The family member of a physician visits the Emergency Department at the hospital where that physician works. The medical team is aware that this is the family member of a colleague. As a result, that patient receives special treatment: they are visited more frequently and attentively by staff, vaulted to the front of the line for diagnostic tests, and brought to the floor as soon as the decision is made to admit them without any wait time in the ED. The medical team is in contact with their physician colleague[1] more frequently than they would be if it was the family member of any other patient. Is this special treatment ethically justified?
What does special treatment consist of?
Special access to care can be provided in many different contexts. It can occur in the outpatient clinic, the emergency department, or on admission to the hospital. Although the clinical context may differ, the types of treatment that may be made available are relatively similar. Special treatment most commonly consists of increased awareness of and attention to the patient in question. It may involve more aggressive pain control, shorter wait times, more frequent visits by clinical staff, and additional diagnostic testing for the purpose of being ‘thorough’, which may result overall in the earlier identification of complications. The care team is likely to involve a physician colleague more in care planning than would be the case for the family members of other patients.
It is unclear whether special treatment leads to better outcomes. This is an understudied area; it is hard to evaluate for practical and political reasons. As a result, there is no systematic evidence about this question. The little anecdotal evidence that is available suggests that professional connections to a patient’s family member can cause “subtle changes in decision making.”[2] These changes may lead either to improved care, or to unnecessary tests and services that may not be clinically meaningful or that may even lead to harm.
Ethical Significance
The ethical significance of this issue is twofold. First and foremost, it concerns the allocation of physicians’ time, attention, and care, which are some of the most important yet underappreciated resources that clinicians possess. These resources are already unevenly distributed: physicians spend more time with patients of certain races and ages, a practice that influences patient satisfaction,[3] which can in turn affect how connected patients feel to care and even how likely they are to seek care in the future. More time spent with some patients means less time for others who may benefit from it.
Second, special treatment raises questions about the nature of professional medical relationships. The culture of medicine relies on a certain degree of support between colleagues. It is often viewed as a professional courtesy to assist colleagues whenever possible, but it is unclear just how far that courtesy extends. Clarifying the ethics of special treatment can help us to understand what is owed to colleagues in professional relationships.
Principles of Resource Allocation
Physician time and attention are scarce medical resources. They are finite, valuable, and affect clinical outcomes. In this section, I examine whether it is justified to provide more of these resources to certain patients by applying widely accepted frameworks for the ethical allocation of scarce medical resources. Many frameworks for allocating scarce medical resources rely on four sets of values.[4] These values are maximizing benefit, giving priority to the worst off, treating people equally, and promoting and rewarding social value. Some of these values are relevant to the issue of special treatment, while others are not.
First, the principle of utility suggests that resources should be allocated in a way that maximizes the benefits that may be obtained. However, this utilitarian principle is irrelevant to the question of special treatment. There is no reason to assume that the family members of physician colleagues would benefit any more or less from medical treatment than would the general population.
Second, priority to the worst off suggests that benefits to those who are worse off should be given more moral weight. This prioritarian principle is important when, for instance, it would be more expensive to provide treatment to some populations even though they are disadvantaged in some way. However, family members of physician colleagues are likely no different in this regard than other patients are, so this principle does not apply.
Third, the value of treating people equally suggests that all people have equal moral status and therefore have equal claims to the distribution of scarce medical resources. Special treatment runs counter to this principle. It asks us to give relative priority to some patients over others even though they all have equal moral standing. Therefore on its own, the value of equality does not support special treatment for some patients.
The fourth value is promoting and rewarding social usefulness. On this value, some people have greater claim to scarce resources based either on instrumental value (forward-looking) or on reciprocity (backward-looking). Instrumental value entails prioritizing certain individuals in order to advance important social values in the future. Reciprocity, on the other hand, implies that we should reward those who have contributed to valued societal goals in the past. Although reciprocity is a controversial way to allocate scarce medical resources, it is increasingly becoming accepted. For example, during the COVID-19 pandemic, hospital staff were assigned higher priority for ventilators if they had cared for COVID-positive patients in the past. The value of reciprocity may be consistent with special treatment. Physician colleagues are engaged in the care of shared patients and help to ensure those patients have good outcomes. Thus, they may be owed special consideration as a result. Of note, this argument only applies to physicians who are colleagues at the same institution.
Equality and reciprocity are opposing values. Equality suggests that all patients should receive the same consideration, but reciprocity supports the claim that some patients are owed special regard. At the most fundamental level, these principles differ in whether they lend credence to any sort of partiality on the part of the treating clinician. Special treatment clearly requires some sort of partiality. What is the right amount of partiality to show to certain patients?
Reasonable Partiality
Partiality is the claim that it is “morally right to give a higher priority in one’s actions to those to whom we stand in certain sorts of relationship than to those to whom we stand in no relationship, all else being equal.”[5] [6] It is, in essence, a normative obligation to favor those with whom we are in close relationship. Many philosophers endorse this approach. For instance, Samuel Scheffler argues that interpersonal relationships generate moral reasons that are by nature stronger than and may supersede impartial or impersonal reasons.[7],[8] Others, such as Thomas Nagel and Peter Singer, disagree. They view partiality as merely the selfish concern with one’s own interests[9], and encourage us to view or responsibilities to distant others as equal in strength to those we owe to whom we are most close.[10]
Partiality exists on a spectrum. It ranges from full impartiality towards all at one end, to the preferential treatment of some persons at the other. Many of our professional relationships depend to a certain degree on partiality, provided that it is applied in the right way. Too much partiality and we run the risk of nepotism; too little, and we fall into anomie.
The practice of medicine clearly depends to a certain degree on partiality. Physicians have obligations of fidelity, truth-telling, confidentiality, etc., that they owe to their patients but not to the stranger.[11] These special moral obligations are owed precisely because physicians and patients enter a therapeutic relationship. It would be impossible for medicine to have a detached impersonality to it; without partiality, the field would be marked by an absence of trust. The doctor-patient relationship is imbued with the expectation of special concern.
But can a physician be more partial to some of their patients over others? After all, that is what special treatment seems to require. The truth is that physicians already routinely show partiality to some patients in medical and non-medical ways. They make house calls[12], attend some patients’ life events and funerals[13], and go above and beyond for some patients in ways that would be impractical to do for all. These practices are consistent with the professional obligation to provide the standard of care; anything above that is supererogatory. Special treatment is merely another instance of supererogatory practice.
Supererogatory medical practices are morally acceptable because they are consistent with reasonable partiality. This degree of partiality suggests that we can place the interests of some patients above the interests of others so long as it is reasonable to do so. What counts as reasonable? As Per Nortvedt has pointed out, physicians have a duty to help their own patients, but not at the cost of someone else’s welfare.[14] For example, the Tarasoff case[15] established that psychiatrists are legally liable if they do not disclose their own patient’s intent to harm another person. Physicians cannot privilege one patient if doing so would result in clear harms to another.
Reasonable partiality is therefore only morally permissible if it does not directly harm or exploit another identifiable individual. These duties are negative constraints against claims to partiality. Reasonable partiality therefore suggests that it is ethically permissible for physicians to give relative priority to certain patients as long as doing so does not infringe upon the rights or the medical care of other patients.
What sort of special treatment is justified?
Physicians often deal with relative or absolute shortages of resources. It would be unethical to provide special treatment in the face of an absolute shortage of resources. For instance, it would be morally impermissible to admit a colleagues’ family member to the last available ICU bed solely based on a professional connection, if doing so would deprive another patient of needed treatment. For special treatment to be acceptable, it cannot result in harms to identifiable patients.
However, it may be acceptable to provide special treatment when there is a relative shortage of resources. For instance, it may be morally permissible for a physician to spend additional time with a patient who is the family member of a colleague or obtain additional imaging for that patient, provided that no other patients’ medical interests are harmed by the delay. Similarly, it may be ethically acceptable to expedite hospital admission from the Emergency Department provided that all patients who need an inpatient bed will ultimately receive one. Reasonable partiality is therefore consistent with special treatment even when there are relative shortages of resources, provided that all patients receive an adequate level of care that is consistent with professional standards.
Discussion
Some may resist the use of partiality specifically because it favors those who are well-connected. It advantages those who are already well-acquainted with the medical system. Though this is the case, there are benefits to reasonable partiality. It assuages the worry of physician colleagues, supports physicians in personally meaningful ways, and may even prevent burnout by increasing physician well-being[16]. The significance of colleague-to-colleague support should not be underestimated.
I recognize that this viewpoint may be provocative. My intention in addressing this challenging and controversial topic is to call attention to a practice that is already widespread yet has flown under the radar in most discussions of ethics. At worst, this viewpoint could be seen as tone-deaf. But at best, it could be seen as delineating the proper bounds of a habit that is already extensively practiced yet so poorly studied that we do not know its impact on patient care. I believe this topic deserves consideration, so that is a risk I am willing to take.
Conclusions
Special treatment of physician-colleagues family members is an ethically controversial area in medicine. This paper addresses the question of what types of support we can reasonably extend to those around us. Physicians can provide care that is reasonably partial to their colleagues’ family members, if doing so does not impact the medical outcomes of other patients.
References:
[1] In this paper, I refer to the family members of physicians, but similar practices are likely to occur with regards to medical staff including nurses, physical therapists, or administrators who have family members who receive medical attention at the hospital at which they work.
[2] Morgan M. Matt Morgan: Treating a VIP patient BMJ 2020; 369 :m1973 doi:10.1136/bmj.m1973
[3] Gross DA, Zyzanski SJ, Borawski EA, Cebul RD, Stange KC. Patient satisfaction with time spent with their physician. J Fam Pract. 1998 Aug;47(2):133-7. Erratum in: J Fam Pract 1998 Oct;47(4):261. PMID: 9722801.
[4] Persad G, Wertheimer A, Emanuel EJ. Principles for allocation of scarce medical interventions. Lancet. 2009 Jan 31;373(9661):423-31. doi: 10.1016/S0140-6736(09)60137-9. PMID: 19186274.
[5] Almond B. Reasonable partiality in professional relationships. Ethical Theory Moral Pract. 2005 Apr;8(1-2):155-68. doi: 10.1007/s10677-005-3285-5. PMID: 16459402.
[6] Blum, L., Against Deriving Particularity, B. Hooker and M. Little (eds.), 2000
[7] Scheffler, S. (2010). Equality and tradition. Questions of value in moral and political theory. Oxford, UK: Oxford University Press.
[8] Nortvedt, P. Needs and closeness—Defending a reasonable partiality in nursing care. Nurs Philos. 2019; 20:e12256.
[9] Nagel, T., Equality and Partiality. Oxford: Oxford University Press, 1991.
[10] Singer, P. (2002). One world. The ethics of globalisation. Yale: Yale University Press.
[11] Winston Chiong (2006) The Real Problem with Equipoise, The American Journal of Bioethics, 6:4, 37-47, DOI: 10.1080/15265160600755565
[12] Rerucha CM, Salinas R Jr, Shook J, Duane M. House Calls. Am Fam Physician. 2020 Aug 15;102(4):211-220. PMID: 32803925.
[13] Berman S. The Importance of Attending Patient Funerals. Pediatrics. 2018 Jul;142(1):e20173977. doi: 10.1542/peds.2017-3977. Epub 2018 Jun 5. PMID: 29871890.
[14] Nortvedt, P. (2001). Needs, closeness and responsibilities. An inquiry into some rival moral considerations in nursing care. Nursing Philosophy, 2(2), 112– 122.
[15] (Tarasoff v. the Regents of the University of California, 1976)
[16] Wallace JE, Lemaire J. Physician well being and quality of patient care: an exploratory study of the missing link. Psychol Health Med. 2009 Oct;14(5):545-52. doi: 10.1080/13548500903012871. PMID: 19844833.