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. June 2017, Volume 19, Number 6: 564-567.
doi: 10.1001/journalofethics.2017.19.6.coet1-1706.

The Code Says

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The AMA Code of Medical Ethics’ Opinions Related to Moral Distress

The AMA Code of Medical Ethics’ opinions related to moral distress and medicine.

BJ Crigger, PhD

The formal policies of health care institutions, as well as informal expectations and practices, can create moral distress for patients and health care professionals in a variety of ways. For example, financial incentives or tools intended to influence decision making can put patients’ interests at odds with those of the institution or physicians who are employed by or have privileges within the institution. The AMA Code of Medical Ethics addresses situations that can create moral distress in several opinions.

Professionalism in Health Care Systems

Opinion 11.2.1, “Professionalism in Health Care Systems” [1], urges physicians in leadership positions in health care institutions to minimize the possible adverse effects of institutional policy and practice by ensuring, among other things, that policies “reflect input from key stakeholders, including physicians and patients” [2]. Physicians are further urged to ensure that incentives, if any, are designed in keeping with sound principles, implemented fairly so as not to disadvantage identifiable populations of patients, supported with appropriate infrastructure and resources, and minimize possible conflicts of interest among patients, physicians, and the institution. Opinion 11.2.1 also requires institutions to recognize that physicians’ primary obligations are to their patients and to enable physicians to respond to the unique needs of individual patients, including “providing avenues for meaningful appeal and advocacy on behalf of patients” [3]. This opinion holds health care institutions responsible for monitoring the effect of incentives and policies and urges all physicians affiliated with an institution to hold leaders accountable for meeting these conditions for professionalism.

Transparency

Although transparency does not preclude moral distress, it can help mitigate the severity of distress that institutional policies or practices may cause patients or physicians. Several opinions stress the importance of transparency in health care. Opinion 11.2.4, “Transparency in Health Care” [4], acknowledges that health plans and other entities should inform patient-members about plan provisions that affect the availability of care and requires that individual physicians disclose incentives that could affect care as well as relevant treatment alternatives, whether or not they are covered by a health plan. This opinion calls on physicians collectively to advocate that health plans and institutions be transparent. Opinion 11.2.3, “Contracts to Deliver Health Care Services” [5], similarly holds that physicians should assure themselves that their contracts with health plans or health care institutions permit them to disclose to patients information that may affect their care.

Finally, Opinion 10.7, “Ethics Committees in Health Care Institutions” [6], calls on ethics committees in faith-based institutions not only to uphold the principles to which the institution is committed but also to “make clear to patients, physicians, and other stakeholders that the institution’s defining principles will inform the committee’s recommendations” [7].

Exercise of Conscience

The Code of Medical Ethics also provides guidance for physicians who in good faith find they cannot adhere to institutional policy or practice in Opinion 1.1.7, “Physician Exercise of Conscience” [8]. Although this opinion focuses on situations that involve conflicts between patients’ values and preferences and physicians’ personal moral commitments, it is also instructive for situations in which physicians’ commitments may be incommensurate with institutional values, policies, or practices.

Opinion 1.1.7 requires that physicians thoughtfully consider the implications of decisions to act (or decline to act) in accordance with “well-considered, deeply held beliefs that are central to their self-identities” [9]. Physicians should consider “how significantly an action (or declining to act) will undermine the physician’s personal integrity, create emotional or moral distress for the physician, or compromise the physician’s ability to provide care” [10]. Physicians should also be “mindful of the burden their actions may place on fellow professionals.”

Contracts with Health Care Institutions

Opinion 11.2.3, “Contracts to Deliver Health Care Services” [5], calls on individual physicians to assure themselves that contracts with health plans or institutions minimize possible conflicts of interest and do not compromise the physician’s own financial well-being or ability to provide high-quality care, for example, by setting unrealistic expectations about utilization of services. This opinion also urges physicians to enter into a contract only if it allows the physician to “exercise professional judgment,” “supports physician advocacy on behalf of individual patients,” and “includes a mechanism to address grievances” [11]. Physicians should negotiate to modify or remove terms that unduly compromise their ability to uphold ethical standards.



References

  1. American Medical Association. Opinion 11.2.1 Professionalism in health care systems. Code of Medical Ethics. https://www.ama-assn.org/sites/default/files/media-browser/code-of-medical-ethics-chapter-11.pdf. Published 2016. Accessed April 10, 2017.
  2. American Medical Association, 4.
  3. American Medical Association, 5.
  4. American Medical Association. Opinion 11.2.4 Transparency in health care. Code of Medical Ethics. https://www.ama-assn.org/sites/default/files/media-browser/code-of-medical-ethics-chapter-11.pdf. Published 2016. Accessed April 10, 2017.
  5. American Medical Association. Opinion 11.2.3 Contracts to deliver health care services. Code of Medical Ethics. https://www.ama-assn.org/sites/default/files/media-browser/code-of-medical-ethics-chapter-11.pdf. Published 2016. Accessed April 10, 2017.
  6. American Medical Association. Opinion 10.7 Ethics committees in health care institutions. Code of Medical Ethics. https://www.ama-assn.org/sites/default/files/media-browser/code-of-medical-ethics-chapter-10.pdf. Published 2016. Accessed April 10, 2017.
  7. American Medical Association, Opinion 10.7 Ethics committees in health care institutions, 6.
  8. American Medical Association. Opinion 1.1.7 Physician exercise of conscience. Code of Medical Ethics. https://www.ama-assn.org/sites/default/files/media-browser/code-of-medical-ethics-chapter-1.pdf. Published 2016. Accessed April 10, 2017.
  9. American Medical Association, Opinion 1.1.7 Physician exercise of conscience, 5.
  10. American Medical Association, Opinion 1.1.7 Physician exercise of conscience, 6.
  11. American Medical Association, Opinion 11.2.3 Contracts to deliver health care services, 6.

BJ Crigger, PhD, is director of ethics policy for the American Medical Association and secretary to the Council on Ethical and Judicial Affairs. Dr. Crigger was formerly editor of the Hastings Center Report and has served as chief of ethics communications for the US Department of Veterans Affairs National Center for Ethics in Health Care.

The Limits of Conscientious Refusal: A Duty to Ensure Access, March 2013

The National Clinician Scholars Program: Teaching Transformational Leadership and Promoting Health Justice Through Community-Engaged Research Ethics, December 2015

Promoting Cost Transparency to Reduce Financial Harm to Patients, November 2015

What Moral Distress in Nursing History Could Suggest about the Future of Health Care, June 2017

Who Is Experiencing What Kind of Moral Distress? Distinctions for Moving from a Narrow to a Broad Definition of Moral Distress, June 2017

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