AMA Journal of Ethics^®

Abstract

In recent decades, organized health care has displaced some traditional solo-practitioner physician roles. As larger organizations become more influential in the health care sector, American Medical Association (AMA) positions on professionalism and organizational development, as outlined in the Code of Medical Ethics, can help physicians navigate organizations’ influence on practice.

Professionalism

Opinion 11.2.1 of the American Medical Association (AMA) Code of Medical Ethics, “Professionalism in Health Care Systems,” offers guidance for health care organizations about “containing costs, promoting high-quality care for all patients, and sustaining physician professionalism.” These goals are important in any health care organization, and, in order to protect patient-physician relationships, physicians are obligated to communicate transparently, mitigate possible financial conflicts, and recognize their primary obligations to patients.¹ Additionally, Opinion 3.1.5, “Professionalism in Relationships With Media,” considers how physicians ought to conduct themselves when reporting on behalf of organizations that are involved in patient care.² Similarly, this opinion suggests the primacy of keeping patients’ information private and upholding confidentiality, and it underscores the importance of deferring to organizational guidelines regarding releasing patient information.

Conflicts of interest are also discussed in the AMA Code. Opinion 1.2.3, “Consultation, Referral and Second Opinions”; Opinion 9.6.5, “Sale of Non-Health-Related Goods”; Opinion 9.6.9, “Physician Self-Referral”; and Opinion 11.2.3, “Contracts to Deliver Health Care Services,” each describe conflicts of interest physicians face regarding referrals, employment contracts, and financial interests.^3,4,5,6 For scenarios involving potential conflicts of interest, the AMA Code offers guidance in Opinion 11.2.2, “Conflicts of Interest in Patient Care.”⁷ The opinion states:

The primary objective of the medical profession is to render service to humanity; reward or financial gain is a subordinate consideration. Under no circumstances may physicians place their own financial interests above the welfare of their patients.

Treatment or hospitalization that is willfully excessive or inadequate constitutes unethical practice. Physicians should not provide wasteful and unnecessary treatment that may cause needless expense solely for the physician’s financial benefit or for the benefit of a hospital or other health care organization with which the physician is affiliated.

Where the economic interests of the hospital, health care organization, or other entity are in conflict with patient welfare, patient welfare takes priority.⁷

This opinion underscores that, above all, the interests of a patient and beneficence must take precedence over a physician’s or institution’s financial gain.

Ethical Intervention

Opinion 10.7 of the AMA Code, “Ethics Committees in Health Care Institutions,” addresses one way in which organizations can develop cultures that promote ethics in medicine—by advocating for organizational and practical oversight.

In making decisions about health care, patients, families, and physicians and other health care professionals often face difficult, potentially life-changing situations. Such situations can raise ethically challenging questions about what would be the most appropriate or preferred course of action. Ethics committees, or similar institutional mechanisms, offer assistance in addressing ethical issues that arise in patient care and facilitate sound decision making that respects participants’ values, concerns, and interests.⁸

Ethics committees can help health care organizations make policy and support practices that both serve patients and minimize harm.

The AMA Code urges individual physicians to promote ethical practice as well. Opinion 1.1.7, “Physician Exercise of Conscience,” calls for organizations to preserve opportunities for physicians to act “in accordance with the dictates of conscience.”⁹ Nevertheless, physicians do not have unlimited freedom to act on their conscience.

Physicians are expected to provide care in emergencies, honor patients’ informed decisions to refuse life-sustaining treatment, and respect basic civil liberties and not discriminate against individuals in deciding whether to enter into a professional relationship with a new patient…. In general, physicians should refer a patient to another physician or institution to provide treatment the physician declines to offer.⁹

In essence, regardless of what an organization may dictate, physicians are expected to act according to these ethical standards in order to ensure quality of care for every patient.

Physicians are also expected to promote public health and community access to care, regardless of their organizational affiliation. In Opinion 11.1.2, “Physician Stewardship of Health Care Resources,” physicians are reminded to “be prudent stewards of the shared societal resources with which they are entrusted” as “[m]anaging health care resources responsibly for the benefit of all patients is compatible with physicians’ primary obligation to serve the interests of individual patients.”¹⁰