Minkoff Howard, Ecker Jeffrey
Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York; and the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
Obstet Gynecol. 2017 Aug;130(2):454-457. doi: 10.1097/AOG.0000000000002138.
Physicians who work in medical organizations are called on to fulfill two roles: guild members who work to advance physician interests (eg, lobbying for tort reform) and professional society members who work to advance patient interests (eg, developing clinical guidelines). Most often, physicians' self-interest and their interest in patient well-being align. When they do not, members of a guild or profession may justify the prioritization of self-interest with a form of motivated reasoning (a process wherein physicians weigh data differently depending on whether it supports their a priori beliefs). This allows physicians to frame self-interest as being in the best interests of their patients (eg, tort reform makes malpractice insurance affordable and allows physicians to continue to serve their patients). When interests conflict, physicians must be cognizant of the forces at play, that is, self-interest or in-group interest on the one hand and obligations to patients on the other. This entails recognition and negation of motivated reasoning. Often the most difficult calculus is evaluating proposed actions that would disadvantage physicians but advantage patients. In such cases, the health care provider must be aware not only of the temptation to oppose the action for financial reasons, but also the equally natural temptation to frame the proposal as a threat to patient well-being. Ultimately recognizing that a central tenet of professionalism is the primacy of patient welfare should help physicians both to maintain their fidelity to patient good and to uphold their reputation for altruism.
一是作为行会成员，努力促进医生的利益（例如，游说侵权法改革）；二是作为专业协会成员，努力促进患者的利益（例如，制定临床指南）。大多数情况下，医生的自身利益与他们对患者福祉的关注是一致的。当两者不一致时，行会或专业团体的成员可能会通过一种动机性推理形式（在这个过程中，医生根据数据是否支持他们的先验信念而对数据进行不同的权衡）来为自身利益的优先性进行辩解。这使得医生能够将自身利益表述为符合患者的最大利益（例如，侵权法改革使医疗事故保险负担得起，从而使医生能够继续为患者服务）。当利益发生冲突时，医生必须认识到起作用的各种力量，即一方面是自身利益或团体利益，另一方面是对患者的责任。这需要认识并否定动机性推理。通常，最困难的权衡是评估那些会对医生不利但对患者有利的提议行动。在这种情况下，医疗服务提供者不仅必须意识到因经济原因而反对该行动的诱惑，还要意识到同样自然而然地将该提议表述为对患者福祉构成威胁的诱惑。最终认识到专业精神的核心原则是患者福利至上，这应该有助于医生既保持对患者利益的忠诚，又维护他们利他主义的声誉。
