Medicine is certainly at the forefront in creating ethical issues for society. The determination of the beginning of life has divided the country and affected the political process for the last twenty years. Transplantable embryos, genetic selection, and liver transplants for celebrity drug abusers are issues unimaginable just ten years ago. Fortunately, these are not the ethical issues that confront me daily in my practice of otolaryngology.

As an ear, nose, and throat surgeon, my most frequent daily ethical dilemma involves patient care decisions. It involves balancing different therapies, their effectiveness, risks, and cost to the patient, society, and myself.

In the past, decisions involving elective surgery for non life-threatening diseases were made by the physician and patient together. These decisions were usually based solely on the risks, success, and cost of the surgery when compared to the risks, success, and costs of other forms of therapy. Since most of my patients had insurance, economic factors did not generally preclude surgery as a therapy.

However, with the explosion of “managed care” insurance (HMOs, PPOs, IHSs), third parties have become actively involved in patient care decisions. Many managed care organizations often will refuse to pay for procedures such as elective surgery. When this occurs, physicians become patient advocates to get these therapies funded. However, when physicians are forced to become lobbyists for their patients, they are viewed as "expensive physicians" by these insurance plans, and risk being excluded from treating those patients.

Closed paneled HMOs and hospital staffs are becoming more common daily. When patient flow—the source of income to a physician—is controlled by an insurance company, it becomes risky for that physician to place his patients’ needs first. When physicians become employees of insurance plans they are tempted to place their employer’s interests before their patients.

Conversely, when physicians are capitated, they must resist the temptation of providing less than optimal care. In a capitation system, physicians are rewarded when they conserve money by rendering less care to a group of patients. The less care given, the greater the reward.

Physicians are honest, ethical people. Certainly not every doctor is perfect, but in my experience, as a group they are highly principled humans. However, the decision making process is complex, and physicians are influenced by numerous factors. Even when decisions seem straightforward, a medical rarity, subtle pressures like patient desires, malpractice concerns, patient or physician convenience, and reimbursement influence the decision making process.

I find that my constant ethical challenge is to keep the extraneous factors from influencing the care given to my patients. Keen awareness of these influences and a concerted effort to be a good physician keep me at peace with myself and my God.