Ethics and Economics in the Delivery of Health Care: A Review of Current Guidelines

1. Ethics and Economics in \the delivery of health care: a review of current ceJa guidelines SCMA ANNUAL meeting APRIL 26, 2019 JOHN M. ROBERTS, M.D.

2. No Disclosures

3. Disclaimer The majority of the content of this presentation is not original. As often the case for this retreat, I gave my wife a rough outline of my thoughts and she began an online search and found most of the information used in this presentation. Consequently, I do not claim the rigorous academic inspection of a reviewed journal. My comments and my opinions are my own. This presentation is meant as food for thought, and as such, I hope it will nourish and promote growth. John M. Roberts, M.D. April 26, 2019

4. Learning Objectives 1. Be able to discuss the role and importance of a code of ethics to a profession

5. Learning Objectives 2. Have a better understanding of the principles of medical ethics of the AMA and the role the Council on Ethical and Judicial Affairs (CEJA) has in interpreting them.

6. Learning Objectives 3. Have a greater understanding of how to use the Code of Medical Ethics, especially as it relates to economic issues in the delivery of health care.

7. Learning Objectives 1. Be able to discuss the role and importance of a code of ethics to a profession

8. Definition of a Profession Allowed to possess the knowledge and skills of a specific area of expertise that is felt to be more complex than the average member of the society can master, but that the society needs for its essential well being.

9. Definitions of a profession A profession must internally regulate itself to protect society, according to a set of standards commonly referred to as a code of ethics.

10. Ethics: codes & guidelines • Date back to the origins of medicine in virtually all civilizations • Developed by the medical practitioners of each era and culture • Ancient India, seventh-century China, and early Hebrew society each had medical oaths or codes that medical apprentices swore to on professional initiation.1 • Their oath was an agreement binding them to adhere to principles of conduct toward patients, colleagues, and society JAMA. 1965;194(12):1319-1320. doi:10.1001/jama.1965.03090250053021

11. The Oath Hippocrates • Dates from the fifth century BC • Brief exposition of principles for physician’s conduct • Protects the right of the patient • Obliges physician to behave in an altruistic manner to patients • Modified in the 10th or 11th century AD to eliminate references to pagan deities

12. Oaths used today • The Hippocratic oath, which graduating medical students swear to at more than 60% of US medical schools, is perhaps the most enduring medical oath of Western civilization.2,3 • Other oaths commonly sworn to by new physicians include the Declaration of Geneva (a secular, updated form of the Hippocratic oath formulated by the World Medical Association, Ferney-Voltaire, France)2,4 • The Prayer of Moses Maimondes, developed by the 18th-century Jewish physician Marcus Herz.3 JAMA. 1965;194(12):1319-1320. doi:10.1001/jama.1965.03090250053021

13. Ethics in Surgery Historical Perspective Thomas Tung, MD; Claude H. Organ Jr, MD Arch Surg. 2000;135(1):10-13. doi:10.1001/archsurg.135.1.10

14. THOMAS PERCIVAL CODIFIER OF MEDICAL ETHICS (1740-1804)

15. THOMAS PERCIVAL CODIFIER OF MEDICAL ETHICS • In 1803, Percival published his Medical Ethics; or, a Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons.1 • The Code of Ethics that was adopted by the AMA in 1847 was attributed officially to Thomas Percival • The rules of conduct and the ethos of the physician remain those postulated by the English codist. First to use The term Medical Ethics JAMA. 1965;194(12):1319-1320. doi:10.1001/jama.1965.

16. dr. Nathan Smith Davis Born January 9, 1817 Died June 16, 1904 age 87

17. Nathan smith Davis, m.d. • “Father of the American Medical Association” • Twice elected president of the AMA • Became the first editor of the JAMA Davis two months before his death

18. Poor standards of medical education Declining of QUALITY of medical education • Before 1800, medical education consisted of • a traditional four-year apprenticeship • followed by stringent examination from a state medical board or the censor of a local medical society • 1800-1840 medical training was in medical colleges, some of which were associated with universities • State licensing requirements eliminated • Graduates were automatically licensed • Qualifications varied widely

19. Nathan smith Davis, m.d. At the May 5, 1846 National Convention of Medical Societies in New York, Davis: • Motioned for the creation of a national organization for the medical profession • Called for a national conference to discuss how to improve American medical education

20. Isaac Hayes Born Aug. 20, 1942 Died Aug 10, 2008

21. Dr. Isaac Hayes American ophthalmologist, editor, American Journal of Medical Sciences. • (1796-1879) Royal College of Physicians and Surgeons of Canada Medical Ethics: Past, Present and Future Heather MacDougall, PhD, Associate Professor, Department of History, University of Waterloo G. Ross Langley MD, FRCPC, MACP, FRCP(Edin), Emeritus Professor of Medicine, Dalhousie University • Image courtesy of Leon Morgenstern MD, Center for Health Care Ethics, Cedars-Sinai Medical Center, Los Angeles, Calif.

22. John Bell, M.D. (1796–1872) Philadelphia surgeon, professor, author, elected to College of Physicians of Philadelphia, member Philadelphia Medical Society

23. Kappa Lambda • Kappa Lambda: Philadelphia exclusive, fraternal, society dedicated to following Percival’s Medical Ethics Code • Recruited like minded physicians: Dr. Bell & Dr. Hayes • 1826 Kappa Lambda Committee to revise Percival's Medical Ethics: • John Bell, chaired the committee • Isaac Hayes was secretary and editor • Governor Emerson, an alumnus of Kappa Lambda was the third on this committee

24. When the delegates met in Philadelphia in 1847, they supported the creation of the American Medical Association (AMA) • And approved the 5000 word code of ethics prepared by ChairmanJohn Bell’s committee that included Isaac Hayes as its editor and secretary Royal College of Physicians and Surgeons of Canada Medical Ethics: Past, Present and Future Heather MacDougall, PhD, Associate Professor, Department of History, University of Waterloo G. Ross Langley MD, FRCPC, MACP, FRCP(Edin), Emeritus Professor of Medicine, Dalhousie University

25. As the first of its kind, the 1847 AMA Code was reprinted by medical societies in Berlin, London, Paris, Vienna, and around the world • Throughout the rest of the 19th century, it was the most commonly printed medical document in the English language. (Baker et al. eds. The American Medical Ethics Revolution, Johns Hopkins University Press, 1999) • Today, the AMA Code remains the only codification of professional conduct for all US physicians regardless of their medical specialty, practice type or location.

26. Revisions of the ama code of ethics • 1909 • 1912 • 1947 • 1957 Principles I-VIII Etiquette Ethics • 1980 Legalistic Influence • 2001 Principles VIII – IX • 2017

28. Francis peabody Two criticisms of young doctors: • Inadequate training on how to take care of patients • Education primarily in the “impersonal hospital” so they, therefore, lacked humanity and compassion in caring for their patients. . Peabody, F.W., The Care of the Patient, JAMA, 1927; 88(12): 882-887

29. Francis Peabody:medical humanities • In 1927, Dr Francis Peabody of Harvard Medical School addressed his concern about the lack of humanities training • “That young graduates have been taught a great deal about the mechanism of disease, … they are too “scientific” and do not know how to take care of patients.” • Including humanities courses in medical education may potentially provide significant benefits not only to future physicians but also to society as a whole. Developing and Evaluating Medical Humanities Problem-Based Learning Classes Facilitated by the Teaching Assistants Majored in the Liberal ArtsA Longitudinal Crossover Study Fen-Yu Tseng, MD, PhD, Jeng-Yi Shieh, MD, Tze-Wah Kao, MD, PhD, Chau-Chung Wu, MD, PhD, Tzong-Shinn Chu, MD, PhD, and Yen-Yuan Chen, MD, MPH, PhD

30. Learning Objectives 2. Have a better understanding of the principles of medical ethics of the AMA and the role the Council on Ethical and Judicial Affairs (CEJA) has in interpreting them.

31. AMA ethics • The American Medical Association (AMA), Chicago, Ill, has made medical ethics a centerpiece of its function since the release of its first Code of Medical Ethics during the 1847 convention at which the group was formed.1,5 •  The AMA was the first national assemblage to bind its membership to a uniform code of ethics.5 • Since then, the AMA has been at the forefront of ethics discussion in the United States, periodically updating the Code of Medical Ethics, and in 1997 forming its Institute of Ethics.5 JAMA. 1965;194(12):1319-1320. doi:10.1001/jama.1965.03090250053021

32. Council on ethical and judicial affairs (ceja) Moses was the first person with a tablet downloading data from the cloud

33. Role and importance of a code of ethicS

34. Pic of mcdonalds

35. ama Officers & Board of Trustees = Administrative Branch House of Delegates = Legislative Branch CEJA = Judicial Branch

36. ceja • Appointed for 7 years • No other AMA roles • Elect Chair and Vice Chair from within • Provide opinions that can be accepted or sent back by House of Delegates • Not voted on for approval or disapproval

37. Council on ethical and judicial affairs (ceja) • When the 1957 Principles of Medical Ethics (Principles) appeared in JAMA, they were interpreted through annotations that evolved into the opinions of CEJA (1985 successor to the Judicial Council) • These reports include background analysis supporting the guidance set out in individual opinions. Code of Medical Ethics of the American Medical Association, 2017, AMA Council on Ethical and Judicial Affairs P 195

38. Council on ethical and judicial affairs • Opinions in the Code of Medical Ethics (Code) are not laws or rules. They are guidance that identifies theessentials of ethical behavior for physicians. • These opinions are offered as ethics guidelines for physicians and are not intended to establish standards of clinical practice or rules of law. Code of Medical Ethics of the American Medical Association, 2017, AMA Council on Ethical and Judicial Affairs p 3

39. Ceja’s INTENT • To respect the accumulated wisdom in its opinions • To ensure that guidance remains timely & useful • To strike a balance between offering general rules for acting and providing tools for thinking about the ethical challenges physicians encounter as practicing clinicians and leaders in a rapidly changing health care environment. Code of Medical Ethics of the American Medical Association, 2017, AMA Council on Ethical and Judicial Affairs p 3

40. The Code of Medical Ethics was adopted at the first AMA meeting in 1847. Much in medicine has changed in169 years, but this founding document — the first uniform code of ethics of its kind — is still the basis of an explicit social contract between physicians and their patients. Code of Medical Ethics of the American Medical Association

41. Code of Medical Ethics of the American Medical Association Publisher: American Medical Association Authors: AMA Council on Ethical and Judicial Affairs The current Code consists of the Principles and CEJA’s interpretive opinions, which provides source of guidance for responsible professional conduct

42. Code of Ethics of the AMA • Principles of Medical Ethics • Ethical Opinions of the Council on Ethical and Judicial Affairs • Reports of the Council on Ethical and Judicial Affairs

43. Code of Ethics of the AMA • Published every other year • CEJA – multi disciplinary • A living document

44. The newly revised, modernized 2016-2017 version of the Code of Medical Ethics is the most extensive Revision of the Code since 1957

45. ceja Throughout the Code, the Council on Ethical and Judicial Affairs uses the words must, should, and may to distinguish different levels of ethical obligation. Code of Medical Ethics of the American Medical Association, 2017, AMA Council on Ethical and Judicial Affairs p 3

46. must • Use of the word must indicates that an action is ethically required of physicians • From the perspective of ethics and professionalism, such actions are near-absolute obligations, not matters about which physicians may use judgement or discretion Code of Medical Ethics of the American Medical Association, 2017, AMA Council on Ethical and Judicial Affairs p 3

47. Should • Should is used to indicate an action or obligation that is strongly recommended as a matter of professional ethics, but which may have some exceptions. • Should is used to indicate what is expected of a physician in most instances, absent special circumstances or considerations. • Should indicates that ethically there is some latitude for physician judgement and discretion. Code of Medical Ethics of the American Medical Association, 2017 AMA Council on Ethical and Judicial Affairs p 3

48. may • The Council uses the word may to indicate that an action is ethically permissible when qualifying conditions set out in the Opinion are met. Code of Medical Ethics of the American Medical Association, 2017, AMA Council on Ethical and Judicial Affairs p 3

49. Learning Objectives 3. Have a greater understanding of how to use the Code of Medical Ethics, especially as it relates to economic issues in the delivery of health care.

50. Marksiegler, m.d