Ethics in cardiothoracic surgery

Deceiving insurance companies: new expression of an ancient tradition¹

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.