- BIOETHICS FORUM ESSAY
The Ethics of Treating the President
Concerns about the health status of sitting presidents of the United States can raise significant questions in medical ethics, notably regarding the scope of a president’s right to confidentiality and of the public’s need—or right—to know about the president’s health, the role and responsibilities of the president’s physician, and the appropriateness of offering unapproved treatments. These concerns are heightened during the global pandemic for which there is no cure or vaccine and limited information about treatments.
In general, patients have the right to confidentiality of their health information and the right to consent to disclosure of it. However, these rights are not absolute. Patient information may be shared without consent for purposes of health care operations and under certain conditions for quality improvement activities and research that can lead to benefits for all patients. Under certain circumstances, we expect patient health information to be disclosed without consent to appropriate parties to protect others—for example, mandatory reporting for public health purposes or to protect a patient or third party when the physician believes the individual poses an imminent risk of harm to himself or herself or threatens serious harm to others.
In important ways, the president of the United States is not like any other patient. The president’s health status carries significant implications for the security and well-being of the polity nationally and, arguably, internationally. The public, therefore, has a strong interest in being informed about the president’s health status and should be able to trust that the information will be timely and accurate. In any context, disclosure should be restricted to the minimum information necessary to serve the public interest. Just what should count as “minimum necessary” is an important question: Only a very basic statement about status and prognosis? A summary of the overall plan of care? Or details about specific proposed interventions? Precisely what information is truly in the public interest will surely vary with circumstances. The severity of the president’s condition, including the risk to the president’s ability to function, and prevailing social and political conditions, such as a public crisis of some sort, would need to be taken into account. But in all cases the public’s “right to know” is not the right, carte blanche, to have curiosity satisfied.
To the extent that the president is a unique patient, the president’s physician has unique responsibilities both to the patient and the public. Given physicians’ fiduciary responsibility, the patient’s interests will dictate treatment decisions. However, the president’s physician is also a public servant, who should be sensitive to the public’s interest in the president’s health.
Military physicians are familiar with the situation of divided loyalties—to the well-being of individual soldier-patients and to the military mission. For military physicians, putting the patient’s interests first can put not only the mission, but also the physician’s individual career at risk. Which of those loyalties should, ethically, prevail is the subject of ongoing debate. When the president’s physician is a member of the armed forces, the physician faces a further dilemma: not respecting the president-patient’s preferences for care when they do not coincide with the physician’s best professional judgment is to decline a direct order from the commander-in-chief; providing treatment that the physician believes will not achieve the desired goals of care contravenes the ethics of medicine.
Under normal circumstances, we assume that physicians will recommend only approved, scientifically validated interventions. However, in some situations, physicians may introduce innovations into clinical practice or support a patient’s access to interventions still in clinical trials.
Innovating in clinical practice includes using an existing, approved intervention in a novel way—such as off-label use of an approved medication—and shares features with both research and patient care. Ethically sound innovation requires that physicians who introduce innovations into their practice should have appropriate clinical expertise and base the innovation on sound scientific evidence. Guidance also calls on them to be aware of financial or other influences not directly related to patient or public benefit that may drive innovation. Physicians should also collect and share information about their use of innovative therapies.
In some circumstances, physicians may also support access to experimental treatment outside of a clinical trial. When there is no approved treatment for a patient’s condition, physicians should consider not only the potential risks of an experimental therapy but also whether the patient would meet inclusion criteria for clinical trials of the therapy. If the patient is unable to participate in a trial, the physician should discuss the implications of seeking access to an investigational therapy through the Food and Drug Administration’s expanded access program.
Use of a therapeutic innovation or an unapproved treatment presents risks to the patient that may differ in significant ways from standard therapy and are not fully understood. Is it ethically appropriate, then, for a physician to prescribe or permit the president to receive such therapy? The answer depends on such factors as the severity of the patient’s condition and urgency of medical need, evidence of likely benefit for the patient, the known or reasonably foreseeable risks, and whether timely alternative options for treatment are available.
As a matter of professional ethics, physicians are not required to offer or provide treatment they cannot be reasonably certain will benefit the patient nor to accede to a patient’s request for unproven treatment—even a patient who has the power, authority, and public significance of the president. Moreover, decisions for a figure as prominent the president carry public messages that may have unintended consequences—for example, encouraging ill-considered use of unproven interventions or undermining willingness to participate in clinical trials. Finally, granting the president or another public figure privileged access to innovative or experimental treatment is consistent neither with physicians’ obligation to be responsible stewards of resources in the public interest nor the duty to ensure that all patients receive the same quality of care without regard to medically irrelevant personal characteristics or financial means.
Elliott J. Crigger, PhD, is director of ethics policy and secretary of the Council on Ethical and Judicial Affairs for the American Medical Association.Read More Like This