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 (AMA) Principles of Medical Ethics provides norms for treating patients, but provides little guidance for physician executives in terms of helping their organizations comply with legal and regulatory requirements, avoiding 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, 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 (ACHE) Code of Ethics

5. American Academy of Pharmaceutical Physicians (AAPP) 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 the AAPP code of ethics, which basically guides ethical decision 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 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 whose job is to adjudicate complaints of unethical behavior.

APA code

For example, many years ago, a district branch of the American Psychiatric Association (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 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 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 of Psychiatric Administrators (AAPA) developed its own principles for psychiatrists working in all types of organizations, not only in managed care. The AAPA code of ethics stipulates that psychiatric administrators are responsible for the well being of the organization that is being administered, in addition to the welfare of patients.

ACHE code

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 process that considers ethical ramifications. The ACHE code is geared toward ACHE members, of which physicians are a minority.

AAPP code

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 does not function as the de facto 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 of conduct developed by various medical organizations appear to have their greatest utility as resources for physician executives. While it is laudable 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, CPE, FACPE

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 and editor of MD/MBA: Physicians on the New Frontier of Medical Management (American College of Physician Executives, 1998). He can be reached by phone at 302-885-4542 or by e-mail at [e-mail]. His opinions are not necessarily those of AstraZeneca, its management or employees.

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