Pharmaceutical representatives use detailing, gift giving, and the donation of free samples as a means to gain access to and influence over physicians. In biomedical ethics, there has been an ongoing debate as to whether these practices constitute an unethical conflict of interest (COI) on the part of the physician. Underlying this debate are the following antecedent questions: (1) what counts as a conflict of interest, (2) when are such conflicts unethical, and (3) how should the ethical physician respond to conflicts? This article distinguishes between two perspectives that have been developed on these issues: a reliable performance model (PM) and a trustworthiness model (TM). PM advocates argue that a conflict of interest can only be established by demonstrating that a particular influence is undermining the reliability of the physician’s judgment, and this requires empirical evidence of negative patient outcomes. TM advocates, on the other hand, argue that because of the fiduciary nature of the patient-physician relationship, physicians have an obligation to develop and be worthy of patient trust. A COI, on this view, is a condition that undermines the warrant for patients to judge a physician as trustworthy. Although there is much that is right in the PM, it is argued that the TM does a better job of responsibly addressing the unique vulnerabilities of the patient. The TM is then applied to the practices of detailing, gift giving, and sample donation. It is concluded that these practices constitute an unethical conflict of interest.

Mr. Hope is a 40-year-old man who has resided at a long-term care facility for the past 10 years. The resident was originally admitted to the nursing home for his inability to care for himself secondary to advanced AIDS and complications from progressive multifocal leukoencephalopathy (PML). When he initially arrived at the nursing home, Mr. Hope was able to smile and appeared to respond to some of the staff’s requests. Now, he responds by wincing when told that procedures are being performed and especially when he is told that he has to go back to the hospital. He is extremely contracted, with his arms wedded to his chest in a crossed fashion, as though he is protecting himself from blows. Mr. Hope’s family consists of a partner, his parents, and one sibling. Numerous conversations have been had with the family, and according to the facility staff, “they persist in continuing aggressive measures with the hope that the patient will wake up and walk out of the facility.” What had been frequent visits to the local hospital ER have increased substantially in the last few months, for what appear to be new infections and pneumonia. During most visits he ultimately spends a few days in the hospital to resolve his acute issues. On his most recent return to the long-term care facility, the medical staff approached the family about Mr. Hope’s code status. The family continues to insist on a full code status and that he be provided every opportunity to “live.” The staff is very concerned about Mr. Hope and his welfare. Many of the nursing staff have grown attached to him over the years, and watching him deteriorate has been distressing. They see part of their role as being his advocate and supporting him in ways that his own family has not. They express very strong reservations about performing CPR on Mr. Hope because they think it will be ineffective and they will have to break his upper extremities in order to gain access to his chest for resuscitation. The staff has contacted the ethics consultation service with the request that Mr. Hope needs protection and that his own family is not making the best decisions for him.

Ethical issues in long-term care settings, although having received attention in the literature, have not in our opinion received the appropriate level they require. Thus, we applaud the Cambridge Quarterly for publishing this case. We can attest to the significance of ethical issues arising in long-term care facilities, as Mr. Hope’s case is all too familiar to those practicing in these settings. What is unique about this case is that an actual ethics consult was made in a long-term care setting. We have seen very little in the published literature on the use of ethics structures in long-term care populations. Our experience is that these healthcare settings are ripe for ethical concerns and that providers, patients, families, and staff need/desire ethics resources to actively and preventively address ethical concerns. The popular press has begun to recognize the ethical issues involved in long-term care settings and the need for ethics structures. Recently, in California a nurse refused to initiate CPR for an elderly patient in a senior residence. In that case, the nurse was quoted as saying that the facility had a policy that nurses were not to start CPR for elderly patients.1 Although this case is not exactly the same as that of Mr. Hope, it highlights the need for developing robust ethics program infrastructures in long-term care settings that work toward addressing ethical issues through policy, education, and active consultation.

In its simplest interpretation, this is a case about goals of care and appropriate code status. At the outset, we must confess that we found this case to be extremely interesting—not for the novelty of the issues or its ethical complexity but because it is truly a case of the ordinary. Too often when teaching or discussing clinical ethics cases, we are distracted by the exotic and the unusual and ignore the mundane cases that every practicing clinical ethicist must be able to competently manage.1,2,3

Mr. Hope’s family’s expectations and his staff’s concerns raise important issues about surrogate decisionmaking, communication regarding prognosis, and staff angst. Unfortunately, Mr. Hope himself is unable to reliably understand and communicate his preferences, especially for complex medical decisions, so the ethics consultant is left to negotiate the disagreement between his family and his healthcare providers, who presumably both believe they are acting in his best interest.

An ethics consult was scheduled for the following day. Prior to the consult, Mr. Hope subsequently decompensated and was transferred to the local hospital. The ethics consultation service continued with the ethics consult to discuss the ethical concerns of the medical staff but in particular to create an open forum for the staff to process their moral distress over the care of this patient and to come to an agreed-on plan on how they would proceed should the resident code. The patient never returned to the long-term care setting. While in the emergency room, the patient took a turn for the worse and appeared to require intubation. The emergency room attending physician contacted the patient’s family and discussed the imminent likelihood of the patient’s demise and the potential harm caused to the patient by resuscitation and intubation, and the family agreed to switch to comfort measures, allowing the patient to pass peacefully. The family stated to the ER physician that they needed to feel as though they had done everything they could to keep their loved one alive and did not want any responsibility for his death. The staff at the long-term care setting still remember Mr. Hope in their daily work and talk about him often.