Loyalty With Honesty

Readers sometimes complain that we favor loyalty over honesty when we defend doctors disciplined or prosecuted for unprofessional conduct.

The classic dilemma is: "Should physicians who know that a colleague has shown faulty judgment, faulty knowledge or skill, or faulty character, honestly acknowledge the fault or loyally defend the colleague and deny or conceal the fault?"

Half of the Hippocratic Oath is about physician-physician relationships; the rest about physician-patient relationships. The Hippocratic physicians at Cos vowed to honor and respect their colleagues, to the point of treating their colleagues' children as their own, and to respect patients by doing them no harm, even to keeping secret what they have learned from and about those patients.

Hippocrates offered no help, though, about what to do when loyalty to a colleague endangers patients and the rest of the medical and public community.

New Codes of Ethics
Codification of ethical principles invariably reflects current ethical hierarchies. The recently revised AMA Code of Ethics says,

"A physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception."

That places honesty above loyalty and puts fraud and deception on an equal footing with deficient character and incompetence. It posits that the short-term discomfort of confronting a deficient or deceptive colleague is outweighed by the long-term benefit of offering a colleague a chance to explain, to change, and to experience our care and concern. The short-term discomfort is also outweighed by the benefit to all affected individuals and the medical and public community and, if applied evenly, is both just and merciful.

If, instead, we do not discuss our observations with our colleague, we are neither loyal nor honest, neither just nor merciful, serving neither community nor long-term interests. Our trust and esteem for our colleague drops, our relationship suffers, the reputation of our profession is put at risk, and our colleague misses a chance to reconsider and change.

Get the Relevant Facts
As with all ethical dilemmas, our first obligation is to be sure of our facts. If we get the story from the colleague, another professional, a patient, the media or an authorized outside investigator, we had best withhold judgment until we have heard "the other side" and collected and impartially processed the relevant data. If we conclude that our compeer has erred medically, legal or ethically, we owe that person, out of loyalty, the opportunity to discuss our observations and conclusions.

That discussion benefits when it includes the errant physician's personal history, often the most relevant but least available part of the story. None of us is immune from faulty thinking, faulty judgment and faulty behavior; all of us are more vulnerable to such behavior in times of personal crisis.

What if the colleague is not doing harm to a patient, "simply" lying to a third party? What if we conclude that the third party has cheated this doctor and others?

The new code of ethics says,
"A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient."

Easier said than done, but retaliatory cheating of third party payers will ere long increase costs to patients, lower payments to doctors and reduce patient benefits. Everyone will suffer from one consequence: reduced trust in us and our profession.

Loyalty to all our colleagues seems to demand total honesty with and about our errant colleague. No one benefits from our joining our colleague in denial.

Always though, we must limit our defense or accusation to what we know - but all that we know. That is where truth and loyalty converge.

Ed_Rudin@macnexus.org