International Medical Graduates
Ethics and Professionalism
Lois Snyder, JD
Director, Center for Ethics and Professionalism
American College of Physians
Adjunct Assistant Professor of Bioethics
University of Pennsylvania Center for Bioethics
Introduction
As defined by Webster's Dictionary, ethics is a theory or system of moral values. In even plainer language, it is what we should do and why. Certain principles are key to doing medical ethics, especially when the issues involve interactions between physician and patient: beneficence-- the duty to do good and to act in the best interest of others; non-maleficence-- the duty to do no harm; respect for autonomy and the individual's right of bodily self-determination; and justice, with a focus on considerations of fair treatment and distribution of resources. Ethical issues in health care are important and compelling in part because they illustrate how real people in real world situations make hard choices about vital matters. Although gene therapy, animal-to-human organ transplantation, and other highly controversial issues often get a lot of press and other attention, more routine bioethics issues like informed consent, caring for dying patients, and conflicts of interest are often the more relevant ones for practitioners and their patients.
Below are some selected ethics issues that are relevant to day-to-day medical practice, including a few excerpts from the College’s Ethics Manual.
The Patient-Physician Relationship
From the College’s Ethics Manual (fourth edition): "By history, tradition, and professional oath, physicians have a moral obligation to provide care for ill persons. Although this obligation is collective, each individual physician is obliged to do his or her fair share to ensure that all ill persons receive appropriate treatment. A physician may not discriminate against a class or category of patients. An individual patient-physician relationship is formed on the basis of mutual agreement on medical care for the patient. In the absence of a preexisting relationship, the physician is not ethically obliged to provide care to an individual person unless no other physician is available, as is the case in some isolated communities or when emergency treatment is required. Under these circumstances, the physician is morally bound to provide care and, if necessary, to arrange for proper follow-up. Physicians may also be bound by contract to provide care to beneficiaries of participating health plans. Physicians and patients may have different concepts of the meaning and resolution of medical problems. The care of the patient and satisfaction of both parties are best served if physician and patient discuss their expectations and concerns."
The Patient and the Medical Record
Patients are ethically and legally entitled to the information in their medical records. As a legal matter, the chart is the property of the physician or the institution, but information in the chart is the property of the patient. The physician must release information to the patient or to a third party at the request of the patient. Concerns for confidentiality dictate that information should only be released with the written permission of the patient or the patient's legally authorized representative.
Confidentiality
From the College’s Ethics Manual (fourth edition): "Confidentiality is a fundamental tenet of medical care. It is a matter of respecting the privacy of patients, encouraging them to seek medical care and discuss their problems candidly, and preventing discrimination on the basis of their medical conditions. The physician must not release information without the patient's consent (often termed a "privileged communication"). However, confidentiality, like other ethical duties, is not absolute. It may have to be overridden to protect individual persons or the public–for example, to warn sexual partners that a patient has syphilis or is infected with HIV–or to disclose information when the law requires it. Before breaching confidentiality, the physician should make every effort to discuss the issues with the patient. If breaching confidentiality is necessary, it should be done in a way that minimizes harm to the patient and that heeds applicable federal and state law. Confidentiality is increasingly difficult to maintain in this era of computerized record keeping and electronic data processing, faxing of patient information, third-party payment for medical services, and sharing of patient care among numerous medical professionals and institutions."
Informed Consent
The patient or an authorized representative’s consent is required for the provision of care. Touching a person without consent is a battery, even in the medical setting. Consent can be expressed, as when written or oral consent is given for a particular procedure. Or it can be implied, such as in medical emergencies, when necessary to maintain life or restore health (unless it is known that the patient would refuse the intervention). So, whether consent was given for a treatment or intervention is one issue. Informed consent goes beyond that to focus on the content and process of consent, and if adequate information to allow a patient (or if necessary, a surrogate decisionmaker) to make an informed decision about what to do, was given. This includes the nature of the medical condition and the objectives of, alternatives to, possible outcomes of, and risks of the proposed treatment. Consent from the patient or his or her surrogate must be given voluntarily to be valid. Adults are legally considered competent to make decisions about medical care unless a court declares them incompetent. In practice, however, it is usually ethically acceptable for physicians and family members to make decisions without a formal competency hearing in the courts for patients who lack decision-making capacity if done with care under appropriate guidelines.
Financial Conflicts of Interest
From the College's Ethics Manual (fourth edition): "The physician must seek to ensure that the medically appropriate level of care takes primacy over financial considerations imposed by the physician's own practice, investments, or financial arrangements. Trust in the profession is undermined when there is even the appearance of impropriety. Potential influences on clinical judgment cover a wide range and include financial incentives inherent in the practice environment (such as incentives to overutilize in the fee-for-service setting or underutilize in the managed care setting), drug industry gifts, and business arrangements involving referrals. Physicians must be conscious of all potential influences and their actions should be guided by appropriate utilization, not by other factors."
End-of-Life Care
Caring for dying patients can raise particularly difficult issues about the withdrawing or withholding of life-sustaining treatment, do-not-resuscitate orders, irreversible loss of consciousness, intravenous fluids and artificial feedings, and determination of death. Who should make decisions on behalf of the incompetent patient, and how, are often among the hard questions that must be addressed. The College has been developing a series of papers on end-of-life care to provide guidance for practice. See the list and published consensus papers at www.acponline.org/ethics/papers.htm. The College also approved a position paper opposing the legalization of physician-assisted suicide in October 2000.
The Physician's Relationship to Other Physicians
In addition to the duties that physicians have to patients and to society, are the responsibilities that they have to each other. This includes sharing knowledge and information with colleagues and patients, and teaching the science, art, and ethics of medicine to medical students, residents, and others. It includes seeking competent consultation whenever the physician and patient feel the need for assistance in caring for the patient. And it includes the responsibility to do peer review and to deal appropriately with an impaired physician.
Research Ethics
Issues in research ethics such as conflicts of interest, finder's fees, and the physician's obligations to the patient in the dual roles of clinician and researcher are becoming of increasing importance as more research is conducted in the office and as contract research organizations are used in addition to or instead of institutional review boards. No matter the setting, research must be potentially of significant value and must be ethically conducted.
Web-links of Interest:
The ACP Center for Ethics and Professionalism Webpage, www.acponline.org/ethics/index.html
Snyder L, Morin K (eds). American College of Physicians Ethics Manual (fifth edition). Ann Intern Med. 2005;128:576-594.
The table of contents and the full text of the Ethics Manual are available online. The Manual is also available for order as a pocket size booklet.
The Ethics Manual Spanish translation is at http://www.acponline.org/ethics/ethicman_sp.pdf
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Other Web Resources (for educational use only, inclusion here does not constitute endorsement): National Bioethics Advisory Commission American Society for Bioethics and Humanities American Society of Law, Medicine & Ethics Center to Improve Care of the Dying Last Acts: Care and Caring at the End of Life Basic Resources in Bioethics Bioethics Resources on the Web Ethics Consultation: A Practical Guide MedEthEx Online National Reference Center for Bioethics Literature Upcoming Events in Bioethics |
Brief bio:
Lois Snyder, JD is Director of the Center for Ethics and Professionalism at the American College of Physicians. She is also Adjunct Assistant Professor of Bioethics and Fellow of the University of Pennsylvania Center for Bioethics. She is a frequent writer and speaker on health care policy, bioethical, end-of-life care and medical-legal issues.
This article was prepared for the ACP IMG Web site in 2000.
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