Physicians Morality among Elderly Patients and their Medical Referrals
Concerns about the well-being of the patient and the proper behavior of doctors are part of the heritage of medicine originated with the Code of Hammurabi, the first set of laws in history (1750 a. C). “A difficult task is to devise, comment or speculate about the ethics and morals of the doctor” [1].
Moral ethics is an old concept; however, the guidelines of moral behavior have not lost their current relevance and must comply with the demands of contemporary practice. Its development is due to the technological advance of medicine and to the questions about its application; to increase the medical knowledge of the population; to the awareness of patients about the decisions they have to participate and the commercialization of some health professionals [2].
Principles and Codes of Medical Ethics and Professionalism of the American Medical Association (AMA) provide standards for the honorable behavior of the medical profession. These standards were designed primarily for the benefit of patients and to serve as a guide in the conduct of the doctor-patient relationship [3,4].
The doctor finds in his/her work innumerable situations that do not have a single answer: a well-defined objective and the same objective information can have different solutions, among which he/she must choose one [5].
The aging of the population, both in the developed and developing countries, has led to an increase in the demand for health resources; this has highlighted several ethical problems related to aging [6].
In the attention of the older adult, ethical and legal problems frequently arise, which imply challenges in the professional practice. Common challenges include determining competence, resolving conflicts among decision makers, determining available treatment options (including suspending or withdrawing treatment), anticipating future decisions and death. These ethical aspects are influenced by factors such as the determination of individual and social benefits, discomfort, available resources and costs [7].
There are ethical aspects in the referral and return of the patient to his/her treating physician, especially in older adults, since they present multimorbidity and it is necessary to refer them to different specialists to solve their health problems. Under these circumstances physicians may have differences of opinion in the diagnosis or in the type of treatment and sometimes this causes “dislikes” among the doctors.
There is little information in the literature to provide statistically significant data on morality in practice among physicians, especially for elderly patients. Older adults live and manage multiple chronic diseases. One study included in-depth interviews with 35 older Canadian adults, ages 73 to 91, who had between three and 14 chronic conditions. Most of the participants were committed to some type of self-care, in order to cope with debilitating physical symptoms and functional loss. They also used self-care because they had reached the limits of available medical treatment options. Finally, it was argued that personal care is a moral responsibility by which our participants handled their illnesses [8].
The moral duty to help the patient is especially difficult when someone is the victim of unfair accusations, discrimination or degrading treatment.
One in 4 doctors always refers the patient to the doctor who sends it, when the ideal is that most of them should do it. When there is a disagreement with the attending physician regarding diagnosis and treatment, 1 in 15 speaks with the attending physician, but 1 in 3 may express disagreement with the patient, but not with the doctor. When a patient asks to see another doctor, half of them refer the patient who makes the request. When a patient speaks against a doctor, 1 in 25 defends a colleague. One in 3 patients has been told by their doctor that the treatment has been questioned by another colleague. One in 3 also justified with the patient when a colleague has expressed badly about him/her with patients. A third of doctors questioned the diagnosis and treatment of a patient only because the doctor is not a specialist, regardless of the level of knowledge, clinical judgment or experience [9].
The competition between doctors and other health professionals is ethical and acceptable, taking into account the economic situation and the difficulties with the employment conditions. Competition should not be a characteristic for making statements that compromise the good reputation of others.
It is worth mentioning that in the struggle to succeed, the discredit and to talk bad about colleagues are used to gain patients, incurring violations of the Code of Medical Ethics, losing the deference and respect.
In a training hospital 15% of doctors have negative appointments in the medical record that question the capacity or disagreement with the treating physician, most of they change the prescribed treatment, mostly residents. Codes of ethics specify a rule according to which doctors should not use the medical file as a battlefield and they should speak with the colleague before making notes [10].
Respect for colleagues is also evident in recognizing their right to have scientific convictions and individual professional bases propitiate an atmosphere of tolerance for ideological diversity that allows peaceful and constructive coexistence. The first obligation is to be a patient advocate. The second, to aid a colleague has clearly marked their specific field of action: achieving the lofty goals of the profession. There are not missing opportunities to exercise with a partner a discrete job of advice and moral support.
It is interesting to observe that in the high levels of moral judgment among older adults, only reasoning based on abstract internalized principles has a significant positive relationship with self-reported help; the personality correlates with helping, and with subjective social integration in the social context of one [11].
By examining both culture and moral intensity, we hope to better clarify the complexities of the ethical determinants of decision making among physicians in their daily practice. Doing so may have potentially practical implications for the ethical training of medical students and doctors [12].
