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April 12, 2000

Fidelity and Deceit at the Bedside

Author Affiliations

Author Affiliation: Georgetown/Johns Hopkins University Program in Law and Public Health, Washington, DC.

JAMA. 2000;283(14):1881-1884. doi:10.1001/jama.283.14.1881

To what extent should physicians act as their patients' advocates in the struggle to gain access to health care resources? Neither the Hippocratic ethical tradition nor contemporary bioethics nor US law speak clearly to this question.1

The physician who recites the Hippocratic Oath pledges, "I will prescribe regimen for the good of my patients according to my ability and my judgment. . . ."2 But the oath says nothing about what, if anything, its adherents should do to secure their patients' access to the "regimen" so prescribed. The dominant stream in contemporary bioethics subsumes professional obligation under 4 principles—respect for autonomy, nonmaleficence, beneficence, and justice.3 Fidelity to patients and advocacy on their behalf are derived from respect for autonomy and, thus, treated as taking their content, case by case, from patients' legitimate expectations. This, of course, begs the question of what expectations are "legitimate" when insured patients want all possibly beneficial care, regardless of cost. The law charges physicians with some duties of loyalty, including the keeping of confidences and avoidance of some conflicts of interest.4 But the law has not developed a duty of patient advocacy,1 akin to the lawyer's duty of zealous advocacy on his or her client's behalf.5

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