OCT 2012

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

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Page 147 of 168

... ethical reasoning becomes frustrating because we frequently can't find a compelling way to prove that this or that ethical argument is the correct one later in the day would experience is the discomfort of their wait. Would the policy then be ethical or not? Why couldn't someone argue that the marginal profits obtained from better insured patients make it possible, through cost shifting, for the poorly insured or uninsured patients to in fact have their surger- ies? This argument would say that it isn't ethically wrong to make the latter bear more discomfort per their waits because they benefit enor- mously from those patients whose insurers pay more for the same pro- cedures. Consequently, the incon- venience of their waits is more than justified (because it is offset) by the benefit they receive from the earlier scheduled patients, whose generous reimbursements to the clinic make their surgeries possible. Nevertheless, others might respond that underinsured or unin- sured patients do "pay" their way because they comprise a large frac- tion of patients on whom medical students and residents have histori- cally practiced on in learning their trade. Although these patients' insur- ance reimbursement might not cover costs, many physician training programs would be severely compromised if not become extinct without them. These arguments and counterar- guments bring up a second point about ethical judgment: Where does one go for the ethically "correct" answer? This is where ethical reason- ing becomes frustrating because we frequently can't find a compelling way to prove that this or that ethical argument is the correct one in the way we can consult the periodic chart of the elements to determine the molecular structure of plutoni- um. Nevertheless, some ethical opin- ions are better than others so that one way of testing whether this oph- thalmologist's scheduling practice at least met a minimal ethical thresh- old is to convene a group of his peers and ask them to analyze the policy's pros and cons. If peer groups of ophthalmologists and other ethi- cally reasonable people would con- sistently and consensually accept or denounce the policy given their vari- ous reasons, then I'd say that's about as "objective" as we can get in matters of ethical reasoning. This doesn't say that 50,000 ophthalmol- ogists can't be wrong, but it does say that if ethically conscientious indi- viduals would consider this case, rea- son as best they could about it, and ultimately find the policy acceptable or unacceptable, then that's probably the best we can do. And doing the best you can is very good, indeed. A third point: Notice that codes of ethics and even legal regulations are often of little help in cases like this. Codes of ethics are nearly always written in too broad a lan- guage to be helpful in down-to-earth cases like this one. Legal regulations and case precedents, on the other hand, might be very helpful, espe- cially if they would directly address the issue at hand. But if there are no legal precedents or rules available— and there frequently aren't—then the law obviously won't be of much help either. Indeed, our case would be an interesting one to analyze from a discrimination standpoint since the patients aren't being denied a service but are "merely" being made to wait extra hours to receive their care. Would the courts deem that wait "unreasonably burdensome" or rule that it singles out a particular group of patients and places them at an undue and unfair degree of risk? A final point is that ethics, as opposed to morality, is ultimately about justification. Whereas moral positions take their correctness for granted, the proof of the ethical pudding is in the quality of the arguments and the reasons we give for our moral positions. Ultimately, if we wonder whether our moral positions are ethically defensible or not, we should put them to our peers and our organizational leader- ship, such as ASCRS, for debate. We should especially ask ourselves if we could defend our positions publicly or would we be embarrassed by them? I've always told physicians that if you can defend your moral practices and beliefs by looking straight into the TV camera and confidently give a thoughtful and coherent account of why you did what you did or believe what you believe, you're probably ethically OK. It's when we refuse to be accountable that we start looking ethically suspicious. OB Dr. Banja is a medical ethicist, Emory University, Atlanta, and the public member of the ASCRS Governing Board. He can be contacted at jbanja@emory.edu. October 2012 • Ophthalmology Business 15

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