AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

AMA Journal of Ethics. January 2016, Volume 18, Number 1: 45-48.

The Code Says

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The AMA Code of Medical Ethics’ Opinions Relevant to Patient- and Family-Centered Care

The AMA Code of Medical Ethics’ opinions related to patient information and involvement of surrogate decision makers such as family in ICU decisions.

Danielle Chaet, MS

This section summarizes content from AMA Code of Ethics opinions.

Therapeutic Privilege

Opinion 8.12, “Patient Information,” explains that it is a “fundamental ethical requirement that a physician should at all times deal honestly and openly with patients” and that “patients have a right to know their past and present medical status” [1]. Opinion 8.082, “Withholding Information from Patients,” elaborates that “withholding medical information from patients without their knowledge or consent is ethically unacceptable” [2]. However, when a physician believes that disclosing certain information could be harmful to the patient, the physician may delay disclosure to a more suitable time, provided there is a definite plan for communicating that information to the patient later. According to this opinion, physicians are encouraged to honor patients’ requests not to be informed of certain medical information or to “convey the information to a designated proxy, provided these requests appear to genuinely represent the patient’s own wishes” [2].

Managing Conflicts among Family Members and Patients

Although Opinion 10.016, “Pediatric Decision-Making,” generally refers to medical decisions for younger patients, the guidance regarding conflict among family members can be useful in other situations. The opinion states that “when disagreements occur, institutional policies for timely conflict resolution should be followed, including consultation with an ethics committee, pastoral service, or other counseling resource” [3]. Drawing upon the best interest principle—the principle that decisions ought to be based on what’s in the best interest (however that’s defined) of the patient—is one way to help facilitate decision making.

For conflicts among family members and patients regarding transplantation specifically, Opinion 2.15, “Transplantation of Organs from Living Donors,” outlines the steps that should be taken to determine if a donor candidate is suitable for the procedure [4]. Because living organ donors are exposed to surgical procedures that pose risks but offer no physical benefits, they require special safeguards and are not, generally, ethically required to participate in organ donation.

Involving Family Members in ICU Decisions

Opinion 2.037, “Medical Futility in End-of-Life Care,” outlines a seven-part “due process approach” to assessing medical futility in specific cases:

  • (a) Earnest attempts should be made in advance to deliberate over and negotiate prior understandings between patient, proxy, and physician on what constitutes futile care for the patient, and what falls within acceptable limits for the physician, family, and possibly also the institution.
  • (b) Joint decision-making should occur between patient or proxy and physician to the maximum extent possible.
  • (c) Attempts should be made to negotiate disagreements if they arise, and to reach resolution within all parties’ acceptable limits, with the assistance of consultants as appropriate.
  • (d) Involvement of an institutional committee such as the ethics committee should be requested if disagreements are irresolvable.
  • (e) If the institutional review supports the patient’s position and the physician remains unpersuaded, transfer of care to another physician within the institution may be arranged.
  • (f) If the process supports the physician’s position and the patient/proxy remains unpersuaded, transfer to another institution may be sought and, if done, should be supported by the transferring and receiving institution.
  • (g) If transfer is not possible, the intervention need not be offered [5].

These steps can also be used to facilitate involvement of family members in ICU decision making [5].

Opinions 2.22, “Do-Not-Resuscitate Orders” [6], and 2.191, “Advance Care Planning” [7], both discuss benefits of considering various life-sustaining interventions prior to the occurrence of a traumatic incident. Both opinions maintain that patients should do their best to make their wishes known, but, in the absence of that knowledge, a formally designated surrogate decision maker (appointed before an event that incapacitates the patient) or next of kin or close family member should make decisions based on the best interest principle or the substituted judgment standard—the standard by which a surrogate does his or her best to imagine and formulate, as accurately as possible, which decision the patient would make if he or she had capacity to do so.

Opinion 5.05, “Confidentiality,” states that “the physician should not reveal confidential information without the express consent of the patient, subject to certain exceptions that are ethically justified because of overriding considerations” [8]. Emergency situations are generally considered to be such exceptions—times at which it is ethically appropriate to disclose information to someone, such as a family member or someone designated by the patient (in cases in which a designee is known), who can make medical decisions for an incapacitated patient.




References

  1. American Medical Association. Opinion 8.12 Patient information. Code of Medical Ethics. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion812.page?. Accessed November 30, 2015.
  2. American Medical Association. Opinion 8.082 Withholding information from patients. Code of Medical Ethics. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion8082.page?. Accessed November 30, 2015.
  3. American Medical Association. Opinion 10.016 Pediatric decision-making. Code of Medical Ethics. https://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion10016.page?. Accessed November 30, 2015.
  4. American Medical Association. Opinion 2.15 Transplantation of organs from living donors. Code of Medical Ethics. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion215.page. Accessed November 30, 2015.
  5. American Medical Association. Opinion 2.037 Medical futility in end-of-life care. Code of Medical Ethics. https://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion2037.page?. Accessed November 30, 2015.
  6. American Medical Association. Opinions 2.22 Do-not-resuscitate orders. Code of Medical Ethics. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion222.page. Accessed November 30, 2015.
  7. American Medical Association. Opinion 2.191 Advance care planning. Code of Medical Ethics. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion2191.page. Accessed November 30, 2015.
  8. American Medical Association. Opinion 5.05 Confidentiality. Code of Medical Ethics. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion505.page. Accessed November 30, 2015.

Danielle Chaet, MS, is a research associate for the American Medical Association Council on Ethical and Judicial Affairs in Chicago. Her work involves researching, developing, and disseminating ethics policy and analyzing current issues and opinions in bioethics. She obtained her master of science degree in bioethics, with a focus on clinical policy and clinical ethics consultation, from the joint program of Union Graduate College and the Icahn School of Medicine at Mount Sinai.

Could Good Care Mean Withholding Information from Patients? January 2016

What’s the Role of Autonomy in Patient- and Family-Centered Care When Patients and Family Members Don’t Agree? January 2016

Should Children be Asked to be Bone Marrow Donors for Siblings? January 2016

Moving Past Individual and “Pure” Autonomy: The Rise of Family-Centered Patient Care, January 2016

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.