1138 ETHICS IN CARDIOTHORACIC SURGERY WATSON ET AL Ann Thorac Surg SERVING AS EXPERT WITNESS FOR PLAINTIFF 2004;78:1137– 41ProDonald C. Watson, Jr, MDT he principle question is important: are thoracic sur- geons ethically obligated to serve as expert witnessesfor the plaintiff? Two ethical arguments follow showing that toward which we should all strive. Relevant virtues include compassion, generosity, integrity, fairness, self- control, and prudence. Then, in the 18th century Kantabsent other disqualifying factors, thoracic surgeons are suggested a rights approach focusing on an individual’sobligated to serve as expert witnesses for the plaintiff or the right to choose. When living in a community, the indi-defense. That of course assumes that the surgeon is able to vidual’s rights include truth, privacy, freedom fromoffer testimony and that the merits of the case justify such harm, and what is promised by a consenting individual.testimony. Doctor Loyall was wrong in refusing on only Finally, the utilitarian approach, a 19th century concep-ethical grounds to testify for the plaintiff. tion of Bentham and Mill, suggested that actions are Ethics discussions help us decide the bases upon which ethical only when they provide the greatest balance ofwe pursue the things we value and the ultimate criteria good over evil.for what we do. However, they serve only as advisory. Four medical moral principles  of behavior haveThe speciﬁcs of each situation vary. Conclusions are evolved with these foundations in ethics. The Hippo-often subjective and almost always involve judgment. cratic Oath suggests that we do no harm and help others,Differences in opinion between competent people can principles of nonmaleﬁcence and beneﬁcence. Patientand do exist on many important ethical issues. We must autonomy, the third principle, has recently risen in im-be respectful of and take into consideration others’ points portance but is not germane to the question posed. Theof view. These ethical considerations, as suggested by fourth principle of justice insists that we do the rightPellegrino , are also undergoing a metamorphosis. The thing for patients and be fair in those actions. Justice is,ethical framework of medicine is changing. more often than not, the most difﬁcult to resolve. Two cautions should be acknowledged. We must be- These foundational principles of ethics and medicine,ware of politically correct actions that have shaky ethical that is, right behavior standards, force us to ask whatfoundations. Armey  suggests, “Politics sooner or later implications naturally follow when applying them to themakes a fool of everyone.” In the long run, actions question posed? These implications are that Dr Loyallsupported by sound ethical principles should prevail. was (1) not serving the common good, (2) treating equalsAdditionally, although used in a different context, a unequally, (3) failing to reach for virtuous goals, (4)political activist suggested, “If we don’t stand for some- ignoring the rights of individuals to truth and freedomthing, we may fall for anything.” Thoracic surgeons must from harm, (5) failing to tip the societal balance of goodstand for moral principles and use professional standards over evil, (6) failing to help future patients, (7) potentiallyor we are likely to fall for the antithesis. allowing harm to future patients, and (8) failing to pro- Two concepts of “ethical” are expanded upon. The ﬁrst vide expert information available for the best possibleinvolves moral, that is, right behavior standards. The sec- evaluation of what was just. It is reasonable to concludeond demands conforming to accepted professional stan- that by refusing, on only ethical grounds, to testify for thedards of conduct. All other criteria being met, each line of plaintiff, Dr Loyall was wrong.reasoning forms an independent ethical justiﬁcation for the A second independent concept of ethical actions de-position that thoracic surgeons are obligated to serve as mands conformity to accepted professional standards ofexpert witnesses for the plaintiff or the defense. conduct. A profession is an occupation whose core ele- A brief summary of ﬁve foundations  of ethical ments require mastery of a complex body of knowledge,thought, in idealized societies, is in order. The ﬁrst ﬁnds used in the service of others, governed by a code of ethics,its basis in early philosophical considerations. Plato de- committed to competence, integrity, morality, altruism, andscribed the common good in a society of individuals. promotion of the public good within its domain.Opining that one’s own good is ﬁrmly linked to the good Our profession has standards and is guided by majorof the community, he concluded that individuals are organizations with established principles of behavior. As aethically bound by the pursuit of common values and matter of ethical behavior, thoracic surgeons are obligatedgoals. Subsequently Aristotle expressed the fairness and to comply with them in their actions. The American Med-justice approach by noting that equals should be treated ical Association (AMA) suggests  that as citizens andequally. In our judicial system, the plaintiff and the professionals, physicians have an ethical obligation to assistdefendant are equals, thus requiring equal treatment for in the administration of justice. The American College ofthe plaintiff and the defendant. As this notion was later Surgeons (ACS) Code of Conduct [5, 6] suggests thatpursued in ethics discussions, favoritism and discrimina- surgeons, in part, must accept responsibilities to serve astion were considered unjust and wrong. Additionally, the effective advocates for patients’ needs, to provide the high-virtue approach maintains the existence of certain ideals est quality of surgical care, and to participate in self-
Ann Thorac Surg ETHICS IN CARDIOTHORACIC SURGERY WATSON ET AL 11392004;78:1137– 41 SERVING AS EXPERT WITNESS FOR PLAINTIFFregulation by setting, maintaining, and enforcing practice not change the response to the question posed. Issues ofstandards. By refusing on purely ethical grounds to testify, correcting a malfunctioning system do not change theDr Loyall was wrong by not fulﬁlling this ethical obligation fundamental goals.to conform to accepted standards of physician conduct. Third, in our daily actions, we must consider practicalDoctor Loyall would not be assisting in the administration consequences. Politically correct actions, which may be inof justice, would not accept responsibilities to advocate for opposition to moral obligations, allow us to get along withinpatients, and would not help to calibrate and improve the our community and to survive with less stress. The penaltyquality of surgical care, or setting, maintaining, and enforc- for violating a strictly moral obligation is primarily per-ing standards of practice. sonal. The penalty for adhering to a moral principle, in In general, when considering two ethical alternatives it violation of loyalty, can be steep. Some surgeons, in allis helpful to ask ﬁve questions , namely, which alter- subspecialties, have stood on moral principle only to havenative (1) best respects the moral rights of those affected, their lives adversely affected because the community(2) leads to the best overall consequence, (3) treats, in viewed that moral stance as not loyal.process, the parties equally, (4) advances the common Fourth, if one is to testify, one should adhere togood, and (5) develops moral virtues? In balance, greater established standards. The ACS  and the Society ofgood over evil is achieved when physician experts pro- Thoracic Surgeons (STS)  have described qualiﬁca-vide the best possible information and advice to a system tions and standards of behavior for expert witnesses.adjudicating a dispute. Physicians are ethically obligated Qualiﬁcations include the following: possess a valid cur-to testify for the plaintiff or the defendant depending on rent and unrestricted license to practice, have board/their ability and the merits of the case. We must stand for specialty certiﬁcation, practice in a specialty appropriatemoral principles of behavior. Professional standards de- to the case, possess familiarity with the standards of careﬁne those principles. at the time and place of the case, have continuing medical A few caveats are in order. First, this issue is emotion- education relevant to the specialty and the case, and haveally charged. Emotional reactions about colleagues testi- the ability to document time spent and fees. The ACS andfying against colleagues are intense. Thoracic surgeons STS suggest there is an obligation to testify when appro-are not exempt from these most human reactions. This priate. Behavior standards include telling the truth, re-response often interferes with our collective ability to viewing the case making fair and honest inferences,objectively engage the question posed. distinguishing between an unfortunate outcome and Second, many other important issues are related to this negligence, reviewing the appropriate standards of prac-ethics question, distracting us from the principle at hand. tice, stating the bases for opinions and alternative views,These distractions include but are not limited to disor- and receiving reasonable compensation not linked to thedered, even chaotic, medical-legal systems, qualiﬁcations outcome of the legal case. The AMA also suggests  thatof experts, legal requirements of experts, adversarial expert witnesses, irrespective of being called by eithernature of legal proceedings, differences between medical the plaintiff or the defense, must not become advocatestruth and legal truth, speciﬁc case circumstances, and and must remain nonpartisan.practicality of testifying. The most distracting appears to In conclusion, based on fundamental ethical principlesbe the nature of our medical-legal systems. Since juris- for behavior of individuals living within a communitydiction for these issues resides at the state level, we have and professional code of conduct standards, Dr Loyallmany systems, one differing from another. This fragmen- was wrong in refusing on purely ethical grounds to testifytation fosters disorder. Another reasonable question, as an expert witness for the plaintiff. The reality ofdistracting us from the issue at hand, arises: what is one medical-legal proceedings in our society, however, pre-to do in a system that appears to be functioning poorly? sents a number of confounding issues making adherenceThis question has great practical signiﬁcance, but does to this ideal practice difﬁcult.ConFrancis Robicsek, MD, PhDS ociety has its way of dealing with important issues. One way is to make them laws. The treating physi-cian is a “factual” witness who has a legal obligation to supposed to render an unbiased opinion in our peculiar medicolegal system, his involvement is called upon only if it promotes the invoking party. If it does not, histestify to the treatment his patient received. In contrast, testimony will neither be given nor heard.just as an uninvolved physician does not have any legal Whenever a physician is asked to render an expertobligation to accept an unknown patient, a medical opinion, he may legally, as well as ethically, decide not toexpert may testify voluntarily, albeit paid. While he is get involved. He may feel unprepared and unwilling to
1140 ETHICS IN CARDIOTHORACIC SURGERY WATSON ET AL Ann Thorac Surg SERVING AS EXPERT WITNESS FOR PLAINTIFF 2004;78:1137– 41be interrogated for hours, have his credentials ques- testimony, others are less than truthful. For our profes-tioned, his family life scrutinized, and his character sional organizations to open the ﬂoodgates of “readilyassassinated by an overzealous attorney. available” witnesses without any quality control of their Or he may be a conscientious objector who believes that testimony would be highly counterproductive. Before weour tort system is wrong and does not help the injured; it accept the concept that it is everybody’s ethical duty todoes not punish the negligent but often hurts the innocent testify, and we provide a list of experts obliged to testify,physician and provides a windfall for the attorney. He may we should fulﬁll our already existing ethical duty to cleanthink the only way to change it is not to participate, but he up expert testifying. Ten years ago I recommended to themight be willing to assist a colleague innocently accused Council of the STS that medical expert testimony shouldand does not consider it his duty to get involved in proce- be reorganized as a professional activity and thus subjectdures against fellow physicians. to peer review, and that a grievance process should be Or he can say the “public trust,” which goes with his made available to both parties. By this mechanism, im-medical license, obliges him to try to make the best of the proper testimony can be readily exposed and false wit-system, to cooperate with it, and make choices on a daily nesses censored and hence removed from the system.basis. This process has now been applied by the American Any of the above may be ﬁtting to one’s own ethical Association of Neurological Surgeons (AANS), which foundchoice and should be respected. It is not unethical. What that one of their members provided “inappropriate andis unethical is for someone to render inappropriate tes- unprofessional” testimony and they suspended his mem-timony for any reason, for any party. That is today’s main bership . The member countersued. The case in whichethical problem and the reason why some physicians are the American Medical Association, the American College ofreluctant to testify. They simply do not want to be Surgeons, and the Illinois State Medical Society ﬁled a jointidentiﬁed with the readily available group of dubious “friend of the court” brief supporting the AANS was re-witnesses who ﬁll our courtrooms with pseudoscience viewed by the Seventh Circuit US Court of Appeals andand are willing to testify “for or against” depending upon decided in favor of the AANS. The US Supreme Courtwho pays their fee. declined to review the case . However, the event was To believe that obliging our profession to testify may labeled by some trial lawyers as an “unacceptable intrusionclean up the situation is naïve. While some attorneys and egregious assault by an overly anxious, embitteredindeed seek an honest reliable opinion, others are look-ing for a witness who says what they want to hear. They group of physicians who are willing to do anything towill go from one potential witness to the other until one pressure their colleagues not to testify.”is found who is either naïve or loose enough to serve Until we make signiﬁcant strides in this regard, or eventheir purpose. thereafter, medical experts testifying should remain an The Trial Bar wants us to actively support the tort issue of personal conscience. I may have testiﬁed in thesystem by providing a readily available list of witnesses. case in question, either for the defendant or the plaintiff,Our answer is this: we are ready if you are ready! Give us depending upon additional information, but I do nota process that fairly and speedily compensates the in- castigate those who exercised their First Amendmentjured patient, punishes the negligent physician, protects right by keeping their mouth shut. My feelings are bestfrom frivolous, costly litigation—and they will not ﬁnd a expressed by the words of Dr Mark Gorney  pub-more cooperative partner than we are. We are ready to sit lished in the Bulletin of the American College of Surgeons:down tomorrow to discuss no-fault insurance, review “The moment of truth is at hand when you must elect allpanels, mandatory mediation, free, impartial witnesses to circumstances considered whether to act as an expertthe court—whatever. witness against a colleague. Only you, in the loneliness of There is indeed a problem with medical experts—not your mind, can decide which road to follow, because inwith those who do not testify, but with some of those who one direction the circumstances may be overwhelmingdo. While some of them, be it motivation by either for it, whereas in the other, something inside is saying,economic or by intent, do provide a fair and honest ‘There but for the grace of God go I.’”Concluding RemarksRobert M. Sade, MDF ew topics stoke a surgeon’s ﬁre as much as malprac- tice litigation. Watson and Robicsek have presentedstarkly contrasting views of how Dr Loyall should have his opinion. The essayists agree on the central ethical imperatives of medical testimony: all testimony should be truthful, as the surgeon understands the truth, and theresponded to the plaintiff’s attorney who was soliciting witness should have expertise in the area under litiga-
Ann Thorac Surg ETHICS IN CARDIOTHORACIC SURGERY WATSON ET AL 11412004;78:1137– 41 SERVING AS EXPERT WITNESS FOR PLAINTIFFtion. After that, their points of view and reasoning plaintiff if the facts justify such testimony is not to saysharply diverge. that he should be hauled into court unwillingly or lose Watson considers ethics of a physician’s moral obliga- his medical license if he refuses to testify. He has a legaltions from two perspectives, classical ethical standards right not to testify, just as Robicsek says. But if Watson’s(ﬁve different approaches) and standards established by view of professional ethics is correct, then Dr Loyall wasprofessional codes. Each of these perspectives leads nevertheless wrong in refusing to testify.Watson to the same conclusion: Doctor Loyall should Robicsek’s commitment to a legalistic view of Dr Loy-testify, even in the face of the many confounding issues. all’s obligation to testify does not require that he rejectThose issues include a chaotic tort system, the adver- professional ethics as Watson has described it. He couldsarial nature of litigation, the fundamentally different have it both ways, asserting both the right not to testifymedical verus legal standards of ”truth,“ and the adverse and the importance of professional ethics, by arguing, asconsequences for the surgeon in his medical community some have, that legal testimony is not part of professionalif he testiﬁes against a fellow surgeon. practice, so should not be subject to the usual ethical Robicsek identiﬁes many of the same general issues of standards of the practice of medicine, to peer review, orthe case, but the core of his argument is a single ethical to oversight by medical licensing boards . He did notprinciple: autonomy. Physicians, like everyone else in our make that argument, however, so we can not be certainsociety, have the right of self-determination, so are enti- where he stands, but I suspect that he is as deeplytled to say yea or nay for their own reasons. Doctor committed to professional ethics as any of us.Loyall, according to Robicsek, was perfectly justiﬁed in Our essayists have persuasively argued distinct visionsdeciding not to testify. of professional decision making. Each of us is likely to The case itself removes most of the issues that usually face similar decisions in the future, unless there is ancomplicate medical-legal discussions. Disdain for the tort early resolution of the malpractice crisis, which seemssystem is not, for Dr Loyall, a barrier to testifying because unlikely. If and when that time comes, our decision to sayhe regularly testiﬁes in lawsuits. His qualiﬁcations as an yes or no will embody the particular view of profession-expert witness in this case are not in doubt. The adver- alism we have embraced.sarial environment of negligence lawsuits and the widechasm between medical (scientiﬁc) and legal (authorita-tive) standards of truth have not bothered him in the Referencespast, as he has not rejected testifying as an expert. We are 1. Pellegrino ED. The metamorphosis of medical ethics. JAMAleft with a single reason for his consistent refusal to 1993;269:1158 – 62.testify for plaintiffs and their attorneys, based in emotion: 2. Armey D. Armey’s axioms. John Wiley & Sons, 2003.he was once deeply stung by the arbitrary injustice of the 3. Markkula Center for Applied Ethics. Thinking ethically: amedical-legal judicial system. There are undoubtedly framework for moral decision making. Available at: http://additional questions of fact related to the patient’s injury www.scu.edu/ethics/practicing/decision/thinking.html. Ac- cessed October 24, 2003.in the case at hand, but Dr Loyall has summarily dis- 4. American Medical Association. E-9.07 Medical testimony.missed them as irrelevant. The central question— Available at: http://www.ama-assn.org/ama/pub/category/whether Dr Loyall was wrong in refusing to testify for the 8539.html. Accessed October 18, 2003.plaintiff—is stark. 5. Gruen RL, Arya J, Cosgrove EM, et al. Professionalism in Watson’s conclusion that Dr Loyall was wrong not to surgery. J Am Coll Surg 2003;197:605–10.testify is based on a nexus of ethical reasoning that 6. Spencer FC, Guice KS. The expert medical witness: con- cerns, limits, and remedies. Bull Am Coll Surg. 2000;85:22–5.stretches across several centuries of ethical thought that 7. Society of Thoracic Surgeons Board of Directors. Statementwould now fall under the rubric of professionalism. on the physician expert witness. STS News 2003;9:6 –7.Robicsek’s ﬁnding that Dr Loyall did nothing wrong is 8. American Medical Association. Board of Trustees reportbased on the narrow grounds of the right of every 5-A-98. Available at: http://www.thruthinjustice.org/American to speak or to remain silent. At issue here is the amareport.htm. Accessed October 18, 2003. 9. Rice B. Malpractice experts: the penalty for bearing falsenature of professional ethics: are the professional deci- witness. Med Econ 2002;15:36 –9.sions and actions of physicians bound only by the laws 10. Hollowell EE, Zaremski MJ, Wecht CH. Expert testimony ingoverning society in general or do physicians bear addi- medical malpractice cases—new hazards. Presented at thetional legitimate extralegal obligations (that is, ethical Annual Meeting of the American Academy of Forensicobligations) by virtue of the special circumstances inher- Sciences, February 21, 2003, Chicago, Illinois. 11. Gorney M. Expert witnesses caught in a moral dilemma. Bullent in the patient-physician relationship? Am Coll Surg 2003;88:11– 4. Ethics and law are closely related, overlapping to some 12. Eitel DR, Hegeman RJ, Evans ER. Medicine on trial: physi-extent, but essentially separate. To say, as Watson does, cians’ attitudes about expert medical witnesses. J Legal Medthat Dr Loyall has an ethical obligation to testify for the 1997;18:345– 60.