Definitions
- To do the good that is due to other people and avoid the evil that harms them and society.
What is Justice?
- “Justice” derives from the Latin “iustitia” meaning “righteousness” or “equity”
- Justice is NOT equality or equity but instead is characterized by INTEGRITY and HONESTY
- Justice concerns both the common good for society and the individual good of others.
- There are multiple types of justice such as legal, reciprocal, and distributive justice.
- Justice is closely connected with sincerity, generosity, and friendliness.
Why should we practice the virtue of Justice?
- Justice is grounded in the practice of beneficence and nonmaleficence of the physician-patient relationship.
- Commutative justice enables us to deal well with other physicians and colleagues.
- Distributive justice accounts for the inequality of the physician-patient relationship and inclines the physician to evenly distribute care and healing materials.
- Justice is necessary in cases of conflicts of autonomy where a doctor must decide between their conscience and the patient’s autonomy.
- Both the physician and the patient are autonomous moral agents who deserve just treatment.
Aristotle’s Doctrine of the Mean
Aristotle’s Doctrine of the Mean emphasizes balance as the essence of virtue, symbolized here by a mountain peak with a flag representing the ideal midpoint. Each virtue lies between two opposing vices—deficiency depicted on the left, and excess, on the right slope. For example, courage is the balance between cowardice (deficiency) and recklessness (excess). In a medical context, this principle guides healthcare professionals to strive for the peak of ethical behavior, avoiding the pitfalls of extremes to ensure thoughtful and compassionate care.
Case Studies
You are an internal medicine resident working your outpatient service. Mrs. N is a 63-year-old female with well-controlled hypertension and hyperlipidemia who presents with a three-month history of increasing numbness in her right hand that has not responded to physical therapy. You review her previous cervical spine radiographs that showed multi-level degenerative changes. You think that an MRI of the cervical spine would help confirm your suspicion of neuroforaminal narrowing as the cause of the hand numbness. Your attending physician agrees and asks you to order a cervical spine MRI with contrast (intravenous gadolinium). You do not remember ordering this exam too often but wonder if the gadolinium is needed so you ask. Your attending says that occasionally we may find something with the gadolinium and besides the insurance company will pay for it.
Next week you are now rotating through radiology hoping to get your contrast questions answered. By good fortune, the radiology resident is reviewing spine imaging requests and sees your order for Mrs. N. You ask the radiology resident regarding the need for gadolinium in patients with cervical spine problems. The discussion revolves around whether the patient has any “red flag” indicators such as concern for infection, history of malignancy or prior neck surgery. You state that Mrs. N does not have any of those and you ordered the study to evaluate for degenerative neuroforaminal narrowing. The resident states that the study would best be done without the gadolinium per American College of Radiology Appropriateness Criteria. However, the radiology resident states that since the insurance approved it and it is difficult to get a hold of any requesting physician to change orders, that the imaging center just does the study besides they get paid more for using contrast.
Discussion Questions
- Who are the moral agents in this scenario and what do they owe each other?
- Is the insurance company a significant moral agent?
- If payment was eliminated from this case, how might each person’s attitude and actions change?
- Physicians and insurance companies frequently have a contentious relationship. How might this influence the ordering habits of physicians and is this just?
- How does reimbursement alter the sense of justice?
- What is the role of “gold-plated” care versus adhering to standards of care such as the American College of Radiology’s Appropriateness Criteria?
- Should the ordering physicians have asked Mrs. N whether she wanted the contrast or not?
- Who has greater responsibility for this discussion, the referring internist, or the radiologist?
- How have institutional practices within medicine placed impediments in our ability to give each their due?
- Are there societal laws and regulations which alter the good practice of medicine resulting in too much or too little testing and/or treatment?
How do we foster Justice?
● Reframing
● Sincerely using time well when studying
● Giving of your time to family and loved ones
● Seek to treat others well even when you are annoyed with them