ACP: Medical ethics should be a daily aspect of care

A guest column by the American College of Physicians, exclusive to

Is medical ethics an important aspect of real world medical practice today? Or a quaint notion for the history books based on mom and apple pie generalisms?

For the patient and for the physician in practice, medical ethics is — or should be — a daily aspect of care. But that doesn’t make it easy. In fact, it is often easier to simply order a patient requested test or medicine than to spend the time explaining to the patient why that may not be the best care.

The ACP Ethics, Professionalism and Human Rights Committee recently completed the sixth edition of the ACP Ethics Manual, published in Annals of Internal Medicine on January 3, 2012. In many ways, the sixth edition confirms that the more things change, the more they stay the same. There are, of course, new topics — for example, online professionalism and the use of social media by physicians; confidentiality and electronic health records; and health system catastrophes. But the principles that guide the practice of medicine are not new. The challenge is applying them to emerging concerns, dealing with change, and reaffirming what is fundamental.

It has become increasingly important to provide concrete guidance on how to provide that “right” care for the patient, which ACP tries to do through the Manual, in its other policy development, and through educational activities such as case studies.

The Manual is 28 published pages and can’t anticipate every issue that might arise in health care and the patient-physician relationship. But even the skeptics admit it provides needed guidance, and perhaps reminds physicians, medical educators, and researchers why they chose medicine in the first place.

But back to those requested tests or medicines. Among issues, a particular concern in today’s environment is the stewardship of health care resources. The Manual reiterates that the physician’s “first and primary duty is to the patient.” But since the first edition in 1984, the Manual has also noted that the physician must practice “humanistic, scientific, and efficient medicine.” Hmmm … efficient medicine. Were you expecting that phrase?

Over the years, that language has expanded to explain that physicians “have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available” and physicians must consider the best evidence, including data on the cost-effectiveness of different approaches, in making recommendations.

This section of the Manual has already generated debate in an accompanying editorial and several press reports, but the basic directive has been there from the beginning of ACP’s code.

Some of the choices doctors make seem straightforward enough. Like declining when asked to change the dose on a prescription so the amount covered by insurance will last twice as long. Newer choices involve how to most effectively use clinical resources, including the allocation of limited face-to-face time to explain various options.

For example, with the USPSTF’s recent changes for PSA screening recommendations, I (Dr. Ralston) explain to my patients on a daily basis why I used to recommend this test and why I no longer do. I emphasize that I will no longer be having that test done on myself. For many patients that is enough. For others, in an era of concern about health care being taken away, it is not that easy and they still “want to know.”

Or patients with low back pain often want an immediate imaging study early in the course of their discomfort when, as ACP showed last year, it is not needed. It often takes a long time and requires special communication skills to explain this. We do need to try our best to have the patient understand the reasons and not simply feel that they were denied a test in the new world of health care.

So, in some instances, “less” care — like avoidance of an unnecessary test or an inappropriate prescription — is actually better (“more”) care. But that might not be immediately apparent in our technologically driven health care system. Which is why getting back to our principles, the principles of medical ethics, might actually help improve health care, health, and patient-physician relationships.

Fred Ralston practices internal medicine in Fayetteville, Tennessee, and is the Immediate Past President of the American College of Physicians.  Lois Snyder is Director of ACP’s Center for Ethics & Professionalism.  Their statements do not necessarily reflect official policies of ACP.

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