- Email: [email protected]
Consensus statement on the ethic of medicine
FROM
THE
ACADEMY
Consensus statement on the ethic of medicine Council of Medical Specialty Societies Because of increasing concern with the ethical challenges to physicians in recent years, a committee of the Council of Medical Specialty Societies (CMSS), under the chairmanship of Sara C. Charles, MD, organized a 2-day symposium on The Ethic of Medicine in April 1997. During this conference 6 workgroup sessions were held for the purpose of developing a consensus among the 17 represented medical and surgical specialties on whether the traditional medical ethic remains applicable or is in need of adaptation or change to guide physician behavior in the 21st century. An initial statement was developed at the time of the meeting, then modified by mail and finally presented to all 17 member societies for further comment. The following is the result of that extended and in-depth review.
W. Mitchell Sams, MD AAD Representative to the CMSS
PREAMBLE The practice of medicine is rooted in a covenant of trust among patients, physicians and society. The ethic of medicine must seek to balance the physicians’ responsibility to each patient and the professional, collective obligation to all who need medical care. This statement articulates core values and principles that are shared by all physicians, in a range of settings and circumstances, including the use of new technologies of communication, regardless of specialty.
THE PHYSICIAN-PATIENT RELATIONSHIP 1. The physician’s primary, inviolate role is as an active advocate for each patient’s care and wellbeing. 2. The physician should treat each patient with honesty, compassion, dignity and respect for individual autonomy. 3. The physician’s commitment to patients includes health education and continuity of care.
THE PHYSICIAN-PHYSICIAN RELATIONSHIP 1. Physicians have a responsibility to maintain moral integrity, intellectual honesty, and clinical competence. 2. Physicians, as stewards of medical knowledge, have an obligation to educate and share information with colleagues, including physicians-in-training. Reprints are not available from the author. J Am Acad Dermatol 2000;42:124-6. 16/1/102638
124
THE RELATIONSHIP OF THE PHYSICIAN TO SYSTEMS OF CARE 1. The physician’s duty of patient advocacy should not be altered by the system of health care delivery in which the physician practices. 2. Physicians should resolve conflicts of interest in a fashion that gives primacy to the patient’s interests. 3. Physicians should provide knowledgeable input into organizational decisions on the allocation of medical resources and the process of health care delivery.
THE RELATIONSHIP OF THE PHYSICIAN TO SOCIETY 1. Physicians have a responsibility to serve the health care needs of all members of society. 2. Physicians have an ethical obligation to participate in the formation of health care policy. 3. Physicians have an ethical obligation to preserve and protect the trust bestowed on them by society.
CLOSING Some of the values and principles that impinge on the relationship of physicians to their patients, colleagues, organizations and the larger society in which they practice are introduced in this document. Further specifications can be developed to fit the particular needs of individual specialties, patient groups and practice circumstances.
THE PRINCIPLES WITH COMMENTS The physician-patient relationship 1. The physician’s primary, inviolate role is
J AM ACAD DERMATOL VOLUME 42, NUMBER 1, PART 1
as an active advocate for each patient’s care and well-being. The physician should always place the interests of his or her patients first. Physicians have a moral obligation and a professional duty to accept ultimate responsibility for their medical decisions. 2. The physician should treat each patient with honesty, compassion, dignity and respect for individual autonomy. The physician-patient relationship mandates empathic communication with the patient, sensitivity to the patient’s wishes and values, and the preservation of confidentiality. An atmosphere of truthfulness and candor is essential to the maintenance of the necessary trust within the relationship. The physician will be ever vigilant not to allow abuse of this relationship. This relationship is built upon the patient’s confidence that the physician is disclosing the full range of diagnostic, prognostic and therapeutic possibilities. The physician should not exclude or discriminate against any patient because of ethnic origin, race, sex, creed, age, socioeconomic status, diagnosis, physical or mental disability or sexual orientation. The physician should remain compassionate and dedicated to patients at the end of life, advise them and their surrogates of available options to alleviate pain and suffering, and use life sustaining therapy appropriately. 3. The physician’s commitment to patients includes health education and continuity of care. The physician should educate the patient, with an emphasis upon primary care, and with consideration of each patient’s unique values and life circumstances, about what care is beneficial and available so that informed decisions can be made. The physician should engage in frank discussion with the patient about the reasons for limitations on availability of resources. The physician should maintain continuity of care consistent with mutually agreed upon goals of care. Referral for consultation, diagnostic, or therapeutic interventions should be timely, clinically appropriate and sensitive to the patient’s wishes. The physician should strive to assure referral to the appropriate consultant. The physician-physician relationship 1. Physicians have a responsibility to maintain moral integrity, intellectual honesty, and clinical competence. Physicians should be aware of the limitations of their expertise and seek consultation or assistance in clinical situations where appropriate.
Council of Medical Specialty Societies 125
Physicians have a responsibility to develop, monitor and maintain their own physical and psychological well being and to recognize and disclose any impairment that would affect the care of their patients. Physicians should expect and promote in their colleagues intellectual honesty, moral integrity, clinical competence, and physical and psychological well-being consistent with their responsibilities. Physicians, individually and collectively, should identify colleagues whose ability to practice medicine becomes temporarily or permanently impaired. Physicians should assist such impaired colleagues to obtain remedial help and modify or discontinue their practice, and assist with rehabilitation when appropriate. Physicians should engage in collegial behavior and avoid any professional arrangements that exploit other physicians. 2. Physicians, as stewards of medical knowledge, have an obligation to educate and to share information with colleagues, including physicians-in-training. Physicians should be committed to a lifetime of learning and continuously improve the knowledge base and clinical skills relevant to their practice. Physicians should advance medical knowledge, promote ethically and scientifically sound research, and educate colleagues. Physicians should be committed to an unfettered exchange of medical information. Physicians should foster communication with other physicians to optimize patient care, respectful of patient confidentiality. The relationship of the physician to systems of care 1. The physician’s duty of patient advocacy should not be altered by the system of health care delivery in which the physician practices. Physicians have the responsibility to advocate for individual patients when organizational, situational or financial circumstances lead unjustly to the withholding or withdrawing of beneficial health care. The physician should seek to reform any system of care in which there is exclusion or discrimination involving any patient because of ethnic origin, race, sex, creed, age, socioeconomic status, diagnosis, physical or mental disability or sexual orientation. Physicians respect the contributions and professionalism of other physicians, non-physician professionals and, when applicable, other team members involved in the care of patients. Whether or not bound by contract to provide care for beneficiaries of systems of healthcare, except for extreme contingencies, physicians should not be
126 Council of Medical Specialty Societies
required to violate personal beliefs and values, standards of clinical practice, or ethical behavior. Physicians should be mindful that the potential to breach patient confidentiality is heightened by new modes of sharing patient information throughout a health system. Physicians should strive to eliminate confidentiality flaws in health systems. 2. Physicians should resolve conflicts of interest in a fashion that gives primacy to the patient’s interests. Conflicts of interest are inevitable in medical practice. Physicians should disclose conflicts of interest to their patients, inform them of the impact of these conflicts on their medical care and of the options for their resolution. As a condition of their participation in a system of care, physicians should require that plans fully disclose the availability of therapeutic alternatives to patients. Physicians should respect the verbal and written contracts into which they enter. Physicians should assure patients’ access to appropriate medical consultation and avoid contractual or other arrangements that restrict their ability or freedom to do so. A physician’s choice of consultant should be based primarily on the consultant’s clinical competence. 3. Physicians should provide knowledgeable input into organizational decisions on the allocation of medical resources and the process of health care delivery. Physicians in health care organizations should encourage ethically appropriate health care decision making. Physicians should assure that high quality medical care is provided in a manner consistent with the efficient use of medical resources. Physicians should not participate in, or contract with, any organization that encourages or requires that care be delivered below minimum professional standards, promulgates financial or disciplinary incentives to withhold appropriate clinical care or engages in deceptive marketing. Physicians should advocate for the adoption of organizational policies and procedures that facilitate access to basic medical care. The relationship of the physician to society 1. Physicians have a responsibility to serve the health care needs of all members of society. Physicians have a collective, professional obligation to serve as advocates for access to basic health care for all members of society and to work against forces that would deny access to underserved segments of our society.
J AM ACAD DERMATOL JANUARY 2000
2. Physicians have an ethical obligation to participate in the formation of health care policy. As primary advocates for patients, physicians should participate in the societal decision-making process regarding health care delivery and the allocation of health care resources. Physicians should participate in societal debates concerning scientific, ethical, moral, economic, and cultural factors that impact the development and implementation of health care policy and access to health care systems. Physicians should educate themselves, their patients, and society at large about advances in the science of medicine and health care policy issues. Physicians should assure that resources expended for the purpose of improving patient well-being are spent in an appropriate manner. Physicians should participate in the process of data collection and analysis and the development of objective criteria for determining the prioritization and allocation of health care resources. Physicians should develop such within a context that focuses primarily on the needs and values of our society as a whole, rather than on political or special interest concerns. Physicians should participate in the process that determines the allocation of health care monies among direct patient care, research, education, and administration (this category may include profit systems where this is a relevant consideration). Physicians’ concern for the common good should not compromise their primary obligation to patients under their care. 3. Physicians have an ethical obligation to preserve and protect the trust bestowed on them by society. Physicians should make medical decisions based on the best interests of their patients without regard to personal and financial gain and, where necessary, challenge the undermining influence of third party payers, contracting agencies, employers, or other organizations and agencies interposed between the physician and the patient. Council of Medical Specialty Societies 51 Sherwood Terrace, Suite M Lake Bluff, IL 60044 Telephone: 847/295-3456 Fax: 847/295-3759 www.cmss.org
THE
ACADEMY
Consensus statement on the ethic of medicine Council of Medical Specialty Societies Because of increasing concern with the ethical challenges to physicians in recent years, a committee of the Council of Medical Specialty Societies (CMSS), under the chairmanship of Sara C. Charles, MD, organized a 2-day symposium on The Ethic of Medicine in April 1997. During this conference 6 workgroup sessions were held for the purpose of developing a consensus among the 17 represented medical and surgical specialties on whether the traditional medical ethic remains applicable or is in need of adaptation or change to guide physician behavior in the 21st century. An initial statement was developed at the time of the meeting, then modified by mail and finally presented to all 17 member societies for further comment. The following is the result of that extended and in-depth review.
W. Mitchell Sams, MD AAD Representative to the CMSS
PREAMBLE The practice of medicine is rooted in a covenant of trust among patients, physicians and society. The ethic of medicine must seek to balance the physicians’ responsibility to each patient and the professional, collective obligation to all who need medical care. This statement articulates core values and principles that are shared by all physicians, in a range of settings and circumstances, including the use of new technologies of communication, regardless of specialty.
THE PHYSICIAN-PATIENT RELATIONSHIP 1. The physician’s primary, inviolate role is as an active advocate for each patient’s care and wellbeing. 2. The physician should treat each patient with honesty, compassion, dignity and respect for individual autonomy. 3. The physician’s commitment to patients includes health education and continuity of care.
THE PHYSICIAN-PHYSICIAN RELATIONSHIP 1. Physicians have a responsibility to maintain moral integrity, intellectual honesty, and clinical competence. 2. Physicians, as stewards of medical knowledge, have an obligation to educate and share information with colleagues, including physicians-in-training. Reprints are not available from the author. J Am Acad Dermatol 2000;42:124-6. 16/1/102638
124
THE RELATIONSHIP OF THE PHYSICIAN TO SYSTEMS OF CARE 1. The physician’s duty of patient advocacy should not be altered by the system of health care delivery in which the physician practices. 2. Physicians should resolve conflicts of interest in a fashion that gives primacy to the patient’s interests. 3. Physicians should provide knowledgeable input into organizational decisions on the allocation of medical resources and the process of health care delivery.
THE RELATIONSHIP OF THE PHYSICIAN TO SOCIETY 1. Physicians have a responsibility to serve the health care needs of all members of society. 2. Physicians have an ethical obligation to participate in the formation of health care policy. 3. Physicians have an ethical obligation to preserve and protect the trust bestowed on them by society.
CLOSING Some of the values and principles that impinge on the relationship of physicians to their patients, colleagues, organizations and the larger society in which they practice are introduced in this document. Further specifications can be developed to fit the particular needs of individual specialties, patient groups and practice circumstances.
THE PRINCIPLES WITH COMMENTS The physician-patient relationship 1. The physician’s primary, inviolate role is
J AM ACAD DERMATOL VOLUME 42, NUMBER 1, PART 1
as an active advocate for each patient’s care and well-being. The physician should always place the interests of his or her patients first. Physicians have a moral obligation and a professional duty to accept ultimate responsibility for their medical decisions. 2. The physician should treat each patient with honesty, compassion, dignity and respect for individual autonomy. The physician-patient relationship mandates empathic communication with the patient, sensitivity to the patient’s wishes and values, and the preservation of confidentiality. An atmosphere of truthfulness and candor is essential to the maintenance of the necessary trust within the relationship. The physician will be ever vigilant not to allow abuse of this relationship. This relationship is built upon the patient’s confidence that the physician is disclosing the full range of diagnostic, prognostic and therapeutic possibilities. The physician should not exclude or discriminate against any patient because of ethnic origin, race, sex, creed, age, socioeconomic status, diagnosis, physical or mental disability or sexual orientation. The physician should remain compassionate and dedicated to patients at the end of life, advise them and their surrogates of available options to alleviate pain and suffering, and use life sustaining therapy appropriately. 3. The physician’s commitment to patients includes health education and continuity of care. The physician should educate the patient, with an emphasis upon primary care, and with consideration of each patient’s unique values and life circumstances, about what care is beneficial and available so that informed decisions can be made. The physician should engage in frank discussion with the patient about the reasons for limitations on availability of resources. The physician should maintain continuity of care consistent with mutually agreed upon goals of care. Referral for consultation, diagnostic, or therapeutic interventions should be timely, clinically appropriate and sensitive to the patient’s wishes. The physician should strive to assure referral to the appropriate consultant. The physician-physician relationship 1. Physicians have a responsibility to maintain moral integrity, intellectual honesty, and clinical competence. Physicians should be aware of the limitations of their expertise and seek consultation or assistance in clinical situations where appropriate.
Council of Medical Specialty Societies 125
Physicians have a responsibility to develop, monitor and maintain their own physical and psychological well being and to recognize and disclose any impairment that would affect the care of their patients. Physicians should expect and promote in their colleagues intellectual honesty, moral integrity, clinical competence, and physical and psychological well-being consistent with their responsibilities. Physicians, individually and collectively, should identify colleagues whose ability to practice medicine becomes temporarily or permanently impaired. Physicians should assist such impaired colleagues to obtain remedial help and modify or discontinue their practice, and assist with rehabilitation when appropriate. Physicians should engage in collegial behavior and avoid any professional arrangements that exploit other physicians. 2. Physicians, as stewards of medical knowledge, have an obligation to educate and to share information with colleagues, including physicians-in-training. Physicians should be committed to a lifetime of learning and continuously improve the knowledge base and clinical skills relevant to their practice. Physicians should advance medical knowledge, promote ethically and scientifically sound research, and educate colleagues. Physicians should be committed to an unfettered exchange of medical information. Physicians should foster communication with other physicians to optimize patient care, respectful of patient confidentiality. The relationship of the physician to systems of care 1. The physician’s duty of patient advocacy should not be altered by the system of health care delivery in which the physician practices. Physicians have the responsibility to advocate for individual patients when organizational, situational or financial circumstances lead unjustly to the withholding or withdrawing of beneficial health care. The physician should seek to reform any system of care in which there is exclusion or discrimination involving any patient because of ethnic origin, race, sex, creed, age, socioeconomic status, diagnosis, physical or mental disability or sexual orientation. Physicians respect the contributions and professionalism of other physicians, non-physician professionals and, when applicable, other team members involved in the care of patients. Whether or not bound by contract to provide care for beneficiaries of systems of healthcare, except for extreme contingencies, physicians should not be
126 Council of Medical Specialty Societies
required to violate personal beliefs and values, standards of clinical practice, or ethical behavior. Physicians should be mindful that the potential to breach patient confidentiality is heightened by new modes of sharing patient information throughout a health system. Physicians should strive to eliminate confidentiality flaws in health systems. 2. Physicians should resolve conflicts of interest in a fashion that gives primacy to the patient’s interests. Conflicts of interest are inevitable in medical practice. Physicians should disclose conflicts of interest to their patients, inform them of the impact of these conflicts on their medical care and of the options for their resolution. As a condition of their participation in a system of care, physicians should require that plans fully disclose the availability of therapeutic alternatives to patients. Physicians should respect the verbal and written contracts into which they enter. Physicians should assure patients’ access to appropriate medical consultation and avoid contractual or other arrangements that restrict their ability or freedom to do so. A physician’s choice of consultant should be based primarily on the consultant’s clinical competence. 3. Physicians should provide knowledgeable input into organizational decisions on the allocation of medical resources and the process of health care delivery. Physicians in health care organizations should encourage ethically appropriate health care decision making. Physicians should assure that high quality medical care is provided in a manner consistent with the efficient use of medical resources. Physicians should not participate in, or contract with, any organization that encourages or requires that care be delivered below minimum professional standards, promulgates financial or disciplinary incentives to withhold appropriate clinical care or engages in deceptive marketing. Physicians should advocate for the adoption of organizational policies and procedures that facilitate access to basic medical care. The relationship of the physician to society 1. Physicians have a responsibility to serve the health care needs of all members of society. Physicians have a collective, professional obligation to serve as advocates for access to basic health care for all members of society and to work against forces that would deny access to underserved segments of our society.
J AM ACAD DERMATOL JANUARY 2000
2. Physicians have an ethical obligation to participate in the formation of health care policy. As primary advocates for patients, physicians should participate in the societal decision-making process regarding health care delivery and the allocation of health care resources. Physicians should participate in societal debates concerning scientific, ethical, moral, economic, and cultural factors that impact the development and implementation of health care policy and access to health care systems. Physicians should educate themselves, their patients, and society at large about advances in the science of medicine and health care policy issues. Physicians should assure that resources expended for the purpose of improving patient well-being are spent in an appropriate manner. Physicians should participate in the process of data collection and analysis and the development of objective criteria for determining the prioritization and allocation of health care resources. Physicians should develop such within a context that focuses primarily on the needs and values of our society as a whole, rather than on political or special interest concerns. Physicians should participate in the process that determines the allocation of health care monies among direct patient care, research, education, and administration (this category may include profit systems where this is a relevant consideration). Physicians’ concern for the common good should not compromise their primary obligation to patients under their care. 3. Physicians have an ethical obligation to preserve and protect the trust bestowed on them by society. Physicians should make medical decisions based on the best interests of their patients without regard to personal and financial gain and, where necessary, challenge the undermining influence of third party payers, contracting agencies, employers, or other organizations and agencies interposed between the physician and the patient. Council of Medical Specialty Societies 51 Sherwood Terrace, Suite M Lake Bluff, IL 60044 Telephone: 847/295-3456 Fax: 847/295-3759 www.cmss.org