Principles of Medical Ethics: Standards for a new era

The AMA House of Delegates will consider updates to its ethical guidelines.

Editorial. Nov. 20, 2000.

At its December Interim Meeting in Orlando, Fla., the American Medical Association House of Delegates will have before it a revision proposed by the Council on Ethical and Judicial Affairs for the Principles of Medical Ethics.

If the house votes to adopt the proposal, the principles will have undergone significant revision for only the fourth time in the AMA's 153-year history.

The council's recognition of the need for an update indicates the rapid change in the medical environment and the need for ethical guidelines that address new and emerging issues not previously covered in the principles.

Some background is in order. When the founders of the AMA met in 1847, one of their priorities was to appoint a Committee on Ethics. That body produced the Association's first Code of Medical Ethics, which incorporated some passages by Benjamin Rush, MD, into an 1803 code prepared by Dr. Thomas Percival, a British physician and ethicist. That document was to serve as American medicine's ethical foundation for more than half a century.

Eventually, however, medicine became more complex, and the AMA acted to address the changes. One milestone was the establishment in 1901 of the AMA Judicial Council (now CEJA) to serve as the high court of medicine. The council drafted a new set of principles, adopted by the House of Delegates in 1912. Subsequently the council issued directives on a wide range of topics, including the corporate practice of medicine, patient solicitation and fee splitting.

In 1957, following two years of discussion in the House of Delegates, a major revision of the principles was adopted with a goal of eliminating specific regulations governing particular conduct and providing fundamental ethical principles instead.

A subsequent revision occurred in 1980, this time after two years of effort by an ad hoc committee headed by the late James S. Todd, MD. The principles adopted at that time eliminated opposition to patient solicitation and salary arrangements (as opposed to fee for service) for group practice physicians.

Now, 20 years later -- and again after extensive input from members of the House of Delegates and physicians all over our nation -- another proposed revision is before the house. Key passages in CEJA's proposed new principles provide a strong statement that the physician's responsibilities to patients are paramount, and make it unmistakably clear that physicians are dedicated to providing care to all and therefore support access to care for all.

As CEJA's recommendations indicate, the environment in which medicine is practiced is constantly evolving. The pace of scientific and social change continues to accelerate, and the need for ethical standards adapted to the changing environment is something that medicine must continually address. Whatever form the next iteration of the Principles of Medical Ethics takes, revisions are likely to be necessary in coming decades.

The ability to continue to set ethical standards in a changing world of medicine is one of the American Medical Association's greatest strengths. The Council on Ethical and Judicial Affairs, which serves as the convener and provides expertise; the Federation, which provides input; and the House of Delegates, which is the final authority, all have roles to play. The end result provides a democratic product that truly is the work of some of the best minds in American medicine.