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Medical Ethics and Professionalism TABLE 9. The Four Guiding Principles of Medical Ethics physician to become sexually involved with a current patient, and sexual relationships with former patients should be Principle Description avoided owing to concerns of continued vulnerability and Beneficence The duty to promote good and act in the best interest of the patient dependence. Physicians also must maintain boundaries dur- ing the history, physical examination, and treatment process Nonmaleficence — The duty to do no harm to the patient by communicating the planned actions in advance, using Respect for patient | The duty to protect and foster a patient's purposeful movements, and communicating the purpose of autonomy free, uncoerced choices these actions. A chaperone should be offered, but is not Justice The equitable distribution of the life- enhancing opportunities afforded by required, during the examination of intimate areas. health care Physicians may be asked to care for persons with whom Reproduced with permission from Sulmasy LS, Bledsoe TA; ACP Ethics, they have an existing nonprofessional relationship, including Professionalism and Human Rights Committee. American College of Physicians Ethics Manual: seventh edition. Ann Intern Med. 2019;170:S1-S32. [PMID: close friends and family members. Caring for these individuals 30641552] doi:10.7326/M18-2160. Based on Beauchamp TL, Childress JF. may be associated with impaired objectivity, insufficient his- | Sena of Biomedical Ethics. 7th ed. New York: Oxford Univ Pr; 2012. a tory taking (e.g., failure to obtain an adequate sexual history), incomplete examination, and incomplete or biased assess-

TABLE 9. The Four Guiding Principles of Medical Ethics physician to become sexually involved with a current patient, and sexual relationships with former patients should be Principle Description avoided owing to concerns of continued vulnerability and Beneficence The duty to promote good and act in the best interest of the patient dependence. Physicians also must maintain boundaries dur- ing the history, physical examination, and treatment process Nonmaleficence — The duty to do no harm to the patient by communicating the planned actions in advance, using Respect for patient | The duty to protect and foster a patient's purposeful movements, and communicating the purpose of autonomy free, uncoerced choices these actions. A chaperone should be offered, but is not Justice The equitable distribution of the life- enhancing opportunities afforded by required, during the examination of intimate areas. health care Physicians may be asked to care for persons with whom Reproduced with permission from Sulmasy LS, Bledsoe TA; ACP Ethics, they have an existing nonprofessional relationship, including Professionalism and Human Rights Committee. American College of Physicians Ethics Manual: seventh edition. Ann Intern Med. 2019;170:S1-S32. [PMID: close friends and family members. Caring for these individuals 30641552] doi:10.7326/M18-2160. Based on Beauchamp TL, Childress JF. may be associated with impaired objectivity, insufficient his- | Sena of Biomedical Ethics. 7th ed. New York: Oxford Univ Pr; 2012. a tory taking (e.g., failure to obtain an adequate sexual history), incomplete examination, and incomplete or biased assess- (3) considering the ethical principles underpinning the ques- ment. Physicians should weigh these considerations carefully

TABLE 9. The Four Guiding Principles of Medical Ethics physician to become sexually involved with a current patient, and sexual relationships with former patients should be Principle Description avoided owing to concerns of continued vulnerability and Beneficence The duty to promote good and act in the best interest of the patient dependence. Physicians also must maintain boundaries dur- ing the history, physical examination, and treatment process Nonmaleficence — The duty to do no harm to the patient by communicating the planned actions in advance, using Respect for patient | The duty to protect and foster a patient's purposeful movements, and communicating the purpose of autonomy free, uncoerced choices these actions. A chaperone should be offered, but is not Justice The equitable distribution of the life- enhancing opportunities afforded by required, during the examination of intimate areas. health care Physicians may be asked to care for persons with whom Reproduced with permission from Sulmasy LS, Bledsoe TA; ACP Ethics, they have an existing nonprofessional relationship, including Professionalism and Human Rights Committee. American College of Physicians Ethics Manual: seventh edition. Ann Intern Med. 2019;170:S1-S32. [PMID: close friends and family members. Caring for these individuals 30641552] doi:10.7326/M18-2160. Based on Beauchamp TL, Childress JF. may be associated with impaired objectivity, insufficient his- | Sena of Biomedical Ethics. 7th ed. New York: Oxford Univ Pr; 2012. a tory taking (e.g., failure to obtain an adequate sexual history), incomplete examination, and incomplete or biased assess- (3) considering the ethical principles underpinning the ques- ment. Physicians should weigh these considerations carefully tion; and (4) understanding the context, including the motiva- and encourage alternative sources of care, except in emergen-

TABLE 9. The Four Guiding Principles of Medical Ethics physician to become sexually involved with a current patient, and sexual relationships with former patients should be Principle Description avoided owing to concerns of continued vulnerability and Beneficence The duty to promote good and act in the best interest of the patient dependence. Physicians also must maintain boundaries dur- ing the history, physical examination, and treatment process Nonmaleficence — The duty to do no harm to the patient by communicating the planned actions in advance, using Respect for patient | The duty to protect and foster a patient's purposeful movements, and communicating the purpose of autonomy free, uncoerced choices these actions. A chaperone should be offered, but is not Justice The equitable distribution of the life- enhancing opportunities afforded by required, during the examination of intimate areas. health care Physicians may be asked to care for persons with whom Reproduced with permission from Sulmasy LS, Bledsoe TA; ACP Ethics, they have an existing nonprofessional relationship, including Professionalism and Human Rights Committee. American College of Physicians Ethics Manual: seventh edition. Ann Intern Med. 2019;170:S1-S32. [PMID: close friends and family members. Caring for these individuals 30641552] doi:10.7326/M18-2160. Based on Beauchamp TL, Childress JF. may be associated with impaired objectivity, insufficient his- | Sena of Biomedical Ethics. 7th ed. New York: Oxford Univ Pr; 2012. a tory taking (e.g., failure to obtain an adequate sexual history), incomplete examination, and incomplete or biased assess- (3) considering the ethical principles underpinning the ques- ment. Physicians should weigh these considerations carefully tion; and (4) understanding the context, including the motiva- and encourage alternative sources of care, except in emergen- tions of those involved. With this information, clinicians can cies. For the same reasons, physicians should not provide

(3) considering the ethical principles underpinning the ques- ment. Physicians should weigh these considerations carefully tion; and (4) understanding the context, including the motiva- and encourage alternative sources of care, except in emergen- tions of those involved. With this information, clinicians can cies. For the same reasons, physicians should not provide balance the ethical principles and individual interests to deter- medical care to themselves if alternatives are available.

tion; and (4) understanding the context, including the motiva- and encourage alternative sources of care, except in emergen- tions of those involved. With this information, clinicians can cies. For the same reasons, physicians should not provide balance the ethical principles and individual interests to deter- medical care to themselves if alternatives are available. mine the range of possible ethical actions. When ethical Patient-physician connections via social media and dilemmas are difficult to resolve, physicians may obtain assis- other electronic communications can lead to confusion over tance through an ethics consultation. the boundaries between personal and professional interac- Professionalism is the foundation of medicine’s relation- tions. Physicians should keep these spheres separate and ship with society and governs the conduct of the physician behave professionally in both. Electronic communication community. Professionalism in medicine is specifically charac- with patients through a secure electronic health record terized by the placement of the patient’s interests above the (EHR) is preferred to email correspondence. Email commu- physician’s self-interests (the fiduciary relationship); acquisi- nication is permissible in an established patient-physician tion, maintenance, and expansion of specialized medical relationship after patient consent, but it should occur only knowledge; adherence to ethical principles; and self-regulation via a secure email server and should be documented in the of members and responsibilities. The obligation of physicians patient’s EHR. Recommended safeguards for online physi- to the welfare of their patients creates an ethical imperative to cian activities are described in Table 10. provide competent and compassionate care to all patients, Patient-physician relationships should generally be estab- regardless of their illness. Refusal to provide appropriate care lished on the basis of an in-person professional encounter. to any group of patients for any reason, including infectivity or Providing care or prescriptions on the basis of only an online disease state, is unethical. questionnaire or phone-based consultation does not meet acceptable standards for quality of care. On-call situations with

mine the range of possible ethical actions. When ethical Patient-physician connections via social media and dilemmas are difficult to resolve, physicians may obtain assis- other electronic communications can lead to confusion over tance through an ethics consultation. the boundaries between personal and professional interac- Professionalism is the foundation of medicine’s relation- tions. Physicians should keep these spheres separate and ship with society and governs the conduct of the physician behave professionally in both. Electronic communication community. Professionalism in medicine is specifically charac- with patients through a secure electronic health record terized by the placement of the patient’s interests above the (EHR) is preferred to email correspondence. Email commu- physician’s self-interests (the fiduciary relationship); acquisi- nication is permissible in an established patient-physician tion, maintenance, and expansion of specialized medical relationship after patient consent, but it should occur only knowledge; adherence to ethical principles; and self-regulation via a secure email server and should be documented in the of members and responsibilities. The obligation of physicians patient’s EHR. Recommended safeguards for online physi- to the welfare of their patients creates an ethical imperative to cian activities are described in Table 10. provide competent and compassionate care to all patients, Patient-physician relationships should generally be estab- regardless of their illness. Refusal to provide appropriate care lished on the basis of an in-person professional encounter. to any group of patients for any reason, including infectivity or Providing care or prescriptions on the basis of only an online disease state, is unethical. questionnaire or phone-based consultation does not meet acceptable standards for quality of care. On-call situations with The Physician and the Patient patients who have an established relationship with a partner or the practice are a notable exception, as are urgent public health Because of the patient’s inherent vulnerability due to illness situations, such as the management of communicable diseases. and the imbalance of expertise, knowledge, and power Telemedicine, or the use of electronic communication and between the physician and patient, patients must be able to technologies to provide health care to patients at a distance, trust that the physician acts for their benefit (beneficence) and may improve physician-patient collaboration, access to care, to minimize their harm (nonmaleficence). The altruism of and reduce costs. The benefits of increased access to care serving the patient’s interests before the physician's interests creates the trust that is essential to the patient-physician through telemedicine must always be balanced against the

The Physician and the Patient patients who have an established relationship with a partner or the practice are a notable exception, as are urgent public health Because of the patient’s inherent vulnerability due to illness situations, such as the management of communicable diseases. and the imbalance of expertise, knowledge, and power Telemedicine, or the use of electronic communication and between the physician and patient, patients must be able to technologies to provide health care to patients at a distance, trust that the physician acts for their benefit (beneficence) and may improve physician-patient collaboration, access to care, to minimize their harm (nonmaleficence). The altruism of and reduce costs. The benefits of increased access to care serving the patient’s interests before the physician's interests creates the trust that is essential to the patient-physician through telemedicine must always be balanced against the relationship. risks associated with the lack of a physical encounter, such as misdiagnosis, inappropriate care, and loss of communication Appropriate Patient-Physician Relationships nuances conveyed with body language. The American College The patient-physician relationship should be based on mutual of Physicians holds the position that a valid patient-physician

relationship. risks associated with the lack of a physical encounter, such as misdiagnosis, inappropriate care, and loss of communication Appropriate Patient-Physician Relationships nuances conveyed with body language. The American College The patient-physician relationship should be based on mutual of Physicians holds the position that a valid patient-physician agreement. Once this relationship has been established, the phy- relationship must be established for professionally responsible sician should strive to understand the patient’s health concerns, telemedicine services to occur; however, this relationship may values, goals, and expectations to guide the provision of care. be formed during a telemedicine encounter through real-time Appropriate boundaries between the physician and audiovisual technology. Telemedicine also may increase col- patient must always be maintained. It is unethical for a laboration and communication between clinicians and expand 12

Medical E thics and Professionalism TABLE 10. Recommended Safeguards for Common Online Physician Activities Online Activity Recommended Safeguards | Communications with patients using email, Establish guidelines for types of issues appropriate for digital communication text, and instant messaging Reserve digital communication only for patients who maintain face-to-face follow-up Use of social media sites to gather information Consider intent of search and application of findings about patients Consider implications for ongoing care Use of online educational resources and Vet information to ensure accuracy of content related information with patients Refer patients only to reputable sites and sources Physician-produced blogs and microblogs, “Pause before posting” and physician posting of comments by others Consider the content and the message it sends about a physician as an individual and the profession Physician posting of his or her personal Maintain separate personas, personal and professional, for online social behavior information on public social media sites Scrutinize material available for public consumption

Physician-produced blogs and microblogs, “Pause before posting” and physician posting of comments by others Consider the content and the message it sends about a physician as an individual and the profession Physician posting of his or her personal Maintain separate personas, personal and professional, for online social behavior information on public social media sites Scrutinize material available for public consumption Physician use of digital venues (e.g., text and Implement health information technology solutions for secure messaging and Web) for communicating with colleagues information sharing about patient care Follow institutional practice and policy for remote and mobile access of protected health information | Adapted with permission from Farnan JM, Snyder Sulmasy L, Worster BK, et al; American College of Physicians Ethics, Professionalism and Human Rights } Committee; American | College of Physicians Council of Associates; Federation of State Medical Boards Special Committee on Ethics and Professionalism. Online medical | professionalism: patient and | public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 201 3;158:621.[PMID: 23579867] | doi: 10.7326/0003-4819-158-8-201304160-00100. ©2013, American College of Physicians.

Physician use of digital venues (e.g., text and Implement health information technology solutions for secure messaging and Web) for communicating with colleagues information sharing about patient care Follow institutional practice and policy for remote and mobile access of protected health information | Adapted with permission from Farnan JM, Snyder Sulmasy L, Worster BK, et al; American College of Physicians Ethics, Professionalism and Human Rights } Committee; American | College of Physicians Council of Associates; Federation of State Medical Boards Special Committee on Ethics and Professionalism. Online medical | professionalism: patient and | public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 201 3;158:621.[PMID: 23579867] | doi: 10.7326/0003-4819-158-8-201304160-00100. ©2013, American College of Physicians. the provision of specialized care to underserved areas, such as colleagues and trainees who face discrimination, as well as the with telestroke systems. nondiscrimination policies of their institutions. There are circumstances in which the patient-physician Challenging Patient-Physician Relationships relationship becomes irreparably compromised because of Conflicts between the physician and patient can arise for lack of trust, lack of mutual goals, or failure to maintain an many reasons, such as patient refusal of a recommended effective working relationship despite efforts to resolve dif- course of treatment. In response to these conflicts, the physi- ferences. In these cases, the physician can terminate the cian should offer the rationale for the proposed intervention relationship so long as the patient’s health is stable enough and explore the patient’s reasoning. A deeper understanding for such a transition. The physician should provide formal, of the patient’s background and rationale for decision making written documentation of the termination and provide the may allow for conflict resolution or prompt a search for more patient with information on obtaining a new clinician. appropriate treatment alternatives. If the patient agrees to but Patient abandonment (withdrawing from an established is not adherent with the physician’s recommendation, a simi- relationship without giving reasonable notice or providing a lar exploration of the patient’s decision making may be helpful competent replacement) is unethical and may be a cause for in discerning the basis for the patient’s behavior (e.g., low legal action. health literacy, financial impediments, or transportation issues). Discriminatory behavior toward the physician can dis- ¢ The benefits of increased access to care through tele- tress the patient-physician relationship and compromise the medicine must always be balanced with the risks asso- health care environment. Although patients may refuse treat- ciated with lack of a physical encounter, such as misdi- ment froma specific clinician, patients do not have the right to agnosis, inappropriate care, and loss of communication demand or refuse care on the basis of clinically irrelevant cli- nuances conveyed with body language. nician characteristics, such as gender, skin color, or religion, ¢ When a physician encounters discriminatory behavior because this behavior results in unequal working conditions by a patient, the physician must determine whether to for clinicians. In general, when faced with a perceived dis- negotiate, accommodate, offer transfer, or limit unac- criminatory request, clinicians should (1) ensure that the ceptable conduct. patient is stable; (2) assess decision-making capacity; and (3) determine the reason for the request before deciding whether e Patient abandonment, or withdrawing from an estab-

the provision of specialized care to underserved areas, such as colleagues and trainees who face discrimination, as well as the with telestroke systems. nondiscrimination policies of their institutions. There are circumstances in which the patient-physician Challenging Patient-Physician Relationships relationship becomes irreparably compromised because of Conflicts between the physician and patient can arise for lack of trust, lack of mutual goals, or failure to maintain an many reasons, such as patient refusal of a recommended effective working relationship despite efforts to resolve dif- course of treatment. In response to these conflicts, the physi- ferences. In these cases, the physician can terminate the cian should offer the rationale for the proposed intervention relationship so long as the patient’s health is stable enough and explore the patient’s reasoning. A deeper understanding for such a transition. The physician should provide formal, of the patient’s background and rationale for decision making written documentation of the termination and provide the may allow for conflict resolution or prompt a search for more patient with information on obtaining a new clinician. appropriate treatment alternatives. If the patient agrees to but Patient abandonment (withdrawing from an established is not adherent with the physician’s recommendation, a simi- relationship without giving reasonable notice or providing a lar exploration of the patient’s decision making may be helpful competent replacement) is unethical and may be a cause for in discerning the basis for the patient’s behavior (e.g., low legal action. health literacy, financial impediments, or transportation issues). Discriminatory behavior toward the physician can dis- ¢ The benefits of increased access to care through tele- tress the patient-physician relationship and compromise the medicine must always be balanced with the risks asso- health care environment. Although patients may refuse treat- ciated with lack of a physical encounter, such as misdi- ment froma specific clinician, patients do not have the right to agnosis, inappropriate care, and loss of communication demand or refuse care on the basis of clinically irrelevant cli- nuances conveyed with body language. nician characteristics, such as gender, skin color, or religion, ¢ When a physician encounters discriminatory behavior because this behavior results in unequal working conditions by a patient, the physician must determine whether to for clinicians. In general, when faced with a perceived dis- negotiate, accommodate, offer transfer, or limit unac- criminatory request, clinicians should (1) ensure that the ceptable conduct. patient is stable; (2) assess decision-making capacity; and (3) determine the reason for the request before deciding whether e Patient abandonment, or withdrawing from an estab- to accommodate, negotiate, offer transfer, or set limits on lished relationship without giving reasonable notice or providing a competent replacement, is unethical and unacceptable behavior (Figure 4). Clinical leadership should be engaged when appropriate. Physicians should support their may be a cause for legal action.

to accommodate, negotiate, offer transfer, or set limits on lished relationship without giving reasonable notice or providing a competent replacement, is unethical and unacceptable behavior (Figure 4). Clinical leadership should be engaged when appropriate. Physicians should support their may be a cause for legal action. 13

Medical Ethics and Professionalism confidentiality and may compromise trust in the physician Assess medical condition and profession. Physicians also must be knowledgeable in the relevant state and federal statutes regarding confidentiality, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA). a4 Vv Confidentiality is not absolute. There are circumstances in Unstable Stable which legitimate competing interests may conflict with the need for confidentiality, and disclosure becomes necessary to | | minimize a greater harm. Physicians are mandatory reporters of neglect or abuse of children or elderly persons and have a Assess decision- Treat A 5 making capacity duty to report when patients may be a threat to themselves or others. Certain infectious diseases also must be reported to

| | minimize a greater harm. Physicians are mandatory reporters of neglect or abuse of children or elderly persons and have a Assess decision- Treat A 5 making capacity duty to report when patients may be a threat to themselves or others. Certain infectious diseases also must be reported to Vv | local, state, or federal institutions. In general, physicians should inform patients when they plan to make a report to a Has decision- Lacks decision- government institution and should do so in a way that heeds making capacity making capacity pertinent laws. In extraordinary circumstances, physicians may withhold medical information from a capacitated patient Vv Vv if disclosure would lead to serious harm (e.g., withholding a Determine reason Persuasion new cancer diagnosis from an acutely suicidal patient), a prac- for request Negotiation tice known as therapeutic privilege. The invocation of this

Has decision- Lacks decision- government institution and should do so in a way that heeds making capacity making capacity pertinent laws. In extraordinary circumstances, physicians may withhold medical information from a capacitated patient Vv Vv if disclosure would lead to serious harm (e.g., withholding a Determine reason Persuasion new cancer diagnosis from an acutely suicidal patient), a prac- for request Negotiation tice known as therapeutic privilege. The invocation of this | privilege should be done in consultation with the institutional ! { ethics committee. Clinically and ethically Decision-Making Capacity Bigotry appropriate reasons All adult patients are presumed legally competent to make

! { ethics committee. Clinically and ethically Decision-Making Capacity Bigotry appropriate reasons All adult patients are presumed legally competent to make f { informed medical decisions unless found otherwise by judi- cial determination. However, in routine clinical care, physi- Discuss options cians must frequently determine the patient’s decision- Accommodate Discuss impact on physician making capacity, including the patient’s ability to understand

f { informed medical decisions unless found otherwise by judi- cial determination. However, in routine clinical care, physi- Discuss options cians must frequently determine the patient’s decision- Accommodate Discuss impact on physician making capacity, including the patient’s ability to understand { relevant information, appreciate the risks and benefits of various treatment options, and communicate a choice con- Negotiate sistent with the information given and the individual’s values Offer transfer Accommodate (Table 11). The presence of depression or early dementia may Limit unacceptable conduct complicate the evaluation but does not preclude the presence of decision-making capacity. FIGURE 4. Considering a patient's request for physician reassignment based Decision-making capacity is not a global determination; on race or ethnic background in an emergency setting. it should be evaluated for each decision to be made. Frequent Reproduced with permission from Paul-Emile K, Smith AK, Lo B, et al. Dealing with racist patients. N Engl J Med. 2016;374:709. [PMID: 26933847] doi:10.1056/NEJMp1514939 ©2016, Massachusetts Medical Society. reassessment is necessary to confirm previous determinations. Whena decision may result in serious consequences, determi-

{ relevant information, appreciate the risks and benefits of various treatment options, and communicate a choice con- Negotiate sistent with the information given and the individual’s values Offer transfer Accommodate (Table 11). The presence of depression or early dementia may Limit unacceptable conduct complicate the evaluation but does not preclude the presence of decision-making capacity. FIGURE 4. Considering a patient's request for physician reassignment based Decision-making capacity is not a global determination; on race or ethnic background in an emergency setting. it should be evaluated for each decision to be made. Frequent Reproduced with permission from Paul-Emile K, Smith AK, Lo B, et al. Dealing with racist patients. N Engl J Med. 2016;374:709. [PMID: 26933847] doi:10.1056/NEJMp1514939 ©2016, Massachusetts Medical Society. reassessment is necessary to confirm previous determinations. Whena decision may result in serious consequences, determi- Respecting Patient Autonomy nation of capacity is of even greater importance. Decisions are more likely valid when consistent with previously stated val- and Decision Making ues, beliefs, and choices. Decisions that run counter to previ- Confidentiality ously expressed preferences may be equally valid; however, Physicians must protect the privacy of patients’ medical infor- when such changes occur, it must be clear that the patient has mation in order to respect patient autonomy, foster trust, and capacity and understands the consequences of the decisions. encourage honest disclosure of sensitive personal details, Patient expression of a wish or therapeutic goal is not suffi- thereby improving patient care. cient to demonstrate capacity. Disclosure of medical information outside of the patient-physician relationship requires patient consent. Informed Consent and Refusal Physicians should be vigilant about protecting patient con- Informed consent and refusal is the process of engaging a fidentiality in the era of EHRs, email, patient portals, and patient with capacity in a meaningful dialogue about his or social media. Communication with and regarding patients her health conditions, assessing the patient’s understanding, should involve secure communication systems and storage. and respecting the patient’s autonomy to accept or refuse care. Discussing patients outside of a clinical or educational setting, Informed consent requires that a patient be provided with all such as in an elevator or via unencrypted texts, violates of the information necessary to determine the acceptability

Respecting Patient Autonomy nation of capacity is of even greater importance. Decisions are more likely valid when consistent with previously stated val- and Decision Making ues, beliefs, and choices. Decisions that run counter to previ- Confidentiality ously expressed preferences may be equally valid; however, Physicians must protect the privacy of patients’ medical infor- when such changes occur, it must be clear that the patient has mation in order to respect patient autonomy, foster trust, and capacity and understands the consequences of the decisions. encourage honest disclosure of sensitive personal details, Patient expression of a wish or therapeutic goal is not suffi- thereby improving patient care. cient to demonstrate capacity. Disclosure of medical information outside of the patient-physician relationship requires patient consent. Informed Consent and Refusal Physicians should be vigilant about protecting patient con- Informed consent and refusal is the process of engaging a fidentiality in the era of EHRs, email, patient portals, and patient with capacity in a meaningful dialogue about his or social media. Communication with and regarding patients her health conditions, assessing the patient’s understanding, should involve secure communication systems and storage. and respecting the patient’s autonomy to accept or refuse care. Discussing patients outside of a clinical or educational setting, Informed consent requires that a patient be provided with all such as in an elevator or via unencrypted texts, violates of the information necessary to determine the acceptability 14

Medical Ethics and Professionalism TABLE 11. Legally Relevant Criteria for Decision-Making Capacity and Approaches to Assessment of the Patient Criterion Patient's Task Physician's Questions for Clinical Comments Assessment Assessment? Approach Communicate a Clearly indicate Ask patient to indicate Have you decided whether Frequent reversals of choice preferred treatment a treatment choice to follow your doctor's (or choice because of option my) recommendation for psychiatric or neurologic treatment? conditions may indicate lack of capacity Can you tell me what the decision is? (If no decision) What is making it hard for you to decide?

Communicate a Clearly indicate Ask patient to indicate Have you decided whether Frequent reversals of choice preferred treatment a treatment choice to follow your doctor's (or choice because of option my) recommendation for psychiatric or neurologic treatment? conditions may indicate lack of capacity Can you tell me what the decision is? (If no decision) What is making it hard for you to decide? Understand the Grasp the fundamental Encourage patient to Please tell me in your own Information to be relevant information meaning of information paraphrase disclosed words what your doctor understood includes communicated by the information regarding (or |) told you about: nature of patient's physician medical condition condition, nature and The problem with your and treatment purpose of proposed health now treatment, possible The recommended benefits and risks of that | |

Understand the Grasp the fundamental Encourage patient to Please tell me in your own Information to be relevant information meaning of information paraphrase disclosed words what your doctor understood includes communicated by the information regarding (or |) told you about: nature of patient's physician medical condition condition, nature and The problem with your and treatment purpose of proposed health now treatment, possible The recommended benefits and risks of that | | treatment treatment, and alternative approaches (including no The possible benefits treatment) and their and risks (or discomforts) benefits and risks of the treatment

treatment treatment, and alternative approaches (including no The possible benefits treatment) and their and risks (or discomforts) benefits and risks of the treatment Any alternative treatments and their risks and benefits The risks and benefits of no treatment Appreciate the Acknowledge Ask patient to What do you believe is Courts have recognized situation and its medical condition describe views of wrong with your health now? that patients who do not consequences and likely medical condition, acknowledge their illnesses |

Appreciate the Acknowledge Ask patient to What do you believe is Courts have recognized situation and its medical condition describe views of wrong with your health now? that patients who do not consequences and likely medical condition, acknowledge their illnesses | Do you believe that you need consequences of proposed treatment, (often referred to as “lack of some kind of treatment? treatment options and likely outcomes insight”) cannot make valid What is treatment likely to decisions about treatment do for you? Delusions or pathologic What makes you believe it levels of distortion or will have that effect? denial are the most common cause of What do you believe will impairment happen if you are not treated?

Do you believe that you need consequences of proposed treatment, (often referred to as “lack of some kind of treatment? treatment options and likely outcomes insight”) cannot make valid What is treatment likely to decisions about treatment do for you? Delusions or pathologic What makes you believe it levels of distortion or will have that effect? denial are the most common cause of What do you believe will impairment happen if you are not treated? Why do you think your doctor has (or| have) recommended this treatment?

Why do you think your doctor has (or| have) recommended this treatment? Reason about Engage in a rational Ask patient to How did you decide to This criterion focuses on treatment options process of compare treatment accept or reject the the process by which a manipulating the options and recommended treatment? decision is reached, not the relevant information consequences and to outcome of the patient's What makes (chosen offer reasons for choice, because patients option) better than selection of option have the right to make (alternative option)? “unreasonable” choices | Questions are adapted from Grisso T, Appelbaum PS. Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. New York: Oxford Univ Pr; 1998. Patients’ responses to these questions need not be verbal. Reproduced with permission from Appelbaum PS. Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357:1836. [PMID: 17978292] ©2007, Massachusetts Medical Society.

| Questions are adapted from Grisso T, Appelbaum PS. Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. New York: Oxford Univ Pr; 1998. Patients’ responses to these questions need not be verbal. Reproduced with permission from Appelbaum PS. Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357:1836. [PMID: 17978292] ©2007, Massachusetts Medical Society. and appropriateness of the proposed treatment or interven- treatment. Information should be communicated in ways that tion. Pertinent information includes the nature of the underly- are sensitive, appropriate for the patient’s literacy level and ing condition; the goals of treatment; and the risks of, benefits language abilities, and attentive to cultural context. For of, and alternatives to treatment, including the option to forgo informed consent to be considered valid, the patient must have 15

Medical Ethics and Professionalism decision-making capacity and be free from coercion. An patient cannot make his or her own decisions. Oral attesta- exception to informed consent is a medical emergency in tions or physician notes documenting preferences have legal which a patient is unable to participate in the decision-making standing and can serve as advance directives in the absence of process; in such circumstances, consent for lifesaving thera- more formal directives. pies should be presumed unless available information or The legal requirements for and implementation of advance directives suggest otherwise. advance directives vary by state, and physicians should be Adults with decision-making capacity who have been familiar with the laws pertaining to advance directives in the informed of treatment options have the legal and ethical right state in which they practice. State laws regarding the with- to refuse any and all medical treatments. A patient’s universal drawal of artificial nutrition and hydration may be particularly right to refuse treatment, which is protected by law, is based variable, and patients who have preferences regarding these on respect for autonomy, the right to self-determination, and interventions should clearly document them in a living will. protection of the patient’s liberty. Refusal of care should be explored thoughtfully and with empathy, with attention to the Requests for Interventions spectrum of reasonable choices, including time-limited trials Patients and their family members may request diagnostic or of therapy. If the patient’s refusal violates the physician’s pro- therapeutic interventions that challenge the physician’s sense fessional integrity, consultation with an ethics committee may of what is best for the patient (e.g., requesting antibiotic ther- be helpful. Conscientious objection by a physician must not apy for a suspected viral infection). Although the physician violate the principle of patient nonabandonment. needs to respect patient autonomy, this duty must be weighed against the physician’s professional judgment and integrity, Surrogate Decision Making the potential harms of inappropriate interventions, and pos- In the absence of patient decision-making capacity, a surrogate sible secondary effects (e.g., antimicrobial resistance caused is charged with making health care decisions. The most appro- by inappropriate antibiotic prescribing). Physicians are not priate surrogate is the person who has been designated power obligated to provide diagnostic or therapeutic interventions of attorney for health care by the patient. If the patient has not they believe to be without clinical benefit. designated a surrogate, a person who is knowledgeable about Particularly difficult requests may occur in the setting of the patient’s expressed preferences should serve as decision ambiguous or conflicting goals of care. For example, a physi- maker. Many states have laws that provide a hierarchy of pre- cian may perceive that a patient with multiorgan failure will ferred surrogates based on relationship to the patient (typically not achieve the goal of returning to his or her previous level of in the sequence of spouse, adult child, parent, and adult functioning and may therefore conclude that continued inten- sibling). sive care is inappropriate. However, family members may have The surrogate generally should adhere to the instructions the goal of extending their loved one’s life for as long as pos- described in the living will and provide thoughtful and appro- sible, regardless of the appropriateness of care. Effective com- priate reasons for deviating from them. If there is no living munication regarding the preferences and goals of the patient will, the surrogate should make decisions based on knowledge and surrogates can often help adjudicate conflicts of values, of the patient’s preferences and values, also known as substi- clarify prognosis and uncertainties, and lead to conflict resolu- tuted judgment. If the surrogate does not have first-hand tion. When resolution cannot be achieved, ethics consultation knowledge of the patient’s preferences or values, he or she can be beneficial. Transfer of care to a physician who concurs should make decisions based on what he or she perceives to be with the patient’s or family’s plan and is willing to provide the the patient’s best interests. requested intervention may be necessary when resolution is not possible.

decision-making capacity and be free from coercion. An patient cannot make his or her own decisions. Oral attesta- exception to informed consent is a medical emergency in tions or physician notes documenting preferences have legal which a patient is unable to participate in the decision-making standing and can serve as advance directives in the absence of process; in such circumstances, consent for lifesaving thera- more formal directives. pies should be presumed unless available information or The legal requirements for and implementation of advance directives suggest otherwise. advance directives vary by state, and physicians should be Adults with decision-making capacity who have been familiar with the laws pertaining to advance directives in the informed of treatment options have the legal and ethical right state in which they practice. State laws regarding the with- to refuse any and all medical treatments. A patient’s universal drawal of artificial nutrition and hydration may be particularly right to refuse treatment, which is protected by law, is based variable, and patients who have preferences regarding these on respect for autonomy, the right to self-determination, and interventions should clearly document them in a living will. protection of the patient’s liberty. Refusal of care should be explored thoughtfully and with empathy, with attention to the Requests for Interventions spectrum of reasonable choices, including time-limited trials Patients and their family members may request diagnostic or of therapy. If the patient’s refusal violates the physician’s pro- therapeutic interventions that challenge the physician’s sense fessional integrity, consultation with an ethics committee may of what is best for the patient (e.g., requesting antibiotic ther- be helpful. Conscientious objection by a physician must not apy for a suspected viral infection). Although the physician violate the principle of patient nonabandonment. needs to respect patient autonomy, this duty must be weighed against the physician’s professional judgment and integrity, Surrogate Decision Making the potential harms of inappropriate interventions, and pos- In the absence of patient decision-making capacity, a surrogate sible secondary effects (e.g., antimicrobial resistance caused is charged with making health care decisions. The most appro- by inappropriate antibiotic prescribing). Physicians are not priate surrogate is the person who has been designated power obligated to provide diagnostic or therapeutic interventions of attorney for health care by the patient. If the patient has not they believe to be without clinical benefit. designated a surrogate, a person who is knowledgeable about Particularly difficult requests may occur in the setting of the patient’s expressed preferences should serve as decision ambiguous or conflicting goals of care. For example, a physi- maker. Many states have laws that provide a hierarchy of pre- cian may perceive that a patient with multiorgan failure will ferred surrogates based on relationship to the patient (typically not achieve the goal of returning to his or her previous level of in the sequence of spouse, adult child, parent, and adult functioning and may therefore conclude that continued inten- sibling). sive care is inappropriate. However, family members may have The surrogate generally should adhere to the instructions the goal of extending their loved one’s life for as long as pos- described in the living will and provide thoughtful and appro- sible, regardless of the appropriateness of care. Effective com- priate reasons for deviating from them. If there is no living munication regarding the preferences and goals of the patient will, the surrogate should make decisions based on knowledge and surrogates can often help adjudicate conflicts of values, of the patient’s preferences and values, also known as substi- clarify prognosis and uncertainties, and lead to conflict resolu- tuted judgment. If the surrogate does not have first-hand tion. When resolution cannot be achieved, ethics consultation knowledge of the patient’s preferences or values, he or she can be beneficial. Transfer of care to a physician who concurs should make decisions based on what he or she perceives to be with the patient’s or family’s plan and is willing to provide the the patient’s best interests. requested intervention may be necessary when resolution is not possible. Advance Care Planning Advance care planning is the process by which a competent Medical Error Disclosure patient articulates preferences, goals, and values regarding his The fiduciary nature of the patient-physician relationship, or her future medical care to assist surrogates and the health respect for the patient’s autonomy, and obligation to justice care team in the event that the patient can no longer make require physicians to be truthful with patients or surrogates independent decisions. Advance care planning should include when a medical error occurs. Several states mandate disclo- written documentation of the patient’s preferences (advance sure in the event of serious harm, and the majority of states directives) and should be available in the medical record. have instituted “apology laws,” which protect physician apolo- Advance directives may include a living will and durable gies and expressions of regret from legal consequences. power of attorney for health care. In a living will, the patient When disclosing an error and the harm or potential harm, can outline specific preferences for treatment decisions (e.g., the physician also should express compassion and concern for use of dialysis or mechanical ventilation). A durable power of the patient and explain institutional efforts being taken to attorney for health care allows the patient to designate a sur- prevent similar harm from befalling others. Information on rogate to be the primary medical decision maker when the how the error occurred may take time to gather, and patients

Advance Care Planning Advance care planning is the process by which a competent Medical Error Disclosure patient articulates preferences, goals, and values regarding his The fiduciary nature of the patient-physician relationship, or her future medical care to assist surrogates and the health respect for the patient’s autonomy, and obligation to justice care team in the event that the patient can no longer make require physicians to be truthful with patients or surrogates independent decisions. Advance care planning should include when a medical error occurs. Several states mandate disclo- written documentation of the patient’s preferences (advance sure in the event of serious harm, and the majority of states directives) and should be available in the medical record. have instituted “apology laws,” which protect physician apolo- Advance directives may include a living will and durable gies and expressions of regret from legal consequences. power of attorney for health care. In a living will, the patient When disclosing an error and the harm or potential harm, can outline specific preferences for treatment decisions (e.g., the physician also should express compassion and concern for use of dialysis or mechanical ventilation). A durable power of the patient and explain institutional efforts being taken to attorney for health care allows the patient to designate a sur- prevent similar harm from befalling others. Information on rogate to be the primary medical decision maker when the how the error occurred may take time to gather, and patients 16

Medical Ethics and Professionalism should be informed of such. Physicians should not rush into euthanasia, in which a physician directly and intentionally apology owing to feelings of guilt or distress, because this administers an agent to cause death, and from interventions may lead to inaccuracies that compound patient suffering. that are administered with the intent of relieving suffering but Disclosure should be performed thoughtfully and sensitively, unintentionally hasten death (known as the principle of dou- accounting for the emotional effect on both the patient and ble effect). clinician. Institutional and clinical leadership also should be Physician-assisted suicide raises profound legal, clinical, involved in error disclosure to ensure that all available and social concerns. It may erode trust in the profession, cause resources are used to support both clinicians and patients. harm to the most vulnerable patients, and hinder progress in Disclosure may benefit physicians by alleviating distress, improving end-of-life care. It fundamentally alters the physi- improving patient-physician communication, and reducing cian’s role in society. The American College of Physicians does litigation. Strategies that focus on early communication and not support legalization of physician-assisted suicide or eutha- response after an error have been associated with fewer mal- nasia and instead emphasizes the need to provide palliative practice lawsuits and lower litigation costs, although these care, relief of suffering, and biopsychosocial support to the outcomes are not the primary goals of such initiatives. patient and family members during the end of life. Several states, however, have legalized physician-assisted suicide. Physicians may be asked to participate in discussions regard- ¢ The presence of depression or early dementia does not ing the practice but may assert a conscientious objection. necessarily preclude the presence of decision-making capacity but may complicate the evaluation. ¢ The American College of Physicians does not support ¢ Informed consent requires that the patient be informed legalization of physician-assisted suicide or euthanasia of the nature of the underlying condition; the goals of and instead emphasizes the need to provide palliative treatment; and the risks of, benefits of, and alternatives care, relief of suffering, and biopsychosocial support to to treatment, including the option to forgo treatment. the patient and family members during the end of life. e Surrogates and physicians are required to act in accor- dance with the patient’s expressed preferences for medical care, and if these are not available, they should serve the patient’s best interests. Providing Care as a HVC e Ifa patient requests diagnostic or therapeutic interven- Physician Bystander tions for which there is no evidence of clinical benefit, Physicians’ specialized knowledge creates a unique opportu- physicians are not obligated to provide these interventions. nity to intervene and benefit other citizens in emergency situ-

apology owing to feelings of guilt or distress, because this administers an agent to cause death, and from interventions may lead to inaccuracies that compound patient suffering. that are administered with the intent of relieving suffering but Disclosure should be performed thoughtfully and sensitively, unintentionally hasten death (known as the principle of dou- accounting for the emotional effect on both the patient and ble effect). clinician. Institutional and clinical leadership also should be Physician-assisted suicide raises profound legal, clinical, involved in error disclosure to ensure that all available and social concerns. It may erode trust in the profession, cause resources are used to support both clinicians and patients. harm to the most vulnerable patients, and hinder progress in Disclosure may benefit physicians by alleviating distress, improving end-of-life care. It fundamentally alters the physi- improving patient-physician communication, and reducing cian’s role in society. The American College of Physicians does litigation. Strategies that focus on early communication and not support legalization of physician-assisted suicide or eutha- response after an error have been associated with fewer mal- nasia and instead emphasizes the need to provide palliative practice lawsuits and lower litigation costs, although these care, relief of suffering, and biopsychosocial support to the outcomes are not the primary goals of such initiatives. patient and family members during the end of life. Several states, however, have legalized physician-assisted suicide. Physicians may be asked to participate in discussions regard- ¢ The presence of depression or early dementia does not ing the practice but may assert a conscientious objection. necessarily preclude the presence of decision-making capacity but may complicate the evaluation. ¢ The American College of Physicians does not support ¢ Informed consent requires that the patient be informed legalization of physician-assisted suicide or euthanasia of the nature of the underlying condition; the goals of and instead emphasizes the need to provide palliative treatment; and the risks of, benefits of, and alternatives care, relief of suffering, and biopsychosocial support to to treatment, including the option to forgo treatment. the patient and family members during the end of life. e Surrogates and physicians are required to act in accor- dance with the patient’s expressed preferences for medical care, and if these are not available, they should serve the patient’s best interests. Providing Care as a HVC e Ifa patient requests diagnostic or therapeutic interven- Physician Bystander tions for which there is no evidence of clinical benefit, Physicians’ specialized knowledge creates a unique opportu- physicians are not obligated to provide these interventions. nity to intervene and benefit other citizens in emergency situ- ¢ Medical error disclosure may benefit physicians by alle- ations, and in this context, physicians may provide care out-

apology owing to feelings of guilt or distress, because this administers an agent to cause death, and from interventions may lead to inaccuracies that compound patient suffering. that are administered with the intent of relieving suffering but Disclosure should be performed thoughtfully and sensitively, unintentionally hasten death (known as the principle of dou- accounting for the emotional effect on both the patient and ble effect). clinician. Institutional and clinical leadership also should be Physician-assisted suicide raises profound legal, clinical, involved in error disclosure to ensure that all available and social concerns. It may erode trust in the profession, cause resources are used to support both clinicians and patients. harm to the most vulnerable patients, and hinder progress in Disclosure may benefit physicians by alleviating distress, improving end-of-life care. It fundamentally alters the physi- improving patient-physician communication, and reducing cian’s role in society. The American College of Physicians does litigation. Strategies that focus on early communication and not support legalization of physician-assisted suicide or eutha- response after an error have been associated with fewer mal- nasia and instead emphasizes the need to provide palliative practice lawsuits and lower litigation costs, although these care, relief of suffering, and biopsychosocial support to the outcomes are not the primary goals of such initiatives. patient and family members during the end of life. Several states, however, have legalized physician-assisted suicide. Physicians may be asked to participate in discussions regard- ¢ The presence of depression or early dementia does not ing the practice but may assert a conscientious objection. necessarily preclude the presence of decision-making capacity but may complicate the evaluation. ¢ The American College of Physicians does not support ¢ Informed consent requires that the patient be informed legalization of physician-assisted suicide or euthanasia of the nature of the underlying condition; the goals of and instead emphasizes the need to provide palliative treatment; and the risks of, benefits of, and alternatives care, relief of suffering, and biopsychosocial support to to treatment, including the option to forgo treatment. the patient and family members during the end of life. e Surrogates and physicians are required to act in accor- dance with the patient’s expressed preferences for medical care, and if these are not available, they should serve the patient’s best interests. Providing Care as a HVC e Ifa patient requests diagnostic or therapeutic interven- Physician Bystander tions for which there is no evidence of clinical benefit, Physicians’ specialized knowledge creates a unique opportu- physicians are not obligated to provide these interventions. nity to intervene and benefit other citizens in emergency situ- ¢ Medical error disclosure may benefit physicians by alle- ations, and in this context, physicians may provide care out- viating distress, improving patient-physician communi- side of the clinical setting to persons who are not their patients.

apology owing to feelings of guilt or distress, because this administers an agent to cause death, and from interventions may lead to inaccuracies that compound patient suffering. that are administered with the intent of relieving suffering but Disclosure should be performed thoughtfully and sensitively, unintentionally hasten death (known as the principle of dou- accounting for the emotional effect on both the patient and ble effect). clinician. Institutional and clinical leadership also should be Physician-assisted suicide raises profound legal, clinical, involved in error disclosure to ensure that all available and social concerns. It may erode trust in the profession, cause resources are used to support both clinicians and patients. harm to the most vulnerable patients, and hinder progress in Disclosure may benefit physicians by alleviating distress, improving end-of-life care. It fundamentally alters the physi- improving patient-physician communication, and reducing cian’s role in society. The American College of Physicians does litigation. Strategies that focus on early communication and not support legalization of physician-assisted suicide or eutha- response after an error have been associated with fewer mal- nasia and instead emphasizes the need to provide palliative practice lawsuits and lower litigation costs, although these care, relief of suffering, and biopsychosocial support to the outcomes are not the primary goals of such initiatives. patient and family members during the end of life. Several states, however, have legalized physician-assisted suicide. Physicians may be asked to participate in discussions regard- ¢ The presence of depression or early dementia does not ing the practice but may assert a conscientious objection. necessarily preclude the presence of decision-making capacity but may complicate the evaluation. ¢ The American College of Physicians does not support ¢ Informed consent requires that the patient be informed legalization of physician-assisted suicide or euthanasia of the nature of the underlying condition; the goals of and instead emphasizes the need to provide palliative treatment; and the risks of, benefits of, and alternatives care, relief of suffering, and biopsychosocial support to to treatment, including the option to forgo treatment. the patient and family members during the end of life. e Surrogates and physicians are required to act in accor- dance with the patient’s expressed preferences for medical care, and if these are not available, they should serve the patient’s best interests. Providing Care as a HVC e Ifa patient requests diagnostic or therapeutic interven- Physician Bystander tions for which there is no evidence of clinical benefit, Physicians’ specialized knowledge creates a unique opportu- physicians are not obligated to provide these interventions. nity to intervene and benefit other citizens in emergency situ- ¢ Medical error disclosure may benefit physicians by alle- ations, and in this context, physicians may provide care out- viating distress, improving patient-physician communi- side of the clinical setting to persons who are not their patients. cation, and reducing litigation. When physicians assist in these situations, patient consent to receive emergency treatment is usually presumed or implied. If the treatment is provided in good faith, Good Samaritan laws usually protect the physician from liability, except in Care of Patients Near the cases of gross negligence. Providing medical care as a bystander End of Life is typically voluntary, with clinicians weighing their ethical Withholding or Withdrawing Treatment obligations to provide assistance; however, state laws vary on Ethically, there is no distinction between withholding (not this point, and several states have “failure to act” laws that are initiating) and withdrawing (removing) treatment. The deci- not specific to physicians. sion to withdraw care can be fraught with guilt or concerns about suffering for family members, and the physician can play an important role in explaining the process and amelio- Professional Self-Regulation rating concerns. An ethics committee or ethics consultation Conflicts of Interest can be helpful in assisting family members struggling with Conflicts of interest are financial, professional, or other per- these decisions. sonal concerns that have the potential to compromise a physi- cian’s objectivity with respect to clinical decision making. Real Physician-Assisted Suicide or potential conflicts threaten the physician’s ability to ensure Physician-assisted suicide, or physician aid in dying, occurs that the patient’s welfare is the primary motivating factor in when a physician provides a lethal prescription to a competent patient care and may undermine trust in the profession. patient who has requested a means by which to end his or her Conflicts of interest exist in clinical care, philanthropic oppor- life. The patient self-administers the drug with the intent tunities, and research. Physicians are obligated to recognize, to cause death. Physician-assisted suicide is different from disclose, and manage all conflicts of interest. Disclosure of

cation, and reducing litigation. When physicians assist in these situations, patient consent to receive emergency treatment is usually presumed or implied. If the treatment is provided in good faith, Good Samaritan laws usually protect the physician from liability, except in Care of Patients Near the cases of gross negligence. Providing medical care as a bystander End of Life is typically voluntary, with clinicians weighing their ethical Withholding or Withdrawing Treatment obligations to provide assistance; however, state laws vary on Ethically, there is no distinction between withholding (not this point, and several states have “failure to act” laws that are initiating) and withdrawing (removing) treatment. The deci- not specific to physicians. sion to withdraw care can be fraught with guilt or concerns about suffering for family members, and the physician can play an important role in explaining the process and amelio- Professional Self-Regulation rating concerns. An ethics committee or ethics consultation Conflicts of Interest can be helpful in assisting family members struggling with Conflicts of interest are financial, professional, or other per- these decisions. sonal concerns that have the potential to compromise a physi- cian’s objectivity with respect to clinical decision making. Real Physician-Assisted Suicide or potential conflicts threaten the physician’s ability to ensure Physician-assisted suicide, or physician aid in dying, occurs that the patient’s welfare is the primary motivating factor in when a physician provides a lethal prescription to a competent patient care and may undermine trust in the profession. patient who has requested a means by which to end his or her Conflicts of interest exist in clinical care, philanthropic oppor- life. The patient self-administers the drug with the intent tunities, and research. Physicians are obligated to recognize, to cause death. Physician-assisted suicide is different from disclose, and manage all conflicts of interest. Disclosure of 17

Medical Ethics and Professionalism conflicts, however, may not be an adequate safeguard against impaired physicians and to assist impaired colleagues. A step- bias in decision making, and potential conflicts should be wise approach should be pursued, in which concerns are first removed if possible. discussed with the colleague if patient harm is unlikely, fol- Physician acceptance of gifts, hospitality, and other items lowed by report to clinical supervisors or the local or state and services of value from industry or grateful patients also medical society if patient harm is possible or imminent. If the can pose ethical problems. In deciding to accept a gift, physi- appropriate action is unclear, physicians should seek advice cians should consider multiple factors, such as the nature of from supervisors or designated officials. Physicians also should the gift, the implications of accepting or refusing it, and the work collectively with institutions to develop methods for possible intention and expectations. Additional guidance to reporting, treating, and remediating impaired or disruptive manage relationships with industry are listed in Table 12. colleagues. Impaired physicians should be allowed the oppor- Physicians must be wary of personal business or eco- tunity to rehabilitate through a physician health program nomic interests taking priority over patient welfare. Self- whenever possible. referral, including referring patients to a facility in which the physician has invested and does not provide care, should Physician Burnout and Moral Distress be avoided. It is unethical and, in some cases illegal, to Physician burnout is a response to chronic unresolvable receive kickbacks or commissions for patient referrals, rec- occupational stress. Burnout includes features of emotional ommendations of medical products, or prescription of exhaustion, depersonalization, and reduced sense of profes- medications. Sale of products (at a reasonable cost) from the sionalism and may lead to classic depressive symptoms. physician’s office should be limited to those relevant to the Common drivers of burnout include a high workload with patient’s care that meet an urgent need. substantial administrative work, lack of autonomy, poor work-life balance, and inefficient EHRs. Moral distress may Physician Impairment and exacerbate or lead to burnout. Moral distress occurs in situa- Colleague Responsibility tions in which physicians are unable to carry out what they A physician may be the first to realize that a colleague is believe to be ethically appropriate actions and feel their impaired or unable to carry out clinical responsibilities safely integrity is jeopardized. Moral distress is associated with a and effectively. Impairment may be caused by substance use, noncollaborative working environment and lack of empow- aging, or mental illness or other disease; however, the pres- erment or autonomy at work. ence of such a disorder does not always signify impairment. Burnout is common and can have a profound result on Physicians have the responsibility to safeguard patients from physicians’ lives and the lives of those around them. Although research on burnout is ongoing, early studies have found that TABLE 12. Guidance for Individual Physicians to Manage Industry Relations and Gifts burnout is associated with shorter life expectancy, substance use, and broken relationships. Physicians experiencing deper- Avoid acceptance of gifts, hospitality, trips, or subsidies from health care industry that might diminish, or appear to others to sonalization are more likely to be involved in patient safety diminish, the objectivity of professional judgment. | incidents and to receive low satisfaction ratings from patients. Even small gifts can affect clinical judgment and heighten the Early-career physicians and medical trainees with burnout | perception and/or reality of a conflict of interest. | and low professional efficacy are more likely to deliver subop- Physicians must regularly gauge whether a gifting relationship timal care. is ethically appropriate by evaluating the potential for influence Initiatives to decrease physician burnout must address on their clinical judgment. This can be done by self-reflecting on the following questions: the underlying systems and organizational factors contribut- ing to the phenomenon. Although improving individual phy- What is the purpose of the industry offer? | sician resiliency may help to some extent, systems-based What would the public or my patients think ofthis initiatives focusing on improving work-life balance, increasing arrangement? | work efficiency (including EHR optimization), and supporting | What would my y colleagues think about this arrangement? | What would | think if my own physician accepted this offer? | sustainable workloads are more likely to have a meaningful | effect.

conflicts, however, may not be an adequate safeguard against impaired physicians and to assist impaired colleagues. A step- bias in decision making, and potential conflicts should be wise approach should be pursued, in which concerns are first removed if possible. discussed with the colleague if patient harm is unlikely, fol- Physician acceptance of gifts, hospitality, and other items lowed by report to clinical supervisors or the local or state and services of value from industry or grateful patients also medical society if patient harm is possible or imminent. If the can pose ethical problems. In deciding to accept a gift, physi- appropriate action is unclear, physicians should seek advice cians should consider multiple factors, such as the nature of from supervisors or designated officials. Physicians also should the gift, the implications of accepting or refusing it, and the work collectively with institutions to develop methods for possible intention and expectations. Additional guidance to reporting, treating, and remediating impaired or disruptive manage relationships with industry are listed in Table 12. colleagues. Impaired physicians should be allowed the oppor- Physicians must be wary of personal business or eco- tunity to rehabilitate through a physician health program nomic interests taking priority over patient welfare. Self- whenever possible. referral, including referring patients to a facility in which the physician has invested and does not provide care, should Physician Burnout and Moral Distress be avoided. It is unethical and, in some cases illegal, to Physician burnout is a response to chronic unresolvable receive kickbacks or commissions for patient referrals, rec- occupational stress. Burnout includes features of emotional ommendations of medical products, or prescription of exhaustion, depersonalization, and reduced sense of profes- medications. Sale of products (at a reasonable cost) from the sionalism and may lead to classic depressive symptoms. physician’s office should be limited to those relevant to the Common drivers of burnout include a high workload with patient’s care that meet an urgent need. substantial administrative work, lack of autonomy, poor work-life balance, and inefficient EHRs. Moral distress may Physician Impairment and exacerbate or lead to burnout. Moral distress occurs in situa- Colleague Responsibility tions in which physicians are unable to carry out what they A physician may be the first to realize that a colleague is believe to be ethically appropriate actions and feel their impaired or unable to carry out clinical responsibilities safely integrity is jeopardized. Moral distress is associated with a and effectively. Impairment may be caused by substance use, noncollaborative working environment and lack of empow- aging, or mental illness or other disease; however, the pres- erment or autonomy at work. ence of such a disorder does not always signify impairment. Burnout is common and can have a profound result on Physicians have the responsibility to safeguard patients from physicians’ lives and the lives of those around them. Although research on burnout is ongoing, early studies have found that TABLE 12. Guidance for Individual Physicians to Manage Industry Relations and Gifts burnout is associated with shorter life expectancy, substance use, and broken relationships. Physicians experiencing deper- Avoid acceptance of gifts, hospitality, trips, or subsidies from health care industry that might diminish, or appear to others to sonalization are more likely to be involved in patient safety diminish, the objectivity of professional judgment. | incidents and to receive low satisfaction ratings from patients. Even small gifts can affect clinical judgment and heighten the Early-career physicians and medical trainees with burnout | perception and/or reality of a conflict of interest. | and low professional efficacy are more likely to deliver subop- Physicians must regularly gauge whether a gifting relationship timal care. is ethically appropriate by evaluating the potential for influence Initiatives to decrease physician burnout must address on their clinical judgment. This can be done by self-reflecting on the following questions: the underlying systems and organizational factors contribut- ing to the phenomenon. Although improving individual phy- What is the purpose of the industry offer? | sician resiliency may help to some extent, systems-based What would the public or my patients think ofthis initiatives focusing on improving work-life balance, increasing arrangement? | work efficiency (including EHR optimization), and supporting | What would my y colleagues think about this arrangement? | What would | think if my own physician accepted this offer? | sustainable workloads are more likely to have a meaningful | effect. | It is the individual responsibility of each physician to enter into | relationships with industry only for the purposes of enhancing patient care. e Physicians are obligated to recognize, disclose, and Many industry payments and transfers of value to physicians manage all conflicts of interest; disclosure of conflicts must be reported under the federal Open Payments Program may not be an adequate safeguard against bias, and and laws of some states. The amount paid to each physician is available to the public at www.cms.gov/openpayments/. | potential conflicts should be removed if possible.

| It is the individual responsibility of each physician to enter into | relationships with industry only for the purposes of enhancing patient care. e Physicians are obligated to recognize, disclose, and Many industry payments and transfers of value to physicians manage all conflicts of interest; disclosure of conflicts must be reported under the federal Open Payments Program may not be an adequate safeguard against bias, and and laws of some states. The amount paid to each physician is available to the public at www.cms.gov/openpayments/. | potential conflicts should be removed if possible. Adapted with permission from Sulmasy LS, Bledsoe TA; ACP Ethics, Professionalism e Systems-based initiatives focusing on improving work- and Human Rights Committee. American College of Physicians Ethics Manual: life balance, increasing work efficiency, and supporting seventh edition. Ann Intern Med. 2019;170:S18. [PMID: 30641552] doi:10.7326/ | M18-2160. © 2019, American College of Physicians. sustainable workloads may decrease physician burnout. 18