AMA Journal of Ethics^®

As professionals, we sometimes act like Jean Piaget’s young subjects who focused on only one feature of a container—e.g., its height—when estimating the quantity of liquid it could hold [1]. Such “centrated” children would, for example, reason that, of several 12-ounce containers of varying heights and widths, the tallest would hold the most. One of the principal tasks of cognitive development in many domains—including the moral domain—is decentration, which occurs as we move beyond the stage of focusing on one salient feature of a task to the exclusion of others [2]. In approaching an ethical problem in clinical care, for example, we may need to consider many different aspects of a situation—competing stakeholders’ interests, ethical or legal norms that need to be balanced, intentions, social processes for resolving disputes, and the consequences of actions. Ignoring any one piece of the puzzle can lead to disastrous results.

Maintaining a Professional Focus on Patients

For physicians, maintaining a broad view in moral decision making can be challenging. The patient-physician relationship is fiduciary, meaning that patients must be able to trust that the physician will prioritize their best interests over his or her own. Thus, it is not contradictory that the American Medical Association’s Principles of Medical Ethics states both:

A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
[and]
A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care [3].

Other articles in this issue of Virtual Mentor explore how weighing one’s own needs and preferences against those of patients in society may lead to very different professional choices, including the choice of a medical specialty.

• Physicians face many challenges to maintain proper professional perspective. Consider the following examples:
• Medical research may redirect physicians’ attention from therapy to generating new knowledge even when there are effective treatments for patients who need treatment [4, 5].
• Financial rewards for performing procedures and diagnostic tests may redirect attention from the patient’s needs to the potential for personal profit [6].
• The needs of one patient may cause one to overlook the needs of another (e.g., in evaluating candidates for living organ donation, patients’ medical suitability may overshadow their financial or emotional unsuitability) [7].

Not one of these examples involves bad choice. To the contrary, new knowledge, financial rewards, and providing a dying patient with a transplanted organ are all good intentions. Shifts in focus need not involve bad will; in fact, some evidence suggests that “self-serving biases” are natural and operate subconsciously [8, 9].

In a complex environment, oversight committees, laws, and professional guidelines help physicians hold patients’ interests about their own. For example, institutional review boards (IRBs) play an important role in ensuring that human subjects are properly protected in medical research [9]; anti-kickback laws can help reduce the exploitation of financial conflicts of interest [10]; and practice guidelines for the evaluation of living organ donors encourage greater attention to the prospective donor’s well-being [7].

Nevertheless, such mechanisms are insufficient to ensure that medicine is patient-centered. First, they are frequently reactive—they arise only in response to problems that have been identified and received broad attention. Second, many issues—such as the selection of career specialization—are best resolved according to one’s own convictions and conscience. Third, such mechanisms risk shifting attention away from patients toward compliance for compliance’s sake [11]. In the end, professional education and mentoring—not regulations and codes—remain essential to engaging matters of focus and integrity.

Bander Center for Medical Business Ethics

With a generous endowment from Steven Bander, MD, Saint Louis University established the Bander Center for Medical Business Ethics in 2008. The mission of the Bander Center is:

To promote ethical business practices in medical care and research through the development of training and investigation opportunities for medical students, residents, and physicians in practice. We are committed to providing learning opportunities for physicians across the full span of their careers, from the first year of medical school through retirement.

The center’s educational and training programs are designed to foster critical reflection and discussion rather than promoting one ideological perspective. Speakers and programs may engage controversial positions, but do so critically and with responses from scholars when feasible. The center seeks to ensure that recommendations regarding practices and policies are grounded in the best available evidence about physician behavior—its influences and impact on patient care. All activities explore how the manifold business dimensions of medical care and research can be managed to preserve a proper focus on the well-being of patients.

One of the center’s most intensive training endeavors involves developing a body of experts in medical business ethics who will serve the university and eventually a broader community of physicians. In the process, a research assistantship (RA) was established to support an MD/PhD student during the doctoral phase of the program in health care ethics. The RA assists in the development of continuing medical education (CME) opportunities, coordinates events, and provides research support for Bander Center faculty and fellows. The RA is encouraged to pursue his or her own research project in the area of medical business ethics. This experience fosters the acquisition of knowledge and academic skills in medical business ethics in an individual who is likely to build a career in academic medicine.

The Bander Center also has a 1-year fellowship program that supports two junior faculty members in the school of medicine each year. The center protects 10 percent of their time for weekly meetings with a mentor, while they research a medical-business-ethics topic of their choice. By the end of the year, they are expected to publish a peer-reviewed article on their topic and produce PowerPoint slides for use in training sessions with medical students or residents. While the Bander Center faculty is interdisciplinary, we believe strongly that physicians should be mentored by physicians. Accordingly, physicians affiliated with the Bander Center direct the fellowship program, mentor residents, and teach medical students.

In addition to these two intensive training and investigation programs, the center offers:

• Small group discussion sessions with medical students.
• Online continuing education units. The first two topics are Physician-Industry Interactions in Medical Care and Ethical Issues Regarding Free Drug Samples.
• Grand Rounds lectures and noon seminars with residents.
• An annual endowed lecture delivered during the Department of Medicine’s Grand Rounds. Our first two lecturers were Matthew Wynia, MD, MPH, director of the AMA’s Institute for Ethics, who spoke on pay-for-performance and Ezekiel Emanuel, MD, PhD, chair of the Department of Bioethics within the Clinical Center of the National Institutes of Health, who spoke on health care reform.
• A web site (www.slu.edu/bander.xml) with information on upcoming lectures, training opportunities, links to ethics codes and regulations, and other materials.

Finally, the Bander Center collaborates with a newly established program at Washington University in St. Louis, the Bander Business Ethics in Medical Research Funding Program, which offers 1-year grants of up to $25,000 to members of the Institute for Clinical and Translational Science to support original research.

Building Support

Each educational endeavor requires significant dedication of time, resources, and backing from those in charge of medical education, as well as from adult learners themselves.

Especially during challenging economic times, it can be difficult to find adequate resources. Relating medical-business-ethics training to the professionalism requirements of the Accreditation Council of Graduate Medical Education (ACGME) can help garner support within academic medical centers. In establishing the center, we worked closely with our associate deans for undergraduate medical education, graduate medical education, and continuing education, which was essential to the mission of reaching out to physicians from their first weeks in medical school through their years of practice as established specialists. Within the first year, we conducted an online survey of medical school faculty and residents inquiring into the medical-business-ethics topics they thought most important to address, the educational formats they preferred (e.g., online, lectures, journal clubs), and their availability at different times during the week and have tried to tailor the center’s programs to the results of that survey.

Throughout all of our efforts as a center, we constantly engage the question “How might our present topic—e.g., financial conflicts of interest, health care reform, free drug samples, or pay-for-performance—affect patient care?” In the increasingly complex business environment in which medicine operates, this question is more relevant than ever before.