Physicians and hospital managers as cofiduciaries of patients: rhetoric or reality?

The reality of physicians and hospital managers as cofiduciaries of patients is of vital importance today. In this article we develop the concept of physicians as fiduciaries of patients based on the work of John Gregory and of hospitals as fiduciaries of patients based on the work of Thomas Percival to supplement the recent literature on organizational ethics in healthcare. To be a fiduciary of patients means that (1) one possesses expert knowledge and skills on how to protect and promote the health-related interests of patients and (2) one is committed to using that expertise primarily for the benefit of the patient and to making self-interest a systematically secondary consideration. This concept is accepted in contemporary medical ethics and law (McCullough and Chervenak 1994). We identify two core virtues--diffidence and compassion--as vital to the fiduciary role. We use these virtues to develop preventive ethics strategies for dealing with two major problems in physician-hospital administrator interactions, what we call strategic procrastination and strategic ambiguity. The main preventive ethics response to both strategic procrastination and strategic ambiguity is to point them out when they occur and to emphasize that they compromise cofiduciary responsibility. As a preventive ethics response to strategic procrastination, physicians and managers should provide role models of accountability and change policy and practice in a timely manner when intellectually obligated to do so. As a preventive ethics response to strategic ambiguity, physicians and managers should be role models of transparency by being explicit in their communications.