The moral obligations of physician executives.A problem has developed for increasing numbers of physicians who assumed executive roles, especially physicians in nontraditional settings. Medical codes of ethics have generally failed to recognize competing values and moral conflicts inherent in health care rendered in different organizational settings, including private practice.
For example, the American Medical Association American Medical Association (AMA), professional physicians' organization (founded 1847). Its goals are to protect the interests of American physicians, advance public health, and support the growth of medical science. (AMA (Automatic Message Accounting) The recording and reporting of telephone calls within a telephone system. It includes the calling and called parties and start and stop times of the call. ) Principles of Medical Ethics medical ethics The moral construct focused on the medical issues of individual Pts and medical practitioners. See Baby Doe, Brouphy, Conran, Jefferson, Kevorkian, Quinlan, Roe v Wade, Webster decision. provides norms for treating patients, but provides little guidance for physician executives in terms of helping their organizations comply with legal and regulatory requirements Regulatory requirements are part of the process of drug discovery and drug development. Regulatory requirements describe what is necessary for a new drug to be approved for marketing in any particular country. , avoiding litigation An action brought in court to enforce a particular right. The act or process of bringing a lawsuit in and of itself; a judicial contest; any dispute.
When a person begins a civil lawsuit, the person enters into a process called litigation. , improving productivity and quality and building organizational trust and integrity.
When conflict exists between the needs of the organization or society and the needs of patients, the physician executive is left in a lurch Lurch
Addams’s zombielike, extremely tall butler. [TV: “The Addams Family” in Terrace, I, 29]
See : Butler , compelled only by an ongoing commitment to the needs of patients.
Using myself as an example--a psychiatrist employed in the pharmaceutical industry--there are at least five distinct sets of ethical principles I could follow:
1. AMA Principles of Medical Ethics
2. AMA Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry
3. AMA Principles of Medical Ethics With Annotations Especially Applicable to Psychiatric Administrators
4. American College of Healthcare Executives The American College of Healthcare Executives (ACHE) is an international professional association of healthcare executives (high-level hospital administrators, CEOs, COOs, health system officers, etc.) Its central offices are located at 1 N. (ACHE) Code of Ethics Code of Ethics can refer to:
5. American Academy The American Academy in Berlin is a non-partisan academic institution in Berlin. It was founded in September 1994 by a group of prominent Americans and Germans, among them Richard Holbrooke, Henry Kissinger, Richard von Weizsäcker, Fritz Stern and Otto Graf Lambsdorff and opened in of Pharmaceutical Physicians (AAPP AAPP Administraciones Públicas (Spanish ministry)
AAPP Assistance Association for Political Prisoners (Burma)
AAPP Association of Asian Parliaments for Peace ) Code of Ethics for the Practice of Pharmaceutical Medicine
The smorgasbord of offerings places physician executives squarely at the crossroads of ethical uncertainty. On one hand, an organization's code of ethics may be irrelevant to a physician executive's job or work setting. Again, using the pharmaceutical industry as an example, many pharmaceutical physicians adhere to adhere to
verb 1. follow, keep, maintain, respect, observe, be true, fulfil, obey, heed, keep to, abide by, be loyal, mind, be constant, be faithful
2. the AAPP code of ethics, which basically guides ethical decision Real life ethical decisions are studied in sociology and political science and psychology using very different methods than descriptive ethics in ethics (philosophy). Not ethics proper making related to patients (subjects) in clinical trials, but not to patients seen in clinical practice.
On the other hand, some codes of conduct may conflict with one other, making it impossible for a physician executive to choose a proper course of action when faced with an ethical dilemma An ethical dilemma is a situation that will often involve an apparent conflict between moral imperatives, in which to obey one would result in transgressing another.
This is also called an ethical paradox or, worse yet, forcing him or her to resign from the job (or from the professional organization whose ethical principles can no longer be followed in good faith).
When a physician's organizational role collides with the ethical tenets of a professional society, a problem may also occur for ethics committees ethics committee A multidisciplinary hospital body composed of a broad spectrum of personnel–eg, physicians, nurses, social workers, priests, and others, which addresses the moral and ethical issues within the hospital. See DNR, Institutional review board. whose job is to adjudicate adjudicate (jōō´dikāt´),
v complaints of unethical unethical
said of conduct not conforming with professional ethics. behavior.
APA (All Points Addressable) Refers to an array (bitmapped screen, matrix, etc.) in which all bits or cells can be individually manipulated.
APA - Application Portability Architecture code
For example, many years ago, a district branch of the American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential world-wide. Its some 148,000 members are mainly American but some are international. (APA) struggled to reach a decision in a case brought against two psychiatrists.
The complaint alleged that, by conducting insurance reviews with the attending physician without the patient's written consent, the psychiatrists were behaving unethically.
The committee was uncertain whether the APA code of ethics even applied to the psychiatrists, as the code was originally written for practicing psychiatrists and predated the era of managed care. (Indeed, it remains controversial whether physicians working in an administrative capacity for managed care organizations are practicing medicine and liable for their decisions.)
The psychiatrists were exonerated, and later an addendum addendum n. an addition to a completed written document. Most commonly this is a proposed change or explanation (such as a list of goods to be included) in a contract, or some point that has been subject of negotiation after the contract was originally proposed by to the APA's code of ethics was incorporated to clarify existing standards for psychiatrists practicing in "organized settings."
The addendum stated: "A psychiatrist shall not conduct reviews or participate in reviews in a manner likely to demean de·mean 1
tr.v. de·meaned, de·mean·ing, de·means
To conduct or behave (oneself) in a particular manner: demeaned themselves well in class. the dignity of the patient by asking for highly personal material not necessary for the conduct of the review. A reviewing psychiatrist shall strive as hard for a patient he or she reviews as for one he or she treats to prevent the disclosure of sensitive patient material to anyone other than for clear, clinical necessity." The APA's philosophy is consistent with its overall approach to resolving ethical conflicts, that is, to resolve conflicts in a manner that results in the greatest benefit to the patient.
In a second addendum to the principles, the APA opined that various specialty groups within psychiatry can develop their own code of ethics "as long as it is additive to the principles ... and does not subtract or change any elements of the [code]."
It was in this spirit that the American Association American Association refers to one of the following professional baseball leagues:
The ACHE code of ethics is even broader. It contains standards of ethical behavior for health care executives in virtually all professional relationships--colleagues, patients, members of the health care executive's organization and other organizations, the community, and society as a whole.
The code also incorporates standards of ethical behavior governing personal behavior, particularly when that conduct directly relates to the role and identity of the health care executive. It is expected that health care executives will lead exemplary lives as moral advocates for the "rights, interests, and prerogatives of others served."
Recently, ACHE revised its code of ethics by more specifically targeting financial conflicts of interest and fraud and abuses of power that compromise patient safety.
ACHE now explicitly recommends that health care executives should:
* Avoid financial and other conflicts of interest while managing their organizations
* Have a plan in place to avoid conflicts of interest when the values of patients and their families differ from those of physicians and employees
* Create an environment in which clinical and management mistakes are reported and addressed
With the revisions, ACHE anticipates its members will have a more concise code that acts as a proactive tool in resolving conflicts and ethical issues. However, the ACHE code does not specifically resolve the ethical dilemma of when a duty to the patient supersedes the health care executive's responsibilities to his or her organization and to others.
Instead, it advises health care executives to provide services consistent with available resources, and when there are limited resources, to ensure the existence of a resource allocation resource allocation Managed care The constellation of activities and decisions which form the basis for prioritizing health care needs process that considers ethical ramifications ramifications npl → Auswirkungen pl . The ACHE code is geared toward ACHE members, of which physicians are a minority.
The AAPP code of ethics is similar to the ACHE code in that it addresses ethical decision making related to patients, as well as their families, doctors, nurses and other health care professionals. However, the AAPP code is unique to that organization's purpose, which is to assure the safe use of medical products.
The AAPP code of ethics draws from basic philosophies underlying major codes, declarations and other documents relevant to research with human subjects. Key among its principles is that clinical trials select subjects fairly and respect their safety and right to informed consent.
Research should demonstrate social value, undergo independent review and be scientifically valid. Unlike the AMA, APA, and ACHE, the AAPP does not have a process for handling ethical grievances and appeals, nor is it incumbent upon AAPP members to report ethical violations of the code.
The AAPP developed its principles with the realization that a pharmaceutical physician is a "guardian of health" rather than a primary provider of health care services. Therein lies a potential problem. Many patients enroll in clinical trials to receive expert medical care (at no cost), but the principal investigator Noun 1. principal investigator - the scientist in charge of an experiment or research project
scientist - a person with advanced knowledge of one or more sciences does not function as the de facto [Latin, In fact.] In fact, in deed, actually.
This phrase is used to characterize an officer, a government, a past action, or a state of affairs that must be accepted for all practical purposes, but is illegal or illegitimate. primary caregiver.
The difference between the patient's expectation of treatment to be received and the principal investigator's expectation of treatment to be rendered may be significant.
Physician executives should not have to operate under different sets of ethical principles depending on what their roles and responsibilities are at a given point in time.
Moreover, no matter what professional roles physician executives may have defined for themselves, it appears that the public will always view them first as doctors. Indeed the AMA and APA principles are binding upon all physician members, even if they are inactive.
Ethical codes Noun 1. ethical code - a system of principles governing morality and acceptable conduct
system of rules, system - a complex of methods or rules governing behavior; "they have to operate under a system they oppose"; "that language has a complex system of conduct developed by various medical organizations appear to have their greatest utility as resources for physician executives. While it is laudable laud·a·ble
Healthy; favorable. that the APA recognized that psychiatrists face special ethical problems that require annotations to the AMA principles, and the AAPA has followed suit, the fact is that no single code of ethics is comprehensive enough to guide physician executives through the vast array of competing imperatives they will likely encounter.
Principles of Ethics Across Different Medical Organizations (1) Principle AMA/APA/AAPA (2) ACHE Patient care Provide competent care Advocate solutions that will with compassion and improve health status and respect for human promote quality health care. dignity and rights. Respect the customs and practices of patients. Honesty Uphold professional Conduct all personal and standards and be honest professional activities with in all professional honesty. Be truthful in all interactions. Report forms of communication. physicians who are Prevent financial fraud and deficient in character abuse. Report ethical or competence, or who violations. engage in fraud and deception. Legal Respect the law and Comply with all laws and seek changes in those regulations pertaining to requirements that are health care management. Ensure contrary to the best a work environment that is interest of patients. free from harassment and coercion, especially to perform illegal acts. Confidentiality Safeguard patient Respect professional confidences and privacy confidences. Ensure the within the constraints existence of procedures that of the law. will safeguard the confidentiality and privacy of patients or others served. Education and Advance scientific Maintain competence and consultation knowledge. Continue to proficiency in health care educate oneself, management through self- patients, and assessment and continuing colleagues. Obtain education. Promote the proper consultation when use of employees' knowledge necessary. and skills. Autonomy Except in emergencies, Ensure the autonomy and self- physicians may choose determination of patients. whom to serve, with Prevent discriminatory whom to associate and organizational practices. where to provide Demonstrate zero tolerance for medical care. any abuse of power. Social value Participate in Encourage and participate in activities that public dialog on health care contribute to the policy issues. Apply short- improvement of the and long-term assessments to community and the management decisions affecting betterment of public both community and society. health. Identify and meet the health care needs of the community. Enhance the health care profession through positive public information programs. Risk-benefit Responsibility to the Provide health care services patient is paramount. consistent with available resources. Provide patients and others accurate information to make them enlightened consumers. Access Support access to Support access to health care medical care for all services for all people. people. Principle AAPP Patient care Give first priority to the well being of participants in research studies. Honesty Apply sound ethical values and judgment in the design of clinical trials and interpretation of results. Legal Adhere to the [regulatory] principles of good clinical practice and research. Confidentiality N/A Education and Foster the educational and professional competence of consultation other pharmaceutical physicians. Question, consult, and advise each other. Seek external opinions, as appropriate. Autonomy Strive to understand and respect differences in values across cultures. Social value Support the dissemination only of scientifically sound information from clinical trials and other investigations, without regard to study outcomes, for the benefit of medicine and society. Risk-benefit Minimize and communicate potential risks to study participants and their physicians. Access Ensure that all [pharmaceutical] industry-based information is fair, balanced, accurate, and easily accessible to patients and physicians. 1 Adapted from each medical organization's web site (see below). 2 Includes only the core principles for these organizations, not the Annotations. Abbreviations: AMA = American Medical Association (www.ama-assn.org) APA = American Psychiatric Association (www.psych.org) AAPA = American Association of Psychiatric Administrators (www.psychiatricadministrators.org) AAPP = American Academy of Pharmaceutical Physicians (www.aapp.org) ACHE = American College of Healthcare Executives (www.ache.org) N/A = Not addressed
By Arthur Lazarus, MD, MBA MBA
Master of Business Administration
Noun 1. MBA - a master's degree in business
Master in Business, Master in Business Administration , CPE (Customer Premises Equipment) Communications equipment that resides on the customer's premises.
CPE - Customer Premises Equipment , FACPE FACPE Fellow of the American College of Physician Executives
Arthur Lazarus, MD, MBA, CPE, FACPE, is a senior director of clinical research for AstraZeneca Pharmaceuticals based in Wilmington, Del.. He is the AAPA liaison to ACPE ACPE Accreditation Council for Pharmacy Education
ACPE American Council on Pharmaceutical Education
ACPE American College of Physician Executives
ACPE Association for Clinical Pastoral Education, Inc. and editor of MD/MBA: Physicians on the New Frontier New Frontier
President John F. Kennedy’s legislative program, encompassing such areas as civil rights, the economy, and foreign relations. [Am. Hist.: WB, K:212]
See : Aid, Governmental of Medical Management (American College American College is the name of: