American College of Physicians Issues New Ethics Manual

Laurie Barclay, MD

January 03, 2012

January 3, 2012 — The sixth edition of the American College of Physicians' (ACP's) Ethics Manual addresses ethical decisions in clinical practice, teaching, and medical research, as well as the underlying principles and the physician's role in society and with colleagues. The updated manual, approved by ACP's Board of Regents in July 2011, is published in the January 3, 2012, issue of the Annals of Internal Medicine.

"ACP's Ethics Manual covers many of the ethical tensions in medicine and attempts to shed light on how existing principles extend to emerging concerns," ACP President Virginia L. Hood, MBBS, MPH, FACP, and the former chair of ACP's Ethics, Professionalism, and Human Rights Committee, said in a news release. "We believe that ACP's Ethics Manual provides the best approach to the challenges addressed in it."

Similar to previous editions, the current update of the ACP's manual covers surrogate decision-making and end-of-life care, use of complementary and alternative medicine, physician-assisted suicide, relationship between physicians and industry, genetic testing, and research ethics.

While exploring these topics in greater depth, the new edition also highlights the patient–physician relationship during health catastrophes, culturally sensitive care, research use of human biologic materials, social media and online professionalism, and industry-sponsored research.

Another topic covered for the first time in the updated manual is the challenges associated with offering care to "very important persons" experiencing unusual fame or prestige.

New or expanded sections also include treatment without interpersonal contact, confidentiality and electronic health records, therapeutic nondisclosure, caring for oneself or persons with whom the physician has a previous nonprofessional relationship, boundaries and privacy, pay-for-performance, interrogation, attending physicians and physicians-in-training, the patient-centered medical home, protection of human subjects, placebo controls, and scientific publication.

"Medicine continues to pose challenging ethical dilemmas for patients and their physicians," said lead author Lois Snyder, JD, director of ACP's Center for Ethics and Professionalism, in the news release. "We hope ACP's Ethics Manual will provide guidance to clinicians, educators, researchers, and policymakers that will enhance trust in individuals, and the profession, by patients and the public."

Since the first ACP Ethics Manual was published in 1984, these manuals often have been cited in medical and ethical literature, and are in widespread use by physicians other than their intended audience of internists. The ACP Ethics, Professionalism, and Human Rights Committee developed this latest update to the fifth edition, which was published in 2005, noting that medicine, law, and social values are not static.

However, the committee also noted that repeating ethical principles that have helped to resolve previous ethical problems may help physicians avoid problems in the future. Although the manual cannot substitute for the experience and integrity of individual physicians, it may shed light on the shared duties of the medical profession.

An accompanying editorial by Ezekiel J. Emanuel, MD, PhD, from the Perelman School of Medicine and the Wharton School at the University of Pennsylvania in Philadelphia, notes that this update of the manual takes specific positions on efficiency, parsimony, and cost-effectiveness of care.

"Inevitably, such an extensive manual will not get every recommendation right, and this document includes some problematic statements," Dr. Emanuel writes. "The most obvious ones are found in new entries related to research."

Nonetheless, Dr. Emanuel concludes that the updated manual is an "important guide for physicians" and "a worthy heir to the tradition of medical oaths and codes that stretches back millennia."

Financial support for the development of the manual came exclusively from the ACP operating budget. Ms. Snyder is a member of the Society of General Internal Medicine Ethics Committee. Other potential conflicts of interest are available on the journal's Web site .

Ann Intern Med. 2012;156:73-104. Article extract, Editorial extract

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