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Financial Arrangements

As professionals dedicated to serving the sick, all physicians should do their fair share to provide services to uninsured and underinsured persons. Financial relationships between patients and physicians vary from fee–for–service to government contractual arrangements and prepaid insurance. Financial arrangements and expectations should be clearly established in advance.

Fees for physician services should accurately reflect the services provided. Physicians should be mindful that forgiving co–payment may constitute fraud. When physicians elect to offer professional courtesy to a colleague, physicians and patients should function without feelings of constraints on time or resources and without shortcut approaches. Colleague–patients who initiate questions in informal settings put the treating physician in a less–than–ideal position to provide optimal care. Both parties should avoid this inappropriate practice.

Financial Conflicts of Interest

The physician must seek to ensure that the medically appropriate level of care takes primacy over financial considerations imposed by the physician’s own practice, investments, or financial arrangements. Trust in the profession is undermined when there is even the appearance of impropriety.

Potential influences on clinical judgment cover a wide range and include financial incentives inherent in the practice environment (such as incentives to over utilize in the fee–for–service setting or underutilize in the managed care setting) , drug industry gifts, and business arrangements involving referrals. Physicians must be conscious of all potential influences and their actions should be guided by appropriate utilization, not by other factors. A fee paid to one physician by another for the referral of a patient, historically known as fee–splitting, is unethical. It is also unethical for a physician to receive a commission or a kickback from anyone, including a company that manufactures or sells medical instruments or medications that are used in the care of the physician’s patients. Physicians should not refer patients to an outside facility in which they have invested and at which they do not directly provide care. Physicians may, however, invest in or own health care facilities when capital funding and necessary services are provided that would otherwise not be made available. In such situations, in addition to disclosing these interests to patients, safeguards must be established against abuse, impropriety or the appearance of impropriety. The acceptance of individual gifts, hospitality, trips and subsidies of all types from the health care industry by an individual physician is strongly discouraged. The acceptance of even small gifts has been documented to affect clinical judgment and heightens the perception (as well as the reality) of a conflict of interest.

Advertising

Advertising by physicians or health care institutions is unethical when it contains statements that are unsubstantiated, false, deceptive or misleading, including statements that mislead by omitting necessary information.

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.

Resource Allocation

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. 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:
  1. 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.
  2. 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.

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.

Expert Witnesses

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. In this role, physicians must give an honest and objective interpretation and representation of the medical facts.

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.

The Physician–s Relationship to Other Clinicians

Physicians share a commitment to care for ill persons with an increasingly broad team of clinicians. The team’s ability to care effectively for the patient depends on the ability of individual persons to treat each other with integrity, honesty, and respect in daily professional interactions regardless of race, religion, ethnicity, nationality, sex, sexual orientation, age, or disability. Particular attention is warranted with regard to certain types of relationships and power imbalances that could be abusive or exploitative or lead to harassment, such as those between attending physician and resident, instructor and medical student, or physician and nurse.

Attending Physicians and Physicians in Training

The very title doctor, from the Latin docere, “to teach,” implies that physicians have a responsibility to share knowledge and information with colleagues and patients. This sharing includes teaching clinical skills and reporting results of scientific research to colleagues, medical students, resident physicians, and other health care providers.

The physician has a responsibility to teach the science, art, and ethics of medicine to medical students, resident physicians, and others and to supervise physicians in training. Attending physicians must treat trainees with the same respect and compassion accorded to other colleagues. In the teaching environment, graduated authority for patient management can be delegated to residents, with adequate supervision. All trainees should inform patients of their training status and role in the medical team. Attending physicians, chiefs of service, or consultants should encourage residents to acknowledge their limitations and ask for help or supervision when concerns arise about patient care or the ability of others to perform their duties.

It is unethical to delegate authority for patient care to anyone, including another physician, who is not appropriately qualified and experienced. On a teaching service, the ultimate responsibility for patient welfare and quality of care remains with the patient’s attending physician of records.

Consultation

In almost all circumstances, patients should be encouraged to initially seek care from their principal physician. Physicians should in turn obtain competent consultation whenever they and their patients feel the need for assistance in caring for the patient. The level of consultation needed should be established first: a one–visit opinion, continuing cooperative care, or total transfer of authority to the consultant. Patients have the option to seek an independent consultation from another physician but may be held financially responsible for their decision. The consultant should respect the relationship between the patient and the principal physician, should promptly and effectively communicate recommendations to the principal physicians, and should obtain concurrence of the principal physician for major procedures or additional consultants. The care of the patient and the proper records should be transferred back to the principal physician when the consultation is completed, unless another arrangement is agreed upon. Consultants who need temporary charge of the patient’s care should obtain the principal physician’s cooperation and assent. The physician who does not agree with the consultant’s recommendations is free to call in another consultant. The interests of the patient should remain paramount in this process. A complex clinical situation may call for multiple consultations. To assure a coordinated effort that is in the best interest of the patient, the principal physician should remain in charge of overall care, communicating with the patient and coordinating care on the basis of information derived from the consultations. Unless authority has been formally transferred elsewhere, the responsibility for the patient’s care lies with the principal physician.

The Impaired Physician

Physicians who are impaired for any reason must refrain from assuming patient responsibilities that they cannot discharge safely and effectively. Whenever there is doubt, they should seek assistance in caring for their patients. Every physician is responsible for protecting patients from an impaired physician and for assisting an impaired colleague.

Fear of being wrong, embarrassment, or possible litigation should not deter or delay identification of an impaired colleague. The identifying physician may find it helpful to discuss the issue with the departmental chair or a senior member of the staff or community. Impairment may result from use of habit–forming agents (alcohol or other substances) or from psychiatric, physiologic, or behavioral disorders. Impairment may also be caused by diseases that affect the cognitive or motor skills necessary to provide adequate care. The presence of these disorders or the fact that a physician is being treated for them do not necessarily imply impairment. Physicians should aid their impaired colleagues in identifying appropriate sources of help. While undergoing therapy, the impaired physician is entitled to full confidentiality as in any other patient–physician relationship. To protect patients of the impaired physician, someone other than the physician of the impaired physician must monitor the impaired physician’s fitness to work. Serious conflicts may occur if the treating physician tries to fill both roles.

Peer Review

It is unethical for a physician to disparage the professional competence, knowledge, qualifications, or services of another physician to a patient or a third party or to state or imply that a patient has been poorly managed or mistreated by a colleague without substantial evidence, especially when such behavior is used to recruit patients. Of equal importance, a physician is ethically obligated to report fraud, professional misconduct, incompetence, or abandonment of patients by another physician. Professional peer review is critical in assuring fair assessment of physician performance for the benefit of patients. The trust that patients and the public invest in physicians requires disclosure to the appropriate authorities and to patients at risk for immediate harm. All physicians have a duty to participate in peer review. Fears of retaliation, ostracism by colleagues, loss of referrals, or inconvenience are not adequate reasons for refusing to participate in peer review. Society looks to physicians to establish professional standards of practice, and this obligation can be met only when all physicians participate in the process. Federal law in most states provide legal protection for physicians who participate in peer review in good faith. Conversely, in the absence of substantial evidence of professional misconduct, negligence, or incompetence, it is unethical to use the peer review process to exclude another physician from practice, to restrict clinical privileges, or to otherwise harm the physician’s practice.

Conflicts Among Members of a Health Care Team

All health professionals share a commitment to work together to serve the patient’s interests. The best patient care is often a team effort, and mutual respect, cooperation, and communication should govern this effort. Each member of the patient care team has equal moral status. When a health professional has major ethical objections to an attending physician’s order, both should discuss the matter thoroughly. Mechanisms should be available in hospitals to resolve differences of opinion among members of the patient care team.

Research

Medical progress and improved patient care depend on innovative and vigorous research. The basic principle of research is honesty, which must be assured by institutional protocols. Fraud in research must be condemned and punished. Honesty and integrity must govern all stages of research, from the initial grant application to publication of results. Reviewers of grant applications and journal articles must respect the confidentiality of new ideas and information, they must not use what they learn from the review process for their own purposes, and they should not misrepresent the ideas of others as their own. Scientists have a responsibility to gather data meticulously, to keep impeccable records of work done, to interpret results objectively, not force them into preconceived molds or models, to submit their work to peer review, and to report new knowledge. Self–aggrandizement, public acclaim, recognition by professional peers, or financial gain should never be primary motivations in scientific research.