Ethics -- a force every day in every aspect of medicine

A message to all physicians from AMA President John C. Nelson, MD, MPH.

By John C. Nelson, MD, MPHis an obstetrician-gynecologist from Salt Lake City, Utah, and was AMA president during 2004-05. Posted Oct. 18, 2004.

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When I talk with other physicians about the reasons I'm proud to be an AMA member, one of the first ideas to surface has to do with ethics. Medicine is rooted in ethics and ethical standards. In fact, part of the classic definition of a profession is to have a code of ethics to which all practitioners "profess" their allegiance.

Far from sentences on a piece of paper filed away in someone's desk, ethics and ethical behavior are knitted into the everyday practices and procedures of medicine, into its education and training, into every stage in a physician's career, into a vital patient-physician trust relationship.

Ethics, in that sense, is a living contract we have with individuals and society at large. In 1847, the American Medical Association came into being with the writing of our Code of Medical Ethics. Today, as we have since 1847, the AMA is pioneering ethical leadership in new ways.

Three outstanding examples of new programs illustrate the AMA's continuing leadership:

  • Expanding access to care. More than a payment issue or a geographic location issue, expanded access is an ethical issue.
  • Improving the quality of care. Health care quality is not just an issue of technical skill. Patients come to doctors with high expectations for ethics, too.
  • Building trust in individual physicians and in the profession. Many forces today make it harder than ever to maintain the trust of our patients. The AMA's Ethics Group is working to maintain and build up this vital trust.


Along with our work on health system reform, our AMA is attacking the barriers to access for the most vulnerable members of our society. We're focusing resources and expertise on the only systems available to those left out of the larger health care system because of financial, linguistic, ethnic or geographic factors.

Eliminating disparities in health care due to race and ethnicity is a major emphasis currently taking three forms:

First, the AMA has launched a nationwide effort to promote and inform physicians and the general public about a major patch to the sometimes ineffective safety net systems out there. A little-known federal regulation creates a national medical liability pool that offers a kind of Good Samaritan protection for physicians operating in free clinics.

When this provision goes into effect next year, physicians in free clinics will be protected from lawsuits as if they were federal employees.

An injured patient would receive compensation from a national liability pool. Doctors providing charitable services will be protected, while no patient will be denied recourse for compensation. Knowing about this legal and financial protection will encourage many physicians to volunteer for free clinic duty -- when concerns about liability might otherwise keep them from following up on their professional instincts to help.

Second, the AMA is funding and guiding two pilot programs in medical student-run free clinics at the University of Minnesota and at the State University of New York at Buffalo. Expanding on their training, medical students participate in a "classroom in charity care." This kind of service learning program not only enhances training but also further eliminates disparities in the system by providing much-needed, basic services to those least able to afford it.

The AMA's funding and providing ideas for these pilot programs are a first step in developing models that can be used elsewhere in the country.

Third, the AMA is helping expand access to care in its own back yard. In Chicago, AMA physician staff help provide physician volunteers for an expanded network of free clinics. Just in its infancy, the program links members of AMA's Ethics Standards group with the urgent needs in some of Chicago's poorest neighborhoods.

Lessons being learned in the pragmatic aspects of doing, not just thinking about, ethical behavior form the basis for an emerging National Resource Center -- a nationwide facility to link physicians with free clinics, community health centers and other emerging institutional responses to need.

Quality of care

In the past, measuring quality in health care has focused on technical issues or customer service. But ethical expectations are qualitative, not quantitative, in nature. Patients come to us with high ethical expectations -- for privacy, informed consent, advocacy, truth-telling and more. Meeting those expectations enhances the precious patient-physician relationship. Not meeting them detracts from it and becomes an ethical issue.

The AMA Ethics Institute is developing a unique set of tool kits to allow hospitals and group practices to measure their success in meeting expectations for privacy in health care. Four hospitals in different parts of the country have used the kit, and the feedback from each has been very positive.

Additional tool kits are being developed to assess how organizations make health care coverage decisions and how well organizations foster patient-centered communication, especially with members of vulnerable populations.

You can learn more about all these efforts online (link).


A large body of research clearly demonstrates that, the higher the level of trust, the higher the rates of healing. However, another body of research tells us that minority patients have a significantly lower level of trust than the majority of patients.

The AMA Ethics Institute is developing strategies to raise that level of trust. A major first step, of course, is simply informing physicians of the sensitivities involved and the historic sources of mistrust, especially among minority patients. Just being attuned to the issues can help establish a strong trust relationship. You can learn more about AMA initiatives to address trust and health disparities at the AMA Ethics Institute Web site (link); click on "ethics and health disparities."

Far from lofty, remote, philosophic pondering, ethics in the AMA is a living, breathing, working facet in the life of physicians. And AMA ethics -- the gold standard of ethical ideas and practices -- remains one of the main reasons I'm proud to be a member of the American Medical Association.

John C. Nelson, MD, MPH is an obstetrician-gynecologist from Salt Lake City, Utah, and was AMA president during 2004-05.

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