Patient Care & Ethical Dilemmas Serving the Best Interests of the Patient

Disclosure The speaker has no financial interest in the subject matter of this presentation and is not representing the Ethics Committee of the American Academy of Ophthalmology with this presentation. For questions about the material contained herein or about the Academy’s ethics program in general, please contact the ethics program manager, Mara Pearse Burke at ethics@aao.org.

Why is this Topic Important? Integrity of the Profession Engenders Patient Trust Acting in the Best Interests of the Patient Putting the Patients’ Needs Before Your Own

Pertinent Rules of the Code of Ethics Rule 1. Competence Rule 2. Informed Consent Rule 3. Research & Innovation In Practice Rule 4. Other Opinions Rule 5. The Impaired Ophthalmologist Rule 6. Pretreatment Assessment Rule 7. Delegation of Services Rule 8. Postoperative Care Rule 9. Medical & Surgical Procedures Rule 10. Procedures & Materials Rule 11. Commercial Relationships Rule 13. Communications to the Public Rule 15. Conflicts of Interest Rule 17. Confidentiality

Ethical Fundamentals Ethics address conduct and relate to what behavior is appropriate or inappropriate, as reasonably determined by the entity setting the ethical standards. An issue of ethics in ophthalmology is resolved by the determination that the best interests of patients are served. Ophthalmological services must be provided with compassion, respect for human dignity, honesty and integrity. It is the responsibility of an ophthalmologist to act in the best interest of the patient.

Challenges to Ethical Patient Care Impairment Improper informed consent Research vs. patient care Appropriate postoperative management Potentially unnecessary procedures/tests Advertising and competition Conflicts of interest Emerging technologies

Rule 1. Competence Work within specific training and experience Maintain competence: Regular experience Continuing education Learn / implement new skills appropriately

Rule 2. Informed Consent The “process” of informed consent A “reasonable” patient; “informed” decision. Rationale, benefits of proposed treatment Risks and complications Alternatives Securing a signature is not informed consent

Rule 3: Research & Innovation in Practice Institutional Review Board (IRB) oversight Special informed consent Clinical investigation vs. “routine care” Research without patient consent is unethical

Rule 4. Other Opinions Respect patients’ request for other opinions Obtain consultations as appropriate

Rule 5. The Impaired Ophthalmologist Impairment: physical, mental, emotional Voluntary withdrawal A duty to act Patient safety is the first priority. Rank does not have “privilege.”

Rule 6. Pretreatment Assessment Document accurately “Stretching it” is unethical Document without bias Falsification or fabrication Don’t do it! Unethical! Serious legal risk!

Rule 7. Delegation of Services Delegation of services, not responsibility Adequate qualification Adequate supervision Disclosure of auxiliaries’ roles

Rule 8. Postoperative Care The operating surgeon is responsible Alternative arrangements made before surgery Mutual consent of providers Arrangements disclosed before surgery May require written (preoperative) consent Commercial relationships, fees must be disclosed

Rule 9. Misrepresentation of Services Truthful description of services Misrepresentation by omission Misrepresentation by distortion Misrepresentation by using or avoiding specific language Appropriate charges for services

Rule 10. Under-treatment & Over-Treatment Extent of care must serve the patient’s interests Over-providing care is unethical (rendering unnecessary services) Under-providing care is unethical (withholding necessary services)

Rules 11 & 15 Commercial Concerns & Conflicts of Interest Commercial interests must not alter judgment Self referral Relationships with industry Unreasonable “co-management” fees Conflicts of interest are not necessarily economic Specific surgical experience Research Notoriety Conflicts of interests must be disclosed

Rule 13. Advertising No false, deceptive or misleading information No deceptive omissions No appeals to patients’ anxiety Must not create unjustified expectations of results Must disclose risks Must not misrepresent credentials No unsubstantiated claims of superiority

Rule 17. Confidentiality Respect the confidential physician-patient relationship and safeguard confidential information consistent with the law.

Back to the Basics Do what is in the Best Interests of the Patient Beneficence Obligation to maximize benefit Obligation to minimize harm Non-maleficence Doctrine of “primum non nocere” No deliberate harm Justice: Equals should be treated equally Autonomy (self governance)