Just as the AMA Principles of Medical Ethics are not laws, but standards of conduct, so too the Opinions in the Code of Medical Ethics are not laws or rules. They are guidance that identifies the essentials of ethical behavior for physicians.
Throughout the Opinions of the Code the Council on Ethical and Judicial Affairs uses the words must, should, and may in their common understandings to distinguish different levels of ethical obligation. Use of the word must indicates that an action is ethically required of physicians. From the perspective of ethics and professionalism, such actions are near-absolute obligations, not matters about which physicians may use judgment or discretion. The Council uses the word should to indicate an action or obligation that is strongly recommended as a matter of professional ethics, but which may have some exceptions. Should is used to indicate what is expected of a physician in most instances, absent special circumstances or considerations. Should indicates that ethically there is some latitude for physician judgment and discretion. The Council uses may to indicate that an action is ethically permissible when qualifying conditions set out in the Opinion are met.
The Council recognizes that circumstances at times impinge on physicians’ ability or opportunity to follow the guidance of the Code strictly as written. Recognizing when such circumstances exist and determining how best to adhere to the goals and spirit, if not the absolute letter, of guidance requires physicians to use skills of ethical discernment and reflection. Physicians are expected to have compelling reasons to deviate from guidance when, in their best judgment, they determine it is ethically appropriate or even necessary to do so.
The more stringent the ethical obligation, the stronger the justification required to deviate from it in any specific instance. Obligations indicated by must can be reversed or violated only in very rare circumstances, for example, when two or more core ethical values conflict in such a way that it is not possible for the physician to uphold both or all and the physician is forced to decide which value will prevail. Guidance introduced by should sets a general expectation for conduct, but permits more latitude for discerning alternative ways to meet the expectation. Obligations indicated by may call on the physician to confirm that qualifying conditions are met sufficiently to warrant taking the action addressed in guidance.
The Council also recognizes that guidance is not always equally applicable to every individual physician, depending on the nature of the physician’s practice. Nonetheless, physicians are expected to be aware of guidance that may not be routinely relevant to their practice, to be sensitive to occasions when such guidance might be pertinent, and to respond in keeping with guidance when such situations occur. In this respect too, then, the Code relies on the reasonable exercise of judgment.
The AMA Code provides ethical guidance for all physicians, regardless of specialty. The AMA recognizes that other physician organizations may also have codes of ethical behavior and that physicians may, at times, have to balance guidance of other professional codes.
Opinions of the AMA Council on Ethical and Judicial Affairs lay out the ethical responsibilities of physicians as members of the profession of medicine. In these opinions, the term “ethical” refers to matters involving moral principles, values, and practices, as well as matters of social policy involving issues of morality in the practice of medicine.
Council opinions articulate the expectations for professional conduct in the areas addressed, at times laying out specific duties and obligations. Conduct that violates these expectations or specific duties and obligations is not acceptable ethically and is unprofessional. Violations of ethical responsibilities may justify disciplinary actions against a physician’s medical society membership.
The relationship between ethics and law is complex. Ethical values and legal principles are usually closely related, but ethical responsibilities usually exceed legal duties. Conduct that is legally permissible may be ethically unacceptable. Conversely, the fact that a physician who has been charged with allegedly illegal conduct has been acquitted or exonerated in criminal or civil proceedings does not necessarily mean that the physician acted ethically.
In some cases, the law mandates conduct that is ethically unacceptable. When physicians believe a law violates ethical values or is unjust they should work to change in law. In exceptional circumstances of unjust laws, ethical responsibilities should supersede legal duties.