So the sixth edition of the manual has just come out. You can go here to access a link to download the entire manual for free. For the most part the language is pretty standard, similar to other codes of ethics we're familiar with, such as that put out by the AMA. Here I will comment on some new areas of content and other aspects of the document that got my attention.
The readability and clarity of the document, particularly the sections on the ethics of decision making and end of life care, should make this a useful resource for clinicians. I found fault with some portions of the manual and will make note below.
Financial conflicts of interest
The ACP ethics manual considers all forms of conflict including those inherent in one's practice arrangement and of course the ever contentious subject of physician-industry relationships as it pertains to gifts, financial subsidies and the like. Concerning the issue of gifts from drug and device companies the manual affirms the College's long held position that this practice is unethical and that even very small, nominal gifts such as ink pens are problematic. Unfortunately there is a credibility gap here because the College has not practiced what it preaches in this area. If you have ever attended one of their national meetings you know what I'm talking about. In the exhibit hall one finds a lavish array of pharmaceutical company displays. Until recently the exhibit hall was a vast repository of industry freebies. The ink pen giveaway is a non-issue now because that particular type of gift has been banned. Still, support received by the College from industry does offset registration fees. So if you attend the ACP national meeting industry, whether you know it or not, is underwriting a substantial portion of your registration fee. Now I'd say that's a pretty substantial gift! The College has come under fire in the past for this duplicity from organizations such as No Free Lunch, but to my knowledge has done nothing about it.
More pervasive financial conflicts of interest are inherent in the environment in which we work. Very few physicians are free of cost incentives. The vast majority of us are under positive or negative incentives or a mixture of both. This is as true of our health care organizations as it is for us as individuals. The ACP manual says all these conflicts should be disclosed. This can be exceedingly difficult. Consider Gramma, who's been on full life support in the ICU for a month. A family member approaches you and asks “How much longer will Medicare pay for all this?” Shall I tell her the truth? She'd better be sitting down because the full disclosure answer is that Medicare stopped paying for Gramma's hospital charges at least two weeks ago! The public is profoundly ignorant of the negative cost incentives of Medicare's Prospective Payment System (DRGs).
And while we're at it maybe we better disclose all our P4P incentives (now euphemistically known as value based purchasing) including the latest one, HCAHPS. When patients wonder why we're so much nicer all of a sudden should we disclose that it's a script we're being paid to perform? It's a financial incentive, and according to my reading of the manual the ACP is saying we need to disclose all this stuff. It won't do the patient much good but if it raises public annoyance at our misguided policies maybe it'll help promote change. After all the new professionalism is as much about the community as it is the individual patient.
Assisted suicide and euthanasia
The College opposes assisted suicide and euthanasia but does so in a very round about way as if to leave wiggle room for future accommodation of the practices. Why couldn't they make a strong simple statement against the practices like the one they made against participation in the execution of prisoners? This strikes me as duplicitous concerning the College's stand on the sanctity of life.
Blogs and social media
The manual deals only briefly with this topic. But this is a growing issue and I expect to see expanded discussion in future editions of the manual. In addition to the usual cautions about patient privacy the manual urges us to maintain a professional demeanor and relate to others on line just as we would in person. Maybe this means that whether we blog openly or anonymously some of us need to turn down the snark.
Complementary and alternative medicine
This portion of the manual was a disappointment. Here the College missed the elephant in the room concerning the ethics of CAM and integrative medicine, which is our profession's egregious acceptance of the infusion of quackery into mainstream medical treatment and, worse, the incorporation of quackery into the curriculum of our teaching institutions, which I once termed quackademic medicine. To add insult the manual cites the NCCAM as a reliable source of information for patients! This amounts, in my view, to an indirect endorsement of non-evidence based, unethical and sometimes even fraudulent medical practices.