Competing and conflicting interests in the care of critically ill patients
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REVIEW
Competing and conflicting interests in the care of critically ill patients Alison E. Turnbull1,2,3*, Sarina K. Sahetya1, E. Lee Daugherty Biddison1, Christiane S. Hartog4,5,6, Gordon D. Rubenfeld7,8, Dominique D. Benoit9, Bertrand Guidet10,11,12, Rik T. Gerritsen13, Mark R. Tonelli14,15 and J. Randall Curtis15,16 © 2018 Springer-Verlag GmbH Germany, part of Springer Nature and ESICM
Abstract Medical professionals are expected to prioritize patient interests, and most patients trust physicians to act in their best interest. However, a single patient is never a physician’s sole concern. The competing interests of other patients, clinicians, family members, hospital administrators, regulators, insurers, and trainees are omnipresent. While prioritizing patient interests is always a struggle, it is especially challenging and important in the ICU setting where most patients lack the ability to advocate for themselves or seek alternative sources of care. This review explores factors that increase the risk, or the perception, that an ICU physician will reason, recommend, or act in a way that is not in their patient’s best interest and discusses steps that could help minimize the impact of these factors on patient care. Keywords: Critical care, Patient-centered care, Research design, Clinical studies as topic, Conflict of interest Introduction Despite often meeting for the first time at admission, most hospitalized patients trust clinicians with their lives. In the intensive care unit (ICU), this trust is born of necessity—after all, most ICU patients are not stable enough to seek care elsewhere. However, it is naïve for clinicians to assume patient trust is invulnerable or entirely rational, especially as public trust in scientific, political, religious, and media institutions falters in some parts of the world [1–3]. Trust is the belief that another person or entity will act in our best interest [4, 5]. Public trust in the medical profession stems in part from policies instructing healthcare providers to prioritize patient interests above other interests. For example, the American Medical Association (AMA) states in its Code of Medical Ethics [6] that
*Correspondence: [email protected] 1 Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument St, 5th Floor, Baltimore, MD 21205, USA Full author information is available at the end of the article
“physicians’ ethical responsibility [is] to place patients’ welfare above the physician’s own self-interest” (Opinion 1.1.1). As a result, unless they belong to a population that has historically been harmed by medical professionals [7–9], patients and their families rarely question clinician motives. But while patient welfare, or well-being, is a clinician’s primary interest, competing interests are ubiquitous [10]. Managing the competing interests of other patients, clinicians, hospital administrators, trainees, and one’s own implicit biases has become so routine that we often forget this balancing act is ever-p
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