OCT 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

Issue link: https://digital.eyeworld.org/i/87458

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Page 146 of 168

Some fundamental observations about ethics by John D. Banja, Ph.D. The primary ethical issue we're looking at is how benefits and burdens were distributed among this physician's patients, and the key justification in his length-of-wait distribution scheme was the amount of reimbursement his clinic received. Apparently, he felt it morally fair that better paying patients should experience less discomfort in their awaiting surgery, while lesser paying or uninsured patients could justifi- ably experience more. The ethical questions are: Is that policy in fact fair? Would it pass ethical muster? I've always thought this to be an B ecause the feature of this issue of Ophthalmology Business focuses on ethics and because I've been calling myself an "ethicist" for 30 years (implying I know some- thing about it), I thought I might make some basic points about ethics itself. The first point concerns the difference between ethics and morality. Technically, morality refers to the beliefs and values that guide a person's behavior and that inform him or her about right and wrong and good and evil. Ethics, however, involves reflecting on and analyzing those values and beliefs with a view to whether they best preserve human rights, accomplish the most good or the least amount of harm, and are fair and just. So any "ism"—libertari- anism, liberalism, totalitarianism, Protestantism, Catholicism, Judaism, atheism—is characterized by a "morality" or a set of moral beliefs and values. But it's when we start rigorously examining that belief structure and asking, "Is this the best we can do? Are these beliefs and values of mine the most reasonable and the most conducive to behaving rightly and decently? Do they hold up to rigorous scrutiny?" that we start doing ethics. Consider this example. In his book Waking Up Blind: Lawsuits Over Eye Surgery (Langdon Street Press, 2009) ophthalmologist Tom Harbin, M.D., relates a story about an Emory ophthalmologist who, 30 years ago, allegedly had a practice of schedul- ing his well-insured patients early in the day, with underinsured or unin- sured patients scheduled much later in the day. Bearing in mind that this latter group of patients were mostly African-American, this meant that they would arrive at Emory early on the day of their surgery but then experience hours and hours of wait- ing. What would the distinction between morality and ethics say about this? 14 Ophthalmology Business • October 2012 interesting case. Some readers might denounce this scheduling practice as discriminatory by saying that bene- fits and burdens should be distrib- uted evenly among patients because they are all equally deserving human beings. Others might condemn the practice on the grounds that as a surgical day wears on and provider fatigue sets in, patients scheduled later in the day will bear a greater risk of harm from errors or bad judg- ment calls. Consistently exposing one particular group of patients, i.e., the less well insured, to that aggra- vated risk of harm is discriminatory. Furthermore, if patients with little or no insurance routinely present with greater disease acuity such that their operations are technically more challenging, then the risk of harm to them from late-in-the-day schedul- ing is compounded even more. These seem to be compelling ethical concerns that I'd say should win the argument. But let's suppose, just hypothetically, that the providers' fatigue levels in this case never fall below a threshold of unreasonable risk so that the only burden that the patients scheduled

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