American College of Physicians - The Physician and Society
Society has conferred professional prerogatives on physicians with the expectation that they will use their position for the benefit of patients. In turn, physicians are responsible and accountable to society for their professional actions. Society grants each physician the rights, privileges, and duties pertinent to the patient-physician relationship and has the right to require that physicians be competent and knowledgeable and that they practice with consideration for the patient as a person.
Obligations of the physician to society
Physicians have obligations to society that in many ways parallel their obligations to individual patients. Physicians' conduct as professionals and as individual citizens should merit the respect of the community.
All physicians must fulfill the profession's collective responsibility to advocate the health and well-being of the public. Physicians should protect public health by reporting diseases, as required by law, to the responsible authority. They should support public health endeavors that provide the general public with accurate information about health care and comment on medical subjects in their areas of expertise to keep the public properly informed. Physicians should regard interaction with the news media to provide accurate information as an obligation to society and an extension of medical practice but must always be mindful of patient confidentiality.
Physicians should help the community recognize and deal with the social and environmental causes of disease. They should work toward ensuring access to health care for all persons and help correct deficiencies in the availability, accessibility, and quality of health services in the community.
Medical care is delivered within social and institutional systems that must take overall resources into account. Increasingly, decisions about resource allocations challenge the physician's primary role as patient advocate. There have always been limits to this advocacy role: For example, a physician is not obligated to lie to third-party payers for a patient or to provide all treatments regardless of their effectiveness (52). Resource allocation pushes these limits further by compelling physicians to consider the best interests of all patients and of each patient. The just allocation of resources and changing reimbursement methods present the physician with ethical problems that cannot be ignored. Two principles are agreed upon:
- As a physician performs his or her primary role as a patient's trusted advocate, he or she has a responsibility to use all health-related resources in a technically appropriate and efficient manner. He or she should plan workups carefully and avoid unnecessary testing, medications, surgery, and consultations.
- Resource allocation decisions are most appropriately made at the policy level rather than entirely in the context of an individual patient-physician encounter.
Physicians should participate in decisions at the policy level; should emphasize the value of health to society; and should base allocations on medical need, cost-effectiveness of treatments, and proper distribution of benefits and burdens in society.
Relation of the physician to government
Physicians must not be a party to and must speak out against torture or other abuses of human rights. Participation by physicians in the execution of prisoners except to certify death is unethical. Under no circumstances is it ethical for a physician to be used as an instrument of government to weaken the physical or mental resistance of a human being, nor should a physician participate in or tolerate cruel or unusual punishment or disciplinary activities beyond those permitted by the United Nations Standard Minimum Rules for the Treatment of Prisoners (53).
Ethics committees and consultants
Ethics committees and consultants contribute to achieving patient care goals by facilitating resolution of conflicts in a respectful atmosphere through a fair and inclusive decision-making process, helping institutions to shape policies and practices that conform with the highest ethical standards, and assisting individual persons with handling current and future ethical problems by providing education in health care ethics (54, 55). Although it is generally agreed that neither ethics committees nor consultants should have decision-making authority, they can advise clinicians, patients, and family members on ethical matters.
Medicine and the law
Physicians should remember that the presence of illness does not diminish the right or expectation to be treated equally. Stated another way, illness does not in and of itself change a patient's legal rights or permit a physician to ignore those legal rights.
The law is society's mechanism for establishing boundaries for conduct. Society has a right to expect that those boundaries will not be disregarded. In instances of conflict, the physician must decide whether to violate the law for the sake of what he or she considers to be the dictates of medical ethics. Such a violation may jeopardize the physician's legal position or the legal rights of the patient. It should be remembered that ethical concepts are not always fully reflected in or adopted by the law. Violation of the law for purposes of complying with one's ethical standards may have significant consequences for the physician and should be undertaken only after thorough consideration and, generally, after obtaining legal counsel.
Physicians have specialized knowledge and expertise that may be needed in judicial or administrative processes. Often, expert testimony is necessary for a court or administrative agency to understand the patient's condition, treatment, and prognosis. Physicians may be reluctant to become involved in legal proceedings because the process is unfamiliar and time-consuming. Their absence may mean, however, that legal decisions are made without the benefit of all medical facts or opinions. Without the participation of physicians, the mechanisms used to resolve many disputes may be ineffective and patients may suffer.
Although physicians cannot be compelled to participate as expert witnesses, the profession as a whole has the ethical duty to assist patients and society in resolving disputes (56). In this role, physicians must give an honest and objective interpretation and representation of the medical facts. Physicians should only accept noncontingent compensation for the time and expenses incurred as expert witnesses.
Strikes by physicians
Physicians should not participate in a strike that adversely affects access to health care. In general, physicians should individually and collectively find alternatives to strikes to address workplace concerns.