Medicine, law and social values are not static. Re–examining 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.

Ann Intern Med. 1998, 128:576–594.

The secret of patient care: Francis Weld Peabody
Some aspects of medicine are fundamental and timeless. Medical practice, however does not stand still. Clinicians must be prepared to deal with changes and yet reaffirm what is fundamental.The 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 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, 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 includes a brief overview of the cultural, philosophical and religious underpinnings of modern medical ethics. In this edition, we refer the reader to that overview and to other sources 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 their 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 non–malfeasance, 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, uncorked choices. 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.

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, teaching or as citizens. It is crucial that a responsible physician perspective be heard as societal decisions are made.

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. 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.