Ethics and Oncology

Ethics and Oncology

George W. Sledge, MD, FASCO

Jan 14, 2011

I learn so much about my profession by listening to my colleagues speak, and attending ASCO's many committees has accelerated my education. Today I sat in on the Ethics Committee meeting, chaired by Dr. Paul Helft. Paul, like most of his fellow committee members, has devoted his career to wrestling with ethics issues in oncology (for an interesting interview with Paul please see this month's ASCO Connection).

I suspect that a common view of ethicists is of a group of up-in-the-clouds guys divorced from reality and spouting philosophical generalities. Ten minutes at the Ethics Committee would dispel this notion. First, because the members of the committee are, by and large, practicing oncologists who wrestle with the same issues all practitioners face. But secondly, because almost everything we do as oncologists touches on ethics issues. And those issues are often difficult ones, without simple, sound-bite answers. As Paul Helft said at the meeting today, ethicists have discussions rather than answers.

To give some sense of the breadth of discussion, we heard about the ethics of futility (when do you tell a patient with metastatic disease that enough is enough? Second line, third, or fourth line chemotherapy?). What do you do with a Medicaid patient that you see in the hospital when the bean counters at the company that owns your practice say that you cannot care for that patient on an outpatient basis? Who owns that portion of chromosome 17 that the BRCA1 gene occupies? What is the ethical duty of a physician to an illegal immigrant seen in a hospital ER with a fungating breast mass when your state says they will not provide care? Some of these have been discussed in ethics vignettes published in the Journal of Oncology Practice, and you can expect to see others in the near future. What comes through, loud and clear, is how eminently practical ethics discussions are for cancer health care professionals, and how important it is for us to keep thinking about and wrestling with these issues.

Indeed, one can argue that ethics is more important than technology, in the sense that there is always something transitory about technology and something permanent about ethics. You can read the oath of Hippocrates and sense that you are part of a long chain of "practicing ethicists," part of that tradition of humanity and decency that makes our field worth joining by young practitioners.

But enough of waxing eloquent. We also discussed conflict of interest (COI) issues at length. I have been impressed over the years how much time and energy our organization devotes to COI. As a provider of education to practicing physicians, we have an ethical (no, practical) obligation to make sure that the research we present at our annual meeting and in our several journals and in our practice guidelines are free of bias. ASCO has led the way on this issue, as our championing of the recent CMSS guidelines suggests. But it remains, and I suspect will remain, a work in progress. How much of COI problems are handled by disclosure? What needs to be disclosed? If a conflict exists, how do you manage it? And where does one draw the line with flat-out prohibition? We have had policies in place on these issues for several years, but they continue to evolve with the times, generally in the direction of increasing transparency and improved reporting.

In this progressive evolution, our colleagues on the Ethics Committee are to be thanked for their efforts on our behalf. They are an exceptionally thoughtful and hard-working group, ably supported by our superb (as usual) ASCO staff (Courtney Storm in particular, backed by several of her colleagues). I would also like to mention that our Leadership Development Program group has tackled the COI issue. Many of you have filled out the online questionnaire they have sent out to our members focusing on COI reporting issues. Those of you who have not still have a little time to weigh in on this important subject.

That's it for now—I am off for Indy.


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