business practices have taken root in health care organizations.

Results of the survey suggest, among other things, that unscrupulous physician behavior occurs frequently in some organizations but is uncommon in others. How can organizational leaders reduce unethical physician business practices to a minimum?

The first step is evaluating character in the process of selecting a medical staff. Can we really do that? Yes, we can. Here are three keys to recognizing ethically acting physicians and attracting them to work in our organization.

The first key is, think positive.

Don't be a modern day Diogenes, cynically assuming that there is no such thing as an honest doctor. Yes, there is a problem with physician integrity but it is not of epidemic proportions. There is no sudden crisis of immorality among medical practitioners. For every doctor on the take, there are several who abhor these stains on the honor of the medical profession.

To confirm that honest physicians exist, think about doctors you know. Unless you are, yourself, a sleazy character, most of your physician friends and co-workers are probably trustworthy. At least you know one admirable physician. He or she is the doctor caring for you and your family.

Similarly, each of your friends knows at least one honest practitioner, and each friend of theirs knows one, and so on and so on. Is honest physician an oxymoron in the 21st century? The answer is: No.

The second key is also, think positive.

Give up the myth that character cannot be evaluated, comforting because it excuses us from spending energy and resources on sharpening character evaluation skills and methods. That is the problem, actually. We think about evaluating character like executives, looking for some formal, foolproof method when none exists. The only way to evaluate character is free and takes hardly any time at all. The method is the informal skill known as reading people. Executives all possess this skill to some degree or other and use it constantly in other contexts.

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Ask a banker or an attorney if character can be evaluated. The most honest answer will be, "Yes, but we get fooled sometimes." We need to get as good at evaluating character as bankers and attorneys are. Indeed, the best way for an executive to evaluate a physician's character is to pretend that he or she is a bank officer and the doctor is applying for a loan.

Actually, we can formalize our character evaluation efforts to some degree using mechanisms that have been in place for years. For example, credentialing specialists have long urged us to make physician interviews more pointed and productive. Why not add to routine interviews the opportunity to observe a physician's thought processes when he or she is confronted with an ethical dilemma?

At some point in the credentialing, contracting or hiring process, ask the doctor some theoretical questions.

"Doctor, the purpose of the following inquiries is to help us maintain organizational integrity. Please bear with us. How do you react to the following scenario? The patient has cancer and the family asks that the doctor not reveal the diagnosis to the patient. What would you do?"

Also, "Doctor, how do you feel about the practice of billing Medicare physician's fees for services that were actually provided by the physician's assistant?"

Other examples (you may think of better ones) include: "A patient with AIDS or a patient addicted to illicit drugs asks you not to write these facts into his or her medical record. What would you do?"

"Oh, doctor, by the way, in the course of clinical consultation you find yourself managing iatrogenic complications caused by a colleague's efforts to beef up income by practicing outside the clinical areas of his or her granted clinical privileges. How would you handle that situation?"

"Finally, tell us this. On the golf course, a fellow club member who is on the board of our rival hospital pumps you for information about this hospital's business plans. How would you respond?"

Most of us are comfortable initiating such productive interactions in routine human resources hiring procedures. But isn't it different with doctors? Might the highly educated and automatically respected physician either become angry that we dare question his or her character or disdainfully dismiss this exercise as needless game playing?

Yes, that might happen. If it does, have we not successfully identified important components of the physician's attitude toward ethical aspects of patient care, the doctor business and organizational cooperation?

The third key relates to attracting ethical physicians.

This key is, think negative. Take a long, hard, critical look in the ethical mirror. How do your organization's business practices look viewed in an objective light? Honestly, is yours the kind of organization that truly ethical physicians want to work in?

The ACPE survey implies, by its very design, that executives are concerned about physician ethics. What would be the results of a complementary survey? That is, would practicing physicians express similar concerns about health care management's ethics?

We don't have to conduct the survey to know that the answer is, "Yes." Indeed, young physicians entering clinical practice are now advised to beware of unethical practices by managed care organizations. (3)

Is the doctor allowed to advise the patient of all needed medical diagnostic studies and treatments? Managed care will probably never fully recover from the ludicrous spectacle a few years ago of physicians being forced to sign "gag orders," management's ill-conceived idea of how to reduce the number of expensive medical services provided to plan members.

If incentive bonuses are paid to doctors for practicing efficiently, are the bonuses small and are patients advised of the practice? Are practice guidelines truly flexible guidelines that allow the physician to exercise prudent clinical decision-making skills in ordering the treatment plan for each patient?

There is no need to identify truly ethical physicians unless you want to attract them to your organization. There is little hope of attracting and holding truly ethical physicians if you believe that unethical business practices are an essential part of successful organizational management.

By the way, did Diogenes ever find an honest person? Not as far as we know. That need not concern us, however, because there is one important difference between his search and yours. You truly want to find honest physicians. Diogenes was just trying to make a point.

References

1. Virtue, Happiness, and Anti-Conventionalism. The Internet Encyclopedia of Philosopy. www.iep.utm.edu/c/cynics.htm

2. Magnet, M. "Why We're Obsessed with Money." Medical Economics 64:25, p. 62. December 7, 1987.

3. Junkerman, C. MD and Schiedermayer, D. MD. Practical Ethics for Students. Interns, and Residents; A Short Reference Manual, 2nd Edition. University Publishing Group, Inc. Frederick, Md. 1998.

By Richard E. Thompson, MD

Richard E. Thompson, MD, can be reached at [e-mail] or 417-848-9435.

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