Respect for patients’ autonomy is a cornerstone of medical ethics. Patients must rely on their physicians to provide information that patients would reasonably want to know to make informed, well-considered decisions about their health care. Thus, physicians have an obligation to inform patients about all appropriate treatment options, the risks and benefits of alternatives, and other information that may be pertinent, including the existence of payment models, financial incentives; and formularies, guidelines or other tools that influence treatment recommendations and care. Restrictions on disclosure can impede communication between patient and physician and undermine trust, patient choice, and quality of care.
Although health plans and other entities may have primary responsibility to inform patient-members about plan provisions that will affect the availability of care, physicians share in this responsibility.
Individually, physicians should:
(a) Disclose any financial and other factors that could affect the patient’s care.
(b) Disclose relevant treatment alternatives, including those that may not be covered under the patient’s health plan.
(c) Encourage patients to be aware of the provisions of their health plan.
Collectively, physicians should advocate that health plans with which they contract disclose to patient-members:
(d) Plan provisions that limit care, such as formularies or constraints on referrals.
(e) Plan provisions for obtaining desired care that would otherwise not be provided, such as provision for off-formulary prescribing.
(f) Plan relationships with pharmacy benefit management organizations and other commercial entities that have an interest in physicians’ treatment recommendations.
AMA Principles of Medical Ethics: I, II, III, V, VI
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