Ethics Manual
(Reprinted from Annals of Internal Medicine. 1998;128: 576-594)
Medicine, law, and social values are not static. Reexamining the ethical tenets of medical practice and their application in new circumstances is a necessary exercise. The fourth edition of the American College of Physicians Ethics Manual covers emerging issues in medical ethics and revisits old ones. It reflects on many of the ethical tensions faced by internists and their patients and attempts to shed light on how existing principles extend to emerging concerns. In addition, by reiterating ethical principles that have provided guidance in resolving past ethical problems, it may help physicians to avert future problems. The Manual is not a substitute for the experience and integrity of individual physicians, but it may serve as a reminder of the shared obligations and duties of the medical profession.
The secret of the care of the patient is in caring for the patient.
- Francis Weld Peabody (1)
Some aspects of medicine are fundamental and timeless. Medical practice, however, does not stand still. Clinicians must be prepared to deal with changes and reaffirm what is fundamental.
This fourth edition of the American College of Physicians Ethics Manual examines emerging issues in medical ethics and revisits older issues that are still very pertinent. Changes in the Manual since its last revision in 1992 include new sections on genetic testing, the changing practice environment and managed care, organ donation, and disability certification. A case method for ethics decision making has also been added. Such issues as patient responsibility and discrimination are discussed more extensively, and the section on decisions near the end of life (which includes physician-assisted suicide) has been revised substantially. The literature of biomedical ethics expands at a rate that does not allow a bibliography to remain current (2); therefore, an exhaustive list of references or suggested readings is not included in this edition of the Manual.
The Manual is intended to facilitate the process of making ethical decisions in clinical practice and medical research and to describe and explain underlying principles of decision making. Because ethics must be understood within a historical and cultural context, the second edition of the Manual included a brief overview of the cultural, philosophical, and religious underpinnings of modern medical ethics. In this edition, we refer the reader to that overview (3, 4) and to other sources (5-8) that more fully explore the rich heritage of medical ethics.
The Manual raises ethical issues and presents general guidelines. In applying these guidelines, physicians should consider the circumstances of the individual patient and use their best judgment. Physicians are morally and legally accountable, and the two may not be concordant. Physician participation in torture, for example, is legal in some countries but is never morally defensible. Physicians must keep in mind the distinctions and potential conflicts between legal and ethical obligations when making clinical decisions and must seek counsel when they are concerned about the potential legal consequences of decisions. We refer to the law in this Manual for illustrative purposes only; these references should not be taken as a statement of the law or of the legal consequences of a physician's actions, which can vary from state to state. Physicians must develop and maintain an adequate knowledge of key components of the laws and regulations that affect their patients and practices.
The law does not always establish positive duties (that is, what one should do) to the extent that professional ethics, especially medical ethics, does. Our current understanding of medical ethics is based on the principles from which positive duties emerge. These principles include beneficence, a duty to promote good and act in the best interest of the patient and the health of society, and nonmaleficence, the duty to do no harm to patients. Also included is respect for patient autonomy—the duty to protect and foster a patient's free, uncoerced choices (9). From the principle of respect for autonomy are derived the rules for truth-telling, disclosure, and informed consent. The relative weight granted to these principles and the conflicts among them often account for the ethical problems that physicians face. Physicians who will be challenged to resolve dilemmas must have such virtues as compassion, courage, and patience in all aspects of their practice.
In addition, considerations of justice inform the physician's role as citizen and clinical decisions about resource allocation. The principle of distributive justice requires that we seek to equitably distribute the life-enhancing opportunities afforded by health care. How to accomplish this distribution is the focus of intense debate. More than ever, concerns about justice challenge the traditional role of physician as patient advocate.
The environment for the delivery of health care is changing. Sites of care are shifting and managed care continues to grow, yet the U.S. health care system does not serve all of its citizens well and major reform is needed. It is unclear how to reform the system to achieve that goal. Health care financing is a serious concern, and society's values will be tested in decisions about resource allocation.
Ethical issues attract widespread public attention, and debate about them is covered regularly in the press. Through legislation, administrative action, or judicial decision, government is increasingly involved in medical ethics. Today, the convergence of various forces—scientific advances, public education, the civil rights and consumer movements, the effects of law and economics on medicine, and the heterogeneity of our society—demands that physicians clearly articulate the ethical principles that guide their behavior, whether in clinical care, research, or teaching or as citizens. It is crucial that a responsible physician perspective be heard as societal decisions are made.
From genetic testing before conception to dilemmas at the end of life, physicians, patients and their families are called upon to make difficult ethical decisions. The 1970s saw the development of bioethics as a field, followed by a series of reports by the U.S. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Important issues then and now included informed consent (10, 11), access to health care (12), genetic screening and engineering (13, 14), and forgoing life-sustaining treatment (15, 16). These and other issues—AIDS, physician-assisted suicide, increasing computerization of medical records, and the physician as entrepreneur—challenge us to periodically reconsider such topics as the patient-physician relationship, decisions to limit treatment, and confidentiality.
This Manual was written for our colleagues in medicine. The College believes that the Manual provides the best approach to the challenges addressed in it. We hope that it will stimulate reasoned debate and serve as a reference for persons who seek the College's positions on ethical issues. Debates about medical ethics may also stimulate critical evaluation and discussion of law and public policy on the difficult ethical issues facing patients, physicians, and society.
Contents
Care of Patients Near the End of Life
The Physician's Relationship to Other Clinicians
Content provided by: Ethics Standards