Patients priorities are always supposed to come first, but doctors can find themselves in ethically challenging situations when their preferred treatment is at odds with how their employer wants them to proceed.
With the high cost of some forms of treatment and a healthcare system constantly searching for the best way to divvy up finite resources, doctors are forced to weigh competing values -- and it's rarely an easy decision, according to Anita Ho, an assistant professor at the W. Maurice Young Centre for Applied Ethics at UBC.
"The physician is in a dual role situation," she said. "They have to be a steward to the organization, they're responsible to make sure their practice is in compliance with what the facility would promote. But at the same time they have an obligation to what's in the best interest of the patient."
Ho cautioned that doctors need to be sure exceptional treatments they recommend are approved by Health Canada and that they're not suggesting an alternative treatment as an experimental trial. She said the procedures they propose must also be safe for the patient.
A myriad of ethical issues came to light surrounding the departure of oncologist Dr. Suresh Katakkar from the BC Cancer Centre for the North. Katakkar resigned as the chief oncologist in June after the BC Cancer Agency launched an investigation into his practices, which included using treatments outside of standard protocols. In a letter to patients, Katakkar insisted he always had his patients' best interests in mind when he made decisions to bend the rules.
The investigation is ongoing and the cancer agency will not comment on the inquiry.
Some of Katakkar's former patients believe the reason he ran afoul of the provincial agency is because he constantly pushed for more expensive treatment options.
The issue of costs come up when a certain treatment is unusually expensive or if the patient isn't covered by provincial health coverage but is in need of specialized treatment.
Ho said it's dangerous to regularly make exceptions and approve an expensive treatment just for one patient because the decisions aren't always made for the right reasons.
"In general doing micro-allocations is very difficult ethically or economically because very often it goes back down to an emotional appeal," she said.
Doctors can also find themselves in a tough spot if they recommend a treatment that may be done in a private clinic or in the United States, but the patient isn't able to pay for it.
"The family may say, 'Well we can't afford it elsewhere. You have the know-how to do it, you should do it for us,' " Ho said. "Then sometimes in those situations the clinician can be in a bind."
Doctors in BC are beholden to the Canadian Medical Association's (CMA) ethics guidelines which cover everything from putting the well-being of the patient first to doctors recognizing their own limitations. The four-page document has 54 points doctors should keep in mind when conducting their business.
The CMA first published a code of ethics in 1868 and has been constantly updating and revising it ever since. The document has evolved drastically over the years -- for instance in the original version patients were strongly discouraged from seeking out second opinions, while the most recent edition encourages the practice.
Doctors receive some ethical training in medical school, but there's no requirement they engage in any further ethics education during their ongoing professional instruction.
A 2005 University of Toronto study which surveyed 12 ethics specialists at Toronto hospitals revealed that conflicts over treatment decisions were the top ethical issues doctors in that city faced. Many of the disputes cited in the study revolved around families of terminally ill patients disagreeing with doctors on how to proceed.
"Disagreements range from withdrawing aggressive treatment from a terminally ill patient to a family physician refusing a patient's request for antibiotics for a viral infection," the report stated.
Ho said both resource allocation and the patient's best interest can be focal points for conflicts in end-of-life care. For instance, inserting a feeding tube may keep a patient alive for a while, but it could increase the chances of an infection.