EXECUTIVE SUMMARY

The American Medical Association’s Code of Medical Ethics has been newly modernized, with hope that increasing numbers of practicing physicians, residents, and medical students will turn to it for guidance. Changes include the following:

  • Opinions were consolidated and terminology was made consistent.
  • Explanations of the ethical principles involved were added.
  • Plain prose replaced terminology that could become outdated.

If a particularly thorny ethical issue presents itself, generations of clinicians have turned to the American Medical Association (AMA)’s Code of Medical Ethics for guidance. After an eight-year project, the code has been modernized.

“It is important that it is updated on a regular basis. As science evolves and societal views change, the code can develop certain inconsistencies,” says Audiey C. Kao, MD, PhD, an internist and the AMA’s vice president of ethics.

A decade ago, it first became clear that a comprehensive review was needed. “We took on this project with great urgency, even though it took longer than we expected,” says Kao.

First, the council did a preliminary review of everything in the code. “The council looked at particular areas that seemed distinctly dated, such as technology that had been superseded by multiple other scientific developments, or where opinions related to an outdated structure of healthcare delivery,” says BJ Crigger, PhD, the AMA’s director of ethics policy and secretary for the AMA’s Council on Ethical and Judicial Affairs (CEJA).

The council then divided itself into teams, and solicited input from the entire Federation of Medicine — all the state, county, and specialty medical societies represented in the AMA’s House of Delegates. Various organizations pointed out parts of the guidance that they viewed as outdated, unclear, or where there was tension between the guidance and state medical policy or state law.

After reviewing all the feedback, CEJA started drafting updated opinions, using a newly adopted format. Crigger describes it as a “two-stranded effort.” The council was looking at the content of the guidance, and at the same time, it was looking at the way the guidance was presented.

In early 2014, a revised draft of the modernized code was posted to an AMA member’s forum for review and feedback. Finally, the council took to it to the House of Delegates formally for the first time for House action at the 2014 interim meeting, making still further adjustments at the annual and interim meetings in June and November 2015. The final code was approved in April 2016.

The multiyear project became so all-encompassing that the council added a minimum of one day to each of its four yearly meetings. “For three years, the council convened for five-day meetings, four times a year,” says Crigger. “That is a huge commitment on the part of practicing physicians.”

Feedback Broad in Scope

Reports by the Council on Ethical and Judicial Affairs deal with controversial issues and often prompt significant debate in the House of Delegates. Surprisingly, the project to modernize the code spurred less controversy than might have been expected. “Certain individuals or groups felt concern about various items, but nothing that rose to the level of debate that we see in some issues, such as aid in dying,” says Crigger.

Some groups or individuals objected to guidance in the existing code that the council had not changed. “Addressing guidance about which some individuals continue to disagree was not part of the modernization process,” explains Crigger. “There are other channels in the AMA to address that.”

The level of scrutiny given to all the feedback received took time. Since the code provides guidance for all physicians, irrespective of specialty, the council had to consider implications of all key stakeholders. They did not want to rush the process.

“This was an important work,” says Crigger. “The council wanted to take the time they thought was necessary to come to a consensus themselves.”

The AMA’s House of Delegates is comprised of 192 organizations, including every state specialty society and medical association. It was important to give them all a say. “This is a process that gave grassroots physicians a chance to voice their opinion,” Kao says. “We needed to make sure everybody had an opportunity to offer their opinion.”

Physicians from every geographic area, practice setting, and specialty weighed in. “We got a rich array of feedback,” says Crigger. “I am confident we heard from every perspective out there.”

For some physicians, being asked to give feedback on the code presented them with an opportunity to study it closely for the first time. “This offered a forum for them to understand what really is in the code,” says Kao. “That was an unexpected silver lining of this process.”

Some delegates suggested the work be done chapter by chapter, covering one subject area at a time, such as genetics or end-of-life care. The council disagreed, arguing that the approach needed to be comprehensive. “There’s no one chapter that will cover everything you need in a given situation,” Crigger says. “They all intertwine in interesting ways.”

Conservative Approach

The council very deliberately reflected on whether they believed the code had intended guidance to be obligatory, ethically permissible, and open to some form of physician discussion or and discretion, or absolutely prohibited.

“To capture all of those meanings, we very consistently used the modal verbs ‘must,’ ‘should,’ and ‘may,’” says Crigger. A preface was added to the code, explaining how these terms should be interpreted.

From the start, the council made a conscious decision to take a very conservative approach. Changes to the guidance were made very sparingly, and focused mainly on updating “egregiously outdated scientific terminology,” says Crigger. “This is the consensus that has emerged from the council and the House after 50 years. It is not something to be overturned lightly.”

The following are some changes that were made:

Opinions were consolidated.

“For example, we ended up consolidating six separate opinions on fees for medical services into a single coherent opinion,” says Crigger.

Elements were identified that were considered obsolete, inappropriately stated, or unclear.

Consistent terminology is used.

Some sections of the code referred to “proxies,” while other sections used the terms “surrogates” or “authorized decision-makers.”

Containing the range of plausible interpretations was one of the council’s concerns. “We use similar terminology, so we are talking about confidentiality in the same way everywhere it occurs,” says Crigger.

Where an opinion didn’t already include a brief opening paragraph highlighting the ethical principles involved, one was added.

“Before, there was a presumption that ‘everybody knows what the underlying values are, so let’s just give the guidance,’” says Crigger. The code now spells out the ethical foundation for the opinion that follows.

For the most part, the council tried to avoid using terms of art that could become outdated, or be subject to evolving interpretation.

The council proposed at one point to introduce the term “right to an open future” in guidance on decision-making involving pediatric patients, for instance.

“A couple of members of the House of Delegates said, ‘What the heck does that mean?’ says Crigger. The language was revised to set out the concept that decisions not be made in such a way that you foreclose the pediatric patient’s own opportunity to make that decision at a later date, when he or she has the capacity to do so.

“Except for terms of art that have been in the literature for decades and will be very familiar to readers, the council decided that if you can say it more clearly in one or two sentences, it was preferable to use the plain prose,” says Crigger.

Use the Code

The ultimate goal is for every physician to understand what is in the code, and what is expected of them, ethically speaking. “Some, but not all, medical schools and residency training programs use the code when teaching future generations of physicians,” notes Kao. “The new format will serve that ‘textbook’ purpose better in the past.”

It’s equally important for practicing physicians to utilize the code. “We need to develop professional educational modules based on various opinions in the code, so physicians use it as part of their lifelong learning,” says Kao.

Crigger notes that the code has traditionally been viewed as “rules for acting,” with clinicians consulting it to determine what should be done, or not done.

“We wanted to make it clear that the code is a resource for thinking through situations a physician may encounter,” says Crigger. In some cases, physicians might even disagree with the guidance that the code gives because they come up with compelling reasons to do things differently.

“In that sense, I can see it being as much a tool for ethics consultants who are not physicians, as for physicians themselves,” says Crigger.

SOURCE

  • BJ Crigger, PhD, Director, Ethics Policy, Secretary, Council on Ethical and Judicial Affairs, American Medical Association, Chicago. Phone: (312) 464-5223. Fax: (312) 224-6911. Email: bette.crigger@ama-assn.org.