February 2012 Critical Care Journal Club

Snyder L.  American College of Physicians Ethics Manual.  Sixth Edition.  Ann Intern Med.  156;1:suppl 73-101. (Click here for a PDF version of the manuscript)

All the fellows, and Drs. Robbins, Bajo, Singarajah and Raschke attended Journal Club.   

This article related concepts of traditional medical ethics to current legal and social values.  The scope was very broad, touching on many bedside patient care issues. 

Our discussion began with some valid criticisms.  The chief among these is something I missed altogether: the author of this article is not a physician, but a lawyer. 

With all due respect to Lois Snyder, this was a mistake.  The very first statement of the article speaks to the fundamental and timeless nature of the patient-physician relationship.  How can someone who has never been a part of this relationship from a physician’s perspective be chosen to express our ethical standard?  The ACP should have looked within our own profession for a qualified author.   

Some reviewers also felt certain areas of the review were condescending, for instance, the section entitled “Sexual contact between physician and patient.  Some rudiments of ethical common-sense on the part of physician audience could probably have been reasonably assumed. 

Others felt there were content errors in the review.  One example was in the section on end of life.  The author states that physicians should not write a do-not-intubate order in the absence of a full DNR, because the patient who dies from respiratory failure will invariably suffer cardiac arrest as a consequence. 

Patients occasionally request do-not-intubate status in our practice, typically after having seen a family member suffer prolonged mechanical ventilation.   We have honored the patient’s wishes, and avoided the theoretical dilemma posed by the author by using common sense.  It is typically apparent when a patient is dying of respiratory failure – of course we wouldn’t perform ACLS in a DNI patient dying from respiratory failure.  But there isn’t any reason why such a patient shouldn’t receive treatment in the event of cardiac arrest, if that is their well-informed wish.

Despite these shortcomings, most of the content of this review was valid, and applicable to patient care. Sections on health care system catastrophes, surrogacy, futile treatments, and the impaired physician were particularly informative.  The explicit statement that physicians have an ethical obligation in regards to medical education is particularly important in a healthcare economy that seems to increasingly devalue trainees and faculty.  

The most important part of the review, from my perspective, had to do with our primary goal as physicians. “The physician’s primary commitment must always be to the patient’s welfare and best interests., . . . regardless of financial arrangements, the health care setting; or patient characteristics . . . “ 

Physicians and healthcare administrators and physicians are increasingly being asked to work together.  The advent of Accountable Care Organizations may hasten this process.   It is therefore increasingly important that we hold our responsibility to our patients foremost as financial goals receive increasing attention.  Maintaining patient welfare might be increasingly challenged by payment systems such as capitation that may disincentivize care.  Other payment systems, such as pay-for-performance, will only be compatible with good patient care if “performance” is defined by important clinical patient outcomes, rather than by compliance or surrogate outcome measures.   

Robert A. Raschke, M.D.

Associate Editor, Critical Care Journal Club

Reference as: Raschke RA. February 2012 critical care journal club. Southwest J Pulm Crit Care 2012;4:51-2. (Click here for a PDF version of the journal club)

Comments

[Richard A. Robbins, MD]

I would agree with the comments by Dr. Raschke. I certainly agree that a medical ethics manual authored by a lawyer is not acceptable and reflects poorly on the ACP. This would seem an extension of the present medical regulatory environment where lawyers seem to have more input into health care than physicians. In this context, it should come as no surprise that many of the recent changes in medicine have resulted in poorer health care at higher costs. This intrusion has reached a level that some state departments of health now have lawyers as their executive directors. This makes as much sense as physicians directing the American or state bar associations or a physician sitting on the Supreme Court.

Several of the fellows found the manual offensive and patronizing. I agree. For example, the section entitled “The Impaired Physician” would imply that only physicians become impaired. What should be done with other impaired healthcare professionals is not discussed.

According to the manual, “Physicians should not engage in strikes, work stoppages, slowdowns, boycotts, or other organized actions that are designed, implicitly or explicitly, to limit or deny services to patients that would otherwise be available. In general, physicians should individually and collectively find advocacy alternatives, such as lobbying lawmakers and working to educate the public, patient groups, and policymakers about their concerns...” -as if that has worked. Physicians are presently viewed by healthcare administrators not as highly trained professionals, but as overpaid labor. Although I agree that physicians are obligated to care for patients in need of emergent care or with whom they have an established relationship, the ACP manual suggests that physicians are ethically obligated to care for all patients at any price.

Conflicts of health care professionals with physicians are also discussed. “When a health professional has important ethical objections to an attending physician’s order, both should discuss the matter openly and thoroughly. Mechanisms should be available in hospitals and outpatient settings to resolve differences of opinion among members of the patient care team.” Not discussed is when a physician has serious objections to care delivered by another member of the health team. Examples might include a respiratory therapist or nurse repeatedly administering excessive oxygen to carbon dioxide-retaining chronic obstructive pulmonary disease (COPD) patients or telling a COPD patient’s family that COPD patients never leave the ICU. This manual implies that only physicians do things that are incorrect or objectionable.

In several instances, important ethical conflicts are not discussed. The manual’s section entitled Attending Physicians and Physicians-In-Training states, “It is unethical to delegate authority for patient care to anyone, including another physician, who is not appropriately qualified and experienced.” We can probably all agree. However, in an effort to reduce costs, some hospitals have inadequate staffing by registered nurses, assigned respiratory therapists to do night time intubations or replaced intensivists with an eICU monitored by physician extenders. Whether it is ethical for physicians to admit patients to a hospital with these or other examples of suboptimal care is not discussed.

In the section subtitled The Changing Practice Environment the manual states, “Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available. In making recommendations to patients, designing practice guidelines and formularies, and making decisions on medical benefits review boards, physicians’ considered judgments should reflect the best available evidence in the biomedical literature, including data on the cost-effectiveness of different clinical approaches.” As we have illustrated in the SWJPCC, loss of physician autonomy has resulted in multiple examples of guidelines that are ineffective and occasionally harmful. The physician’s ethical obligation in this instance is not discussed.

Although there are many areas where the ACP Ethics Manual is “spot on”, there are also multiple deficiencies. Physicians and their patients would be better served by an ethics manual that discusses and makes recommendations regarding controversial areas such as those above by practicing physicians familiar with these issues.

Richard A. Robbins, M.D.
Editor, Southwest Journal of Pulmonary and Critical Care