Reporter: Aviva Lev-Ari, PhD, RN
Spotted on
Exclusive: How US and UK Physicians’ Ethics Differ
Nov 20, 2012
Introduction
US and UK physicians receive medical training so similar that they can readily practice in either the United States or the United Kingdom. They share a common history and culture and speak the same language, more or less.
There were notable contrasts on attitudes toward what doctors regard as
- futile care,
- maintaining patient confidentiality in certain situations,
- alerting patients about poor-quality physicians, and
- telling patients the truth about terminal conditions.
- Their biggest difference seen was about whether to defer to the treatment wishes of patients’ families (Table).
But a newMedscape survey of nearly 25,000 US and UK physicians found that doctors in the 2 nations hold markedly different views on some thorny medical ethics issues.
Table. Differences in Attitudes Between US and UK Physicians, Medscape 2012 Ethics Report
| Question | US Physicians | UK Physicians |
|---|---|---|
| Would you ever go against a family’s wishes to end treatment and continue treating a patient whom you felt had a chance to recover? | Yes: 23% | Yes: 57% |
| Is it ever acceptable to perform “unnecessary” procedures due to malpractice concerns? | Yes: 23% | Yes: 9% |
| Is it right to provide intensive care to a newborn who either will die soon or survive with an objectively terrible quality of life? | Yes: 34% | Yes: 22% |
| Would you ever hide information from a patient about a terminal or pre-terminal diagnosis if you believed it would help bolster the patient’s spirit? | Yes: 10% | Yes: 14% |
| Would you give life-sustaining therapy if you believed it to be futile? | Yes: 35% | Yes: 22% |
| Should physician-assisted suicides be allowed in some situations? | Yes: 47% | Yes: 37% |
| Would you inform a patient if he or she were scheduled to have a procedure done by a physician whose skill you knew to be substandard? | Yes: 47% | Yes: 32% |
| Is it acceptable to breach patient confidentiality if a patient’s health status could harm others? | Yes: 63% | Yes: 74% |
| Would you ever decide to devote scarce or costly resources to a younger patient rather than to one who was older but not facing imminent death? | Yes: 27% | Yes: 24% |
© Medscape 2012
Several factors contribute to the differences: different views toward patient-centeredness; different medical liability climate; the way physicians are paid; national religious attitudes; and the nature of the relationship between physicians, patients, and patients’ families.
The survey was conducted as part of Medscape’s Physician Ethics Report 2012. Survey questionnaires were sent to physicians in a wide range of medical specialties in each country. Completed questionnaires were received from more than 24,000 US physicians and 940 UK physicians. The statistical significance of the differences in responses between US and UK doctors was not calculated.
One obvious difference that could affect attitudes is that most US physicians work either independently or for private hospital and medical groups and receive fee-for-service payment, while most UK physicians work directly or indirectly for the country’s socialized National Health Service (NHS). In Great Britain, most medical specialists work as salaried staff in publicly operated hospitals, while most primary care physicians work independently and receive a mix of fee-for-service payments, per-patient global payments, and salary.
“The big difference is the way the system is funded and the culture of the United Kingdom,” says Brian Jarman, MD, a medical professor at Imperial College in London who serves on the NHS’s advisory committee on resource allocation. “I don’t think our decisions are as affected by financial considerations as in the US.”
Another major distinction: There’s less medical malpractice litigation in the UK. On top of that, UK medical specialists receive liability coverage through their hospital, while general practitioners have their premiums offset by NHS payments. In the US, physicians worry a lot more about malpractice suits, and doctors in independent practice are responsible for paying sizable liability premiums on their own.
The largest percentage difference in the survey — and one of the most provocative findings — was seen on the question of whether the doctor would ever go against a family’s wishes to end treatment and continue treating a patient who the doctor felt had a chance to recover. Most UK physicians in the survey — 57% — said yes, compared with just 23% of US physicians. That finding cut against the view that UK doctors are more likely to ration, and it also highlighted an important cultural gap.
“In most places in the world, doctors think they know the right treatment and do it,” says Dr. Lachlan Forrow, MD, a Harvard University medical ethicist and palliative care specialist. “My German friends say patients and families expect doctors to make decisions. In the US we might defer more to the patient and family.”
On top of that, he adds, families in the US probably express their wishes with more vehemence than in the UK and are more likely to file a lawsuit if the doctor goes against their wishes.
Differences Were Surprising
But differing attitudes and responses to survey questions didn’t always fall along lines predictable by economics.
It’s often thought that UK doctors are more cost-conscious and more apt to ration services than US doctors are, given that US doctors are paid more for providing more procedures and services, while UK doctors work in a budgeted, socialized medicine environment. The responses to the survey, however, suggest that this is true in some situations and not true in others.
Even so, the experts found more similarities than differences in the responses, with large percentages of doctors from both countries responding to many of these tough ethical questions by choosing “it depends.” Indeed, the responses of US and UK doctors were comparable on most of the questions, including informing patients about medical errors, reporting impaired colleagues, performing abortions regardless of personal beliefs, and notifying patients about risks of a procedure when obtaining informed consent.
“One of the findings is how remarkably small the differences are,” says Don Berwick, MD, a pediatrics and health policy professor at Harvard University and former head of the Centers for Medicare & Medicaid Services who has done extensive quality-improvement consulting work with the UK’s NHS.
For a majority of issues, US and UK physicians are generally in agreement. For example, on the question of whether it’s right to provide intensive care to a newborn who either will die soon or survive with poor quality of life, US physicians were more likely than UK physicians to say yes — 34% to 22% . But the largest group in both countries — about 40% — said that it depends.
Dr. Forrow says this finding shows that doctors in both countries properly base decisions on individual circumstances. “What if grandma wants to see the baby before she dies and the baby won’t suffer? So it does depend.”
Candor With Patients
Another intriguing difference came on the question of whether the doctor would hide information from a patient about a terminal or pre-terminal diagnosis if the doctor believed it would help the patient’s spirit. Far more US than UK doctors – 72% vs 54% — said, “No, I am always completely truthful about diagnoses,” while more UK than US doctors — 33% vs 18% — said that it depends.
Dr. Berwick says this difference may result from a stronger sense of customer focus in the US. “Patient-centeredness as a fundamental property is better developed in the US than in the UK,” he says. “US doctors say it’s the patient’s right to know, while British doctors might say, ‘In my judgment it would be better for patients for me to not always be completely truthful.'”
Doctors in the 2 countries also differed on the question of whether they would ever give life-sustaining therapy that they believed to be futile, with 35% of US doctors and just 22% of UK doctors saying yes. About 40% of both groups said that it depends.
“The implication is that there is a financial incentive in the US to maintain the end-of-life patient in the hospital, and that incentive is not there in the UK,” Dr. Jarman says.
Societal and Religious Differences
Similarly, US and UK doctors differed on the question of whether it’s right to provide intensive care to a newborn who either will die soon or survive with poor quality of life, with US physicians more likely to say yes.
Both Dr. Forrow and Dr. Jarman agreed that there likely are societal religious factors influencing these differences over whether to provide what could be called futile care.
“The US is a more religious society,” Dr. Forrow says. “We do all kinds of things that are not medically necessary but the patient thinks they are necessary. When doctors think something is futile, patients and families object more. They say, ‘Give God a chance.'”
In contrast, Dr. Jarman says, “The UK is not a religious country and people don’t go to church as much, so those considerations wouldn’t be there.”
Despite greater religiosity in the US, American doctors were somewhat more likely than UK doctors to say that physician-assisted suicide should be allowed in some situations — 47% to 37%. That could be related to the fact that physician-assisted death for terminally ill patients is legal in 3 US states but remains illegal in the UK.
Protecting Other Physicians?
US doctors also were more likely than UK doctors to say that they would inform a patient if they felt a doctor scheduled to perform a procedure on the patient had substandard skill levels — 47% to 32%. Nearly 40% in both countries said that it depends.
“British doctors are more protective of their colleagues than US doctors are,” Dr. Berwick says. “This implies that US doctors are getting a little more comfortable about transparency on clinical performance.”
Dr. Jarman said that this difference in attitude could be a holdover from his country’s old General Medical Council rule, abolished in the 1980s, under which a doctor who reported a colleague for doing something wrong risked being barred from practice.
Finally, the survey showed a difference in attitude toward patient confidentiality and reporting communicable diseases. UK doctors were more likely than US doctors to say that it’s acceptable to breach patient confidentiality if a patient’s health status could harm others — 74% to 63%.
Dr. Berwick explained that by saying that more UK doctors than US doctors receive public training that encourages reporting of communicable diseases, and that the US has a very strong patient confidentiality and privacy law.
Dr. Jarman noted that the General Medical Council rules encourage physicians to break confidentiality and report patients’ communicable diseases or other conditions posing harm or risk to others. “If someone is causing harm to others, doctors are correct in breaking confidentiality for the good of the state,” he says.
Dr. Berwick says that the results of the Medscape survey are complex, revealing some important differences between US and UK physicians. But overall he feels reassured by their shared ethical values.
“A significant portion in both countries say that they will make decisions based on the details of the case,” he says. “They are willing to consider treatment efficacy. They are sensitive to the social world of the patient and what the families are feeling. They are connecting in the most humane way to the patient’s entire circumstance.”
Dr. Jarman says he found the survey interesting and challenging. “You know the correct answers but you also know that with certain patients you’ve got to be human and not totally follow the rules,” he says. “You have to be a little bit human about it.”
http://www.medscape.com/viewarticle/774737
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