title: Fiduciary disparity clarity: Ethics of divided allegiances.
abstract: An experienced senior vascular surgeon, Dr H. O. Nest, at a university medical center is asked to evaluate a patient with a rare complex vascular problem. The patient is a high-ranking university official, Mr N. Otable, well known to all in the university setting. Dr Nest has had very limited experience with the condition. He has viewed presentations about it but is aware of a world expert at another institution. He discusses transfer with the patient, who agrees on that approach. Later that day, when Dr Nest receives a visit from the Chief-of-Staff and the hospital CEO asking about Mr Otable, they are very concerned that transfer will reflect badly on the medical center's reputation. Dr Nest is strongly requested to reconsider his recommendation--almost at gunpoint. What should he do? A. If he believes that the outcome will be satisfactory, he should schedule the operation. B. He should explain the situation to the patient and let him choose where he wishes to have his surgery. C. He should continue with the plan to refer the patient to another center. D. He must understand his limits and base his decision accordingly. E. He should arrange a conference with the surgeons in the vascular division and the administrators.
authors.affiliation: The Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Tex. Electronic address: jwjones@bcm.edu.
authors.forename: James W
authors.initials: JW
authors.lastname: Jones
authors.affiliation: The Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Tex.
authors.forename: Laurence B
authors.initials: LB
authors.lastname: McCullough
mesh_terms: D002983:Clinical Competence; D016265:Conflict of Interest; D006801:Humans; D061214:Patient Safety; D010360:Patient Transfer / Q000941:ethics*; D012017:Referral and Consultation / Q000941:ethics*; D018570:Risk Assessment; D012307:Risk Factors; D066231:Surgeons / Q000941:ethics*; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000941:ethics*