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Updated ACP ethics manual provides 6-step approach to dilemmas

By Will Boggs MD

NEW YORK (Reuters Health) - The 2019 edition of the American College of Physicians (ACP) ethics manual provides a 6-step approach to resolving ethical dilemmas and adds or expands sections that address emerging issues in 21st century medicine.

"The Manual provides succinct guidance on issues that affect the patient-physician relationship, and also issues that have to do with the physician's relationship to other clinicians, the physician's role in society, practice environment issues, and medical teaching and research," Lois Snyder Sulmasy, JD from the American College of Physicians, Center for Ethics and Professionalism, Philadelphia, Pennsylvania told Reuters Health by email. "Topics are also addressed in more detail in ACP position papers on ethical issues and our ethics case study series." (

Snyder Sulmasy and Dr. Thomas A. Bledsoe from the Warren Alpert Medical School, Brown University, Providence, Rhode Island drafted the Manual's seventh edition on behalf of the ACP Ethics, Professionalism and Human Rights Committee. As with earlier additions, this updated version asserts that "the physician's first and primary duty is to the patient."

In order to address emerging issues, ACP's latest ethics manual includes new or expanded sections on electronic communications, telemedicine ethics, electronic health record ethics, precision medicine and genetics, social media and online professionalism, the changing practice environment, population health, physician volunteerism, and research and protection of human subjects.

The updated manual also includes a revised method for ethics decision-making. This 6-step process begins with assessing the medical situation and proceeds through framing the medical decision and ethical question, determining the principles and interests involved in the ethics question, identifying the participants and their motivations, balancing principles and interests to reach resolution, and considering how the ethical dilemma might have been avoided in the first place.

The section on telemedicine insists that a valid patient-physician relationship should be in place for a professionally responsible telemedicine service to take place. Any sort of telemedicine relationship should adhere to the standard of care required for in-person visits, and the benefits of increased access to care through telemedicine need to be balanced against the risks associated with the loss of the in-person encounter.

Ethical precision medicine and genetics must address issues of patient and physician education, counseling, privacy, confidentiality, cost, the patient's best interests, and justice. Patients must be informed of the risks, benefits, limitations, and costs of testing before - not after - testing takes place so that they can make well-informed decisions about testing and disclosure of their genetic information.

The manual strongly discourages the acceptance by physicians of gifts, hospitality, trips, and subsidies of all types from the healthcare industry "that might diminish, or appear to others to diminish, the objectivity of professional judgment."

"It may seem obvious that new issues in medicine are constantly emerging, and the Manual acknowledges that, but it is also critical to recognize that elements such as the patient-physician relationship are fundamental, timeless, and need to be reaffirmed in the face of technological and other challenges," Snyder Sulmasy said. "ACP says physicians must be prepared to deal with relevant changes and to identify and reaffirm what is fundamental, applying principles and reasoned arguments in debates. The seventh edition of the Ethics Manual examines emerging issues in medical ethics and professionalism and revisits older issues that are still very pertinent."

"The practice environment today is very challenging, with seemingly endless time pressures and other barriers to doing the right thing for patients," she concluded. "The Manual continues to remind us that the patient must come first and of the centrality of the patient-physician relationship (and involvement of loved ones in care as desired by the patient). These are core responsibilities and also key to improving the delivery of health care and to 're-enchanting' medicine for patient and physician."

Dr. J. S. Blumenthal-Barby from Baylor College of Medicine's Center for Medical Ethics and Health Policy, Houston, Texas, who co-authored an editorial related to this report, told Reuters Health by email, "This manual is a wonderful resource for physicians, but ultimately, the 'heart' behind this manual is a spirit of professionalism whereby each physician sees herself as part of a larger community of individuals who are committed to acting with integrity and critical thought to preserve the integrity of the profession."

"It is not always clear what the 'right' answer is, but this commitment along with guiding principles of putting patient's interests first, respecting patient autonomy and fostering informed and uncoerced choices, and working towards justice in the distribution of the life-enhancing opportunities afforded by health care will go a long way in leading physicians when encountering tough ethical issues," she said.

Dr. Blumenthal-Barby added, "As we point out in our editorial, there are several areas that are potentially controversial, including the positions on physician aid in dying, care of unauthorized immigrants, brain death, and potentially inappropriate ('futile') treatments. The manual could have acknowledged more explicitly that there is considerable disagreement among thoughtful positions on these issues, as well as analyze the reasons for such disagreement. In a country where these issues are deeply contested, recognizing disagreements is an important first step in respecting patients and colleagues who have different views."

Dr. Rosamond Rhodes, Director of Bioethics Education at Icahn School of Mount Sinai, New York, is troubled by a number of conceptual problems in this and similar ethics statements. She told Reuters Health in an email interview, "In their discussion of the patient-physician relationship, the authors assert that 'The relationship has mutual obligations.' I understand that physicians would wish this to be true and that (they) sincerely want patients to regard themselves as being obligated to maintaining their own health, but it is nowhere explained why patients have obligations or what they are. Can that be true of children or the demented? This is a feature of the document that I find troubling. A parent cannot abdicate responsibilities to a young child claiming that the child has not fulfilled her/his obligations. Similarly, I don't think doctors should feel free to abdicate responsibilities to a patient."

She noted, "In that section they also repeat the assertion that physicians must 'serve the best interests of the patient,' and later in the section on medical risk they assert that 'Physicians' ethical obligation to the welfare of patients is fundamental.' At the same time, they maintain that a physician need not accept a patient and may dismiss a patient. That apparent contradiction is not explained. It also raises problems in the sections on obligations to society, resource allocation, and research which the authors describe as 'tension.' These serious problems should alert the authors to the fact that they have overstated the obligation to the individual patient."

Despite these and other problematic aspects she found in the sections on catastrophes and futile treatment, Dr. Rhodes said, "On the whole, I don't notice anything that is seriously troubling or dramatically controversial in this newest version of the American College of Physicians Ethics Manual. It is a cautious document that is in line with other statements on medical and research ethics."

The complete updated manual appears in the January 15th Annals of Internal Medicine.


Ann Intern Med 2019.

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