1. Medicine and Ethics Chapter 6
This chapter examines ethics in medicine, making ethical decisions, and the ethics involved with various issues in health care.

2. Introduction
Ethics concerns itself with the philosophies underlying ideal relationships between human beings, as well as the promotion of the highest good for humanity as a whole.
Decisions that people make based on ethical beliefs can quite possibly alter the course of human existence.
As medical technology increases, ethics become more and more important and medical professionals often disagree about the standards surrounding new procedures, treatments, and views.

3. This chapter will examine:
Rights and duties as related to ethics
Four types of ethical problems
Making ethical decisions
The impact that CEJA has had on ethical decisions made by healthcare professionals
The reasons that confidentiality is an ethical issue
CEJA opinions
Students will learn how to make an ethical decision and how to recognize the types of ethical problems that healthcare professionals face in the industry.

4. History of Ethics in Medicine
Ethics explores the moral right or wrong of an issue.
Ethics should not be confused with etiquette.
Etiquette refers to courtesy, customs, and manners.
A breach of ethics is not always illegal. Etiquette and ethics are different – etiquette is politeness and concerned with making introductions or how to act at a dinner table. Ethics is concerned with whether an action is right or wrong morally. Since people disagree about the degree of right and wrong, ethics is a debatable field studied at most universities throughout the country.

5. Code of Hammurabi Earliest written code of ethics
Written in approximately 2250 B.C.
Elaborated on the conduct expected of a physician
Set the fees a physician could charge
Talk about the fact that ethical opinions differ; so how does a set code of ethics exist, when there are people who disagree with the code?

6. Oath of Hippocrates Written in approximately 400 B.C. by Hippocrates
Greek physician
Known as the Father of Medicine
Administered to medical school graduates even today
Research the Oath of Hippocrates and discuss its elements in the classroom. Talk about which elements are valid today and which are outdated, if any.

7. Percival’s Code of Medical Ethics
Thomas Percival
Physician, philosopher, and writer from Manchester, England
Published his Code of Medical Ethics in 1803
Research and discuss Percival’s Code of Ethics.

8. AMA Code of Ethics Formulated in 1847 at the first annual AMA meeting
Specifically acknowledged Percival’s Code of Ethics as its foundation
The American Medical Association is involved with making ethical decisions and then publishing them. Often physicians base their ethical decisions upon the ones made by the AMA.

9. American Medical Association
AMA was established in 1846
Provides information and support to physicians
Research the AMA website to determine what type of information is available to the general public. Talk about when and why this information might be accessed by a medical assistant throughout the medical career.

10. Council on Ethical and Judicial Affairs
CEJA consists of nine active members of the AMA
Includes one resident physician
Includes one student member
CEJA is responsible for interpreting the AMA Principles of Medical Ethics as adopted by the House of Delegates
Examine CEJA on the AMA website and talk about the members and their backgrounds. Talk about how the member’s differing backgrounds might influence their ethical views. Discuss how diversity and background influences the ethical views of class members.

11. Components of the AMA Code of Ethics
Four components:
Principles of medical ethics
Fundamental elements of the patient-physician relationship
Current opinions of the CEJA with annotations
Reports of the CEJA
Talk about the value of CEJA to the medical profession. What needs does the organization meet?

12. Publications Code of Medical Ethics: Current Opinions with Annotations
Contains the first three components Contains discussion of more than 135 ethical issues encountered in medicine
Reports of the Council on Ethical and Judicial Affairs
Discusses the rationale of the Council’s opinions
Discuss the process that must take place in making ethical decisions at the AMA. Talk about how the nine members of CEJA might go about their debates and how the final decisions might be made. Discuss how this is similar to other decision-making processes.

13. Making Ethical Decisions
We must first understand…
the elements of ethics.
types of ethical problems.
the decision-making process.
Learning the decision-making process for ethical issues will be valuable to the medical assistant throughout his or her career in medicine.

14. Elements of Ethics Three general elements of ethics
Duties: Obligations that a person has or perceives himself or herself to have
Rights: Claims that a person or group makes on society, a group, or an individual
Character traits: A disposition to act in a certain way
Talk about the difference between duties and rights. Relate these to everyday occurrences in the students’ lives. Revisit the Bill of Rights and remind students of the rights we have as American citizens. Determine if the students agree with the rights set forth in the Bill of Rights. Discuss what is not there that perhaps should be.

15. Types of Duties Nonmaleficence
Refraining from harming oneself or another person
Beneficence
Bringing about good
Fidelity
Concept of promise-keeping
Veracity
Telling the truth
Discuss the importance of each of the listed duties in relation to medical practice. Talk about how each duty is present in daily decisions and activities in the medical office.

16. Types of Duties Justice
Fair distribution of benefits and burdens among individuals and groups in society having legitimate claims on those benefits
Reparations
Righting a wrong
Gratitude
* Feeling grateful after being the beneficiary of someone’s goodness
Discuss the importance of each of the listed duties in relation to medical practice. Talk about how each duty is present in daily decisions and activities in the medical office.

17. Rights Versus Privileges
The Bill of Rights guarantees certain liberties that we enjoy as U.S. citizens.
Americans do not have the RIGHT to healthcare services; it is a privilege.
Rights apply to all people within a group without prejudice.
Consider the phrase “the RIGHT to life.”
Talk about rights and the difference between rights and privileges and discuss examples related to medical practice.

18. Character Traits
Not always an indication as to how a person will act in every situation.
No human being is perfect.
Humans are often unpredictable.
Talk about the value of the medical assistant’s character traits and why a predictable character is of value in the physician’s office. Describe a predictable person and the message sent when a usually predictable person acts in a manner out of character.

19. Types of Ethical Problems
Ethical Distress
A situation in which certain course of action is indicated, but some type of hindrance or barrier prevents that action
Discuss the diagram of this ethical problem. Talk about real examples that occur in the medical field.

20. Ethical Distress
Discuss the diagram of this ethical problem. Talk about real examples that occur in the medical field.
From Purtilo R: Ethical dimensions in the health professions, ed 4, Philadelphia, 2005, WB Saunders.

21. Types of Ethical Problems
Ethical Dilemma
A situation in which an individual is faced with two or more choices that are acceptable and correct, but doing one precludes doing another
Discuss the diagram of this ethical problem. Talk about real examples that occur in the medical field.

22. Ethical Dilemma
Discuss the diagram of this ethical problem. Talk about real examples that occur in the medical field.
From Purtilo R: Ethical dimensions in the health professions, ed 4, Philadelphia, 2005, WB Saunders.

23. Types of Ethical Problems
Dilemmas of Justice
Focuses on the fair distribution of benefits to those who are entitled to them
Discuss the diagram of this ethical problem. Talk about real examples that occur in the medical field.

24. Dilemmas of Justice
Discuss the diagram of this ethical problem. Talk about real examples that occur in the medical field.
From Purtilo R: Ethical dimensions in the health professions, ed 4, Philadelphia, 2005, WB Saunders.

25. Types of Ethical Problems
Locus of Authority
Two or more authority figures have their own ideas about how a situation should be handled, but only one of those authorities will prevail
Discuss the diagram of this ethical problem. Talk about real examples that occur in the medical field.

26. Locus of Authority
Discuss the diagram of this ethical problem. Talk about real examples that occur in the medical field.
From Purtilo R: Ethical dimensions in the health professions, ed 4, Philadelphia, 2005, WB Saunders.

27. Recognizing Ethical Problems
It is not always easy to recognize the type of ethical problem present.
Sometimes, a mixture of problems exists.
Discuss issues that might be a mixture of more than one ethical problem. How would the medical assistant make an ethical decision when working with more than one ethical problem? Talk about whether one problem would take precedence over the other and how to resolve that situation.

28. The Ethical Decision-Making Process
Purtillo presents a five-step method for making ethical decisions:
Gather relevant information
Identify the type of ethical problem
Determine the ethical approach to use
Explore practical alternatives
Complete the action
Choose one of the CEJA opinions and take it through each step of the decision-making process. Discuss the progression of the issue through each step and any hindrances that may delay decisions or force the students to repeat a step or go back to the beginning of the process. Explain to students that during discussions, when disagreements arise, they must remain professional and not attack or degrade other students for their beliefs, and must respect differing opinions. Students must learn to allow others to express their views even if they are in opposition. Insist that the discussions remain professional in the classroom and if students become unprofessional, teach them why that their comments would be considered unprofessional and how they can adjust what they say to make it a professional comment. The most important issue to teach in this section is to respect and tolerate differing opinions, and to express views in a professional manner.

29. Current Opinions of CEJA
Abortion
Should a woman who has been raped and become pregnant have an abortion?
Discuss the case study with the students.

30. Current Opinions of CEJA
Abuse
What harm can come to a patient’s family if medical professionals are incorrect about their assessment of abuse?
Discuss the case study with the students.

31. Current Opinions of CEJA
Allocation of Health Resources
If the CEO of American Airlines, the winner of last year’s Best Actor Oscar, and a drug-abusing mother of three were all equally ill and needed a liver transplant, who should receive it?
Discuss the case study with the students.

32. Current Opinions of CEJA
Artificial Insemination
A man fertilized eggs that were frozen for later use, but he died without having made provision for the use of those eggs after his death. Should the man’s wife be able to use the eggs?
Discuss the case study with the students.

33. Current Opinions of CEJA
Stem Cell Research
A medical student is recruited to work with a physician who is researching paralysis. Once the project is underway, the student discovers that the physician is using embryos that have been questionably obtained. What should the student do?
Discuss the case study with the students.

34. Current Opinions of CEJA
Surrogate Motherhood
What is a fair length of time to give a surrogate mother to petition to void a surrogacy contract?
Discuss the case study with the students.

35. Current Opinions of CEJA
Human Cloning
If a couple loses their child through death but it were possible to clone the child, what concerns would be present for the family?
Discuss the case study with the students.

36. Current Opinions of CEJA
Genetic Counseling
What could happen if parents were to “design” a baby, but it arrived flawed in some way or did not meet their expectations?
Discuss the case study with the students.

37. Current Opinions of CEJA
Physician-Assisted Suicide
If a patient mentioned in passing that he or she would want the right to commit suicide in the event of a terminal illness, would you support that decision if the situation did arise?
Discuss the case study with the students.

38. Current Opinions of CEJA
Surrogate Decision Making
A physician recommends that a patient be taken off life support. The patient lives with his homosexual partner and has not seen his parents in 10 years. The partner does not wish to remove life support, stating that the patient would want every opportunity to live. If the parents disagree, whose decisions should prevail?
Discuss the case study with the students.

39. Current Opinions of CEJA
Withholding or Withdrawing Life-Prolonging Treatment
How would a medical assistant handle the family of a patient who asks for advice about withdrawing life-prolonging treatment? To whom should the medical assistant defer the question?
Discuss the case study with the students.

40. Current Opinions of CEJA
Quality of Life
A mentally ill single woman who is institutionalized becomes pregnant and refuses to give up her maternal rights so that the child can be adopted. Even if she were to reconsider, what complications would result if the child were born deaf and with a severe liver disorder? Should the child be fed and cared for by the hospital staff?
Discuss the case study with the students.

41. Current Opinions of CEJA
Clinical Trial and Investigation
If your brother were homosexual and wanted to participate in clinical trials for a vaccination against HIV, would you support his decision?
Discuss the case study with the students.

42. Current Opinions of CEJA
Cost of Healthcare Services
Should an 87-year-old patient with cardiovascular disease and stomach cancer undergo expensive breast reconstructive surgery?
Discuss the case study with the students.

43. Current Opinions of CEJA
Organ Donation
A woman dies with a living will that states that she wishes her organs to be donated. Her mother, still living, disagrees and does not want her daughter’s organs donated. What should the health professional do in this situation?
Discuss the case study with the students.

44. Current Opinions of CEJA
Capital Punishment
A very emotional patient, the parent of a child who was raped and killed, has been given the opportunity to attend the execution of the murderer. During a visit to her family physician, she expresses concerns about being able to cope with the memory of her daughter during the execution and asks you if you would attend in the same situation. How to you handle this?
Discuss the case study with the students.

45. Ethical Issues Surrounding HIV
HIV-positive individuals deserve privacy, as do all patients.
Unique identifiers help maintain confidentiality.
Discuss the reasons that HIV is a special case in confidentiality. Talk about how this affects patients outside of the medical realm.

46. Ethics and the Human Genome
Human Genome Mapping Project was completed in 2003.
Data will be studied for years to come.
Access to genetic information presents privacy concerns as to who owns the genetic information and who controls it.
As genetic technology advances, the application of ethics to that technology must also be considered.
Talk about the ownership of genetic information. Discuss situations in which ownership might be at issue. Talk about controlling genetic information. Could there be times that a physician might be faced with a decision about disclosing or not disclosing genetic information to a patient? Whose ultimate decision would that be?

47. Other Ethical Issues Interprofessional Relationships
Medical professionals should speak up when errors by other professionals are suspected.
Referrals to other professionals should be made only when one is confident in his or her ability.
Physicians in private practices are free to decide whom they will treat.
Sports medicine physicians must consider the patient first and not make medical decisions based on potential game outcomes.
Discuss the way that a medical assistant can confront a person who may have made an error. Talk about the difficulty involved in this process and the difference between confronting a co-worker, a supervisor, and a physician.

48. Other Ethical Issues Confidentiality and Patient Privacy
It is unethical and unacceptable to divulge any information about a patient to any person not directly involved in the patient’s care.
All information in the record must be kept in strict confidence.
Talk about the healthcare professionals involved in patient care. In the physician’s office, that would probably include all employees, but what about other health facilities? Discuss actual cases wherein medical workers were prosecuted for accessing medical records (research Roy Williams, Britney Spears, etc.)

49. Confidentiality restrictions apply to all patient medical records, including separately filed x-rays, etc.
Discuss the difficulties involved in keeping all medical records confidential.

50. Other Ethical Issues Advertising
Only deceptive trade practice regulations govern advertising by medical facilities and practitioners.
Talk about physicians who advertise for their services and the types of practices they operate. Discuss the reason that many feel physician advertising is unethical. Debate why advertising is necessary in today’s healthcare environment.

51. Other Ethical Issues Communications with the Media
Medical professionals cannot discuss any patient with any member of the media without his or her written permission.
Talk about the fascination of the public with celebrity medical records. Do such people merit additional protections of confidentiality as opposed to “regular” people? Talk about why or why not.

52. Other Ethical Issues
Physician Obligations in Disaster Preparedness and Response
Physicians are ethically obligated to provide emergency care during disasters.
Examples include natural disasters, such as a severe hurricane, epidemics, and terrorist attacks.
Discuss the Good Samaritan Law and any challenges to the law in recent years. Explain the elements of the law. Talk about what might lead a patient to challenge the care that he or she received from a professional acting as a Good Samaritan. Discuss whether the standard of care and scope of practice still applies to emergency situations. How does giving CPR as directed by a operator come under the jurisdiction of the Good Samaritan law?

53. Other Ethical Issues Malevolent Use of Biomedical Research
Physicians must assess the possible ramifications of participation in research before engaging in projects.
Talk about how physicians in private practice participate in research trials.

54. Other Ethical Issues Racial and Ethnic Healthcare Disparities
Patients are entitled to the same quality of care regardless of their race or ethnic background
Talk about how the medical assistant can make certain that all patients are treated equally and discrimination can be avoided in the medical practice.

55. Other Ethical Issues Diagnostic Imaging on Request
Physicians should perform diagnostic imaging only when they believe that the benefits of the imaging service outweigh the risks involved.
Talk about how managed care influences whether medical imaging and other diagnostic tests are done. Discuss whether the physician should discuss the limitations of the policy with the patient. Talk about whether diagnostic tests should be limited based upon the policy or done regardless of the policy.

56. Other Ethical Issues Computers
All authorized personnel must comply with HIPAA regulations with regard to computer use.
Talk about how computer use might breach patient confidentiality. Discuss safeguards that help the physician keep information stored on the computer private. Discuss issues surrounding the electronic medical record and keeping it confidential.

57. Other Ethical Issues
Charging or collecting an illegal or excessive fee is prohibited
Fee Splitting and Contingent Fees
The practices of fee splitting and accepting contingent fees are unethical
Fee Splitting
Accepting a payment from another physician solely for the referral of a patient
Contingent Fees
Accepting a patient and collecting fees based on the outcome of treatment
Discuss why each of these issues is considered unethical.

58. Other Ethical Issues Insurance Forms
Facilities are allowed to charge for completing multiple insurance forms.
Talk about why physician’s offices might charge to complete multiple insurance forms.

59. Other Ethical Issues Waiver of Insurance Copayments
Routine waiver of insurance copayments may violate the contracts with the insurance company or managed care organization.
Talk about the ethics of asking for the copayments prior to the patient seeing the physician. Discuss how the medical assistant can professionally explain this growing practice to patients who feel that they should not have to pay the copayment until they have actually seen the doctor.

60. Other Ethical Issues Professional Courtesy
Physicians may offer professional courtesy discounts, but this practice has become less common in recent years.
The office policy manual should provide strict details and guidelines about the issue of professional courtesy.
Discuss the ethical problems that might be created when extending professional courtesy.

61. Other Ethical Issues Appointment Charges
It is completely ethical to charge a reasonable fee for missed appointments that are not cancelled or rescheduled in accordance with the office policy manual.
Patients must be informed as to the policy regarding missed appointments.
Talk about the use of the missed appointment charge. Discuss situations that might justify waiving the charge. Discuss whether it would be ethical to charge a fee to patients who arrive late to their appointments.

62. Other Ethical Issues Prescribing Drugs and Devices
Physicians should not be influenced in the prescribing of drugs, devices, or appliances by a direct or indirect financial interest in the supplier.
Distinguish between a direct or indirect financial interest in a supplier. Talk about how a patient would know that the physician had a financial interest in a drug, device, or appliance. Talk about how a physician should treat the situation wherein a physician owns a local pharmacy.

63. Other Ethical Issues Professional and Contractual Relationships
Physicians should negotiate the wording of contracts such that there is no question of financial incentives for the physician that would in any way compromise professional judgment or integrity.
Legal representation may be needed to comply with some ethical issues. Talk about the various reasons that a physician needs legal counsel.

64. Other Ethical Issues Health Facility Ownership by a Physician
Physicians may own a health facility or have a financial interest in such a facility but must disclose this connection to the patients before referring them to the facility.
Talk about how a physician can disclose financial interests to the patients, such as the example given earlier of a physician owning a local pharmacy. Discuss added difficulties involved if the pharmacy happens to be the only one in a very small town or in a remote rural area.

65. Other Ethical Issues Ghost Surgery
It is unethical to substitute surgeons without patient knowledge and consent.
Talk about when a situation might arise in which ghost surgery would be considered by a physician. Talk about how the situation can be avoided.

66. Other Ethical Issues Discipline within Medicine
Physicians should expose incompetent, corrupt, dishonest, or unethical conduct by members of the profession.
Discuss the ramifications of this situation. Talk about the willingness of physicians in reporting other physicians. What are the pros and cons of reporting or not reporting?

67. Other Ethical Issues Physician Health and Wellness
A physician who knows that he or she has an infectious disease should not engage in any activity that would cause a significant risk to patients.
Discuss whether the physician’s illness, such as HIV infection, affects the patients. Talk about whether it is ethical to expect the physician to sacrifice his or her practice because of a private medical condition.

68. Other Ethical Issues Substance Abuse
It is unethical for physicians to practice medicine when under the influence of a controlled substance.
Healthcare providers who are aware of colleagues who engage in such activities must be reported to the appropriate authorities.
Talk about the ethics involved in a medical assistant reporting a physician that he or she suspects is abusing drugs.

69. Other Ethical Issues Unethical Conduct
Be absolutely sure of all information.
Decide whether the information should be reported, and to whom it should be reported.
Determine if working for the professional who engages in unethical behavior is in the best interest of the medical assistant.
Talk about some examples of unethical conduct that a physician might perform.

70. Summary of Scenario
There are always at least two sides to each ethical situation.
Be nonjudgmental toward patients and coworkers.
Never inflict personal opinions onto patients.
Periodically perform a self-evaluation regarding ethical views.
Discuss how a medical assistant might inflict personal views onto a patient and how to regulate themselves to avoid doing so.

71. Closing Comments
Keep abreast of current issues that have ethical implications.
Study of ethics requires serious thought and introspection.
Determine personal views about each of the opinions in the text.
Belief systems should be personally created, not adhered to simply because parents held certain beliefs.