Defensive practice is indefensible: how defensive medicine runs counter to the ethical and professional obligations of clinicians.

Defensive medicine has become pervasive. Defensive medicine is often thought of as a systems issue, the inevitable result of an adversarial malpractice environment, with consequent focus on system-responses and tort reform. But defensive medicine also has ethical and professionalism implications that should be considered beyond the need for tort reform. This article examines defensive medicine from an ethics and professionalism perspective, showing how defensive medicine is deeply problematic. First, a definition of defensive medicine is offered that describes the essence of defensive practice: clinical actions with the goal of protecting the clinician against litigation or some adverse outcome. Ethical arguments against defensive medicine are considered: (1) defensive medicine is deceptive and undermines patient autonomy; (2) defensive medicine subjugates patient interests to physician interests and violate fiduciary obligations; (3) defensive medicine exposes patients to harm without benefit; (4) defensive medicine undermines trust in the profession; and (5) defensive medicine violates obligations of justice. Possible arguments in favor of defensive medicine are considered and refuted. Defensive practice is therefore unethical and unprofessional, and should be viewed as a challenge for medical ethics and professionalism.

Overdiagnosis and overimaging: an ethical issue for radiological protection.

AIMS AND OBJECTIVES: This study aimed to analyse the key factors that influence the overimaging using X-ray such as self-referral, defensive medicine and duplicate imaging studies and to emphasize the ethical problem that derives from it. MATERIALS AND METHODS: In this study, we focused on the more frequent sources of overdiagnosis such as the total-body CT, proposed in the form of screening in both public and private sector, the choice of the most sensitive test for each pathology such as pulmonary embolism, ultrasound investigations mostly of the thyroid and of the prostate and MR examinations, especially of the musculoskeletal system. RESULTS: The direct follow of overdiagnosis and overimaging is the increase in the risk of contrast media infusion, radiant damage, and costs in the worldwide healthcare system. The theme of the costs of overdiagnosis is strongly related to inappropriate or poorly appropriate imaging examination. CONCLUSIONS: We underline the ethical imperatives of trust and right conduct, because the major ethical problems in radiology emerge in the justification of medical exposures of patients in the practice. A close cooperation and collaboration across all the physicians responsible for patient care in requiring imaging examination is also important, balancing possible ionizing radiation disadvantages and patient benefits in terms of care.

Defensive Medicine: Is It Legitimate or Immoral?

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A comparison of medical litigation filed against obstetrics and gynecology, internal medicine, and surgery departments.

BACKGROUND: The aim of this study was to review the typical factors related to physician's liability in obstetrics and gynecology departments, as compared to those in internal medicine and surgery, regarding a breach of the duty to explain. METHODS: This study involved analyzing 366 medical litigation case reports from 1990 through 2008 where the duty to explain was disputed. We examined relationships between patients, physicians, variables related to physician's explanations, and physician's breach of the duty to explain by comparing mean values and percentages in obstetrics and gynecology, internal medicine, and surgical departments with the t-test and χ(2) test. RESULTS: When we compared the reasons for decisions in cases where the patient won, we found that the percentage of cases in which the patient's claim was recognized was the highest for both physician negligence, including errors of judgment and procedural mistakes, and breach of the duty to explain, in obstetrics and gynecology departments; breach of the duty to explain alone in internal medicine departments; and mistakes in medical procedures alone in surgical departments (p = 0.008). When comparing patients, the rate of death was significantly higher than that of other outcomes in precedents where a breach of the duty to explain was acknowledged (p = 0.046). The proportion of cases involving obstetrics and gynecology departments, in which care was claimed to be substandard at the time of treatment, and that were not argued as breach of a duty to explain, was significantly higher than those of other evaluated departments (p <0.001). However, internal medicine and surgical departments were very similar in this context. In obstetrics and gynecology departments, the proportion of cases in which it had been conceded that the duty to explain had been breached when seeking patient approval (or not) was significantly higher than in other departments (p = 0.002). CONCLUSION: It is important for physicians working in obstetrics and gynecology departments to carefully explain the risk of death associated with any planned procedure, and to obtain genuinely informed patient consent.

Trust and distrust between patient and doctor.

To trust someone is to have expectations of their behaviour; distrust often involves disappointed expectations. But healthy trust and distrust require a good understanding of which expectations are reasonable, and which are not. In this paper, I discuss the limits of trustworthiness by drawing on recent studies of trust in the context of defensive medicine, biobanking and cardiopulmonary resuscitation decisions.

Defensive medicine and outcomes for medical malpractice liability.

Defensive medicine is a significant force driving the high costs of healthcare systems and has a substantial influence on physicians' behavior because they primarily concern about malpractice liability and not patient's health protection. This attitude disagrees with deontological duties and could impair physicians' ability of judgment and clinical reasoning. Reducing defensive medicine also could mean improving the quality in healthcare systems and eliminating unnecessary costs.

How not to think: medical ethics as negative education.

An implicit rationale for ethics in medical schools is that there is a perceived need to teach students how not to think and how not to act, if they are to avoid a lawsuit or being struck off by the GMC. However, the imperative to keep within the law and professional guidance focuses attention on risks to patients that can land a doctor in trouble, rather than what it means to treat a patient humanely or well. In this paper I explore the gap between learning how not to think and act as a doctor, and learning to be reflective and responsive to patients as fellow human beings. This gap is exposed by the difference between a GMC web resource for doctors, and a detailed ethical discussion by Gawande in his book Complications. The latter raises fundamental questions of meaning, and exemplifies an approach to ethical thinking as the appropriate management of doubt that, according to the argument of this paper, is of utmost importance for doctors.

Medical practice guidelines as malpractice safe harbors: illusion or deceit?

American medicine has long sought to control the standard of care that physicians are expected to provide to their patients. One effort to insulate the standard of care from external interference, called a "safe harbors" approach, would enable physicians to avoid liability for malpractice if they adhered to medical practice guidelines. The idea is to eliminate the "battle of experts" and reduce defensive medicine by requiring judges and juries to accept guidelines as conclusive evidence of the standard of care. Yet current efforts to improve the guideline development process, including the use of evidence-based guidelines, are unlikely to be able to overcome the shortcomings that led a similar safe harbors initiative to fail in the early 1990s. Moreover, there is no adequate justification for conferring this degree of self-regulatory power on the medical profession.

On the cutting edge: ethical responsiveness to cesarean rates.

Cesarean delivery rates have been steadily increasing worldwide. In response, many countries have introduced target goals to reduce rates. But a focus on target goals fails to address practices embedded in standards of care that encourage, rather than discourage, cesarean sections. Obstetrical standards of care normalize use of technology, creating an imperative to use technology during labor and birth. A technological imperative is implicated in rising cesarean rates if physicians or patients fear refusing use of technology. Reproductive autonomy is at stake since a technological imperative undermines patients' ability to choose cesareans or refuse use of technology increasing the likelihood of cesareans. To address practices driven by a technological imperative I outline three physician obligations that are attached to respecting patient autonomy. These moral obligations show that a focus on respect for autonomy may prove not only an ideal ethical response but also an achievable practical response to lowering cesarean rates.