Ethical questions linger over surgeons’ actions

Stacy J. Willis

Saturday, July 13, 2002 | 11:30 a.m.

Orthopedic surgeon Dr. Michael Daubs once believed his calling was to heal one person at a time -- with a scalpel and 14 years of training.

But in the midst of Las Vegas' medical malpractice insurance dilemma, his calling has changed. Daubs, like other physicians, has become more engaged in the politics of healing an entire community.

He's taking phone calls from lawmakers and reporters. He's answering questions about the legal climate. He resigned his position as on-call surgeon at UMC's trauma center in a battle over the liability risks physicians face under Nevada's tort laws.

But his choice to leave the trauma center presented a tough ethical dilemma -- one with which doctors throughout southern Nevada are struggling, even as some return to work at UMC.

How does a doctor balance his primary obligation -- to heal individual patients -- with mounting financial, legal and political challenges?

The Hippocratic Oath mandates that doctors "do no harm" and "follow the system of regimen which, according to (his or her) ability and judgment, is for the benefit of the patient." How, then, do doctors walk away from the best trauma facility available?

"I agonized over this decision," said Daubs, who has since agreed to return to UMC after an attorney general's decision relieved doctors of some liability. "It was not easy. But we have to limit our risk in some way."

When UMC's more than 50 on-call surgeons left, the trauma center closed, and the public was left to fear that someone would die as a result. While doctors agreed to go back -- at least temporarily -- after they were relieved of some liability, the issue still is a quandary for doctors.

"I guess there are all kinds of opinions about the Hippocratic Oath," said Dr. Raj Chanderraj, immediate past-president of the Clark County Medical Society. "But ethically, morally and religiously, doctors are first obligated to their families. From my point of view, I am supposed to serve to the best of my personal, physical and emotional abilities. If I am at the point at the end of the day where my profession compromises my own personal life, that's a problem."

Trauma surgeons resigned from their on-call positions at UMC because, they said, they are a target for medical malpractice lawsuits and excessive jury awards.

UMC and staff doctors are covered under a $50,000 liability cap, while lawsuits against on-call doctors at the trauma center could be for unlimited amounts. Daubs' policy, like most physicians', covers up to $1 million in damages, leaving him and his family liable for any amount beyond that.

Las Vegas' liability challenges are among many non-scientific concerns that cause today's doctors to view their ethical obligations in a different manner than Hippocrates did.

Physicians in this era have seen their practices limited by managed care, squeezed by malpractice premiums and threatened by a lack of lawsuit limits. And more often than not, they were not trained in medical school on these issues or to deal with the ensuing ethical questions.

"A lot of doctors are really naive about this when they get into it," Marshall Kapp, author of the book "Our Hands Are Tied: Legal Tensions and Medical Ethics," and a professor at Wright State University School of Medicine in Dayton, Ohio. "They need to be more aware that they are going to be practicing medicine within a legal, political, social environment."

Daubs, who grew up in Las Vegas, said he is "disappointed" by the politics he's involved in.

"I became a doctor because I liked science and liked taking care of people. All of the rest of this slapped me in the face. I had no idea about the business end of it," Daubs said.

Dr. Larry Allen, a family physician in Las Vegas, said most physicians aren't prepared for -- or particularly interested in -- the business and legal sides of their practices.

"Up until five years ago I never looked at insurance. I never thought about it. But now physicians have to be businessmen, and we were offered nothing in training for that," Allen said.

"I was only trained in medicine, not business. And believe me, I'd rather just treat patients."

With wider responsibilities comes broader ethical concerns, said Dr. Donald Palmisano, president-elect of the American Medical Association. With the complexities of modern medicine stretching beyond the Hippocratic Oath, doctors increasingly rely on professional organizations such as the AMA for ethical guidelines that apply to insurance and business topics.

"At the AMA, we have a vast array of ethical opinions to address these sorts of issues," Palmisano said.

The AMA website posts dozens of such opinions on topics such as "Conflict of Interest Under Capitation" and " Restrictions on Disclosure in Managed Care Contracts."

After flipping through catalogs of AMA ethical opinions, Palmisano reads part of one he believes to be applicable to UMC's trauma surgeons: "A physician shall be free to choose whom to serve."

"This trauma center decision in Las Vegas was a tough one for physicians, but it's not about ethical shortcomings. You can't put yourself in a situation where you may not be able to keep your office open, or you may lose your home. Unless the bank says, 'Don't worry, Doc, we will give you a free mortgage note,' I don't know what else they are supposed to do. ...

"If society creates an environment where it's hostile for the practice of medicine, society needs to fix it."

Kapp, too, said modern medical ethics apply not just to doctors, but to the entire community.

"We can say that usually physicians have an obligation to put their patients in front of themselves. At the same time, they do have a legitimate obligation to themselves and their families," Kapp said.

"But another argument might be made that if physicians permit and participate in a dysfunctional legal system, in the long range they may be jeopardizing the ability of the health care system to function. So an argument can be made that they have an obligation to improve the legal climate," Kapp said.

Larry Matheis, executive director of the Nevada State Medical Association, said UMC's trauma center closure reflects on the community's ethics, not the individual doctors'.

"It's a real ethical dilemma for doctors, yes," Matheis said. "But I don't know that I would find the closure of the trauma center as evidence of an ethical shortcoming on behalf of these individuals (doctors). It's evidence of a public that lacks community spirit.

"This community lacks the sense of social obligation it needs. This system shut-down shows just how vulnerable that makes us. People move to southern Nevada and think they can get away with never participating in the responsibilities of the community.

"We need to look to leaders -- business leaders, religion leaders, political leaders -- to set that agenda," Matheis said. "This is everybody's system, not just the doctors'."