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JAMA. 1988 Aug 12;260(6):812-5.

Ethical problems in the medical office.

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Division of General Medicine, University of Virginia, Charlottesville.


The majority of health care in this country is provided to patients in the office setting. This study, conducted in an internal medicine office practice, describes the ethical problems encountered in medical offices. Two hundred eighty consecutive patients, a total of 562 office visits, were prospectively evaluated. Ethical problems were defined as being present when specific ethical issues came into conflict with the physician's moral obligation to benefit the patient. The majority of the patients studied were white (214) and were women (212). The mean age of the patients was 49 years, with a range from 17 to 98 years. Ethical problems were present in 84 (30%) of the patients and in 119 (21%) of the office visits. The most common ethical problems for the patients were costs of care (11.1%), psychological factors that influence preferences (9.6%), competence and capacity to choose (7.1%), refusal of treatment (6.4%), informed consent (5.7%), and confidentiality (3.2%). Ethical problems were more common in patients over 60 years of age. This study establishes an educational as well as a research base for a broad study of biomedical ethics that looks beyond the problems encountered in the hospital.


In an effort to broaden the traditional focus of biomedical research and education on problems that occur in the hospital, the authors describe the prevalence and range of ethical problems encountered by 280 outpatients during 562 office visits to a community-based general internal medicine practice. Their study, which compiles statistics about the frequency of ethical problems during office visits according to sex, race, age, and classification of ethical issues, indicates that almost one third of the patients seen in office visits present ethical problems that influence their health care. Failure to teach students skills in this area may leave young physicians unable to cope with ethical problems, which may compromise good quality health care and diminish both the physicians' and the patients' satisfaction with medicine in general.

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