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November 3, 1999

Serving Two Masters: Medical Practice vs Administrative Ethics

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JAMA. 1999;282(17):1678-1679. doi:10.1001/jama.282.17.1678-JMS1103-5-1

Miscoding looks like the quick movement of a black pen. If one stood and watched 1000 doctors miscode and 1000 doctors check the appropriate boxes there would be no telling the white hats from the black hats. Perhaps a certain doctor chewed her pen a moment before scribbling. Perhaps the other paused thoughtfully before writing down his recommendations. Good physicians who feel forced to miscode must first consider a number of moral issues. They must be able to discern the greater good and must believe that the miscoding deception serves the greater good. Given that, when the physician's conscience and the larger ethics of professional conduct would allow the omission of an appropriate diagnosis and when those same ethics condone inserting a new one, the physician may ethically miscode a patient's diagnosis.

A debate on miscoding leads nowhere if a physician is not allowed to deceive under any circumstances. Benign deception, however, is widely practiced in medicine. Every physician commits ethical errors of omission during a commonplace physically for instance, telling the patient who queries about a thump, "I'm just seeing what's going on," or "I'm just listening to your lungs here." The physician has decided not to discuss all possible diagnoses with the patient. Few physicians would argue that every patient who comes in with swollen lymph nodes should be told that he or she might be carrying the plague. Hopefully, the doctor has dismissed that possibility by the end of the examination and the omission has served both the physician and the patient.

Withholding an obscure diagnosis for 5 minutes so that it can be dismissed quietly is a minor breach, if one at all, and perhaps attributable more to a nebulous pool of "people skills" than to an ethical dilemma. Perhaps the idea of misinformation is better illustrated by examining a more active lie. Mr J, an 82-year-old gentleman, walks into a clinic in a small town presenting with a complex spectrum of complaints. The new doctor begins to take his history and Mr J reveals that he has a "bad back" and it is being effectively treated by his family doctor. The physician asks how it is being managed. The patient responds that he is being treated with pills, specifically "pyruvate precursor," which he has brought with him. Tipping the prescription container reveals nothing more exciting than a handful of M&Ms.

The placebo is an ancient crutch of medicine. It would be a heartless clinician indeed who would deprive Mr J of his M&M back pills either by snatching them out of his grasp or by shredding the illusion of their effectiveness. There is a time and a place for placebo medications, and there is certainly a point where their use is deleterious. Judicious use of placebos, however, has allayed a great deal of suffering.

These cases intimately relate to the original question of miscoding because they establish benevolent deception as a tool of physicians. We do not vilify physicians who occasionally practice this form of deception. Rather, we call them compassionate and look up to them as keen students of their patients' needs. If we as a profession will admit to these deceptions, then it is not a large leap to apply deceptions in other situations, similarly warranted by necessity and the greater good.

Miscoding appears at first, however, to be a greater ethical breach than prescribing placebos. The physician must pick up a pen and check the wrong box. He or she must fill in a date and time and affix a signature, just as if no error in judgment were occurring. To make matters more difficult, the physician may even find it necessary to scribble "Rule out _______" in a hand quite unrecognizable in many ways from his or her usual, honest scrawl. There it sits, a black and white testimony to the physician's arrogance, using someone else's money to cure the patient's illness. The act does not seem like something to take pride in. Prescribing placebos and checking the wrong box are, after all, both acts of lying, and are therefore not different in nature.

Miscoding may be ethically inappropriate because physicians can always try to change the insurance rules. The ethically untainted solution would be for the physician to appeal to the insurance company, document the evidence, and request a special dispensation. On discovering that the special permission has been denied, the physician could then crusade to have the disease recategorized so that the test is covered for everyone who presents with similar symptoms. That course of action is pleasing but impractical in the real world. Not only does a physician not have the time or inclination to rail against the corporate structure each time an institutional blockade is presented, but other patients in the practice would necessarily suffer from inattention.

The physician who is considering miscoding must be assured (1) that the test truly is the best and only means of obtaining the necessary information and (2) that the test will bring substantial gain to the patient relative to inaction as well as to alternate, perhaps multiple, insured actions. This logic applies to all tests, treatments, therapies, and procedures, regardless of cost. Size or price does not alter ethical responsibility.

These breaches of confidence, by omission and by commission, must be balanced against some nebulous idea of the greater good. The most weighty question concerns determining whether the physician has the ability to discern the greater good. Every day, decisions are placed in physicians' hands that involve weighing the good of the one against the good of the many. Is it appropriate to give antibiotics if the overuse of antibiotics may increase resistant organisms? It is the family physician who must decide every day. Is this particular newborn really the best use of these cardiac funds? The cardiac team must make that decision. If we refuse to admit that physicians are equipped to make decisions about the greater good, we make the profession impotent. Society should expect physicians, as professionals, to be able to make responsible decisions about the allocation of medical resources. If that prerogative is refused, then the practice of medicine must grind to a standstill. We must therefore conclude that doctors can and should make decisions pertaining to the greater good.

But does the miscoding truly represent the greater good? The process of being forced to miscode heightens a physician's awareness of the circumstances that led to the miscoding. If a desired procedure is unavailable, the physician must either miscode—a situation that is ethically disturbing—or cumbersomely work around the unavailable procedure. Either way, a large enough number of physicians sufficiently troubled about the same problem will eventually create a critical mass, enabling direct appeal to insurance companies to change their policies. In the meantime, the physician has continued to serve patients to the best of his or her abilities. Being able to serve both the patient and the administrative machinery of medicine can be an elusive goal. Achieving a reasonable balance between these ends, though, speaks of a decision rooted in the greater good.

The process of assuring an ethical miscoding depends on the ability of the physician to exercise sound judgment. The only way to sort out these judgments is, first, to convince oneself that the miscoding is the best clinical opinion available and, second, that the miscoding substantially and materially helps the patient. The third task is for the physician to weigh the immediate gain for one patient against the cost to society. Society relies on physicians not only to look after people's medical health but also to prevent other sectors of society from disrupting medical care. Miscoding to save a patient is the last resort for the physician with experience and talent. If physicians are not granted the ability to apply their judgment and do not take the responsibility into their own hands, there is no other source to fill the void.