Altruism, Self-interest, and Medical Ethics

Nothing more exposes a physician's true ethics than the way he or she balances his or her own interests against those of the patient. Whether the physician is refusing to care for patients with the acquired immunodeficiency syndrome (AIDS) for fear of contagion (the subject Zuger and Miles1discuss in this issue ofJAMA) or withdrawing from emergency department service for fear of malpractice suits, striking for better pay or fees, or earning a gatekeeper's bonus by blocking access to medical care, the question raised is the same. Does medicine entail effacement of the physician's self-interests—even to the point of personal and financial risk? Is some degree of altruism a moral obligation, or is nonmaleficence the limit of the physician's mandatory beneficence? How far does physician advocacy go?2What does the concept of physician as advocate mean?3 As Zuger and Miles' article points out, although the question