Clinicians and ethicists can use a newly revised Ethics Manual from the American College of Physicians as a resource. Included are:
• a six-step problem-solving approach to ethical decision-making;
• positions on controversial areas such as care of unauthorized immigrants, brain death, and potentially inappropriate treatments;
• a statement opposing legalization of physician-assisted suicide or euthanasia.
There was no shortage of new ground to cover when the American College of Physicians (ACP) set out to revise its Ethics Manual. Genetic testing, the protection of human subjects, social media professionalism, precision medicine and genetics, telemedicine, and physician volunteerism are just some of the ethical challenges clinicians now face.1
“It is critical for physicians to reflect on long-held ethical tenets and principles, applying them to new circumstances on an ongoing basis,” says ACP president Ana Maria Lopez, MD, MPH, FACP.
The manual emphasizes the centrality of the patient-physician relationship and the need for physicians to put patients’ interests first. These ethical obligations, says Lopez, “are fundamental, timeless, and need to be continually reaffirmed in the face of technological and other challenges.”
The Ethics Manual was last updated in 2012. The seventh edition includes a six-step approach to ethical decision-making, which “could very well help physicians make ethical decisions on their own,” says Matthew DeCamp, MD, PhD.
DeCamp, an associate professor at University of Colorado’s Center for Bioethics & Humanities, says the manual “can be seen as a moral compass that will help physicians act rightly in the face of new challenges.”
New forms of electronic communication and questions about the fundamental role of medicine in society are two examples. “The fact that the manual was revised is an indication of how important it is for ethicists to continually re-examine the challenges physicians and patients are actually experiencing in the real world,” says DeCamp.
ACP includes more than 150,000 members. Thus, says DeCamp, “the manual can be seen as taking the pulse of a large and important part of the medical profession regarding its current thinking on contemporary ethical issues.”
Rapidly Evolving Changes
Particularly helpful to review, says J.S. Blumenthal-Barby, PhD, are “issues that practicing physicians encounter frequently but where there is rapid change and evolution.” Several areas covered in the manual are controversial. These include care of unauthorized immigrants, brain death, and potentially inappropriate 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,” says Blumenthal-Barby, who co-authored a recent editorial on this topic.2
Recognition that these issues are deeply contested is an important step in respecting patients and colleagues with different views, says Blumenthal-Barby, an associate director of medical ethics at Baylor College of Medicine’s Center for Medical Ethics and Health Policy in Houston.
“Thus, ethicists looking to the manual for direction might draw a distinction between areas of consensus and areas of controversy, and tread more carefully in areas of controversy,” says Blumenthal-Barby.
DeCamp anticipates that these two parts of the manual may garner particular attention:
• The very clear statement opposing legalization of physician-assisted suicide or euthanasia, despite what appears to be an increasing trend toward legalization in the United States.
“The uncertain legal and moral status of the practice can be difficult to manage institutionally and individually,” says DeCamp.
• The absence of drawing clear lines around what truly constitutes “futile” or “ineffective” medical care.
This reflects both the difficulty of defining terms like “ineffective” and the lack of consensus on what those terms mean, says DeCamp. Patients, physicians, and institutions may have different ideas about what constitutes effectiveness — is it survival alone, or survival with some quality of life? What chance of benefit is meaningful (1 in 100? 1 in 1,000? 1 in 10,000?) also is subjective. Thus, says DeCamp, “there can be challenges in interpreting physicians’ obligations to provide or not provide a particular intervention.”
Patients’ Obligations at Issue
Rosamond Rhodes, PhD, director of bioethics education at Icahn School of Medicine at Mount Sinai in New York City, describes the revised manual as “a cautious document.”
“For the most part, it is in line with other statements on medical and research ethics. It also shares a number of conceptual problems that pop up in similar ethics statements,” says Rhodes.
Regarding the patient-physician relationship, the manual refers to “mutual obligations, but does not specify why patients have obligations, or what they are. Can that be true of children, the unconscious, or the demented?” asks Rhodes. “This is a feature of the document that I find troubling.”
Physicians take an oath and explicitly undertake obligations, but patients do not, says Rhodes. The manual also states 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,” says Rhodes.
The manual includes a section on “futile treatment” and claims that the physician is not ethically obliged to provide it if ineffective or harmful. Rhodes sees the term “futile treatment” as a misnomer: “Interventions that provide no benefit and only inflict harm should not be offered and should not be called ‘treatment.’” Conversely, says Rhodes, interventions that are likely to sustain life should not be considered “futile.” They do offer the benefit of prolonged life, even when they are not likely to cure the underlying condition. “Readers would be better served by an unequivocal and clear account of the justification for refusing to provide interventions that provide no benefits,” concludes Rhodes.
1. Sulmasy LS, Bledsoe TA; ACP ethics, professionalism and human rights committee. American College of Physicians ethics manual. Seventh edition. Ann Intern Med 2019; 170:S1-S32.
2. Blumenthal-Barby JS, Lo B. Building on the American College of Physicians ethics manual. Ann Intern Med 2019; 170:133–134.
• J.S. Blumenthal-Barby, PhD, Associate Director of Medical Ethics, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston. Phone: (713) 798-3785. Email: email@example.com.
• Matthew DeCamp, MD, PhD, Associate Professor, Center for Bioethics & Humanities, University of Colorado. Phone: (303) 724-4098. Email: firstname.lastname@example.org.
• Rosamond Rhodes, PhD, Director, Bioethics Education, Icahn School of Medicine at Mount Sinai, New York City. Phone: (212) 241-3757. Email: email@example.com.