ACP Ethics Guidance Now Addresses Health Technology

Marcia Frellick

January 16, 2019

The American College of Physicians (ACP) has updated its ethics guidance to include information on electronic health records (EHRs), telemedicine, social media, and genetic testing.

The seventh edition updates, published online January 14 as a supplement in the Annals of Internal Medicine, are the first since 2012 and were written by Lois Snyder Sulmasy, JD, with ACP's Center for Ethics and Professionalism, in Philadelphia, Pennsylvania, and Thomas A. Bledsoe, MD, with the Alpert Medical School at Brown University in East Providence, Rhode Island, for the ACP Ethics, Professionalism and Human Rights Committee.

Two ethics experts point to the guidelines as a valuable resource but feel some areas are lacking.

Susan Dorr Goold, MD, MHSA, professor of internal medicine and a medical ethics specialist with the University of Michigan in Ann Arbor, told Medscape Medical News that updating manuals periodically is essential, especially when there are new circumstances, such as widespread use of EHRs, or new public health threats, such as Ebola.

"Sometimes, believe it or not, there are advances in ethical thinking and analysis," she said.

There are several ethics manuals for physicians, including the American Medical Association's (AMA's), she notes, adding, "in some states AMA Code carries the force of law."

However, she said, "the ACP has, over the years, been a real leader in calling on physicians to live up to their professional obligations and responsibilities. They were one of the first to address conflicts of interest, for instance."

There are disappointments in this update, she said. One is that "the majority of the manual suffers from an overemphasis on informed consent as moral justification for action. Consider, for instance, the section on precision medicine and genomics. Family interests are relevant, and consent by an individual ignores that."

Another was what Goold called an "unwritten assumption" that internists had ready access to specialists and other resources, which, she notes, is not true for all.

The guidelines do a good job of helping navigate aspects of evolving practice environments, including the way physicians are paid, in acknowledging the challenge of public and professional understanding of genetic "prediction" vs susceptibility or risk, and in providing firm guidance about financial conflicts of interest, Goold said.

Electronic Health Records

The new guidelines state that entries in an EHR must have the same degree of accuracy and completeness whether they are entered in person, by telephone, or by letter.

"Ethically and legally, patients have the right to know what is in their medical records. Legally, the medical record is the property of the physician or institution, although the information in the record is the property of the patient," the authors state.

Additionally, if patients ask that EHR information be released to themselves or a third party, the physician must release it, even if the patient has unpaid medical bills, for instance.

As to use of EHRs, the guidelines make the point that functions such as cut and paste should be used "only if they help reflect the physician's thought processes about the current patient encounter."

Telemedicine

For a professionally responsible telemedicine encounter to take place, physicians must establish a valid relationship with the patient. If there has been no previous relationship before a telemedicine episode, steps must be taken to start a relationship with the same care that would be given during an in-person visit. Alternatively, a physician may consult with another physician who does have a relationship with the patient, the guidelines state.

Genetics/Precision Medicine

Because there are few qualified geneticists and the demand for genetic tests is booming, physicians will increasingly be asked to counsel patients before they take tests and help them interpret results.

Clinicians should make clear the benefits, risks, and limitations of the tests. If they don't feel qualified to provide such counseling, they should have a system for referring patients to the appropriate clinician, the guidance advises.

Patients should also understand the possible adverse uses of the information by employers or insurers, the authors add.

Some Long-Held Positions Stand

The ACP reiterated in this update that it does not support legalization of physician-aided dying.

"After much consideration," the authors write, "the College concluded that making physician-assisted suicide legal raised serious ethical, clinical, and social concerns."

What's Missing in Guidelines

In an accompanying editorial, Jennifer Blumenthal-Barby, PhD, with the Center for Medical Ethics and Health Policy at Baylor College of Medicine in Houston, Texas, and Bernard Lo, MD, from the Greenwall Foundation in New York City, called the guidelines "a tremendous resource to physicians," but pointed out some ways the guidelines could better help physicians in making ethical decisions.

They note that the guidelines repeatedly call for physicians to act in the "best interest" of their patients. But that could mean many things, they note.

They give the example of a 67-year-old man newly diagnosed with low-risk localized prostate cancer after prostate-specific antigen screening.

Is it in the patient's best interest for him to undergo active surveillance because it is associated with the same mortality risk as immediate treatment without the risk for impotence and incontinence? Or would attacking the cancer be in the patient's best interest because it minimizes the patient's anxiety?

The guidelines would also be improved by integrating behavioral science into the ethical decision making process, they write.

For instance, using the same example of the 67-year-old, if a physician knows that the man may be driven by a compulsion to act to rid his body of cancer, regardless of the potential side effects, it might be better to present the information on risks first (since information presented first is heard better) and find a way to present the choices that goes beyond statistics.

Financial support for the development of the manual came exclusively from the ACP operating budget. Lois SnyderSulmasy is an employee of the ACP and reports that her husband speaks on bioethics topics. Dr Bledsoe has disclosed no relevant financial relationships. Disclosures for ACP editors can be found on the journal website. Dr Blumenthal-Barby has disclosed no relevant financial relationships. Dr Lo has received personal fees from Kaiser Permanente, University of Texas Southwestern, and Mayo Clinic for giving grand rounds and royalties from Wolters Kluwer for a book outside the submitted work. Dr Goold served on the ACP Ethics, Professionalism and Human Rights Committee from 1998 to 2002 and on the AMA Council on Ethical and Judicial Affairs from 2007 to 2014, the final year as chair.

Ann Intern Med. Published online January 14, 2019. Full text, Editorial

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