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Position Papers |

Ethics Manual: Fifth Edition

Lois Snyder, JD; Cathy Leffler, JD, Ethics and Human Rights Committee, American College of Physicians*
[+] Article and Author Information

From the American College of Physicians, Philadelphia, Pennsylvania.


Acknowledgments: The American College of Physicians and the ACP Ethics and Human Rights Committee are solely responsible for the contents of the Manual. Both thank former Committee members who made contributions to the development of this Manual through their reviews of drafts and work on previous editions: Troyen A. Brennan, MD; Richard J. Carroll, MD; Kenneth V. Eden, MD; Saul J. Farber, MD; Arthur W. Feinberg, MD; Steven Miles, MD; Gail J. Povar, MD; William A. Reynolds, MD; Bernard M. Rosof, MD; David L. Schiedermayer, MD; Gerald E. Thomson, MD; and James A. Tulsky, MD. They also thank additional reviewers of the Manual: Dan Brock, PhD; Linda Hawes Clever, MD; Martin L. Evers, MD; Michelina Fato, MD; Robert L. Fine, MD; Charles L. Junkerman, MD; Walter J. McDonald, MD; Richard L. Neubauer, MD; Henry S. Perkins, MD; Robert L. Potter, MD; Ralph Schmeltz, MD; James R. Webster Jr., MD. Finally, they thank Emily Mok for research assistance and Laura Gregory for administrative support.

Requests for Single Reprints: Lois Snyder, JD, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.


Ann Intern Med. 2005;142(7):560-582. doi:10.7326/0003-4819-142-7-200504050-00014
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Medicine, law, and social values are not static. Reexamining the ethical tenets of medical practice and their application in new circumstances is a necessary exercise. The fifth edition of the College's Ethics Manual covers emerging issues in medical ethics and revisits old ones. It reflects on many of the ethical tensions faced by internists and their patients 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 obligations and duties of the medical profession.

*Current and former members of the Ethics and Human Rights Committee who developed this fifth edition of the Manual: William E. Golden, MD (Chair); Harmon H. Davis, II, MD (Vice Chair); David A. Fleming, MD; Susan E. Glennon, MD; Vincent E. Herrin, MD; Virginia L. Hood, MD, MPH; Jay A. Jacobson, MD; Stephen R. Jones, MD; Allen S. Keller, MD; Joanne Lynn, MD; Clement J. McDonald, MD; Paul S. Mueller, MD; Steven Z. Pantilat, MD; David W. Potts, MD; and Daniel P. Sulmasy, OFM, MD, PhD. Approved by the Board of Regents on 17 July 2004.

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position paper for internist on medical ethics by lawyers
Posted on April 16, 2005
Vijay Rajput
Robert Wood Johnson Medical School, Cooper University Hospital
Conflict of Interest: None Declared

To the Editor It is well written manual or position paper on medical ethics by two distinguished and dedicated lawyers. But it was disheartening that we have more than one hundred thousand internists as members for this organisation and there are several physicans on ethics and human rights committee, but not a single soul was strong enough to come out as co-author for this maunal. If I interpret, intervention by the law is too blunt a way tackling the delicate ethical dilemmas which internist have to face as indivdual human being, guided by personal experiences and by prevailing public and professional standards.We as internist must confront and resolve the day-to-day ethical issues of medical practice. Which can be learned by the lawyers but may be best understood as physicans. Relationship between law and medicine has been constrained by the outside influences and the conduct of the doctors is circumcscribed by the the public conscience. Physicans name on author list could have validated both internist and public consciences together.

Conflict of Interest:

None declared

Physician Authorship of ACP's Ethics Manual
Posted on April 26, 2005
Robert Doherty
American College of Physicians
Conflict of Interest: None Declared

In response: We thank Dr. Rajput for his letter. The author attribution is the standard form that the College uses for all ACP position papers. Staff prepared the document in collaboration with the ACP Ethics and Human Rights Committee, whose members served as co-authors of the Manual-- hence the listing Snyder and Leffler for the ACP Ethics and Human Rights Committee.

The Ethics Manual is based on over two years of dedicated work of the members of the Ethics and Human Rights Committee. The policies in the Manual were discussed, debated, and approved by Committee members, and recommended to and approved by the College's Board of Regents.

This is very much the work product of internists... assisted by a dedicated bioethics staff, one member of which has served the College for 18 years.

William E. Golden, MD, FACP Chair, ACP Ethics and Human Rights Committee, 2004-2005

Robert B. Doherty Senior Vice President, ACP Governmental Affairs and Public Policy

Conflict of Interest:

None declared

Withdrawal of Nutrition and Hydration
Posted on May 2, 2005
Kenneth J. Simcic
University of Texas Health Sciences Center San Antonio
Conflict of Interest: None Declared

"Despite research findings to the contrary, there remain understandable concerns that discontinuing use of feeding tubes will cause suffering from hunger or thirst. Physicians should carefully address this issue with caregivers". These statements from the most recent edition of the American College of Physicians Ethics Manual(1) are certain to be controversial, but they are very appropriate. It has become the "party line" in medicine that death by starvation and dehydration is painless for cognitively disabled patients(2). Some "authorities" even assert that such deaths are accompanied by feelings of "euphoria"(3). It will probably never be possible to know with certainty the subjective experience of death by dehydration and starvation due to the delirium that results from the associated hypotension, uremia and severe hypernatremia. Therefore, it would seem in the best interest of patients to assume that such deaths may be accompanied by significant discomfort and suffering for even the minimally conscious. While it is possible that a fleeting and agonal sense of euphoria is associated with even the most painful of deaths, the question is what is experienced in the days and hours before this final stage.

Some direct evidence is provided by the experience of Kate Adamson who collapsed from a devastating and incapacitating stroke at age 33(4). Initially, she was misdiagnosed as being in a persistent vegetative state (PVS) when she was actually conscious in a "locked-in" state. Her feeding tube was pulled for 8 days and despite being given intravenous fluids, she describes the associated discomfort as "sheer torture" accompanied by a "desperate" sense of thirst. Adamson has since recovered almost completely and has resumed her life as a wife and mother.

It is also worth examining withdrawal of nutrition and hydration from a common sense pespective. If dehydration is a "good death", then why are pet owners prosecuted when their neglected pets die in this fashion? If such deaths are painless, then why is assisted suicide even an ethical issue? It would seem that suffering patients desiring suicide could simply stop eating and drinking and die in a comfortable manner. Death by dehydration and starvation is likely an uncomfortable death even for the cognitively disabled. This is undoubtedly why it was widely reported that Terri Schiavo was given intravenous morphine in her final days despite her disputed diagnosis of PVS(5). References: 1. Snyder L, Leffler C. Ethics Manual, Fifth Edition. American College of Physicians. Ann Intern Med. 2005:142:560-582. 2. Brink S. Inside Terri's Brain. U.S. News & World Report. April 4, 2005:24. 3. Garloch K. Was Schiavo's death free of suffering? Charlotte Observer. April 11, 2005. Accessed at http://www.charlotte.com/mld/observer/living/health/11363830.htm on May 1, 2005. 4. Smith W. A Painless Death? The Weekly Standard. November 12, 2003. Accessed at http://weeklystandard.com/Utilities/printer_preview.asp?idArticle=3370&R=C4FE592 on April 29, 2005. 5. Schiavo's parents, hoping for a miracle, go into seclusion. USA TODAY. March 25, 2005. Accessed at http://www.usatoday.com/news/nation/2005-03-25 -schiavo_x.htm on May 1, 2005.

Conflict of Interest:

None declared

An Ethical Lapse
Posted on May 19, 2005
Carl E. Bartecchi
U. of Colorado School of Medicine
Conflict of Interest: None Declared

To The Editor:In my review of the Ethics Manual, Fifth Edition, in the April 5, 2005 Annals of Internal Medicine, I found that the section on Complementary and Alternative Care was in many ways deficient, to the disadvantage of physicians and ultimately, their patients. That section should have included something to the effect that the physician should explain to the patient that alternative treatments frequently have little or no evidence to support their efficacy. If an alternative medicine treatment was supported by proof, it would then fall in the category of conventional medicine. The enlightened physician, concerned about the health and safety of his or her patient, is best able to help his or her patient by determining the particular alternative practice that the patient is pursuing and presenting the fact that there may be no support for that particular treatment, and thus unworthy of pursuit. The recommendation to "encourage the patient to seek literature and information from reliable sources" is inadequate and inappropriate. For Example: If one of my patients was seeking an alternative medicine approach to his knee osteoarthritis, he might go to the December 04' Annals of Internal Medicine which touts acupuncture, or to the December 04' British Medical Journal which suggests magnets. I would feel obligated to warn my patient of editorial and reviewer bias, and the fact that even well recognized journals can be wrong.I would tell my patient that it is also important to read the rapid responses to such articles so as to get the whole picture. I would also warn my patient that he might even come across misguided and valueless contributions in journals by professors from places such as Harvard, an example being one promoting magnets for osteoarthritis of the knee in the journal Alternative Therapies, March/April 2004 I feel strongly that few patients are sophisticated enough to understand the alternative medicine literature with it's many biases and it's disrespect for scientific principles. Carl E. Bartecchi, M.D., FACP Distinguished Clinical Professor of Medicine U. of Colorado School of Medicine

Conflict of Interest:

None declared

No Title
Posted on February 5, 2007
Frederick E. Turton
American College of Physicians
Conflict of Interest: None Declared

To the Editor:

The American College of Physicians continues to evaluate issues related to relationships between physicians and industry and physician organizations and industry, and to work to emphasize relationships that maximize the interests of the patient. Recently, the College approved a revision to position #1 of our position paper part 1 on physician-industry relations.1 The revision was developed by the Ethics and Human Rights Committee to help clarify the statement, including by moving some of the language from the rationale directly into the position.

The revised position is: Position 1: Industry Gifts, Hospitality, Services and Subsidies

The acceptance by a physician of gifts, hospitality, trips, and subsidies of all types from the health care industry that might diminish, or appear to others to diminish the objectivity of professional judgment, is strongly discouraged. As documented by some studies, the acceptance of even small gifts can affect clinical judgment and heighten the perception and/or reality of a conflict of interest. Accordingly, physicians need to gauge regularly whether any gift relationship is ethically appropriate and evaluate any potential for influence on clinical judgment.

In making such evaluations, it is recommended that physicians consider such questions as: "What would the public or my patients think of this arrangement?"; "What is the purpose of the industry offer?"; "What would my colleagues think about this arrangement?"; and "What would I think if my own physician accepted this offer?" In all instances, it is the individual responsibility of each physician to assess any potential relationship with industry to assure that it enhances patient care and medical knowledge and does not compromise clinical judgment.

We hope that clinicians will find this revision and the rest of the content of the 2002 position paper helpful, and will continually evaluate their relationships with industry as well. Thank you.

Frederick E. Turton, MD, FACP Chair, ACP Ethics and Human Rights Committee

Lois Snyder, JD Director, ACP Center for Ethics and Professionalism

Conflict of Interest:

None declared

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