We invited an ethicist from each of three generations to review the fourth edition of the American College of Physicians Ethics Manual. Each was asked to consider the role of the professional society in promulgating an ethics code as the medical profession approaches the next century. Each was also asked to focus on a specific issue: the formal field of bioethics in historical context-that is, where we have come from; how ethics codes are regarded by those outside the profession-where we are now; and ethics in a changing practice environment-where we are going. The result is a thought-provoking set of commentaries from various perspectives. We think that they enrich our understanding of the new edition of the Manual and will usefully inform subsequent editions.
Dr. Edmund D. Pellegrino: Thirty-five years ago, medical ethics entered an era of unprecedented change [1]. The rapidity of this change is reflected in the fact that the American College of Physicians has issued a fourth edition of its Ethics Manual in slightly more than a decade. How many more editions there will be, or what shape they will take, we do not know-we only know that there will be many.
Such rapid change is worrisome both to traditionalists and modernists. With each change, the former are concerned about losing the best from the past, and the latter, about not enough change from the past. Both need to be reminded that changes will continue to occur. What must not change is the moral heart of medicine, that which gives the profession its ethical identity-the primacy of the welfare of the patient.
The new manual must be examined keeping in mind that change was as much a feature of the past as it is today; only the rate of change differs. The Hippocratic ethic itself was a sharp departure from the craft and tradesman ethic of most Greek physicians. The Hippocratic ethic itself was then shaped and reshaped many times: in antiquity by the ethics of the Stoics; in late antiquity and the Middle Ages by Judaism, Christianity, and Islam; in the 18th century by the ethics of the English gentlemen John Gregory and Thomas Percival; and in the 19th century by the 1847 Code of the American Medical Association, which, in turn, has been revised and emended many times, so that today it comprises some 196 pages [2].
The process of change is more complicated today than in the past. The physician must practice ethically in an environment of enormous technological complexity, where authority has shifted to insurers and risk, to the profession; where ethnic, cultural, and religious pluralism, especially in the "human life" issues, divide the profession and the public; where moral skepticism is the order of the day; and where law, economics, and patient autonomy demand to be heard at the bedside.
These realities will force future emendations of the Manual. Given the diversity of moral opinion on these fundamental questions, universal approval is very unlikely. This author, for example, dissents on several issues. But this is not the place to argue differences. What is important to note is the formidable dimension of the task and practical utility of the guidelines for most clinical decisions.
Crucial to the validity of these recommendations is their foundation in the ethics of the patient-physician relationship. This was more thoroughly delineated in earlier editions of the Manual. Herein lies the signature that can unify the profession. No matter what happens in the social, political, or cultural milieu, a universal reality in the predicament of illness imposes obligations on anyone who professes to be a healer. Across history, culture, and nation, ill persons are vulnerable, dependent, nervous, fearful, and exploitable. They are dependent on the physician's technical knowledge and skill. The physician invites trust-and the patient is forced to trust. Fidelity to this trust is the moral compass that must always be the profession's guide.
Dr. Arthur L. Caplan: Many a sociologist has wrestled with the question, "What is a profession?" Although there is no consensus about the attributes that describe a profession, every analysis that I have encountered defines professions in moral terms. Professions distinguish themselves by placing special ethical obligations and responsibilities on their members. To be a member of the medical profession is not merely a matter of specialized knowledge or acting in the role of healer. Physicians are expected to adhere to a code of conduct that defines what it is to be a physician and lets those who are outside medicine know why some autonomy, discretion, and moral slack can and should be cut for those obligated by special norms.
Those who are not physicians but are interested in ethics, such as me, are keenly alert to the reality that codes of conduct ask more of those who are enjoined to abide by them but also promise less in terms of external oversight, regulation, and control to those who do. Because the moral rules of professional codes are self-imposed, outsiders (including many persons in contemporary bioethics) tend to approach any effort at code construction, even so well-crafted a document as the fourth edition of the Ethics Manual, with equal parts awe and terror.
When internists draw up a document that states unequivocally that "physicians and health care organizations are obligated to provide competent and humane care to all patients, regardless of their disease state" or succinctly warns that "fears of being wrong, embarrassment, or possible litigation should not deter or delay identification of an impaired colleague," it is enough to take the wind right out of the most suspiciously windy nonphysician moralist. These are principles that moralists practicing assiduously in front of a blackboard or in an armchair need not heed, much less honor.
But when that very same Manual complains that "patients should make every reasonable effort to carry out the aspects of care that are in their control" or huffs that "insured patients and their families should try to understand the possible implications of their insurance," indignation on the part of nonphysician ethicists is inevitable. Where, the nonphysician wonders, does the College get off imposing any sort of duty on a group-patients-who have no say in the advancement of College principles? If internists think that insurance policies can be understood by any mortal, let alone ordinary ones, let them explain their own insurance policies to their mother or brother-in-law whenever the urge to exhibit superhuman capacities of comprehension arises.
Physicians' codes can impress when they focus on the conduct of physicians. When they slip into injunctions aimed at patients, professionalism is in danger of degenerating into arrogance or worse. That said, it is vital that medicine stay on the job of constructing, refining, and disseminating its professional ethic. Although some bioethicists are loath to admit it, there is moral work to be done in medicine that only medical doctors can do. Issues of privacy, disclosure, confidentiality, care of vulnerable and dying patients, and ways to end the treatment relationship must reflect the experience and privilege of serving as a physician, a role that only experienced physicians can fully know. Calls to the profession to face the risk of infectious disease with courage, to press for a humane practice environment, to avoid conflicts of interest, and to strive to keep patient interests center-stage despite the political din of fiscal constraint are most likely to be heeded when they are issued from those close to the bedside or the laboratory bench. Most important, when the College puts on paper the norms that it believes are at the core of defining medical professionalism, it makes plain for all to see, physicians and nonphysicians, where the profession has moral certainty, where it is wavering, where it is searching, and where it has slipped.
For those outside medicine, the Manual is invaluable because it permits a look directly into the heart of the profession. Viewed in this fashion, an outsider can marvel at the integrity of medicine's defining core while wondering whether the ethos set forth in the manual is enough to guide practitioners in an increasingly challenging moral environment.
Dr. Susan Dorr Goold: The pressure to be cost-conscious, particularly while working in a rapidly changing health care system, challenges physicians to maintain and reexamine medical professionalism. The fourth edition of the Ethics Manual rightly pays careful attention to this context. Although it reaffirms the position that the physician's primary obligation is to the patient, greater attention than in past editions is given to limited resources, to working honestly within a system, and to potential financial conflicts of interest. On the latter topic, the Manual reflects the general lack of scholarly consensus [3]. Physicians are asked to avoid "even the appearance of impropriety or conflict of interest." But any way that physicians are paid has the potential to influence individual patient care decisions, as acknowledged elsewhere in the Manual. Conflict of interest is unavoidable, and differences among payment types are differences of degree, not of kind. To complicate matters, a single plan may pay physicians in multiple ways, and physicians often have contracts with multiple payers. Yes, physicians should subjugate their financial self-interest when making clinical recommendations. But more important, physicians should examine contracts for potentially influential characteristics and clauses before they sign them [4, 5].
Institutional policies and culture also exert pressure on clinical decisions [6]. Monthly meetings on utilization subtly pose the threat of "deselection" and may profoundly influence practice. The amount of patient visit time available, fulfillment (or lack thereof) with one's daily work, and peer recognition can make the difference between a patient-centered and a profit-centered culture.
While it reaffirms the primary obligation to the patient, the Manual asks physicians to be efficient and responsible stewards of pooled resources. Physicians can and must have a role in ensuring that resources are used wisely; patient advocacy is not without limits. Teachers properly see that children with greater needs have access to greater resources (including teacher time) but must also see that each student is treated fairly within the constraints of limited resources. Similarly, physicians are obliged to ensure that resources are distributed equitably, primarily according to need and potential benefit. Although some allocation decisions should be made at the policy level, an inflexible set of rules will never be as sensitive as physicians to the individual needs and preferences of real patients. Although advocacy has limits, the expectation by the patient that his or her physician will act on the patient's behalf, will try to benefit the patient, and will keep the patient's secrets is vital to the maintenance of trust. Without trust, the patient–physician relationship disintegrates and, with it, the core of the health care experience. For the physician, balancing advocacy for the individual patient with that for a population of patients while being a prudent user of resources is a challenge that will confront physicians for the foreseeable future. The College has tackled this with courage and insight.
Physicians working within integrated delivery systems have additional responsibilities to make these organizations deliver better care to patients. They are well placed to monitor quality and to determine when policies are compromising good patient care. They can advocate for patients outside of the examination room by participating in quality improvement efforts and striving to incorporate patient preferences and values, thereby improving care provided to the entire population of patients in the plan. Working in an integrated delivery system provides opportunities for continuity and preventive, population-based health care heretofore undreamed of in a fragmented system of fee-for-service financing. In addition, physicians in integrated systems should spearhead initiatives aimed at improving communication and continuity with clinicians in various arenas. Professionalism demands work at many levels-the patient, the community, and the organization. The College pays attention to patients, urging physicians to ensure access to quality care for uninsured and insured patients. Future editions should expand on what physicians can do at the community and organizational levels to improve health care for all patients.
Edmund D. Pellegrino, MD
Center for Biomedical Ethics
Washington, DC 20007
Arthur Caplan, PhD
University of Pennsylvania
Philadelphia, PA 19104
Susan Dorr Goold, MD
University of Michigan Medical School
Ann Arbor, MI 48109
Dr. Caplan: Center for Bioethics, University of Pennsylvania, 3401 Market Street, Suite 320, Philadelphia, PA 19104-3308.
Dr. Goold: Program in Society and Medicine, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0376.
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