Most physicians would agree that ethics enter into all aspects of medicine and care. Yet despite this near universal acknowledgment, ethics lack a defined structure that would enable physicians to navigate the complex trappings of a medical practice. In a heterogeneous world in which third-party reimbursement, medical malpractice, fiscal policies, and employee management are just some of the factors requiring physicians' continued attention and consideration, ethical standards are always in flux.

In dermatology, the array of ethical dilemmas could arguably be considered more expansive than in other medical specialties because of changing conditions of practice and new directions in research. With cosmetic dermatology playing a larger role and the overall face of dermatology changing all the time, physicians are charged with great responsibility to patients, employees, and to dermatology.

Ahead, we will take a look at what ethics means to some dermatologists and examine the number of ways in which ethical conflicts figure into daily practice.

Inherent Conflicts
There are many potential manifestations of ethical conflicts in the practice of dermatology, but some experts argue that most of these conflicts follow the same underlying theme. "The fundamental tension in modern-day medicine and dermatology involves monetary interests conflicting with the Hippocratic oath to which all physicians strive to adhere," observes Jacob Levitt, MD, Assistant Clinical Professor at Mount Sinai School of Medicine in New York City. A number of issues beg to be examined regarding this connection, but Dr. Levitt observes that the relationship of these two principles—the patient's right to health and the doctor's right to profit—represent the foundation of the wide number of ethical quandaries in medical practice. "Our oath and position demands that if the means exists for making a patient healthy, we should employ them," he says. This notion is sound in concept but can lose some of its value when considering the everyday realities of medicine, Dr. Levitt explains.

These symbolic concepts appear to cleanly contrast one another, but their relationship is far more intricate. In fact, one could argue that neither functions in isolation of the other. In other words, there are no perfect world scenarios in which you can always maximize profit while treating patients unconditionally and fairly. Clouding this scenario is the fact that financial factors are so closely tied to medical considerations and decisions, many of which surface in everyday clinical encounters and patient encounters.

These situations may occur frequently in dermatology due to the visual nature of the specialty, according to Joseph Jorizzo, MD, Former and Founding Chair of Dermatology at Wake Forest University School of Medicine. "You may encounter a textbook diagnosis of actinic keratoses, but what you disclose to the patient could impact the treatment plan," says Dr. Jorizzo. He points out that a majority of physicians would not fail on their oaths to provide accurate diagnoses and beneficial treatment, noting the importance of making every consideration even in seemingly straightforward clinical situations. "Every exam room encounter is linked to a larger network of healthcare, from billing to dermatopathology, which is why it is essential to provide as honest and informed assessment as you can, even in seemingly routine cases," Dr. Jorizzo observes. That network is dense with financial and legal nuance, making it sometimes seem easy to gloss over detail or to rationalize certain clinical assessments.

Dermatologists treat a plurality of conditions, from basic skin tags to malignant cancers. Often, physicians make clinical judgments based on visual evaluation and limited discussion with patient. They then decide on a course of treatment all in a matter of moments. Every decision made in an exam room results in notations in coding for reimbursement, which then impact the welfare of the practice and the patient's immediate and possibly long-term health. "Physicians can and should do everything they can to always be as fair and honest as possible inside and outside the examination room," notes Dr. Levitt.

This turns out to be a struggle, however, especially in light of the physicians' familiarity and investment in their practice. For example, although doctors should not base their clinical decisions on reimbursement rates, refusing to acknowledge these rates when making decisions in the exam room is unrealistic and unlikely. Since coverage varies between companies and policies, some procedures will likely result in greater reimbursement than others, notes Dr. Levitt. "When faced with the choice of two procedures that would result in a similar outcome for the patient, a physician might be tempted to do the higher paying procedure. These situations occur every day in practice and are inevitable," he explains. But according to Dr. Levitt, the question is how much one's knowledge of these rates can or should influence a decision, especially if there is a gray area regarding the benefits of a chosen treatment

In an ideal scenario, the doctor would see the patient, be ignorant of reimbursement rates, perform or prescribe the appropriate treatments, document them, and then hand the records over to a coder, says Dr. Levitt. "But because doctors are familiar with reimbursement policies, their decisions are at least partly dictated by which option will pay more," he notes. Sometimes it's the difference between freezing actinic keratoses or using a cream, or doing both. According to Dr. Levitt, this only becomes a major issue when the physician knowingly prescribes a lesser treatment because it is better for the physician. But there are levels of ambiguity that arise from the specific nature of the specialty, he explains. "For example, you may have a patient who comes to your office for one problem. You could bill it with a lower paying code. However, noting another diagnosis, even if it is not relevant to the patient's well-being, sometimes results in higher reimbursement," says Dr. Levitt. "So, there is an incentive for the doctor to do more work, in this case finding a second diagnosis, than she or he otherwise might have." Dr. Levitt sees no fault in physicians seeking reimbursement, but he also acknowledges potentially slippery ethical terrain.

"Physicians might not deliberately search everywhere on the patient's body to find more, but there may be an unconscious temptation to examine patients more thoroughly in search of that second condition to make the visit a higher level of reimbursement," Dr. Levitt says. Other potential ethical quandaries include performing unnecessary biopsies or doing a limited exam instead of a complete exam so that a patient would have to return for a follow-up visit, resulting in reimbursement for two visits instead of one, observes Dr. Levitt. While the threat of a malpractice lawsuit balances out egregious and over-extensive procedures, physicians would benefit more from keeping themselves in check, he says.

Another component in this discussion is the simple fact that the majority of patients cannot identify skin conditions in the way that dermatologists can, Dr. Levitt suggests. If you are examining a patient with one or more benign moles, there is always a question of how much to disclose before initiating a procedure. "That is, most doctors would opt to observe things they genuinely felt were benign. Others would opt to remove things with even a remote possibility for malignant potential," says Dr. Levitt. "The way you present the need for removal should be dictated not by the reimbursement for the biopsy but by the gut feeling of the physician." Unfortunately, the counseling leading up to such procedures and the procedures themselves can fall in a gray area.

Also a consideration is who to charge, how much, and when to do it. "Selectively charging for procedures raises a number of ethical questions about fairness and equal care," Dr. Levitt notes. Each patient likely arrives in your office under different economic and social circumstances, he notes. The physician may know about some of these circumstances and others not. These factors may inevitably influence a doctor's decision to charge or not charge for some minor procedures, which presents unique challenges that perhaps can't be fully addressed.

These are only a few examples of how everyday decisions and procedures can carry great ethical weight. Dr. Levitt therefore reminds dermatologists to consider all angles when deciding on a course of therapy. Obviously, the extent of these considerations cannot be infinite, but Dr. Levitt implores only that doctors be mindful of these details.

Ethics in Cosmetic Dermatology
Ethics also play a role in the increasingly prominent realm of cosmetic dermatology. Dr. Levitt observes that cosmetic dermatology warrants different considerations than medical and surgical dermatology, stemming from financial and social reasons. First, he notes, the incentive structure is unlike other areas of the specialty, simply because third party reimbursement plays no role. Because patients mostly pay out of pocket, physicians are not incentivized beyond the services they provide. While some patients have a precise idea of what they want, others' interest is curiously unsure. Doctors should always be acting in the interest in the patient, but Dr. Levitt notes that the significance of that "interest" greatly changes in cosmetic situations, since doctors are actually selling something elective. "The patient approaches the doctor to buy something rather than in a capacity to seek medical help, such as excising a melanoma," he says.

Of course, one can argue that cosmetic procedures enhance the patient's self-esteem and psychosocial functioning, making it a legitimate medical procedure. However, for better or for worse, society's standard labels these procedures as elective and in most cases extraneous or unnecessary. "In that light, does the doctor have free reign to suggest that a patient should undergo more procedures than the patient originally came in for?" Dr. Levitt asks. Most cosmetic dermatologists would argue that they suggest strictly what they feel would make the patient look and feel the best about themselves. Sometimes that involves suggesting fillers in addition to the patient's original request for just Botox (to the doctor's economic advantage), or suggesting that a patient not use a filler and just use Botox when s/he originally requests both (against the doctor's economic advantage for that visit, at least). But there are many considerations that physicians should make, according to Dr. Levitt. "In the case of someone with body dysmorphic disorder, the latter scenario would hopefully be in effect. The physician has to make a judgment as to whether or not to proceed with a requested, even high paying, procedure."

Perhaps the most commonly perceived ethical misstep arises when the doctor suggests additional procedures more on the basis of his or her own financial gain rather than on optimizing patient outcomes. Indeed, some procedures probably don't contribute much to the patient's appearance but also carry minimal risk. "So, couched in the disclaimer that it could help and wouldn't hurt, some physicians might strongly advocate for such a procedure," says Dr. Levitt. "I would view this as an ethical dilemma where full and fair balanced disclosure to the patient helps mitigate the problem."

A Dialogue
Most doctors would attest that negotiating the everyday ethical challenges of being a physician is so challenging because of high level of ambiguity associated with the practice of medicine. Trying as these ethical conflicts may be, physicians' responsibility to themselves and their patients is to upkeep a personal standard of ethics and continually try to improve on them. While this may sound simple enough, it can be difficult without a tangible set of tasks or operations for maintaining and bettering individual codes of ethics.

According to Dr. Jorizzo, there are many ways for dermatologists to make ethics a more prominent part of their practice. "The most effective means for improving theses standards is to make ethics the subject of discussion in the medical community and in our own communities," Dr. Jorizzo says. He recommends that dermatologists participate in local and regional dermatologic societies. "The built-in flaw to the notion of an ongoing dialogue is that those who would be most likely to be part of the vocal minority of unethical doctors would probably not attend local or regional medical society meetings," he explains. Nevertheless, for the majority of physicians who pride themselves on sound ethical considerations, active involvement in these groups will likely yield higher overall ethical standards, Dr. Jorizzo argues.

For a starting point, Dr. Jorizzo cites the American Academy of Dermatology as an excellent source of information. "The AAD has a big role in generating healthy discussion amongst the dermatology community, within the scope of its official program and also through less formal interaction among members," he observes. Outside this, Dr. Jorizzo recommends investigating dermatologic, other medical, and non-medical groups, such as university or community discussion groups, regarding ethics and related topics that might be of interest. "These meetings provide healthy ways for physicians and their peers to discuss the wide variety of issues pertaining to ethics," he says.

Since ethics have so many meanings and applications in medical settings, dialoguing helps physicians to understand their decisions and actions in practice, according to Dr. Jorizzo. By understanding how their peers perceive ethics and discussing the role of ethics, physicians will enabled themselves to incorporate sound ethical approaches into their own practice. On the whole, Dr. Jorizzo believes that physicians are already doing this. "A sweeping majority of dermatologists maintain a rigorous ethical standard when in the examination room," he says.

Through discourse and action, physicians can enact greater ethical standards in all aspects of medicine. And as the face of dermatology continues to morph and grow, these higher standards are all the more relevant.

Standard Improvement
Renowned linguist and philosopher Noam Chomsky once noted that the key difference between morals and ethics is that where morals are rhetorically structured as absolute, ethics are contingent. This distinction makes for great philosophical reflection, but it also may provide a sound foundation for thinking and talking about ethics in medical practice in the circuitous environment of contemporary medicine. Without absolute standards for ethics and medicine, Dr. Jorizzo reminds, dermatologists should keep the dialogue about ethics alive and well. "Dermatology functions in a wide array of capacities, each of which presents unique ethical challenges," he explains. This is especially important as new procedures, drugs, and research continue to take the specialty in new directions.

Physicians must be more than experts on patient care and disease management, according to Dr. Levitt. "They must also negotiate the ethical challenges of delivering top care in a manner that is honest and respectful of patients, themselves, and the institution of medicine," he says. As dermatology continues to grow, perhaps it's most useful to view the specialty as a collection of people who make it up— physicians, patients, medical professionals, pharmaceutical representatives, etc. While there is no officially documented code of ethics that can address every clinical situation, the specialty's standard of ethics is defined by the actions of its facilitators. The day-to-day actions of all dermatologists affect that balance, and where one individual strives to improve, so too will the specialty.