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American College of Physicians

Ethics Manual

Ad Hoc Committee on Medical Ethics

Reprinted from Annals of Internal Medicine

  August 15, 1989

CONTENTS

Preface    1

The Historical Evolution of Medical Ethics: An Overview 2

1.00    The Physician and the Patient 4

1.01    The Physician-Patient Relationship 4

1.02    Initiating and Discontinuing the Treatment Relationship 4

1.03    Medical Risk to the Physician 5

1.04    Financial Arrangements 5

1.05    Confidentiality    5

1.06    The Patient and His Medical Record 6

1.07    Disclosure    6

1.08    Consent    6

1.09    Consultation    7 

1.10    Conflicts of Interest 7

1.11    Sharing Fees    8

1.12    The Physician and Non-Scientific Medical Systems 8

1.13    Secret Remedies    8

2.00    The Physician’s Relationship to Other Physicians 8

2.01    Teaching    8

2.02    Medical Students and Resident Physicians 8

2.03    The Impaired Physician 8

2.04    Criticism of a Colleague 9

2.05    Advertising    9

3.00    The Physician and Society 10

3.01    Obligations of the Physician to Society 10

3.02    The Relationship of the Physician to Government 10

3.03    Other Physician-Government Issues 10

3.03a    Torture    10

3.03b    Punishment    10

3.03c    Execution    10

3.03d    Distortion of Clinical Criteria 11

3.04    The Relationship of the Physician to Other Health Professionals 11

3.05    The Relationship of the Physician to the News Media 11

3.06    Strikes by Physicians 11

4.00    Research    11

4.01    Clinical Investigation 12

4.01a    Others Concerned with the Ethics of Research 12

4.01b    Innovative Medical Therapies 12

4.02    Scientific Publication 12

4.03    Public Announcement of Research Discoveries 13

5.00    Initiating and Foregoing Life-Sustaining Treatment 13

5.01    Who Should Make the Decision? 13

5.01a    Competent Patients 13

5.01b    Incompetent Patients 14

5.02    Importance of Advance Directives 14

5.03    Living Wills    14

5.04    Quality-of-Life Considerations 15

5.05    Special Clinical Situations and Life-Sustaining Treatment Decisions 15

5.05a    Brain Death    15

5.05b    Terminally Ill Patients 15

5.05c    Irreversible Loss of Consciousness 15

5.05d    Impaired Cognition 16

5.06    Withholding or Withdrawing Certain Types of Life-Sustaining Interventions 16

5.06a    Orders Not to Resuscitate (DNR Orders) 16

5.06b    Other Life-Sustaining Interventions 17

5.06c    Fluids and Nutritional Support 17

5.07    Euthanasia    17

6.00    Responsibilities of Physicians 17

7.00    Other Ethical Issues

7.01    Ethics Committees and Ethics Consultants 18

7.02    Resource Allocation 18

7.03    Abortion and Contraception 19

7.04    Medicine and the Law 19

Conclusion    19

References    19

American College of Physicians Ethics Manual.

Part 1: History; The Patient; Other Physicians

 The second edition of the Manual was developed by the College's Ethics Committee, whose members for the 1988-89 term were: Lawrence Scherr, MD, Chairman; Saul J. Farber, MD; Eugene A. Hildreth, MD; Richard J. Kahn, MD; Edmund D. Pellegrino, MD; Mark Siegler, MD; and Lee Dunn Jr., Esq. (consultant). Ex-officio members of the Committee were: Michael Bernstein, MD; Norton J. Greenberger, MD; Edwin P. Maynard, MD; Ralph 0. Wallerstein, MD; and John R. Ball, MD, JD. Staff contributions were made by Lois Snyder, JD; and Linda Johnson White. The Manual  was approved by the College's Board of Regents on 10 April 1989.

PREFACE

In 1913 Dr. Heinrich Stern, a visionary young physician, visited the Royal College of Physicians of London and recognized that the United States needed an educationally oriented organization of "internists," an organization comparable to the distinguished English College. In the United States the progress of medicine had been slow, but the various spe­cialties of medicine had begun to emerge.

Dr. Stern's vision led to the founding of the American College of Physicians in New York City in 1915. The ensuing years saw steady growth as the College began to mature as a na­tionally recognized professional society, and as the definition of the in­ternist gained clarity with the establishment of the American Board of Internal Medicine in 1936. The College now includes 74 chapters/regions represent­ing 50 states, the District of Columbia, branches of the Armed Forces and Department of Veterans Affairs, the U.S. Public Health Service, and regions of Canada, Central and South America, and the Caribbean. Since its inception, the College has stood for the highest standards in education, practice, and research.

Although in the College's early years no formal code of ethics had been published, con­formity to rig­orous moral and ethical standards had al­ways been an un­spoken aspect of College life. The College ex­pects the highest levels of social responsibility, per­sonal integrity, and profes­sional excellence; these are the hallmarks of College membership.

This second edition of the ACP Ethics Manual is an effort to address major contempo­rary is­sues that con­front every physician in practice. Medicine, law, and social values are not static; and so, additions, re­vi­sions, and some updat­ing were in order. Like the first edi­tion, this edition is designed to facilitate the process of making ethical decisions in the prac­tice of medicine by suggesting relevant issues that need consideration. It is neither a compre­hen­sive review of medical ethics nor a policy man­ual. The manual is not a statement of legal principles While medical ethi­cal precepts may remain essentially uniform and stable over time throughout this country, the law can differ from state to state and change over time with regard to specific issues. It is important to un­der­stand that the manual should serve as a guide to making ethical decisions. For pur­poses of this man­ual, the terms "ethical" and "moral" are used inter­changeably.

It is essential to remember that physicians are morally as well as legally accountable, and that the two may not be synonymous. Segregation and slav­ery, for example, were once legal in this country, but never morally defensible. Moreover, law rarely establishes positive duties such as beneficence. By con­trast, professional medical ethics makes benefi­cence a primary obligation. Physicians must keep the distinctions and potential conflicts between legal and ethical duties in mind in their clinical decisions.

The physician who is concerned about the legal ram­ifications of acts undertaken on the basis of ethi­cal precepts should seek appropri­ate legal counsel. When reference is made to the law in this manual, it is done solely for general, illus­trative purposes, and those refer­ences should not be viewed as a statement of the law or of the legal consequences of a physi­cian's actions.

The College's Ethics Committee, which is com­posed of practicing internists, medical ethicists, and educa­tors, has written this man­ual for our colleagues in medicine. It presents some of the principles of medi­cal ethics that have evolved in Western culture and are now widely accepted as guidelines for the protec­tion and care of persons who are sick or vul­nerable because of illness. Effective medical practice requires scientific knowledge and mastery of tech­nol­ogy, as well as the art of taking care of the pa­tient, but it must be guided by appropriate sensitivity to ethical issues.

The decision to produce and periodically update this manual was occasioned by a sharp increase re­cently in the number and complexity of ethi­cal prob­lems arising each day in the practice of medicine. Many of these questions are the con­sequence of new knowl­edge and technologic advancement. They also stem from a continu­ing analysis by physicians, ethi­cists, philoso­phers, the legal system, the public, and others, of the changing values of society as they re­late to medicine. An additional purpose of this man­ual is to stimulate reasonable debate so as to widen the area of agreement on medical ethics. Such a de­bate may also stimulate a criti­cal eval­uation of law and public policy in ac­cord with, and sensitive to, the difficult ethical issues fac­ing patients and physicians.

There has been no attempt to include an ex­haus­tive list of references or suggested read­ings within this manual. However, an anno­tated bibliography of medical ethics prepared by Drs. Mark Siegler and Peter A. Singer of the Center for Clinical Medical Ethics, University of Chicago, and Dr. David Schiedermayer of the Center for the Study of Bioethics and the Department of Medicine, Medical College of Wisconsin, is also available from the College. This list emphasizes recent articles written by clinicians that appeared in high-impact journals; it includes both empirical and analytic studies. These readings can en­large the internist's view and knowl­edge of medical ethics, and may assist physicians in making sound clinical decisions within the frame­work of the physician's traditional commitment to moral principles of conduct and conscience.

The Historical Evolution of Medical Ethics: An Overview

One characteristic of a learned profession is its ad­herence to a code of ethics, to a set of spe­cific stan­dards of conduct by which it guides the behavior of its members. Since its earliest recorded history medicine has had such stan­dards, conformity with which has been a hall­mark of the good physician and a safeguard of the patient's welfare.

Medical ethics is grounded in the moral, re­li­gious, and philosophical ideals and principles of the society of which it is a part. In addition, physicians are held to certain special ethical standards that are determined by the nature of the decisions and per­sonal relation­ships charac­terizing the practice of medicine.

Most medical codes have intermingled eti­quette and ethics. Etiquette provides guidelines on re­lation­ships with other physicians and proper decorum in the presence of patients. Ethics concerns itself with the moral principles that underlie the physician's obliga­tions to the sick and to society.

From very early times, society and physi­cians have been concerned with the moral aspects of medi­cal practice. The first existing documents that men­tion the priest-physician are the Egyptian papyri (from about the 16th cen­tury BC); they outline meth­ods of establishing diag­noses, making decisions about whether to treat, and what therapy is appropri­ate. As long as physicians followed the rules, they were held nonculpable should the patient die. On the other hand, if physicians transgressed, tried a new form of treatment, and the patient died, they might lose their own lives.

Medicine developed in Mesopotamia in parallel with its growth in Egypt. Hammurabi, one of the great kings of Babylon, devised in about 2000 BC an elaborate code of laws for those who practiced medicine and surgery. (This code was written 500 years before Moses brought the Ten Commandments down from Mount Sinai.) Hammurabi set surgical fees ac­cording to the social status of the patient and established punishment for poor technical per­for­mance. Thus, both Egyptian and Babylonian soci­eties issued rules and sanctions to control the activi­ties of physicians and surgeons.

The Jewish tradition in medical ethics is a rich one dating back to Biblical times. It derives medical ethics from the norms of the divine law as found in the written law (Torah) and its rabbinic interpreta­tions and applications (Talmud). From the begin­ning, Jewish medical ethics has emphasized the close, rela­tionship of medicine and religion and the primacy, in all its norms, of respect for human life. It also ex­celled in the judicious application of absolute norms to individual cases.

The Greeks absorbed the experiences of the Babylonians, Egyptians, and others with whom they traded. Their medical model was the deified Aesculapius, who was believed to have ministered, with his sons, to the Greek army at the siege of Troy. The priests of Aesculapius healed through art and magic and had little science. They stressed equality of care for rich and poor.

The writings of Hippocrates (460 to 377 BC) in­tro­duced the tradition of clinical obser­vation and criti­cal reasoning. From the Hippocratic school came the Oath, which has been the touchstone of medical ethics for 2500 years. The moral content of the Oath was based in the strict moral code of the Pythagoreans which was, however, not the credo of the ma­jority of Greek physicians. The Oath was later supple­mented by the many books of the Hippocratic Corpus. The ethical norms and the particular etiquette promulgated in the books of the Hippocratic Corpus became the Hippocratic ethic, the essential feature of which is the re­sponsibility of the physician for the patient. This is the source for the benign paternalism that has characterized much of Western medicine up to our own times.

Greek medicine firmly separated itself from for­mal religion. Its spirit was pragmatic. It permitted with­holding the truth from patient and family if it served the patient's good. In contrast with Aesculapian medicine, it tolerated different standards of care for the rich and the poor. Hellenic medicine carried for­ward the Hippocratic tradition and inter­mingled it with the ethical teachings of Plato, Aristotle, and the Stoics.

Hindu medical mores were akin to those of the Babylonians and the Greeks. A Hindu oath of initia­tion into the medical profession con­tains the follow­ing statements: "Day and night, thou shall endeavor for the relief of patients with all thy heart and soul. Thou shall not desert or in­jure thy patient even for the sake of thy living." This oath is similar to a statement from Hippocrates: "As to disease, make a habit of two things, to help or at least to do no harm."

Chinese medicine, with a heritage of over a thou­sand years, had established similar pre­cepts. A canon of medicine written some time between 200 BC and AD 200 holds that the physician should have "mercy on the sick and pledge himself to relieve suffering among all classes. Aristocrat or commoner, poor or rich, aged or young, beautiful or ugly, enemy or friend, native or foreigner, educated or unedu­cated, all are to be treated equally. He should look upon the misery of the patient as if it were his own." This canon contains much that ac­cords with Aesculapian ethics.

Roman medical ethics was strongly influ­enced by Stoic philosophy with its emphasis on virtue and duty. Galen (AD 130-201), who worked in Rome, was a Greek. Like Hippocrates, he sought to ad­vance the science of medicine. His ethical stance combined Hippocratic, Stoic, and Hellenic ethics. After Galen, and largely due to his influence, dog­matism became the prevailing medical philoso­phy. There was little original inquiry and knowledge be­came static. All aspiring physi­cians were required to learn the proto­cols and teachings of Galen, especially in therapeu­tics. Galen's doctrines were not seri­ously ques­tioned until Vesalius (1514-1564) published his monumental anatomical work, De Humani Corporis Fabrica Libri Septem, in 1543.

During the Middle Ages, medical science and philosophy were sustained and transmitted to the West by the Arabs and their allies as they moved along the Mediterranean littoral and into Spain. Two Persians, Avicenna (AD 980-1036) and Rhazes (AD 865-925), were renowned physicians, philosophers, and clini­cians. Rhazes, for example, differentiated measles from smallpox, wrote more than 100 medi­cal treatises and compiled his canon, a compendium of all the medical knowledge ex­tant in his time.

At this time, also, the Hippocratic ethic particu­larly the Oath-was incorporated into the teach­ings of Moslum, Jewish, and Christian physi­cians and thus spread throughout Europe and the Middle East. In this same era, Moses Maimonides (AD 11351204), one of the great­est physician-philosophers, compiled his Canon of Jewish Law and Medicine, which has remained influential to this day. St. Thomas Aquinas (AD 1224-1274) integrated the philos­ophy and ethics of Aristotle with Christian theology in his Summa Theologica and devel­oped the classical doctrine of virtue ethics to a high sophistication.

In AD 1200, Frederick II of Sicily involved the state in the governance of medicine. He estab­lished pro­gressive rules for the education of future physi­cians, their method of practice, charges for their ser­vices, and mechanisms for assuring the purity of drugs.

In 1520, the Royal College of Physicians of London drew up a penal code for physi­cians, but in 1543 the word "penal" was changed to "ethical" to avoid the implication of criminality. When the American Medical Association was founded in 1847 "to elevate the quality of medical education and to im­prove the effective­ness of medical practice," its code of ethics was, in part, based on the code of the Royal College. It was based also on Samuel Bard's A Discourse upon the Duties of a Physician (1) and especially Thomas Percival's Medical Ethics: Or a Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons (2), published in 1769 and 1803, respectively (3).

All these codes, including that of the British Medical Association (1858), mix rules of be­havior and eti­quette with elements of true ethics. The 1957 revi­sion of the American Medical Association's ethi­cal code begins by noting the physician's responsi­bility to his pa­tient: "The principal objective of the medical profession is to render service to humanity with full respect to the dignity of man... rendering to each a full measure of service and devotion." The 1980 version begins, "A physician shall be dedicated to providing competent medical ser­vice with compas­sion and respect for human dignity."

In 1948, the World Medical Association adopted the Declaration of Geneva. This docu­ment, designed for those being admitted to the medical profession, represented a revision of the Hippocratic Oath. About the same time, the Nuremberg Code and the Declaration of Helsinki emphasized the concept of voluntary consent for human research subjects and ex­pressed two significant characteristics of mod­ern medicine: a heightened responsiveness to the needs, wants, and rights of patients as in­dividuals and an acknowledgment of the need to balance the rights of the individual and of society. Both are general guide­lines and do not help in resolving the difficult conun­drums pre­sented by many specific situations that oc­cur in modern medical practice.

Medical morality and philosophy have evolved grad­ually, following a long and some­times un­even path­way. Today, medicine and society face an un­prece­dented array of complex ethical problems. The con­vergence of many forces-scientific advances, public education, the rise of participatory democracy, the civil rights and consumer movements, the effects of law and economics on medicine, and the moral hetero­geneity of our society-poses serious challenges to the long-held, noble vision of Hippocratic ethics. As a result, more change has occurred in medical ethics in the last two decades than in its entire preced­ing history. Neither the public nor the profession has yet assimilated all these changes. Sometimes they are confused by them and yearn for a return to the sim­plicity of the past. But such a return is no longer possible.

Each age views its own situation with alarm when change forces a reconsideration of cher­ished beliefs. Yet, never has medical ethics been forced to under­take a more searching ex­amination and never has there been a greater need for heightened moral sensi­tivity than in our time. This latest revision of the manual tries to confront the magnitude and rapidity of change. It seeks to preserve what is vital from the past and add from the present what the past could not foresee, while at the same time pre­serving the noble spirit of the ancient tradition.

1.00  The Physician and the Patient

The primary goals of the physician are to pre­vent disease and untimely death and to care for the sick. The physician should treat and cure when possible, help patients cope with ill­ness, disability, and death, and relieve suffer­ing. In all instances, the physician must help maintain the dignity of the person. The pa­tient's welfare must be the physician's main concern. All the physician's acts toward these ends stem from the patient-physician relation­ship. Ethical be­havior toward patients furthers these goals and strengthens the patient-physi­cian relationship and the relationship between the physician and society.

1.01    Patient-Physician Relationships

In the absence of a medical emergency, the re­la­tion­ship usually begins when the patient chooses a physician and the physician agrees to care for him or her; belief and confidence in the physician, essential ingredients of healing, come easier when choice is free. Whatever the treatment setting, at the beginning of a success­ful relationship the physician must dis­cern the patient's complaints and underlying feelings and expectations. After defining the problem before them, the physician presents one or more courses of action. If agreeable to both parties, the patient may then empower the physician to initiate a course of ac­tion, and the physician accepts the responsibility. Through effective communication, the relationship is sealed by understanding, mutual acceptance, trust, and respect. The physician must be pro­fessionally competent; he or she should also be interested in the patient, who is to be treated with kindness and re­spect and as a unique per­son. The patient should un­derstand and ap­prove the treatment, and should par­ticipate re­sponsibly in the care. The physician de­serves compensation for services rendered. Professionalism and a sense of duty to the pa­tient and to society should take precedence over concern about compensation; the physician's highest com­mitment is to the patient.

The physician's primary obligations to the patient remain unchanged, even though the pa­tient-physician relationship may be affected in various ways by the system through which health care is delivered or other factors. The patient's interests should always be protected whether care occurs in the fee-for-ser­vice set­ting, health maintenance organizations, pre­ferred-provider organizations, the Armed Forces, the Veteran's Administration, or pub­licly supported medical facilities; or whether the patient is mentally competent, incompetent, permanently unconscious, chronically or acutely ill, or a minor or elderly.

Physicians and patients often come from differ­ent cultures and may have different ideas of what the problem is and what they wish to ac­complish. The care of the patient and satis­fac­tion of both parties are best served if the physician and patient discuss their expectations and concerns openly. If the physician and pa­tient develop differences that prevent a suc­cess­ful relationship, the physician must provide care to the patient until such time as the patient-physician relationship becomes comfortable or can be ended in an appropriate fashion (see "Initiating and Discontinuing the Treatment Relationship"). Since patient care is a dynamic process, a harmonious working arrangement between patient and physician requires continu­ing negotiation and modification. The physician cannot be asked to violate his or her stan­dards of medical practice or the law. Patients may refuse any recommended therapy, but they can­not re­quire the physician to do everything they want, par­ticularly when it runs contrary to the physician's medical or moral standards or en­dangers others.

Spiritual needs and desires of patients vary greatly. The physician should respect the wishes of the pa­tient and cooperate in all rea­sonable ways with reli­gious representatives, insofar as this allows the pro­vision of high-quality care to the patient.

There are occasions when the patient's be­liefs dictate decisions that run counter to medi­cal advice. The physician must judge whether ac­ceding to the pa­tient's wishes compromises his or her sense of medi­cal responsibility to the pa­tient to an unaccept­able de­gree. The physi­cian must try to understand clearly the beliefs and the viewpoints of the patient. If the physi­cian is unable to carry out patient wishes, the physi­cian must withdraw and transfer care of the pa­tient or seek the assistance of the courts (see "Consent").

1.02    Initiating and Discontinuing the     Treatment Relationship

A patient-physician relationship is based on mu­tual agreement to care for the patient. A physician may not discriminate against a class or category of pa­tients, but has no ethical obli­gation to see an indi­vid­ual patient unless no other physician is available, as in some isolated communities; or emergency treat­ment is re­quired, under which circumstances the physi­cian is morally bound to provide care and, if necessary, to arrange for proper follow-up.

A patient is free to change physicians and is enti­tled to have the information contained in the medical records provided to him or her, or transferred to the new physician. The physician may discontinue the professional relationship by notifying the patient and, with the approval of the patient, transfer to another physician the information in the record, providing ad­equate care is available to the patient elsewhere and the patient's health is not jeopardized in the pro­cess. Continuity of care must be assured to the best of the physician's ability.

1.02    Medical Risk to the Physician

It is unethical for a physician to refuse to see a patient solely because of medical risk, or per­ceived risk, to the physician. Especially since the late 19th century, the ethical impera­tive to provide care has overridden risk to the treating physician. This was especially true in the early 20th century when many infections caused un­controllable disease. In recent decades, with better control of such risks, gen­era­tions of physicians have been trained when risk has not been a prominent concern. Recently, however, with the appearance of the acquired immunod­efi­ciency syn­drome (AIDS), this has changed, necessi­tating reaf­firmation of the ethical im­perative and re­lated con­cerns. The College's position paper on AIDS (4) ex­amines issues raised by AIDS and the human im­mun­odefi­ciency virus (HIV) and empha­sizes the follow­ing principles: Health professionals and insti­tu­tions are obligated to provide competent and hu­mane care to all patients; the denial of appro­priate care to a class of patients is unethi­cal; health profes­sionals must be aware of risks in­volved, how to avoid risk, and how to re­spond if exposed, thus minimizing danger to all; and HIV testing should be done only when it will benefit the patient or contacts to whom the or­ganism may have been transmitted or for the protection of the public.

1.04    Financial Arrangements

Financial relationships between patients and physi­cians vary (for example, fee-for-service, gov­ernment contractual arrangements, and pre­paid insur­ance). At the beginning of patient-physician contact, it is good practice for pa­tients to have a general knowledge of physi­cians' fees and the probable overall costs of medical care. Financial arrangements should be clar­ified and means of payment or inability to pay should be established. Once the patient-physi­cian relation­ship has been established, how­ever, the physician's duty is to see that ap­propriate care is ren­dered, unless the relation­ship is discontin­ued.

As a professional dedicated to public ser­vice, the physician also has a moral obligation to contribute services to the neglected and poor and to give quality medical care to all patients.

Another aspect of free care relates to "professional courtesy": Its recipients may feel that they are impos­ing on the physician, thus crippling the healing pro­cess. Physicians should assure these pa­tients that they have full rights to physicians' time, knowledge, and in­terest in them. Patients who re­main uncomfort­able receiving professional courtesy, should, at their request, be charged a mutually agree­able fee. All participants should also be aware of an­other risk re­lated to such "professional cour­tesy." In such ar­rangements, the patient often initiates ques­tioning in informal settings, putting the treating physician in a less than ideal position to provide op­timal care. Both parties should prevent such inappro­priate practice.

1.05    Confidentiality

The patient's right to the confidentiality of his or her medical record is a fundamental tenet of medical care. The physician must not release information without the patient's consent, un­less required by the law or fulfilling a duty to warn another. Confidentiality should be pro­tected to the greatest extent possible, consistent with the duty to protect others and to pro­tect the public health. Confidentiality may have to be broken, for example, to warn sexual partners that a patient is infected with the AIDS virus. If the physi­cian thinks that commit­ment to the pa­tient's welfare overrides duty to the law, the physi­cian can ethically refuse to give infor­ma­tion not re­leased by the patient, but must rec­og­nize that this is an act of conscientious ob­jection that may have legal consequences.

The loss of privacy in modern societies, comput­erized record keeping and electronic data processing, third-party payment for medi­cal services, and the sharing of the patient's care among numerous medi­cal professionals and institutions have made confi­den­tiality in­creasingly difficult to maintain. Physicians should keep abreast of these develop­ments and work to prevent increased invasion of pa­tients' privacy. Also, within their own institutions, physicians should advocate policies and proce­dures to secure the confi­dentiality of patients' records.

Physicians should know the laws of their state re­garding the right of adolescent patients to confiden­tiality and the adolescent's legal ability to consent to treatment. Family involve­ment is important in caring for the adolescent patient, but it must be balanced with need for confiden­tiality and the right of the ado­lescent to exercise autonomy and self-determina­tion in health-care decisions and in his or her rela­tion­ships with health-care providers (5).

The discussion of the problems of an iden­tified pa­tient by professional staff in public vio­lates patient confidentiality and is unethical.

1.06    The Patient and the Medical Record

Legally, the patient has the right to know what is in his or her medical record. The actual chart is the property of the physician or institu­tion. Whether the patient should be allowed personal access to the medical record is debat­able; the legal right in this re­gard varies from state to state. In practice, physicians generally exercise the clinical prerogative of deciding how chart information should be provided, but they have the obligation to release information to the pa­tient or to a third party at the patient's request. To protect confidentiality, information should only be released with the written per­mission of the patient.

Physicians should assure that, at all times, pa­tients have easy access to information con­cerning their critical health-care needs. In addi­tion, travelers, military personnel, and patients who may require treatment away from home should be encouraged to have a summary of their medical records.

1.06    Disclosure

The patient must be well informed to make health-care decisions and work intelligently in part­nership with the physician. The patient is seeking expert knowledge and professional opinion. Effective physician-patient communi­cation can dispel uncer­tainty and fear. Healing and the satisfaction of the pa­tient are enhanced.

Information that the patient needs for deci­sion making should be given in terms the pa­tient can un­derstand. The physician should heed cues from the patient in setting the pace of disclosure, particularly when the illness is grave. If for some reason the pa­tient is unable to comprehend, there should be a full disclo­sure of the patient's condition to his or her au­thorized representative. Disclosure should never be a mechanical or perfunctory process. Distressing news and information should be presented to the patient in a way that minimizes despair.

In general, full disclosure is a fundamental ethical re­quirement. However, ethicists recog­nize the "therapeutic privilege," which is an ex­emption from the most detailed disclosure when such disclosure might inflict serious emotional damage, impair ra­tional decision-making, or otherwise harm the pa­tient. On bal­ance, the therapeutic privilege should be inter­preted narrowly; if it is invoked without justifi­cation, it can undermine the whole concept of in­formed consent.

1.07    Consent

The issue of patient consent is a complex and changing one, with both ethical and legal aspects. It has received heightened attention in recent years for many reasons, including in­creased recognition of pa­tient autonomy, and efforts toward improved risk management. Most simply it is the physician's obli­gation to ensure that the patient or his or her surro­gate be appropriately informed as to the nature of the pa­tient's medical condition, the objectives of pro­posed treatment, treatment alternatives, and the risks in­volved.

Most medical care is provided within the implied consent context: The patient presents for evaluation and care, the nature of the under­lying condition and treatment is explained or known to the patient, and treatment is rendered and not refused. Under such circumstances, the physician may proceed on the ba­sis of implied consent. Express consent most often occurs in the hospital setting where express written or oral consent is given to undergo a particular pro­ce­dure.

If the patient is incapable of giving consent, con­sent should be obtained from someone who is legally au­thorized to consent for the patient. In medical emer­gencies, consent to treatment necessary to maintain life or health can be im­plied.

The doctrine of informed consent goes be­yond the question of whether consent was given for a par­ticu­lar treatment. Rather, it fo­cuses on the content of that consent: specifi­cally, on whether the patient knew enough about the nature of the treatment, the alterna­tive methods of treatment, and what would happen in the absence of treatment to make an in­formed deci­sion. The legal theory is that the physi­cian knows far more than the patient about the true nature of the pa­tient's condition, the nature and ex­tent of the pro­posed or alternative treatment, and the ef­fects which these treatments (or no treatment at all) would have upon the patient. Given the imbalance in knowledge and exper­tise between the physician and the patient, the physician must provide the patient with enough knowl­edge to allow the patient to make an in­formed judgment as to how to proceed. The physi­cian's pre­sentation should be understand­able and unbiased; the patient's or surrogate's con­cur­rence must be obtained without coercion; the physi­cian must not take advan­tage of a sit­uation in which he or she may hold psycholog­ical dominance.

Truly informed consent is most apt to be achieved through effective communication be­tween patient and physician; it is not achieved by the perfunctory sign­ing of a "legal" consent form. The thoughtful physi­cian communicates with the patient in a warm, com­fortable, and open manner that con­veys competence, loyalty, and respect for the patient in an attitude that en­genders trust and confidence. Using language that can be understood, the physician endeav­ors to pre­sent the patient with a basic under­standing of the problems they face together and makes it clear that the patient has the right to make the final choice in accept­ing or rejecting the proposed plan of diagnosis and treatment. Physicians must not abandon patients who do not accept their advice. If the patient rejects the physician's recommendation, the physician may seek the assistance of the courts if he or she feels morally or legally constrained to do so; the physician may withdraw from the case only after providing no­tice and when alternate care is as­sured.

Physicians should also be aware that the tests as to what constitutes informed consent may vary from state to state, and, therefore, they should seek local counsel as to the law in the jurisdiction in which they practice.

Physicians should also obtain consent of the pa­tient with respect to the disposal and use of tissue, or­gans, or other portions of the pa­tient's body re­moved during diagnostic or op­erative procedures. The law in this area is changing, but it is consistently protec­tive of the patient's property rights to his or her own body.

1.09    Consultation

A physician should obtain consultation when the physician feels the need for assistance in caring for the patient. When consultation is re­quested by the pa­tient or legally authorized rep­resentative, it should be obtained.

The level of consultation required should be established from the beginning: a one-visit opinion, continuing cooperative care, or total transfer of au­thority to the consultant. The con­sultant should care­fully and respectfully explain any recommendations to the referring physician and obtain concurrence for major procedures or the calling in of additional con­sultants. The pa­tient and the proper records should be trans­ferred back to the referring physician when the consultation is completed. Care must be taken not to undercut the authority and dignity of the referring physician in this process.

The welfare of the patient is always paramount in the consultation process. When the consul­tant is con­vinced that he or she, rather than the referring physi­cian, should have temporary charge of the patient's care, the con­sultant should tactfully attempt to obtain the re­ferring physician's cooperation and assent. Both the primary physician and the consultant should have the patient's interest as their main con­cern. The referring physician who does not agree with the con­sultant's recommendations is free to call in another consultant. Any differ­ences between referring physi­cian and consul­tant should be resolved in the light of what is best for the patient. The referring physician should receive no fee from the consultant.

Under certain circumstances a complex clinical situa­tion may require several consulta­tions. These must be defensible on the basis of medi­cal necessity. They must also be defensi­ble against charges of col­lusion for profit.  One physician must remain in charge of the overall management of the patient and the uti­lization of in­formation derived from the con­sul­tations. Unless he or she has formally trans­ferred au­thority elsewhere, the ultimate re­sponsibility for the patient's care lies with the referring physician.

1.10    Conflicts of Interest

When conflicts arise, the moral principle is clear. The welfare of the patient must at all times be paramount, and the physician must insist that the medically ap­propriate level of care take primacy over fiscal con­siderations imposed by other institutions or by the physi­cian's own practice, investments, or fi­nancial arrangements.

Activities of physicians relating to the busi­ness aspects of practice should be guided by the principle that such activities be intended for the reasonable support of the practice and for the effective provision of quality care to pa­tients. The physician should avoid any busi­ness arrangement that might, because of per­sonal gain, influence his or her decisions in the care of a patient. Collusion with any health-care provider for personal gain is morally reprehen­sible.

With the above principles in mind, the issue of in­vestment in a hospital or other facility in which the physician practices or to which he or she refers pa­tients poses complex ethical dilemmas. If such in­vestments are made, they should be undertaken for the purpose of mak­ing available necessary services for patients. Otherwise, these investments make the physi­cian vulnerable to the accusation that his or her actions are influenced by such ownership. The wis­est course is to avoid all ethically compro­mising sit­ua­tions.

Gifts, hospitality, or subsidies offered by medi­cal equipment, pharmaceutical or other manufacturers or distributors ought not to be accepted if acceptance would influence the ob­jectivity of clinical judgment.

As long as the care of patients is not com­pro­mised, there is no ethical objection to a physi­cian be­ing en­gaged in any proper busi­ness un­related to his or her medical practice.

1.11    Sharing Fees

A physician's professional fees should be re­ceived for the services rendered directly to a patient. The of­fering or receiving of a shared fee from an­other physician involved in the care of the patient is unethi­cal. It is also unethical for a physician to re­ceive a commission or "kickback" from anyone, in­cluding a company that manufactures or sells medical instru­ments or medications that may be used in the care of patients.

1.12    The Physician and Non-Scientific     Medical Systems

Requests by patients for care outside the rec­og­nized methods of medical care pit the physi­cian's commit­ment to provide optimal medical care against the pa­tient's acknowledged right to choose what care he or she wishes and from whom. Such a request warrants the physician's considerate attention. Before advis­ing a patient, the physician should de­termine the reason for the change: dissatisfaction with current care or merely inducement by claims for the nonsci­en­tific treatment. Next, the physician should be sure that the patient understands, in the spirit of informed con­sent, his condition, treatment, and outlook. The physician and the patient can then discuss realistically and dis­passionately what the pa­tient can expect from the two methods of care. The physician should not abandon the pa­tient who elects to try a non­scientific remedy and should accept the pa­tient's decision with grace and compassion. The physician should not par­ticipate in such treatment. Where the treatment is clearly harm­ful to patients, the physician should seek the best route by which to protect the patient and, where possible, have the dangerous therapy chal­lenged.

1.13    Secret Remedies

In keeping with the principle of the open shar­ing of knowledge, the use of secret reme­dies cannot be condoned, whether or not there is fi­nancial gain. Development and sale of a se­cret remedy are unethi­cal.

2.00     The Physician's Relationship to      Other Physicians

The physician entering the profession shares with all other physicians a commitment to care for the sick. This traditional bond be­tween physicians is a power­ful aid in the ser­vice of patients and must never be used for per­sonal advantage. In daily professional interac­tions between physicians this standard must be upheld (see "Consultation").

2.01    Teaching

The very title "doctor," from the Latin do­cere, "to teach," implies a responsibility to share knowledge and information with col­leagues and with patients. This sharing in­cludes the teaching of clinical skills and report­ing of re­sults of scientific research to col­leagues, medi­cal students, resident physicians, other physi­cians, and other health-care providers. It in­cludes communicating clearly with and teaching pa­tients so that they are properly prepared to participate in their own care and in the mainte­nance of their health.

2.02    Medical Students and Resident     Physicians

It is the responsibility of the physician to teach what he or she knows of the science, art, and ethics of medicine to medical students, resident physicians, and others. It is also the physi­cian's obligation to su­pervise those in training. In the teaching environ­ment, graded authority for management can be dele­gated to residents under conditions of appropriate su­pervision. However, it is unethical to delegate the author­ity for the care of a patient to anyone, includ­ing another physician, who is not appro­priately qualified and experienced. In a teaching ser­vice, ul­timate re­sponsibility for the welfare of a patient re­mains with the patient's attending physician of record who must assure appropri­ate supervision and care of the patient.

2.03    The Impaired Physician

It is the responsibility of every physician to pro­tect the public from an impaired physician and assist a colleague whose professional ca­pability is impaired because of ill health. Such assistance may sometimes take the form of of­fering medical care to the sick physician or providing care for the physician's pa­tients until he or she has recovered.

A physician's incapacity may result from the use of habit-forming agents (including al­cohol and other abuse substances) or from psy­chi­atric, physiological, or behavioral disorders that interfere with patient care. Physician im­pairment may also be the result of disease enti­ties that affect the physician's ability to function with the cognitive or motor skills necessary to meet standards of care. All steps must be taken to assure that no patient is harmed because of actions or decisions made by an impaired physician. The physician who feels unable to help an impaired col­league should suggest other sources of help. The le­gal responsibility of a physician to act and to report such inca­pacity varies, but there is a moral respon­sibility to report the incapacitated physician to an ap­propriate authority (such as chief of service, chief of staff, an institutional committee, state medical au­thorities, or regulatory authorities). In all instances the reporting physician must follow procedures dic­tated by the hospital, state laws and regulations, and by his own con­science.

The warning of patients about a specific, im­paired physician should be tailored to the particular circum­stances and, at a minimum, should include warnings to an identifiable pa­tient if the risk of harm is direct and immediate.

2.04    Criticism of a Colleague

It is unethical and harmful for a physician to dis­par­age without good evidence the profes­sional com­pe­tence, knowledge, qualifications, or services of an­other physician to a review body or a patient. It is also unethical to imply by word, gesture, or deed that a patient has been poorly managed or mistreated by a col­league without good evidence. Such improper be­havior, especially when used to induce a per­son to become one's patient, is unethical. Care to avoid such inducement is especially neces­sary for the physician who has been called into consultation by another physician (see"Consultation").

Equally, it is unethical for a physician not to re­port fraud, professional misconduct, in­com­petence, or abandonment of a patient by an­other physician. lt is here that professional peer review becomes critical in assuring fair assessment of physician performance for the benefit of the patient. The trust invested in physicians by patients and the public requires such disclosures to the appropriate authorities and to pa­tients at risk of immediate harm.

2.05    Advertising

Advertising is defined as a form of com­muni­ca­tion designed to inform the general pub­lic about the avail­ability and nature of products and services. Below are examples of the types of useful informa­tion that could be included in "ethical advertising." These are examples only and should not be inter­preted as ex­cluding other relevant information consis­tent with the ethical guidelines described in this man­ual.

1.    Type of practice or specialty.

2.    Specialty residency training, fellowships, and professional society memberships.

3.     Specialty board certification.

4.     Hospitals to which a physician admits pa­tients.

5.     Office hours and after-hours coverage.

6.     Appointment requirements.

7.     Office location, telephone, and conve­niences (such as proximity of public trans­portation, parking facilities, ramp, eleva­tor, wheelchair).

8.    Description of services (such as in-office roentgenograms, other diagnostic tests, pre­scription of birth-control devices).

9.    Ranges of fees for specific services and tests.

10.    Acceptance of Medicare and Medicaid pa­tients.

11.    Acceptance of credit cards.

12.    Languages spoken.

American College of Physicians Ethics Manual.

Part 2: The Physician and Society; Research; Life-Sustaining Treatment; Other Issues

3.00     The Physician and Society

The professional prerogatives of the physi­cian are conferred by society. In turn, the physician is re­sponsible and accountable to so­ciety for his or her professional actions. Society grants to the physician the rights, privi­leges, and duties pertinent to the pa­tient physi­cian relationship. This grant can be with­drawn by society from the individual physician or from the entire pro­fession. Society has a signif­icant interest in the professional activities of physicians and others in the health-care field and will seek to control and regulate such pro­fessional activities to suit what it perceives as its own best interests. Society has con­ferred great authority on the medical profession in the belief that physicians will use such power for the benefit of patients. Society has the right to require that physicians be competent and knowledgeable and that they practice with con­sidera­tion for the patient as a person.

3.01    Obligations of the Physician to     Society

Like any other good citizen, the physician should strive for the well-being of the com­munity and of so­ciety. He or she should work toward ensuring the availability of adequate medical care for all persons and should support community health endeavors. In particular, the physician should seek to make optimal use of all health-related resources in a technically ap­propriate and effective manner. The physician's con­duct, both as a professional and as a citizen, should merit the respect of the community. He or she should help the community increase its capacity to recognize and deal with social and environmental causes of dis­ease.

In addition, the physician has the following spe­cial obligations:

1.    To fulfill, with his or her colleagues, the profes­sion's collective responsibility to be advocates for the health of the public.

2.    To be aware of the availability, accessibil­ity, and quality of health services in the area in which he or she practices and to partici­pate in reasonable efforts to correct defects in such availability, ac­cessibility, and qual­ity.

3.    To encourage, support, and assist efforts to pro­vide the general public with accurate knowledge relative to its health and health-care needs.

4.    To act for the protection of society by re­porting those diseases, as required by law, to the re­sponsible public-health authorities.

5.    To be aware of limitations of health-care re­sources but to assure the provision of qual­ity care. If conflict arises over the ex­pendi­ture of re­sources on a particular pa­tient, the physician is obligated to protect the pa­tient's welfare.

3.02    The Relationship of the Physician to          Government

The physician should lend his or her exper­tise to the development of health policy at the local, state, and national levels by expressing views as both a cit­i­zen and a professional.

Efforts at cost containment may cause physicians to be caught between their tradi­tional commitment to serve their patients' inter­ests and their new, resource allocation role (see "Resource Allocation" below). The challenge for society and its physicians will be to redefine the level of care that can be made available to all patients regardless of their financial resources. Physicians should not become agents of the state for the rationing of beneficial medical care. If a treatment is unavailable for economic reasons, the patient should be informed; otherwise a political decision as­sumes the ap­pearance of a medical decision. More than ever before, the physician will have to be the ad­vo­cate of the patient in these times of limited re­sources. Patients must know that their best in­terests are being served.

3.03    Other Physician-Government Issues

3.03a  Torture

Under no circumstances is it ethical for a physi­cian to be used as an instrument of gov­ernment for the pur­pose of weakening the physical or mental re­sistance of another human being.

3.03b  Punishment

Participation in, or tolerance of, punish­ment of a prisoner by a physician beyond the punish­ments al­lowed by the United Nations Standard Minimum Rules for the Treatment of Prisoners is unethical (6).

3.03c  Execution

Participation by physicians in the execution of pris­oners is unethical.

3.03d  Distortion of Clinical Criteria

It is unethical for a physician to participate in the formulation or application of diagnostic, therapeutic, or prognostic principles that are subverted or dis­torted for the purpose of pun­ishing prisoners.

3.04    The Relationship of the Physician to     Other Health Professionals

The interests of the patient have primacy in all aspects of the patient-physician relationship. The physician should act as an advocate and coordinator of care for the patient and should assume appropriate responsibility, especially when utilizing the help of other health profes­sionals. The physician should col­laborate only with competent health professionals when sharing the care of the patient. Delegation of treatment or technical procedures must be lim­ited to persons who will conduct such proce­dures with skill and thoughtfulness; the physi­cian who has primary charge of the patient's care must retain ultimate re­sponsibility for all aspects of the patient's manage­ment. Society has identified the physician as pos­sess­ing the necessary training to undertake this re­spon­si­bility, and such responsibility is implied in the rela­tionship between patient and physician.

Physicians and nurses both strive to serve the pa­tient. The lines of communication be­tween physi­cians and nurses must always be open, and commu­nication must always be characterized by mutual re­spect. Whereas the physician's expertise on technical and scientific matters may be greater than that of the nurse, when it comes to moral judgment, physicians and nurses are equal. When a nurse believes a physi­cian's order is contrary to his or her per­sonal values or to usual medical and nursing practice, the nurse must share this opinion with the physician so that the matter can be dis­cussed. Conflict-of-opinion policies and proce­dures in hospitals should be devel­oped to fur­ther guide the resolution of such conflicts.

Medical capability has not always pro­gressed hand-in-hand with medical availability. The un­even­ness and disparity in patient-to-physician ratios across the country have been factors in the remark­able increase in nonphysi­cian practi­tioners who rep­resent a broad spec­trum of edu­cational background, training, ex­pe­rience, and skill. Limits imposed by li­cen­sure for non­physician practitioners vary.

3.05    The Relationship of the Physician to     the News Media

Certain patients will be in the public eye either be­cause they seek public acclaim and at­tention through their work, or have been thrust there by events be­yond their control. Physicians at­tending such patients should re­member that they are not free to discuss or dis­close infor­mation about a patient's health with­out the ex­press consent of the patient. The physician al­ways has the ethical and legal obli­gation to maintain the confidential nature of the physi­cian-patient rela­tionship, and this obliga­tion does not change simply because the patient may be in the pub­lic eye.

Commentary by physicians on medical sub­jects within their areas of expertise can help keep the pub­lic properly informed. Those physicians who are able to help provide the public with accurate information should regard interacting with the news media as an obliga­tion to society and, in a manner of speaking, an extension of medical practice.

3.06    Strikes by Physicians

The withholding of medical services by physi­cians through strikes is a serious action; it is unethi­cal and cannot be condoned. Physicians, both indi­vidu­ally and as a group, have suffi­cient social posi­tion, politi­cal aware­ness, and initiative to find alter­native ways of dealing with problems that would seem to jus­tify dras­tic social and political action.

4.00     Research

Scientists have a responsibility to provide re­search results of high quality; to gather facts meticu­lously; to keep impeccable records of work done; to interpret results realistically, not forcing them into precon­ceived molds or mod­els; and to report new knowl­edge through ap­propriate scientific channels. Self-aggrandize­ment, public acclaim, recognition by pro­fes­sional peers, or financial gain should never be the primary motivating factors for carrying out scien­tific research. Coauthors of research re­ports must be well enough acquainted with the work of their coworkers that they can person­ally vouch for the in­tegrity of the study and the validity of the findings and must have been ac­tive in the research itself.

The basic principle underlying all research is hon­esty. Institutional protocols must be in place to as­sure this. Jacob Bronowski has said in The Common Sense of Science (7), "The institution of science in­volves an implicit social contract between scientists so that each can de­pend upon the trustwor­thiness of the rest.... The entire cognitive system of science is rooted in the moral integrity of aggregates of individ­ual scientists."

Advances in medical knowledge and tech­nol­ogy can occur rapidly. Often it is possible for the clinical application of such progress to pro­ceed swiftly, even before the medical com­mu­nity has had an opportu­nity to establish guide­lines for appropriate and ethical use. It is the responsibility of the medical profession to en­sure verification of the safety and efficacy of new technologies and treatment. Medical con­sensus de­velopment should be open to public scrutiny.

4.01    Clinical Investigation

Advances in the diagnosis and treatment of dis­ease are based on well-designed, carefully con­trolled, and ethically conducted clinical studies. The medical pro­fession must assume the responsibility for ensur­ing that the experi­ment is worth doing. Subjects must be in­structed concerning the nature of the re­search; con­sent must be truly informed and given freely; re­search must be planned thought­fully, so that it has a high probability of yield­ing sig­nificant results; risks to patients must be mini­mized; and the risk/benefit ra­tio must be suffi­ciently low to justify the research ef­fort.

Generally, clinical research is of three types: in­dividual research projects, collabora­tive clini­cal stud­ies, and drug trials. Each insti­tution where clini­cal re­search is conducted with fed­eral support is re­quired by federal law to create an institutional review board for the pro­tection of human subjects. All pro­posed clinical re­search, regardless of the source of support, should be approved by the local institutional review board, which has the responsibility of ensur­ing that the research plans are reasonable and that mecha­nisms for providing protection for research subjects are adequate and opera­tive.

Although this formal system of review is de­signed to protect research subjects, the premise on which all ethical research is based is mutual trust and respect between research sub­jects and researchers. This premise requires that physi­cian-investigators who design or carry out re­search plans have primary con­cern for the sub­jects of these investigations.

4.01a  Others Concerned with the Ethics of      Research

Although the responsibility for ensuring rea­son­able protection of human subjects resides with the plan­ners of the research and the local institutional re­view board, the clinical-research community as a whole is involved indirectly through the advocacy of enlight­ened attitudes and support of ethical research. Physicians re­ferring their patients for participation in re­search protocols must satisfy themselves that the program follows established ethical guide­lines and provides for informed consent, rea­sonable assur­ances of safety, and an acceptable risk/benefit ratio. If the research risks become too great or if continued partic­ipation cannot be justified, the physician must be willing to ad­vise the patient to withdraw. The physi­cian of record does not abdicate overall re­sponsibility for the patient whom he or she has re­ferred to a re­search project.

In addition to the above, local or national agen­cies (such as the Food and Drug Administration) may, in certain circumstances, enter into design and interpre­tation of research. Finally, the peer-review process in medical re­search is a fundamental aspect of design, over­sight, and results review. Peer review con­tributes in a major way to the quality, safety, and ethical principles vital to research.

4.01b  Innovative Medical Therapies

Somewhere along the continuum that lies be­tween established practice and research falls the problem of innovative medical therapy. Physicians who are fully engaged in clinical practice outside the academic arena will obvi­ously confront the ethical dilemmas of inno­va­tive practice more frequently than the ethical prob­lems attached directly to medical re­search itself. Within the category of innovative thera­pies lies a wide range of activities, including the use of uncon­ventional dosages of standard medications, previ­ously untried applications of known proce­dures, and the use of approved drugs for nonap­proved indica­tions.

In ethical terms, deviating from standard therapy is clearly not fully equivalent to con­ducting research, when research is defined by the intent to produce generalizable knowledge. Using unconventional dosages of standard medications, for example, is not traditionally seen as requiring institutional review board oversight because, in the strict sense, this is not thought to constitute research. At the same time, certain fundamental principles of research and prac­tice ethics are very much involved in considerations of innovative therapy (8).

Thus, innovation is viewed positively be­cause the history of medicine is replete with ex­amples of im­por­tant advances that emerged from suc­cessful in­no­va­tions. However, inno­vation should always be ap­proached with cir­cumspec­tion. Especially when there is no precedent for an innovative therapy, it has been suggested that some type of consultation with peers, an institutional review board, or other expert group is necessary to assess whether the inno­vation is in the patient's best interest; the risks of the inno­vation; and probable outcomes of not using a stan­dard therapy (8). The expec­ta­tions of informed con­sent are par­ticu­larly im­portant and may be particu­larly vexing when innovative therapies are at issue.

4.02    Scientific Publication

Scientists must use valid scientific methods in mak­ing their discoveries or in confirming the work of predecessors. As stated earlier, scien­tists can pro­ceed with confidence only if they can assume that the pre­viously reported facts on which their work is premised have been re­ported accurately. All scientists have a profes­sional responsibility to their contempo­raries, as well as to future investigators, to record their observations, to ensure that their conclusions are justified by the data, and then to publish the ma­terial in peer- reviewed journals. Again, the guiding prin­ciple governing the ethics of au­thorship is hon­esty: Only observations that were actually made can be re­ported; the manuscript must make clear what in­for­mation derives from the author's work and what comes from the work of others (and where it was published); readers must be assured that research has been carried out in accord with ethical principles; and authorship must be as­signed only to persons who merit and accept it.

Plagiarism is unethical. To consciously in­corpo­rate the words of others, either verbatim or through paraphrasing without appropriate attribution, is unac­ceptable in scientific litera­ture.

4.03    Public Announcement of Research     Discoveries

In this era of rapid communication and in­tense media and public interest in medical news, it has be­come commonplace for clinical investiga­tors to call press conferences and make public announcements of new research developments. Although it is desir­able that the media obtain valid, factual information about newsworthy scientific developments, it is in­cumbent upon researchers to approach public pro­nouncements with caution and circumspec­tion. Announcements must be presented in lan­guage that does not invite misinterpretation or extrapo­lation be­yond what the investigator in­tended.

Most public knowledge about medicine is derived through the media, and the pro­nouncements of sci­en­tists receive a great deal of media attention. An "announcement of pre­liminary results," although couched in the most careful terms, is frequently re­ported as a "breakthrough." Besides creating false expec­tations in the public mind and causing embar­rassment to the scientists involved, such pro­nounce­ments can result in the loss of credibility of the sci­en­tific community as a whole.

Ethical guidelines for public announcement are indis­tinct because it is unfamiliar terrain for most sci­en­tists. Thus, some caveats may prove useful: The risk/ benefit ratio of the event must be carefully con­tem­plated; cautious assurance must be given that con­clusions are justified from data (which have satisfied rigorous scien­tific methodology); and carefully cho­sen lan­guage must be incorporated into all decisions about public pronouncements.

5.00     Initiating and Foregoing Life-          Sustaining Treatment

Considerations about initiating or foregoing life-sus­taining treatment arise most frequently in patients who are severely and critically ill, terminally ill, per­manently unconscious, or who suffer from irre­versible cognitive or physical impairment. These cases (about which the law varies from state to state) frequently present perplexing clinical and ethical chal­lenges to patients, physicians, and families for the following reasons: They involve life and death mat­ters; certain types of decisions (for example, do-not-resuscitate [DNR] issues) arise more frequently; pa­tients are often not ca­pable of participating in the de­cision-making process and may never regain deci­sion-making capacity; and there is frequently need to involve decision-makers other than the patient. For these reasons, such cases have a clinical and psycho­logical intensity that distinguishes them from more routine clinical encounters in physi­cians' offices or in hospitals. Although this section highlights some of the special features of end-of-life decision-making, this central point must be remembered: The basic principles of informed consent, shared decision-making, and the use of surrogate decision-makers when necessary that have been described earlier in this manual apply to end-of-life decisions as well.

In the light of this crucial proviso, clinical-ethical issues relating to life-sustaining treat­ment will be ex­amined under the following five headings:

1.    Who should make the decision?

2.     In which special clinical situations are such deci­sions frequently made?

3.    What are the types of life-sustaining inter­ven­tions being considered?

4.    Euthanasia.

5.    What are the responsibilities of physicians in such cases?

5.01    Who Should Make the Decision?

5.01a  Competent Patients

Patients who have decision-making capac­ity and who have been adequately informed of their clinical situa­tion and options usually have the right to accept or refuse any recommended medical treatment, in­clud­ing life- sustaining treatment. The only exception is when the law forces a patient to accept treatment over his or her objections, as in, for example, certain cases involving members of Jehovah's Witnesses. This right of the patient is based on the philo­sophical concept of autonomy, the common-law right of self-determination, and the more recently enunciated constitutional right to pri­vacy. The crux of the issue is that the compe­tent patient's (rather than the physi­cian's) assessment of the benefits and burdens of treatment should determine what treatment is admin­is­tered or withheld.

Generally, patients with decision-making capac­ity will accept physician recommendations about life-sustaining treatment, but, in some instances, particu­larly those of terminal or irre­versible illness, compe­tent patients may elect to forgo life-sustaining inter­ventions. Because physicians invest so much in ac­quiring the nec­essary knowledge for making diag­nostic and therapeutic decisions, it is often difficult for them to accept the fact that what is the "best" de­cision for a particular patient (in the opinion of the patient) may not be the "right" decision for that pa­tient (in the opinion of the physi­cian).

5.01b  Incompetent Patients

In contrast to decisions made by competent pa­tients, decisions regarding life-sustaining treatment for pa­tients thought to lack decision-making capacity are very complicated for the following reasons: There is no reference stan­dard-legally or clinically-for assessing deci­sion-making capacity and competence; there is lack of agreement on how the determination of decision-making capacity should be made and whether it should be done at the bedside by clinicians or in courts by judges; even when all agree that a pa­tient lacks decision-making ca­pacity (for example, when the patient is co­matose), there is no consensus on who should serve as a surrogate decision-maker for the pa­tient-a relative, a friend, the physician, or a court appointed guardian; and, even when all agree that a particular surrogate decision-maker is the right one (for example, a loving spouse), there remains considerable uncertainty about how to apply the cri­teria the surrogate should use in reaching a decision for patients without decision-making capacity.

Surrogate or proxy decision-makers must be morally as well as legally valid representa­tives of the incom­petent patient's interests. They should know the pa­tient's values well and be free of obvious fiscal or emotional conflicts with the patient. The physician should take rea­sonable care to ensure that the surro­gate's de­cisions are motivated by respect for the pa­tient's interests and values. The physician is the pa­tient's advocate and has a duty to the patient and to no other person during the interim.

One approach adopted by the courts is that of "substituted judgment" in which the surro­gate at­tempts to make the judgment that the pa­tient, if com­petent, would have made. Other courts have adopted a "best interests" approach in which the surrogate, or the court, attempts to determine the choice that is in the patient's best interest. The physician should seek counsel as to the applicable standards in the state in which he or she practices.

In these cases, clinicians should be guided by the following suggestions:

1.    It is never easy to reach life-and-death de­cisions for patients who lack decision-making capacity and who have not left clear advance directives. Therefore, clini­cians should work with the fam­ily and guardians of such patients to reach the best decisions in light of the patient's medical condition, prognosis, and the presumed prefer­ences of the patient as articulated by the surro­gate.

2.    Physicians should diminish the need for specu­lating about life-and-death decisions for patients without decision-making ca­pacity. To accom­plish this, physicians should, when the patient is competent, at­tempt to obtain, either orally or preferably in writing, the treatment preferences of their patients in circumstances where the pa­tient later may be unable to participate in such decisions.

3.    Whenever possible, these decisions should be reached in the clinical setting by re­sponsible physicians, family, and other caregivers.

5.02    Importance of Advance Directives

Recognizing the difficulty of assessing prefer­ences when a patient lacks decision-making ca­pacity, physicians should encourage competent patients to make plans about treat­ment in ad­vance of medical crises. This ad­vance planning should specifically ad­dress two key points: the type of treatment the patient would wish to re­ceive in different circum­stances and the person whom the patient wishes to have serve as a sur­rogate decision-maker when he or she becomes unable to par­ticipate in decision-making. This pro­cess of discussion with the patient informs the physi­cian of the patient's preferences and values, im­proves communication between physician and pa­tient, and often reduces the patient's anxieties be­cause the pa­tient knows the physi­cian is willing to discuss these highly sensitive issues and will be re­sponsive to the patient's wishes. Discussions about the wishes of pa­tients should be documented in the medi­cal record. Patients should be encouraged to for­malize their ad­vance directives, for example, by us­ing a living will (see below) or through a durable power of attorney.

5.03    Living Wills

These documents are valid ethically because they provide insight into a patient's preferences at a time when the patient lacks the capacity to communicate. Physicians must apply clinical judgment to know whether the general lan­guage of a living will applies to the specific cir­cumstances of a particular patient. Therefore, when a patient prepares a living will, the patient should be encouraged to provide a copy of it to the physician, so that it can be discussed and un­derstood and entered in the medical record. This will ensure that the patient's wishes are known, even when the patient comes under the care of different physicians in various institu­tional settings. Because patients can and do change their minds, both oral conversations and written directives should be up­dated peri­odically so that choices made by the patient are contemporary with the progress of treatment, and thus carry greater weight.

5.04    Quality-of-Life Considerations

Individuals often take account of their own qual­ity of life in reaching decisions about their care. By con­trast, when quality-of-life stan­dards are used by par­ties other than the patient to reach a clinical deci­sion, decision-makers must be aware of the personal and subjective values that may influence such qual­ity-of-life evaluations. Thus, an assessment of a pa­tient's quality of life may vary according to the deci­sion-maker's age, present health, history of personal ill­ness, cultural background, religion, and long-stand­ing personal knowledge of the patient. Clinical deci­sions that hinge on assessing quality of life should be undertaken with great care, with full cog­nizance of the subjectivity of the assessment, and with full par­ticipation of the patient, or, in cases of in­competent patients, with participation of knowl­edgeable and concerned relatives or guardians.

5.05    Special Clinical Situations and Life-    Sustaining Treatment Decisions

5.05a  Brain Death

Irreversible death of the entire brain, includ­ing the brain stem, is now accepted by most clini­cal, le­gal, and religious groups as an ac­ceptable standard for determining death when the use of cardiopul­monary life support pre­cludes the use of traditional criteria. There may arise circum­stances, such as the need to pre­serve organs for transplantation, the need to coun­sel and com­fort the family, or the presence of a viable fe­tus, in which physicians may elect to sup­port the body when clinical death of the whole brain has oc­curred. Definitions of death vary from state to state (and may be statutorily defined), and, therefore, physicians should avail them­selves of legislative, ju­dicial, or pro­fessional guidance regarding the use of brain-death stan­dards.

5.05b  Terminally Ill Patients

Terminally ill (dying) patients are those whose con­dition is irreversible whether treated or not and who have a high probability of dy­ing in a relatively short time (for example, 3 to 6 months). The general guidelines for shared de­cision-making proposed for initiating and for­going life-sustaining treatment apply also to cases of terminal illness. Although the under­ly­ing disease cannot be cured, the physician must work closely with the patient to make the pa­tient as comfortable as possible by reducing physical and psychological suffering, discom­fort, and dysfunc­tion. Palliative care, such as is emphasized by the hospice concept, often in­cludes pain relief and psy­chological and social support but also may include surgery, radiation therapy, and the administration of antibiotics when any of these are needed to make the pa­tient more comfortable. It appears that many physicians continue to undertreat pain even in termi­nally ill patients. Therefore, it is essential for physi­cians to become more knowledgeable and skilled in the appropriate use of narcotics and other methods of pain relief, particularly in the treatment of terminally ill patients. Finally, the physician must not forget the important re­sponsibility to provide support to the pa­tient's family, friends, and care providers.

5.05c  Irreversible Loss of Consciousness

The question of discontinuing life support for per­sons who are permanently unconscious but are not terminally ill or brain dead (such as per­sons in a per­sistent vegetative state) remains a perplexing one. The current legal and ethical mainstream position is to make treatment deci­sions about such patients in the same manner as for other patients, insofar as that is possible. If the patient's previous wishes for or against life-sustaining treatment are known, the physician has a presumptive obligation to act on these wishes. Unfortunately, most permanently un­con­scious patients have not provided unam­biguous ad­vance statements of preferences. The best clinical recommendation in these diffi­cult cases is for the physician to elicit the opin­ions of the patient's fam­ily, friends, clergy, primary-care physician, and other caregivers in an effort to determine what the patient would wish in these circumstances. Failing at that, there has emerged a tendency to withdraw more complex interventions such as ventilators, renal dial­ysis, and intensive-care nursing from per­manently unconscious patients. When such pa­tients continue to survive, clinicians are divided about when antibi­otics, fluids, and nutritional support should be with­held. In recent years, when such cases have been brought to court, they sometimes have been decided under a "best interests" standard in which the treat­ment is dis­continued because the burdens of contin­ued interven­tions are seen as disproportionate to the minimal ben­efits (primarily continuation of physical life) that pa­tients derive from such treatment. A physician who has strong moral feelings about this matter must fol­low his or her own conscience in making a decision in a particular case (see  "Medicine and the Law").

5.05d  Impaired Cognition

Currently, except in cases where advance di­rec­tives have been provided, patients with se­vere and ir­re­versible cognitive impairment who are not perma­nently unconscious should con­tinue to receive basic supportive care. In the current medical environment, which empha­sizes cost containment, physicians should not use quality-of-life standards that may lead to the undertreatment of various groups of pa­tients, including those with physical and cogni­tive disabili­ties, unconsciousness but still un­settled prognosis, and severe dementia. Patients whom some perceive to be responsible for their own illness (such as those who suffer from alcohol abuse, drug abuse, or the ac­quired immunodeficiency syndrome [AIDS]) must be treated with the same care and accord­ing to the same ethical considerations as others.

5.06    Withholding or Withdrawing Certain     Types of Life-Sustaining Interven-    tions

5.06a  Orders Not to Resuscitate (DNR           Orders)

The goal of DNR orders is to provide opti­mum qual­ity care to patients. A decision to withhold car­diopulmonary resuscitation (CPR) does not imply that other aggressive therapies should be withheld or withdrawn, and a DNR order should not affect any other aspects of the pa­tient's care. There is general agreement that it is not good medical practice to carry out CPR on all patients who experience a cardiac or res­pira­tory arrest (9): "The purpose of cardiopul­monary resuscitation (CPR) is the prevention of sud­den unexpected death. Cardiopulmonary resuscita­tion is not indicated in certain situa­tions, such as cases of terminal irreversible ill­ness where death is not unex­pected."

For both clinical and historical reasons, DNR orders that override the presumption of carrying out CPR in patients who sustain car­diac or respiratory ar­rest have become the paradigm for institutional proto­cols that address the problem of providing or with­holding life-sustaining therapies. The unique clinical feature of CPR is that it is an emergency treatment that must be applied immediately to be suc­cessful. Because there is limited time during the cri­sis for de­liberation and decision-making, all deci­sions about the use or withholding of CPR should be determined in advance of the clinical crisis. When it is agreed that CPR should be done, physicians and nurses should not carry out half-hearted efforts (so-called "slow codes"). When appropriate procedural safe­guards exist, including proper documentation so that mem­bers of the health-care team are aware of the deci­sions, DNR orders and other decisions about with­holding life-sustaining therapies have been widely ac­cepted as reason­able standards of clinical practice. Recently, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has man­dated that accredited acute-care and long-term-care facilities de­velop and implement institu­tional policies on with­holding CPR. The JCAHO re­quires that institutions develop DNR policies that en­sure that patients' rights are re­spected; provide pro­cedures for resolving con­flicts; make the physician responsible for writing the DNR order; and require that the DNR order be docu­mented in the patient's medical record (10).

The two guiding principles that should de­termine whether a DNR order is written for a competent pa­tient are the medical indications and the patient's pref­erences. Ideally, these considerations are dis­cussed by the patient and physician, and they reach a joint and acceptable decision. Discussions of a DNR order can be initiated either by the physician or the patient at any time but are essential in clinical situa­tions where a cardiorespiratory arrest is likely. Such discussions that have occurred when patients are relatively stable often provide physicians with guide­lines for develop­ing a comprehen­sive treatment plan for the patient. When treat­ment is judged useless, or when CPR would only prolong the dying process, then, if the pa­tient agrees with the plan, an order not to re­susci­tate such a patient is ethical. In cases of conflict be­tween the competent patient and the physician, the patient's wishes should prevail. For reasons of con­science, the physician may elect to withdraw from the case.

A DNR order should not be discussed with a compe­tent patient's family unless the patient autho­rizes such a discussion. If the patient signifies his prefer­ence for a DNR order, this preference becomes the paramount considera­tion. If the competent pa­tient's preference is contrary to the desires of the spouse or others, the latter have no legal, ethical, or moral standing to enforce their desires unless a court de­clares the patient to be legally incompetent and ap­points a guardian to make treatment de­cisions for the patient.

A DNR decision for an incompetent patient or for a patient who lacks decision-making ca­pac­ity raises the same issues discussed earlier in this section re­gard­ing incompetent patients. For persons who have been declared legally in­ca­pacitated, DNR orders must never be written solely on the basis of the mental condition but for the same reasons as for competent patients. Family members and friends often serve as rep­resentatives of the patient's moral community and frequently are most knowledgeable about the pa­tient's values and preferences. Physicians should work closely with family and friends of incompetent per­sons to determine the patient's preferences. Legally, the physician would be well advised to rec­ommend to the patient's family that they have one member of the family appointed as the patient's guardian so that the physician will have a person to deal with who has the legal authority to make all treatment de­cisions for the patient.

Even when resuscitation would provide no medi­cal benefit, the family should be told the medical sit­ua­tion, and the physician should at­tempt to persuade them of the reasonableness of a DNR order. Full dis­cussion with the spouse or other close relatives about the indica­tions for CPR, the DNR order, the legal aspects of such orders, and the physician's role as the patient's advocate will nearly always re­sult in a deci­sion that is ethically correct.

5.06b  Other Life-Sustaining Interventions

The general rules developed for competent and in­competent patients, and their specifica­tion re­gard­ing DNR decisions, apply also to decisions about other complex and simple life-sustaining interven­tions such as ventilators, dialysis, transfusion of blood prod­ucts, and antibiotic administration. When pos­sible, •physicians should work with their patients in ad­vance of a clinical crisis to develop a mutu­ally agree­able, general-care plan that considers which, if any, life-sustaining interventions should be withheld or withdrawn in various clinical circumstances. These discussions should be documented in the pa­tient's medical record. Such information is especially impor­tant if, at a later time, the pa­tient lacks decision-mak­ing capacity.

5.06c  Fluids and Nutritional Support

Another debate has focused on the with­holding or discontinuation of artificial feeding. It is not unethical to discontinue or withhold fluids and nutri­tional sup­port under certain cir­cumstances. An emerging clini­cal and judicial position is that enteral and parenteral nutrition and hydra­tion should be likened to other medi­cal inter­ventions and may be withheld or with­drawn according to the principles developed in this section. The most difficult situation in­volves a non­terminally ill, permanently uncon­scious pa­tient whose previous wishes are not known. In such cases, some hold that there is no obliga­tion to pro­vide fluids and nutrition be­cause the burdens of even such simple inter­ventions ex­ceed the limited benefits of sustain­ing organic life in a person who will never re­cover cogni­tive function. Another viewpoint cau­tions that in withholding simple inter­ven­tions like fluids and nu­trition, physicians may be contributing to the death of nonterminally ill persons, and that such a policy may be danger­ous for vari­ous groups of vulnerable pa­tients. In deciding between these two positions, the physician must exercise his or her own judg­ment about what is morally permis­sible and should seek guidance concerning the law in his or her lo­cale.

5.07    Euthanasia

Recently, the Council on Ethical and Judicial Affairs of the American Medical Association (11) made the following statement about euthanasia: "What is termed 'active euthanasia' is a euphemism for the in­tentional killing of a person; this is not part of the prac­tice of medicine with or without the con­sent of the pa­tient. Legally, a person who kills an­other per­son under these circumstances is guilty of homicide. A motive of mercy is not a defense." The Ethical and Judicial Council (11) also reaf­firmed their policy statement on euthanasia made in 1977: "The inten­tional termination of the life of one human being by another-mercy killings-is contrary to public pol­icy, medical tradition, and the most fundamental mea­sures of human value and worth."

Physicians should draw a firm line between the for­going of life-sustaining interventions (sometimes called "passive euthanasia") and medical killing (sometimes called "active euthanasia," "mercy killing," or "assisted sui­cide"). Medical killing would involve the ad­ministration of a lethal agent (such as a delib­erate overdose of morphine) to a patient with the clear intention of causing the patient's im­mediate death. Although a patient may refuse a medical inter­vention and the physician may comply with this re­fusal, the physician must never intentionally and di­rectly cause death or assist a patient to commit sui­cide. Active euthanasia remains illegal in all jurisdic­tions of the United States. Even if legalized, how­ever, such an action would violate the ethical stan­dards of medical practice (see "The Relationship of the Physician to Government").

6.00     Responsibilities of Physicians

The primary responsibility of physicians is to apply medical knowledge to help patients iden­tify and achieve their medical goals. Medical goals fre­quently sought jointly by pa­tients and physicians may include prevention of disease, cure of disease, prolongation of life, relief of symptoms, restoration or mainte­nance of func­tion, and, at times, the with­holding or with­drawing of life-sustaining treatment. The fac­tors that define the goals of a particular pa­tient-physician encounter include the nature of the disease and its prognosis, the values and pref­erences of the patient and physician, and the social, eco­nomic, and legal constraints on pos­sible choices. This view of excel­lent mod­ern medical practice im­poses the following specific responsibilities on con­scientious physicians:

1.    Physicians must be knowledgeable, com­petent, and skilled in determining the pa­tient's diagno­sis, prognosis, the range of treatment choices (including the risks and benefits of alternative choices), and the patient's preferences.

2.    Physicians must be capable and willing to com­municate effectively with and advise patients so that patients can make informed decisions re­gard­ing their own treatment or nontreatment prefer­ences.

3.    Physicians have a responsibility to respect the treatment decisions of all patients who retain de­cision-making capacity. If unable to honor the wishes of a competent patient, the physician may seek the assistance of the courts if he or she feels morally con­strained to do so, or the physi­cian may withdraw from the case if the patient is provided sufficient advance warning and alter­nate care is assured.

4.    Physicians should elicit from all competent pa­tients-but especially from those patients at high risk of dying or of becoming in­competent-the patient's treatment prefer­ences regarding life-sustaining treatment and the patient's choice of a surrogate de­cision-maker. These discussions should be documented in the medical record.

5.    Physicians should encourage patients to prepare a legally valid advance directive.

6.    The physician should periodically review and update oral and written advance direc­tives with the patient so that the prefer­ences of patients are contemporary.

7.    Physicians should participate in assessing the decision-making capacity of patients because such an assessment determines how physicians ought to respond to a par­ticular choice made by a patient. In emer­gency and life-threatening sit­ua­tions, when psychiatric consultation and judi­cial inter­vention are not feasible, the treating physi­cian is solely responsible for deter­mining if a pa­tient retains sufficient deci­sion-making ca­pacity to make a choice to receive or refuse life-sustain­ing treatment.

8.    In those cases where patients lack deci­sion-making capacity, the physician must determine which surrogate decision-mak­ers should be con­sulted and whether insti­tutional or legal guidance is necessary.

9.    Physicians should not breach the confi­dential nature of the patient-physician rela­tionship by discussing the competent pa­tient's care with per­sons who are not au­thorized by the patient to be made aware of the patient's diagnosis, progno­sis, and treatment.

7.00     Other Ethical Issues

7.01    Ethics Committees and Ethics     Consultants

Ethics committees and ethics consultants offer two different approaches to the same goal: im­proving the care of patients by attending to the ethical issues that frequently arise in clinical settings. Ethics com­mittees and consultants contribute to achieving the goals re­lated to pa­tient care primarily by develop­ing educa­tional programs in the institution, by coor­dinat­ing institutional resources, by providing a forum for dis­cussion among medical and hospital pro­fes­sionals, and by assisting institutions to de­velop sound poli­cies and practices. Although it is generally agreed that neither ethics commit­tees nor consultants should have decision-making authority, it is less well estab­lished whether they should serve in an advisory ca­pacity for physicians who are confronted with dif­fi­cult ethical matters about particular pa­tients. Neither ethics committees nor ethics consultants have been ade­quately evaluated prospectively to know whether they can serve a useful advisory function. The legal status and potential legal liability of ethics committees re­main unclear, and physicians are strongly ad­vised to seek legal counsel about the current state of local law in this unsettled area.

When a conflict arises over a treatment de­cision, and the conflict is thought to include ethical issues, physicians have the discretion to seek consultation from clinical colleagues, re­view committees on pa­tient care, ethics com­mit­tees, ethics consultants, or legal advisors. Of course, final moral responsibility for the deci­sion rests with the patient and the attend­ing physician and not with a consultant or a com­mit­tee.

7.02    Resource Allocation

The physician has a responsibility to serve the best interest of the patient, even in a world of limited re­sources. The guiding principle should always be care consistent with human­istic, sci­entific, and effi­cient medicine. If exter­nal pres­sures arising from limited institutional re­sources prevent the provision of opti­mal care, the physician should inform the pa­tient of the nature of the situation. In the final analy­sis, no external factors should interfere with the dedi­cation of the physician to provide optimal care for his or her patient.

Physicians, nevertheless, also have a re­sponsibil­ity to avoid unnecessary expenditures by careful planning of workups, and by avoiding unnecessary medication, operations, and consultations. Good medicine is still the most economical medicine and a primary obli­gation of the physician.

Finally, physicians have a collective obli­gation through their professional associations to be advo­cates for a just allocation of re­sources to the sick. They should participate in local and national deci­sions affecting the distri­bution of society's resources be­tween health care and other social goods and among various kinds of health care.

7.03    Abortion and Contraception

A physician who objects to abortion on moral, reli­gious, or ethical grounds need not become in­volved, either by proffering advice to the pa­tient or by in­volvement in the surgical proce­dure. The physi­cian does have a duty to assure that the patient is provided the option of receiv­ing competent medical advice and care from a qualified colleague who does not im­pose his or her personal convictions upon the patient.

Social, political, and religious beliefs have ex­tended the issue of abortion beyond medical consid­erations. The physician must be familiar with the law relating to abortion in his or her locale.

If a patient who is a minor requests termi­nation of pregnancy without her parents' knowledge, the physician may have a conflict between the ethical duty to maintain confiden­tiality and the physician's responsibility to the patient's par­ents or guardian un­der the law. In this case, the physician should seek local coun­sel as to the specific requirements of state and federal law.

Recommendations similar to those dis­cussed re­lating to physician's participation in decisions about abor­tion also apply to the physician's re­sponsibility re­garding the pre­scribing of con­traceptive measures or devices to adults, or to minors without obtaining parental consent.

7.04    Medicine and the Law

Physicians should remember that all citi­zens are equal under the law, and the fact that a patient may be ill does not diminish his or her right or expectation to be treated like all other persons. Stated another way, illness does not, in and of itself, change a patient's legal rights or permit a physician to ignore the fact that the patient's le­gal rights must be observed at all times.

The physician holds an honored, respected, and, in certain aspects, unique position in so­ciety. There may be instances in which the physician's ethics are in conflict with the law or with the patient's legal rights. In those situa­tions, the physician must decide if he or she is willing to violate the law for the sake of what he or she considers to be the dictates of medical ethics, thereby possibly jeopardizing his or her own legal position or the legal rights of the pa­tient. It should be remembered that ethical con­cepts are not always fully reflected in or adopted by the law. Violation of the law for purposes of complying with one's ethical stan­dards may have significant conse­quences for the physician and should only be under­taken after thorough consideration and, most often, after obtaining professional legal counsel.

Conclusion

It is the hope of the College that this up­dated hand­book will help practicing physicians ad­dress some of the challenging ethical dilem­mas that con­front them each day as they deal with patients. As was stated in the beginning, this is a manual written by physicians for physicians to help us all find our way through this difficult terrain. The ultimate intent of any ethical guide­line is to improve the quality of care provided to patients. We hope that in some small mea­sure this manual will help to achieve that goal.

References

1.    Bard S. A Discourse upon the Duties of a Physician with Some Sentiments on the Usefulness and Necessity of a Public Hospital: Delivered before the President and Governors of King' College at the Commencement Held on the 16th of May, 1969, as Advice to Those Gentlemen Who Then Received the First Medical Degrees Conferred by That University. New York: A. & J. Robertson; 1769.

2.    Percival T. Medical Ethics: Or Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons. Manchester, England: J. Johnson; 1803.

3.    Pellegrino ED. Percival's Medical Ethics: the moral phi­losophy of an 18th-century English gentleman. Arch Intern Med. 1986; 146:2265-9.

4.    Health and Public Policy Committee, American College of Physicians and the Infectious Disease Society of America. The ac­quired immun­odeficiency syndrome (AIDS) and infection with the hu­man immunodeficiency virus (HIV). Ann Intern Med 1988; 108:460-9.

5.    Health and Public Policy Committee, American College of Physicians. Health care needs of the ado­lescent. Ann Intern Med. 1989; 110:930-5.

6.    United Nations, First Congress on the Prevention of Crime and the Treatment of Offenders. Standard Minimum Rules for the Treatment of Prisoners; 1955.

7.    Bronowski J. The Common Sense of Science. Cambridge, Massachusetts: Harvard University Press;  1978.

8.    Lind SE. Innovative medical therapies: between practice and research. Clin Res. 1988; 36:546-51.

9.    National Conference Steering Committee. Standards for cardiopulmonary resuscitation (CPR) and emergency car­diac care (ECC). JAMA. 1980; 244:453-509.

10.    Joint Commission on Accreditation of Healthcare Organizations. Accreditation Manual for Hospitals. Chicago, Illinois: JCAHO; 1988.

11.    The Council on Ethical and Judicial Affairs of the American Medical Association. Chicago: American Medical Association; 1988; AMA Council Report C/A-88.

A reprint of the manual will be available from the College in late September. Ordering infor­mation may be obtained from the American College of Physicians, Subscriber Services, Independence Mall West, Sixth Street at Race, Philadelphia, PA 19106-1572. Telephone in­quiries may be directed to (800) 523-1546, ex­tension 2600 or (215) 351-2600.