Editor's Note
Playing by the Rules
Physicians are connoisseurs of rules. Our exposure to their importance began with biochemistry, when we learned about long pathways that make their way to their final metabolic products by obeying the laws of thermodynamics. Then came the Henderson-Hasselbach equation, a perplexing but seemingly indispensable physiological truism that has baffled generations of medical students learning the rules of acid and base. As medical students, we also tackled the deluge of information we needed to memorize with rules—mnemonics, silly and scatological. Today, rules from HIPAA, Medicare, and hospital committees invade the practice of clinical medicine. And lurking inside every physician are rules that guide our professional lives—rules that aren’t found in any book and that defy numbers or calculations or memory tricks. Ethics is this murky, mercurial set of rules.
Ethics is murky because right and wrong in the world of sickness, life, and death are not as simple as obeying stoplights. Weighing benefit and risk rarely yields a crystalline yes or no as decisions get muddied by cost, family, society, and, of course, patients.
Ethics is mercurial because medical science and society both change. As what we can do for and to patients expands, what we should do becomes more problematic. As medical “miracles” become commonplace, people begin expecting and demanding the miraculous. As our society ages, thinking about the previously unthinkable, such as dialysis or coronary bypass for 90-year-olds, becomes mandatory. And as money for physicians, hospitals, and research gets tighter and pharmaceutical companies come knocking with funds, the ethical conflict between patient welfare and financial self-interest gets tested. The deeper we dive into biomedical ethics, the more questions seem to pop up.
Most textbooks on biomedical ethics ask a lot of important questions, and you will find a passel of ethical questions in this issue of Minnesota Medicine. Should practicing physicians shun any financial connection to pharmaceutical companies? Should researchers cut their financial ties to pharmaceutical firms? Should medicine and government reconsider the ban on organ sales?
Classic biomedical ethics, which stands on the principles of patient autonomy, nonmaleficence, beneficence, and justice, may help us find answers. But these four deceptively clear “rules” get blurry quickly when we try to apply them to the real-world problems discussed in our issue. What is the role of autonomy during a pandemic when the actions of one infected person can threaten a whole city? Justice, autonomy, and beneficence do battle trying to solve this riddle.
So how do you unravel these knotty problems? Is there any rule that physicians can follow now and 10 years from now no matter what society is like, no matter what medical science can do, no matter who’s making money and who isn’t? I think so. It’s the trust test. If what you do as a physician or what your hospital or corporate employer does jeopardizes the trust patients have in your placing their welfare ahead of everything else, then it’s the wrong thing to do. Rule No. 1, now and always.
Charles R. Meyer, M.D., editor in chief
Dr. Meyer can be reached at
cmeyer1@fairview.org