Lois Snyder, JD; for the American College of Physicians Ethics, Professionalism, and Human Rights Committee (*)
The activity questions have been updated and revised by ACP staff and members of the Ethics, Professionalism and Human Rights Committee in December 2014: Lois Snyder Sulmasy, JD, Jessica Mozersky, PhD, Patrick Alguire, MD, FACP, Carrie Horwitch, MD, FACP, and Daniel B. Kimball, Jr., MD, FACP. The following persons have disclosures: Ms. Snyder Sulmasy: Other relationships: Member of Society of General Internal Medicine Ethics Committee. Member of Journal of General Internal Medicine Editorial Board. Dr. Horwitch: Payment for consultantship and curriculum review for I-TECH/University of Washington. Former board member for AAHIVM. Board Member of Virginia Mason Medical Center (employer, no payments). Dr. Alguire: Stock Options/Holdings: UpToDate, AmGen, AT&T, Bristol Myers Squibb, Catepillar Inc, Cisco Sys Inc, Covidien PLC, Deere & Company, Disney, Dow Chemical Co, Dupont, Express Scripts, Ford Motor Company, General Electric, GlaxoSmithKline, Lockheed
Martin Corporation, Medtronic, Paycheck Inc, Pimco, Stryker Corporation, Teva Pharmaceuticals, Zimmer Orthopedics. Nothing to disclose: Jessica Mozersky PhD, Daniel B. Kimball, Jr., MD, FACP.
The activity has been reviewed and approved by members of the ACP Ethics, Professionalism and Human Rights Committee in December 2014: Ana Maria López, MD, MPH, FACP (chair), Thomas A. Bledsoe, MD, FACP (vice chair), John R. Ball, MD, FACP, Mitch Biermann CPT, Carrie A. Horwitch, MD, FACP, Daniel B. Kimball, Jr., MD, FACP, Banu E. Symington, MD, FACP, Jon C. Tilburt, MD, FACP, Julie R. Rosenbaum, MD, FACP. The following persons have disclosures: Dr. Horwitch: Payment for consultantship and curriculum review for I-TECH/University of Washington. Former board member for AAHIVM. Board Members of Virginia Mason Medical Center (employer, no payments). Ana Maria López, MD, MPH, FACP: Board Member: AMWA, Southern Arizona Komen for the Cure, National Hispanic Medical Association. Research Grants/Contracts: NIH, HRSA, Southern Arizona Komen for the Cure. Julie R. Rosenbaum, MD, FACP: Stock Options/Holdings: Pfizer, Merck, Monsanto. Nothing to disclose: John R.
Ball, MD, FACP, Mitch Biermann, Thomas A. Bledsoe, MD, FACP, Daniel B. Kimball, Jr., MD, FACP, Banu E. Symington, MD, FACP, Jon C. Tilburt, MD, FACP.
Process: The ACP Ethics Manual, first published in 1984, is reviewed and updated every few years. Members and staff of the ACP Ethics, Professionalism, and Human Rights Committee from 2009 to 2012 developed this sixth edition. It updates the 2005 fifth edition, which served as the starting point for line-by-line review and debate by Committee members and staff following literature reviews and an environmental assessment to determine the scope of issues, what new topics to include, and other changes. The Committee met 13 times in person, by conference call, and by Webinar, reaching consensus on issues through facilitated discussion. A draft Manual then underwent external peer review and review by College councils and leadership. After review and revisions based on those comments, the Manual was approved by the Committee and reviewed and approved by the Board of Regents. The Ethics Manual is official ACP policy. ACP members pledge “to uphold the
ethics of medicine as exemplified by the standards and traditions of this College,” and we hope the Manual is a resource to all physicians and to others, as well.
Acknowledgment: The College and the ACP Ethics, Professionalism, and Human Rights Committee thank former Committee members who made contributions to the development of this Manual through their work on previous editions. They thank reviewers of this edition of the Manual: Rebecca Andrews, MD; Clifton R. Cleaveland, MD; Charles Cutler, MD; Serle M. Epstein, MD; David A. Fleming, MD; Angela C. Johnson, MD; Edwin P. Maynard, MD; David W. Potts, MD; William A. Reynolds, MD; James R. Webster, MD, MS; and Steven E. Weinberger, MD. They also thank staff to the Committee and the ACP Center for Ethics and Professionalism who worked on the Manual: Michael S. Barr, MD, MBA; Eileen M. D'Amico; Carol R. Dembe, MD, JD; Sheryl Mitnick, MPH, RN; and Lois Snyder, JD.
Financial Support: Financial support for the development of the Manual came exclusively from the ACP operating budget.
Potential Conflicts of Interest: Ms. Snyder: Other relationships: Member of Society of General Internal Medicine Ethics Committee. Dr. Hood: Employment: ACP (president-elect, 2010–2012); Grants/grants pending: American Medical Group Association Hypertention Learning Foundation; Payment for lectures including service on speakers bureaus: American Society of Nephrology; Stock/stock options: mutual funds. Dr. Kutty: Employment: The Medical College of Wisconsin; Royalties: Wolters Kluwer; Stock/stock options: Medtronic. Dr. Fins: Support for travel to meetings for the study or other purposes: ACP; Board membership: ACP Foundation; Employment: Weill Cornell; Grants/grants pending: RWF; Payment for lectures including service on speakers
bureaus: various entities; Royalties: Jones and Bartlett; Payment for development of educational presentations: Weill Cornell. Dr. López: Grant: NIH, HRSA, Komen; Consulting fee or honorarium: GlaxoSmithKline; Grants/grants pending: American Cancer Society, NIH, Komen. Dr. Braddock: Board membership: Foundation for Informed Medical Decision Making. Dr. Calvano: Travel/accommodations/meeting expenses unrelated to activities listed: ACP. Dr. Faber-Langendoen: Support for travel to meetings for the study or other purposes: ACP; Employment: SUNY Upstate Medical University; Travel/accommodations/meeting expenses unrelated to activities listed: ACP. Dr. Herrin: Payment for lectures including service on speakers bureaus: Gentech Speakers Bureau. Dr. Mir:
Employment: NSLUHS. Dr. Moreno: Support for travel to meetings for the study or other purposes: ACP; Other relationships: Governor, American College of Legal Medicine (February 2011–present); member and pro bono consultant, Physicians for Human Rights (1997–present); member of Board of Directors and President Elect, Texas Chapter of the ACP and ACP Services; pro bono advisor, Center for Survivors of Torture. Mr. Pasha: Support for travel to meetings for the study or other purposes: ACP. Dr. Turner: Employment: Annals of Internal Medicine Executive Deputy Editor, November 2009–November 2010. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-1111.
Requests for Single Reprints: Lois Snyder, JD, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, email@example.com.
Snyder L, for the American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual: Sixth Edition. Ann Intern Med. 2012;156:73-104. doi: 10.7326/0003-4819-156-1-201201031-00001
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Published: Ann Intern Med. 2012;156(1_Part_2):73-104.
Medicine, law, and social values are not static. Reexamining the ethical tenets of medicine and their application in new circumstances is a necessary exercise. The sixth edition of the American College of Physicians (ACP) Ethics Manual covers emerging issues in medical ethics and revisits older ones that are still very pertinent. It reflects on many of the ethical tensions in medicine and attempts to shed light on how existing principles extend to emerging concerns. In addition, by reiterating ethical principles that have provided guidance in resolving past ethical problems, the Manual may help physicians avert future problems. The Manual is not a substitute for the experience and integrity of individual physicians, but it may serve as a reminder of the shared duties of the medical profession.
The secret of the care of the patient is in caring for the patient.
Changes to the Manual since the 2005 (fifth) edition
VIP = very important person.
Table 1. Principles That Guide the ACP Ethics Manual Recommendations
Definition of medical profession as used in the Manual
Shifting principles guide the patient–physician relationship during catastrophes
Physicians and social media
Table 2. Advance Care Planning and Surrogate Decision Making
Patients first and stewardship of resources
Physician–industry relations and gifts
The duty to teach
Human subjects research
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Thomas A., Tyma, MD, PLLC
January 18, 2012
The recent publication of the American College of Physicians Ethics Manual, Sixth Edition, seems complete but misses an immensely important and under-recognized obligation - that of the patients' obligation to their physicians. I have yet to see as thorough a statement by Medical Professional Organizations of the Rights of Physicians to expect the full and absolute disclosure of patient information to us. Misleading information occurs in many ways, including non-disclosure of prior and even current physicians, treatments, hospitalizations and ER visits. Misinformation may also include manipulations that can cloud the use of addictive and other medications. I believe that future efforts to discuss and publish a similar Manual would be met with great support from all practicing physicians. If we are expected to provide the most ethical and complete medical care, then should we not expect the same in return?
Vijay, Rajput, physician, Krysta Marie Contino
Cooper University Hosptial, Cooper Medical School of Rowan University and Robert Wood Johnson Medica
January 21, 2012
Prudent is better than "Parsimonious"
To the Editor: The Sixth Edition of the American College of Physicians Ethics Manual has raised a great deal of discussion. This is not secondary to the actual content or concepts addressed; rather, it due to the use of the word parsimonious as it pertains to stewardship in medicine. (1) According to the Merriam-Webster dictionary, the actual definition of the word is "frugal to the point of stinginess ." (2) The issue is rooted in the current fundamental structure of the US health care system and ways in which medical care is provided to patients. In looking at the ethical concept of distributive justice, physicians as stewards of medicine, meaning that these individuals are essential to ensuring that limited resources are shared fairly among all; however, the question then arises, "Is health care a right or a privilege?" A frugal approach to caring for patients implies that physicians are no longer driven to provide care to the patient based on what is best for that particular individual. Instead, those not directly involved in patient care (i.e. lawmakers, insurance companies, etc.) are creating standards by which physicians are being forced to abide. This consequently establishes a conflict between the ethical principles of beneficience/non-maleficence and distributive justice as harm to the patient may actually result, since the focus if being taken from the patient's situation and placed heavily on strict guidelines aimed at cutting health care costs. The debate is not that we should continue to spend health care dollars frivolously; instead, we must evaluate each patient based on his/her particular needs, in that social and patient value context referred as contextual based practice. In today's litigious society, physicians are being forced to practice defensive medicine by either over treating diseases or over-ordering tests or being forced to adhere to strict guidelines, even if such practices are not in the best interest of the patient. Our suggestion is that before being able to implement such ethical guidelines, the current broken system in its most fundamental nature must be restored to a workable structure. Furthermore, using the word parsimonious, insinuates that patient care is based solely on monetary measures, and does not account for a physician to use their fiduciary judgment for individual patient. We would suggest that the word prudent, meaning wise or sensible in action or thought, be substituted. (3)
Krysta Marie Contino, BS
Vijay Rajput, MBBS
1. Snyder, Lois. "American College of Physicians Ethics Manual." Annals of Internal Medicine 156 (2012): 73-104.
2. "Parsimonious." Merriam-Webster.com. 2011. http://www.merriam- webster.com (17 January 2012).
3. "Prudent." Merriam-Webster.com. 2011. http://www.merriam- webster.com (17 January 2012).
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