AMA House of Delegates

AMA meeting: Doctors get to see how ethics bar is set

■ An AMA-sponsored fellowship adds to its online curriculum the study of how ethics policy is made at the Annual Meeting.

By Kevin B. O’Reilly — Posted June 29, 2009

Chicago -- When St. Louis anesthesiologist Joseph F. Kras, MD, rose to speak at a House of Delegates reference committee meeting, he testified against the adoption of a Council on Ethical and Judicial Affairs report. But he was not just expressing his viewpoint; he was doing his homework.

Dr. Kras' visit to the AMA Annual Meeting in June was part of an online bioethics training program co-sponsored by the Medical College of Wisconsin and the American Medical Association.

The four-course AMA-MCW Online Fellowship in Physician Ethics and Professionalism, started in 2002, is not alone in offering Internet-based bioethics training. But the program, open only to doctors, is unique in that it gears its offerings toward the pragmatic concerns of practicing physicians who take on responsibilities related to ethics. The fellowship also highlights the importance of physician organizations in codifying professional ethical standards.

While the rest of the instruction is conducted online, program fellows must see the AMA's policy-making in action in Chicago and write a short paper analyzing one of the proposed ethics policies. They get to meet CEJA members, sit in on some of the council's planning meetings and watch delegates debate in reference committee and on the house floor.

"What we're doing here is creating a cadre of doctors who understand very well how the AMA works and what its social role is with regard to professionalism and professional standards," said Matthew K. Wynia, MD, MPH, co-director of the fellowship program and director of the AMA's Institute for Ethics. "Every person who comes sees some policies they favor get through and sees some policies they favor get turned back, and they see the whole sausage-making process of deliberative democracy in action. And I think that's a powerful lesson you can't get any other way except to watch it happen."

More than 20 doctors have graduated from the fellowship program. Eight have gone on to pursue a master's degree in bioethics at MCW, which requires completing another four classes online. One course all fellows must take is called "History and Meaning of Ethics and Professionalism in Medicine," which Dr. Wynia teaches.

"Professionalism is inherently a group activity, so we spend a lot of time exploring the difference between an individual's swearing an oath and the profession's adopting a code that applies to everyone, and to what extent codes supersede individuals' own standards," Dr. Wynia said. "We look at a set of ethical issues -- physician participation in torture and capital punishment, the problem of dual loyalties -- that are very important to physicians as a group and not the same as the issues that show up in your typical bioethics coursework."

Meeting practical needs

Joseph F. Kras, MD, addressed CEJA as part of his coursework in a bioethics training program.

Dr. Kras became interested in the fellowship program when he took over as director of residency education for the anesthesiology department at Washington University in St. Louis School of Medicine. Responsible for training and evaluating medical residents on professionalism and ethics, Dr. Kras said he felt "not totally qualified." Now he is one paper short of completing the fellowship program and plans to pursue the bioethics master's degree at MCW. Each of the fellowship courses costs about $2,000.

Dr. Kras, an AMA member, said he had not really understood how the Association crafts ethics standards before joining the fellowship program. While CEJA's ethical opinions go through months, and sometimes years, of exhaustive research and careful formulation, Dr. Kras was struck by the seriousness with which delegates approached proposals covering matters ranging from industry funding of continuing medical education to end-of-life care.

"I've been impressed by the level of involvement and the sophistication exhibited by the physician delegates," Dr. Kras said. "They come to this House of Delegates meeting very prepared, and they know what they're talking about. It's obvious they've worked hard on these issues."

Special value

Studying CEJA and the AMA policy-making process up close is of special value to doctors, said Arthur R. Derse, MD, co-director of the fellowship program.

"One of the complaints we often hear from students is that we will talk about cases and they will say, 'Just tell us what to do in black and white,' " said Dr. Derse, director for medical and legal affairs at the MCW Center for the Study of Bioethics. "CEJA gets as close to that as possible in medicine, offering practical advice on what do, step by step."

Walter Limehouse, MD, attended the 2008 Annual Meeting as part of the fellowship, which he took to help with his work chairing the ethics committee at the Medical University of South Carolina. He called the diversity of specialties and practice settings among delegates impressive.

What did he think after seeing the sometimes contentious ethics policy-making process in action?

"Morality reflects the community in which we live," said Dr. Limehouse, assistant professor of emergency medicine at MUSC. "And you're going to have people who have strident or differing opinions, but ultimately to have this be a democratically chosen route, I think it's actually best for the profession."

ADDITIONAL INFORMATION

Meeting notes: Medical ethics

Issue: Breaches of electronic medical records security can compromise privacy and harm patients physically and emotionally. When such breaches occur, what responsibilities do physicians have toward their patients?
Proposed action: An ethical policy recommending that physicians promptly inform patients of any breach and the potential for harm, describe how the breach happened and what steps patients can take to minimize any adverse results. [Adopted]

Issue: Physician assistants and nurse practitioners are increasingly taking on ownership roles in practices such as retail health clinics. This gives rise to the ethically problematic situation where a doctor is hired to supervise the work of a midlevel practitioner who also owns the practice and is the physician's employer.
Proposed action: An ethical policy that acknowledges the conflicts inherent in such an arrangement. The opinion says physicians have a duty to always exercise their independent professional judgment in patients' best interest, even if it puts them at odds with their employers. [Adopted]

Issue: Some hospital patients with racial or other prejudices are hostile to the physicians assigned to care for them or refuse their treatment, but hospitals do not have uniform guidelines to address these situations.
Proposed action: Direct the AMA to work with other organizations to encourage hospitals and health systems to adopt policies allowing patients to change doctors and have mechanisms to address abusive patient behavior and ensure continuity of care for a patient who declines care from the attending physician. [Adopted]

Issue: So-called chimeric embryos -- created when human genetic material is introduced into a nonhuman embryo or transferred into an enucleated nonhuman egg, creating a hybrid -- are being explored as an alternative to stem cell research techniques that destroy human embryos.
Proposed action: The Council on Ethical and Judicial Affairs said there is a lack of policy or scientific and ethical consensus on chimeras, and the issue affects few physicians. The council proposed examining the issue as part of its review of opinions relating to medical genetics in the AMA Code of Medical Ethics. [Adopted]

Issue: Working with patients to plan in advance for end-of-life care situations is a legally complicated and ethically fraught area for doctors.
Proposed action: Direct the AMA to develop an educational session on advance care planning at an upcoming Annual or Interim Meeting and ask CEJA to update its ethical guidance on end-of-life issues. [Adopted]