Snyder L. American College of Physicians Ethics Manual. Sixth Edition. Ann Intern Med. 156;1:suppl 73-101. (Click here for a PDF version of the manuscript)
All the fellows, and Drs. Robbins, Bajo, Singarajah and Raschke attended Journal Club.
This article related concepts of traditional medical ethics to current legal and social values. The scope was very broad, touching on many bedside patient care issues.
Our discussion began with some valid criticisms. The chief among these is something I missed altogether: the author of this article is not a physician, but a lawyer.
With all due respect to Lois Snyder, this was a mistake. The very first statement of the article speaks to the fundamental and timeless nature of the patient-physician relationship. How can someone who has never been a part of this relationship from a physician’s perspective be chosen to express our ethical standard? The ACP should have looked within our own profession for a qualified author.
Some reviewers also felt certain areas of the review were condescending, for instance, the section entitled “Sexual contact between physician and patient. Some rudiments of ethical common-sense on the part of physician audience could probably have been reasonably assumed.
Others felt there were content errors in the review. One example was in the section on end of life. The author states that physicians should not write a do-not-intubate order in the absence of a full DNR, because the patient who dies from respiratory failure will invariably suffer cardiac arrest as a consequence.
Patients occasionally request do-not-intubate status in our practice, typically after having seen a family member suffer prolonged mechanical ventilation. We have honored the patient’s wishes, and avoided the theoretical dilemma posed by the author by using common sense. It is typically apparent when a patient is dying of respiratory failure – of course we wouldn’t perform ACLS in a DNI patient dying from respiratory failure. But there isn’t any reason why such a patient shouldn’t receive treatment in the event of cardiac arrest, if that is their well-informed wish.
Despite these shortcomings, most of the content of this review was valid, and applicable to patient care. Sections on health care system catastrophes, surrogacy, futile treatments, and the impaired physician were particularly informative. The explicit statement that physicians have an ethical obligation in regards to medical education is particularly important in a healthcare economy that seems to increasingly devalue trainees and faculty.
The most important part of the review, from my perspective, had to do with our primary goal as physicians. “The physician’s primary commitment must always be to the patient’s welfare and best interests., . . . regardless of financial arrangements, the health care setting; or patient characteristics . . . “
Physicians and healthcare administrators and physicians are increasingly being asked to work together. The advent of Accountable Care Organizations may hasten this process. It is therefore increasingly important that we hold our responsibility to our patients foremost as financial goals receive increasing attention. Maintaining patient welfare might be increasingly challenged by payment systems such as capitation that may disincentivize care. Other payment systems, such as pay-for-performance, will only be compatible with good patient care if “performance” is defined by important clinical patient outcomes, rather than by compliance or surrogate outcome measures.
Robert A. Raschke, M.D.
Associate Editor, Critical Care Journal Club
Reference as: Raschke RA. February 2012 critical care journal club. Southwest J Pulm Crit Care 2012;4:51-2. (Click here for a PDF version of the journal club)