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Ignorance and Altruism

The trade-off between a present case and less tangible, but equally real and important, future cases represents a classic ethical dilemma. Is it appropriate to do less than we can for a needy patient, investing the savings in a program that might help many in the future? For a physician who engages in both clinical practice and research, a version of this dilemma might seem to appear in the form of a conflict between the roles of personal caregiver and scientist, the one whose commitment is to the needs of the present patient and the other who, by contributing to knowledge, seeks to serve the more general good. Although the dilemma may well be unresolvable in general, it should not be a factor in the clinical decisions of the physician-scientist. As Maurie Markman concludes in “Ethical Difficulties with Randomized Clinical Trials Involving Cancer Patients,” “Above all, the physician’s responsibility is to the individual patient, and the need to increase knowledge to improve the lot of future patients must always take second place.” Here there is no dilemma--the interests of the present patient must prevail. But a problem remains--Markman’s conclusion is often interpreted as meaning that physicians should participate in a randomized clinical trial only when they truly have no preference for either treatment. This would represent a severe handicap to medical progress. Important trials are sometimes conducted by the proponents of a new therapy, who see the randomized trial as the most effective way to convince skeptics and thereby to improve patient care. And it is certainly true that many if not most physicians who participate in randomized clinical trials--while not sure which treatment will turn out to be better--have a definite opinion. If their participation were prohibited, then many fewer trials could be done. I would like to suggest that the priority of the patient’s interests