e-Ethics November 2002
"What Specialist Would You Recommend?"
Blending Professional and Organizational Ethics
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At Nightingale Hospital's cancer
center, the manager of radiology
has brought a nagging concern
to the administrative director.
Non-physician staff members,
including nurses and radiology
technicians, receive calls from
newly diagnosed patients asking
for referrals to an oncologist or
surgeon. Staff puzzle over how
best to handle these requests. As
one puts it, "You just know that
some physicians have a higher
skill level than others."
Currently, some staff members
simply avoid the problem: they provide,
without comment, an alphabetical
list of specialists' names and
office numbers. Other staff, feeling
an obligation to offer anxious
patients some guidance, provide
the same names but list high-volume
or highly respected special-ists
first. Still others omit the
names of physicians whom they
feel they cannot, in good conscience,
even suggest. A few
explicitly recommend "the best"
specialists.
How should the cancer center
and its staff approach these
requests?
Discussion
Patients have long sought recommendations
about physicians
from non-physician members of
the healthcare team. Physician
referral services may not supply
the kind of guidance that patients
want most. Information from
strangers can leave patients yearning
for human contact—even by
phone—with a healthcare professional
the patient has met person-ally.
Patients may turn to non-physicians
rather than physicians
for such advice because they find
non-physicians more approachable.
Thus it is important that staff members
listen carefully to their
patients' requests and respond
compassionately. But the staff may
feel that requests for physician recommendations
are "loaded" from
both a professional and a political
standpoint. Most rightly approach
such inquiries with some caution.
Professional codes of ethics
may offer the staff some guidance.
For example, while the American
Nurses Association (ANA) Code of
Ethics for Nurses does not address
physician referrals directly, some
of its provisions appear relevant.
The Code stresses nurses' overarching
commitments to practice
with compassion and respect for
patients, put patients first, and
protect patients' health and safety.
1
From this perspective, a nurse's
primary focus in responding to
referral requests would be the
patient's well-being. Further, nurses
are to treat colleagues in other
disciplines with respect and
should refrain from "prejudicial
actions" toward them.
2
Any ques-tion
about another professional's
competence should be based on
"accurate reporting and factual
documentation, not merely opinion."
3
It seems reasonable to infer
that professional objectivity and
interprofessional respect should
characterize the nurse's response—
and, by extension, that of other
professionals—to referral requests.
Staff members who directly or
by insinuation recommend some
specialists over others doubtless
have patients' well-being in mind.
Yet the ANA Code's statements on
interprofessional relationships
raise questions about such
responses. For instance, while the
volume of patients seen is a matter
of "factual documentation,"
other criteria staff members use to
assess specialists seem less objective.
Ultimately, a decisive test for
some staff may be their personal
estimate of a specialist's ability or
the esteem in which a specialist is
held. Such a test falls uncomfortably
close to the realm of "mere
opinion." It could even be—or
appear to be—"prejudicial," and
thus discriminatory.
It is appropriate that this concern
has reached the cancer center's
administrative director. As a matter
of physician relations, the referral
issue raises organizational questions
that have significant ethical
implications. Radiology staff members
are not only professionals who
base their actions on professional
ethics and personal moral values;
they are also employees who cannot
avoid acting as representatives
of the cancer center when they
make recommendations to patients
who call the center. Thus the cancer
center, and indeed Nightingale Hospital,
has a moral stake—and is implicated—
in their conduct. When staff members
offer patients well-intentioned advice
about choosing physicians, they may,
as representatives of the center and the
hospital, favor (or appear to favor)
some physicians over others. They
involve their organization, at least indirectly,
in promoting some physicians'
practices to the potential detriment of
others'. And when staff have varying
criteria for evaluating physicians, their
judgments can appear to be more or
less arbitrary—especially if the criteria
are unstated or depend, even in part,
on hearsay.
It may seem that the ethically
sound—and safest—administrative
approach is a policy directing staff to
provide no referral information, or
offer only an alphabetical list of all relevant
specialists. But such an
approach is not enough. It fails to
address the underlying concern
behind patients' requests—at the
least, a desire for guidance and support
in a trying time. Thus it does little
to promote the patient's well-being. Is
there a way to respond in a more
helpful—and caring—way while avoiding
other ethical pitfalls?
As an alternative, organizational
guidelines might suggest that staff
members invite patients to reflect on
what they want from a specialist, e.g.,
surgical competence, relational skill,
compassion, diagnostic skill, inclusion
of the patient in the treatment plan,
attention to pain management, and so
on. (Staff members who lack time for
such involved conversation could suggest
that the patient think these things
over at home and make a written list for
her own benefit.) A staff member might
further suggest that the patient return to
her primary physician with these considerations
in mind, and ask that physician
to make a referral that takes the
patient's criteria into account. In addition,
the newly diagnosed patient might
be encouraged to contact a cancer support
group. In talking with others who
have similar illnesses, the patient might
incidentally receive some of the "word-of-
mouth" recommendations that many
value in selecting a physician.
When patients seek staff members'
counsel in choosing a physician,
staff may be helpful without identifying
some physicians as "better" and
others as "worse." Such recommendations
too often rely on dubious,
possibly unfair, "evidence" and raise
significant ethical concerns about the
employee's role as a representative of
the healthcare organization. Providing
staff with guidelines to follow when
such requests arise can reduce these
moral risks, and may alleviate the
staff's own moral distress about what
and how much to say.
1. American Nurses Association, Code of Ethics
for Nurses with Interpretive Statements
(Washington, D.C.: American Nurses
Association, 2001), p. 4.
2. Ibid., p. 9.
3. Ibid., p. 15.
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