Ethics in cardiothoracic surgeryDeceiving insurance companies: new expression of an ancient tradition1
Section snippets
Deception in medicine, recent shift to honesty
For purposes of this discussion, I distinguish between deceiving and lying, after Sissela Bok: To deceive is to communicate messages intended to make others believe something the deceiver does not believe to be true, including omission of relevant information. To lie is to speak or write an intentionally deceptive message. Thus, lying is a subtype of deception [3].
The use of deception by physicians has deep roots. The tradition of deceiving patients “for their own good” was well established in
The new deception: lying to insurance companies
Despite this recent apparent change in attitude toward telling patients the truth, a new manifestation of deceit in medicine has appeared recently: misrepresentation of patient information to insurance companies. Consider the following case:
A 60-year-old man has severe emphysema for which no treatment other than an operation for lung volume reduction is beneficial. This relatively new operation is considered experimental, is being studied under a National Institutes of Health protocol, and is
The insurance company as the enemy
The AMA code of medical ethics advocates dealing honestly with patients and colleagues, as noted above. The code, however, goes further than this, extending the principle of honesty to dealing with insurance companies: “Physicians shall make no intentional misrepresentation to increase the level of payment they receive or to secure noncovered health benefits for their patients” [12]. Truth telling is clearly held in high regard by many ethicists. Why, then, as pointed out in the studies cited
Deception serving self-interest
Some kinds of deception are clearly self-serving and unrelated to benefiting patients, such as upcoding removal of a sternal wire to “sternal debridement,” or embellishing an incidental single suture closure of a patent foramen ovale by naming it “repair of atrial septal defect.” I confine my discussion here, however, to the morally more ambiguous case of miscoding ostensibly for the benefit of the patient.
It is not altogether clear when a surgeon lies to an insurance company for the benefit of
Benefits and harms of deception
The paramount ethical consideration in the practice of clinical medicine traditionally is balancing benefits and harms [14]. In evaluating a proposed action, benefits should outweigh harms. How does this balance play out in considering lying to insurance companies? Both short- and long-term effects of deception must be considered.
In the short term, when surgeons lie to insurance companies, benefits accrue to both the patient and the surgeon. The patient receives an operation or service he or
Conclusion
Surgeons have many motivations to deceive insurance companies. Some of them serve the patient’s interests, whereas some serve the surgeon’s interests. Clearly defining the relative power of the several motivations is difficult. Personal conversations with colleagues have persuaded me that many believe their only motivation in misrepresenting patient information to an insurance company is to help the patient. Often, they believe this in the face of clear evidence to the contrary (eg, when lying
Acknowledgements
I am grateful for the critique of this paper provided by M. Carmela Epright, PhD, who provided many improvements, especially for her identification of harmful effects of deceptive practices on vulnerable patients. Critical discussions with the Bioethics Committee of the South Carolina Medical Association also contributed substantially to this paper, as did the helpful comments of several anonymous reviewers.
References (18)
Health care reformimplications for clinical medicine
Ann Thorac Surg
(1994)- et al.
The efficacy of personal ethicsthe AMA code of ethics in historical and current Perceptive
Hastings Cent Rep
(2000) - Council on Ethical, and Judicial Affairs, American Medical Association. Code of medical ethics: current opinions with...
What to tell cancer patientsa study of medical attitudes
JAMA
(1961)- et al.
Changes in physicians’ attitudes toward telling the cancer patient
JAMA
(1979)
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This editorial inaugurates a planned series of articles, published at irregular intervals, which address contemporary ethical issues facing general thoracic and cardiac surgeons. Dr Robert M. Sade, Associate Editor for Ethics, will lead this effort and plans a series of editorials and pro and con discussions. The intent of these articles is to raise the sensitivity of our readers to ethical issues and to support the high standards and integrity of our profession. L. Henry Edmunds, Jr, MD, Editor