AMA House of Delegates

AMA meeting: Delegates weigh ethics committee's role

The CEJA open forum also explored the potential conflict of interest facing doctors who are employed by nurses or PAs.

By Kevin B. O’Reilly — Posted Dec. 1, 2008

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Nearly all hospitals have ethics committees to help resolve dilemmas facing physicians, patients and families, especially regarding end-of-life care. Yet surveys have found the typical ethics consultation service handles only three cases a year.

When should ethics services be consulted? Who should sit on ethics committees? Should they tell doctors and patients what to do, or just offer advice?

These were some of the questions delegates debated at the AMA Council on Ethical and Judicial Affairs' open forum during the Interim Meeting in November.

Richard Pieters Jr., MD, an alternate delegate for the Massachusetts Medical Society, said the ethics consultations should be a function of the medical staff. "I have a great deal of concern about the idea of the profession losing control of ethics committees to trained ethicists," said Dr. Pieters, a radiation oncologist. "It is important that the committee include people from specialties who have an interest in the patients but who may not have had ethics training."

Other delegates complained that ethics services too often operate in secrecy and avoid cases that could pose challenges for the organization.

"How do you make an ethics panel stick to its job and solve the problems brought to them?" asked Stephen L. Brotherton, MD, a delegate for the Texas Medical Assn. "Physicians should get regular reports on what [ethics committees] are doing and how they're dealing with different cases. Ethics belongs to the whole community. It's not the committee's job to cover the hospital's butt."

Conflict with midlevel relationships

Delegates reacted passionately to another question explored at the forum -- can physicians manage the potential conflict of interest that arises when employed by nonphysicians they are responsible for supervising?

Nurse practitioners and physician assistants are increasingly setting up independent practices and hiring doctors to provide legally required supervision. Can doctors supervise the midlevel health professionals who are paying them?

"I'm amazed that we even have to think about whether this is ethical or not," said Michael E. Greene, MD, an alternate delegate for the Medical Assn. of Georgia. "To put doctors in the ... employee role of those they are supervising is ludicrous."

Dr. Greene, a family physician, said the situation poses an untenable conflict for doctors. "Yes, in a perfect world, my ethics say, 'We shouldn't do this or that,' but then they say, 'Thanks very much. You're no longer employed here.' "

Michael A. Williams, MD, a delegate for the American Academy of Neurology, said the relationship can be handled professionally.

"There is a lot of temptation to frame this as a scope-of-practice issue and a financial issue," said Dr. Williams, an employed physician who supervises a physician assistant. "But the physician responsibility in any kind of relationship is the same."

Sham supervisory relationships formed to skirt the law are obviously wrong, Dr. Williams said. But he argued it would be difficult for CEJA "to make the case across the board" that it is ethically impermissible for doctors to supervise midlevels who employ them.

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Meeting notes: Medical ethics

Issue: The AMA's Code of Medical Ethics has not been comprehensively reviewed in more than 30 years.
Action: The AMA Council on Ethical and Judicial Affairs will undertake a three-year project to reorganize the code to make it easier to use and to consolidate opinions and identify gaps in policy.

Issue: Drug- and device-maker funding of graduate and continuing medical education can pose conflicts of interest for physicians and unconsciously bias the content of educational activities.
Action: CEJA and the AMA Council on Medical Education are working together to issue recommendations at the 2009 Annual Meeting on how best to manage these conflicts. An open call for comments will be posted to the AMA Web site.

Issue: Some hospitals, required to provide uncompensated long-term care for immigrant patients have had the patients deported to home countries, where appropriate care is often lacking.
Proposed action: The AMA should adopt policy opposing the deportation of patients. [ Referred for study ]

Issue: The AMA has no ethical policy explicitly outlining physicians' duty to provide the right care to the right patient at the right time through continuous quality improvement.
Proposed action: A CEJA report spelled out physicians' ethical obligation to provide high quality care. Some delegates objected that the proposed policy placed untenable demands on doctors in underserved areas. [ Referred for study ]

Issue: Health care organizations are increasingly using "secret-shopper" patients to report on physician and hospital performance in areas ranging from customer service and patient-centeredness to hand hygiene and decor.
Proposed action: A CEJA report stated that secret-shopper patients could be used as one way to assess and improve quality. But, the council said, these pseudo patients should not deprive real patients from getting care and should be used only with the approval of physicians. Delegates overwhelmingly objected that secret-shopper patient programs are inherently deceptive and misallocate scarce health care resources.[ Not adopted ]

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