According to Wikipedia and most dictionaries, “moral agency” is an individual’s ability to make moral choices based on some notion of right and wrong and to be held accountable for these actions. A moral agent is someone “who is capable of acting with reference to right and wrong” and who is responsible for correcting their own errors.

As a health care educator with three decades of research experience in public health policy for treatment of pain and addiction, I am increasingly concerned. It seems to me that American medicine and large numbers of doctors are very much in danger of losing their moral agency, if they have not already done so.

One dimension of this problem is aptly expressed in an article by Helen Ouyang, MD, in New York Times Magazine. She is a physician and associate professor at Columbia University and her article is titled “How A.I. Might Change The Way Doctors Think.” She asks, “For generations, writing up a summary of a patient exam was a vital step for physicians trying to make an accurate diagnosis. What happens when A.I. does it for them?”

The question is appropriate. Dr. Ouyang takes as her point of departure the increasing use of AI-based electronic scribes in making case notes during patient exams. Such tools can generate absolutely clean case notes in proper English grammar and without the untidiness of handwritten (sometimes illegible) notes taken “on the fly” by clinicians or their human assistants. The interviewing clinician then needs only to read the AI’s notes, make corrections if warranted, and sign off on them before final entry into the patient’s electronic health records.

And therein lies the rub. Because the clinician is relieved of the task of rethinking their notes during cleanup, they may also miss issues where deeper reflection might prompt additional review. Likewise, because doctors are under ever-increasing pressure from employers to see more patients, this more cursory review of AI-generated case reports may be enforced by employers, as a measure of “efficiency” rather than accuracy.

When patients spend less time with their doctors, they feel less heard. As a health care educator, I often hear from patients who say that when they are under time pressure, they may suppress or simply forget comments they intended to make. Such additional patient input can lead the doctor to a different diagnosis or treatment plan, generating better results for the patient.

There is no denying that AI-based large language models (LLMs) can place an enormous library of published data at the fingertips of clinicians. But such a library is not an unmixed blessing. It is well known that at their present state of development, LLMs favor quantity over quality in the answers they generate to user inquiries. Unless a doctor remembers to ask about minority opinions and contradictory data sources, they may never be exposed to additional information that could lead to very different diagnosis and treatment conclusions. In a high-pressure practice environment, it is all too possible for doctors to forget such nuances, and for patients to be harmed as a result.

In my view, artificial intelligence should be viewed as a documentation assistant, not as a surrogate for clinical reasoning. The value of an AI-generated note lies in its ability to accurately capture the patient’s history and the doctor’s review of systems, medications, and portions of the examination.

The physician’s moral and professional responsibility begins when those observations are integrated into a coherent assessment and treatment plan. History, physical examination, laboratory findings, imaging, and the patient’s unique circumstances must be synthesized into clinical judgment. If AI-generated notes are accepted without this process of integration, the risk is not merely poor documentation but degradation of medical reasoning itself.

Harms to patients and clinicians are a frequent theme in health care industry publications these days, and even more so in social media. I personally hear widespread concerns from people who have lived these issues as patients or doctors. The following are close paraphrases:

• “When I contacted the office of Dr. X to ask about becoming one her patients, I was told by the receptionist that their practice does not accept new patients for pain management using opioids.” (This by a receptionist? And with absolutely zero assessment of the patient’s needs? Something is very wrong here!)
• “My doctor says I must reduce my dose of OxyContin to less than 90 morphine milligrams equivalent per day, or he will be forced to discharge me. He is concerned that armed U.S. DEA agents may come knocking at his door to destroy his practice.”
• “I am scheduled for colon surgery next week. But the surgeon refuses to commit to treating me during my post-op hospital stay with anything more than intravenous Tylenol.”
• “I read a newspaper article last week that said the U.S. Centers for Disease Control is still blaming doctors ‘over-prescribing’ as the cause of the opioid crisis. But I’m a hypermetabolizer with a 20-year history of severe pain conditions. I have never been able to find medications that work for me, other than a cocktail of opioid pain relievers that adds up to more than 400 MMED. What am I supposed to do if they cut me off?”
• “I was admitted to a hospital last month with sharp chest pain and super high blood pressure. When a nurse asked me about my medications, I was honest with her. She then confiscated my prescriptions from my purse and refused to give them back. The on-call doctor refused to see me and entered a note in my records that accused me of being a drug seeker.”
• “A pharmacist refused to fill my prescription for opioid pain relievers and a benzodiazepine anxiety drug. I’ve been unable to find anyone else who will do so. My doctor says I can have one or the other but not both. My pain levels are rising and I can’t sleep. What can I do?”

These horrible quotations are not exceptions. They are common and current conditions for many thousands, if not millions, of U.S. patients. And they reflect what we can only interpret as a loss of moral agency by both doctors and regulators. Under pressure from health care insurance companies, the U.S. Centers for Disease Control, the Veterans Administration, and FDA, doctors are losing their capacity to tell right from wrong.

The modern spirit of the Hippocratic Oath is being forgotten. Patients desperately need their doctors to return to and honor the phrase “First do no harm.”

Richard A. Lawhern is a nationally recognized health care educator and patient advocate who has spent nearly three decades researching pain management and addiction policy. His extensive body of work, including over 300 published papers and interviews, reflects a deep critique of U.S. health care agencies and their approaches to chronic pain treatment. Now retired from formal academic and hospital affiliations, Richard continues to engage with professional and public audiences through platforms such as LinkedIn, Facebook, and his contributions to KevinMD. His advocacy extends to online communities like Protect People in Pain, where he works to elevate the voices of patients navigating restrictive opioid policies. Among his many publications is a guideline on opioid use for chronic non-cancer pain, reflecting his commitment to evidence-based reform in pain medicine.