Medical Ethics Issues: Position Papers & Resources

Position Papers

• Artificial Intelligence in the Provision of Health Care: An American College of Physicians Policy Position Paper
  (June 4, 2024)

Position Papers

• Standards and Ethics Issues in the Determination of Death: A Position Paper From the American College of Physicians
  (September 4, 2023)
• Ethics, Determination of Death, and Organ Transplantation in Normothermic Regional Perfusion (NRP) with Controlled Donation after Circulatory Determination of Death (cDCD): American College of Physicians Statement of Concern
  (April 17, 2021)

Comments and Letters

• ACP letter to the Uniform Law Commission Committee about updating the Uniform Determination of Death Act (UDDA) (June 7, 2023)

Other

• Does Normothermic Regional Perfusion Violate the Ethical Principles Underlying Organ Procurement? Yes. (Chest. 2022;162(2):288-90)
• Rebuttal From Dr. DeCamp et al. (Chest. 2022;162(2):292-3)

Ethics Manual

electronic patient-physician communication, electronic health records, telemedicine, and online professionalism

• Initiating and Discontinuing the Patient–Physician Relationship
• The Medical Record
• Boundaries and Privacy

Case Studies

• Lab Results Reporting, Ethics, and the 21st Century Cures Act Rule on Information Blocking CME/MOC

• Ethics, Electronic Health Record Integrity and the Patient-Physician Relationship CME/MOC
  (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2021)

• Ethics, Professionalism, and the Physician Social Media Influencer CME/MOC
  (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

• ”Doctor, Can’t You Just Phone a Prescription In?” and Other Ethical Challenges of Telemedicine Encounters CME/MOC
  (ACP Ethics Case Studies Series. MOC and CME by Medscape. 2019)

• Maintaining Medical Professionalism Online: Posting of Patient Information CME
  (ACP Ethics Case Studies Series. CME by Medscape. 2018)

• Addressing a Colleague's Sexually Explicit Facebook Post CME
  (ACP Ethics Case Studies Series. CME by Medscape. 2017)

• Copied and Pasted and Misdiagnosed (or Cloned Notes and Blind Alleys) CME
  (ACP Ethics Case Studies Series. CME by Medscape. 2015)

Position Papers

• American College of Physicians Ethical Guidance for Electronic Patient-Physician Communication: Aligning Expectations
  (J Gen Intern Med. published online 22 June 2020)

• Ethical Implications of the Electronic Health Record: In the Service of the Patient
  (J Gen Intern Med. 2017;32:935-9)

• Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings
  (Ann Intern Med. 2015;163:787-9)

• Online Medical Professionalism: Patient and Public Relationships
  (Ann Intern Med. 2013;158:620-7)

Ethics Manual

• Care of Patients Near the End of Life

Case Studies

• Show Codes, Slow Codes, Full Codes, or No Codes: What Is a Doctor to Do? CME/MOC
  (ACP Ethic Case Studies Series, MOC and CME by Medscape. 2023)

Comments and Letters

• 2011 Letter and 2009 letter to Congressman Blumenauer regarding ACP’s support for legislation to pay for voluntary end-of-life care consultations (see H.R. 1898, the Life Sustaining Treatment Preferences Act of 2009).

Resources

End-of-Life (PEACE) Brochures
(ACP. 2014)
The PEACE brochures were developed by the Patient Education Work Group, which was convened in conjunction with the Consensus Panel project. Order copies of printed brochures

• Improving Your End-of-Life Care Practice
• Living with a Serious Illness: Talking with Your Doctor When the Future is Uncertain
• When You Have Pain at the End of Life
• Making Medical Decisions for a Loved One at the End of Life
• Improving Your End-of-Life Care Practice

ACP-ASIM End-of-Life Care Consensus Panel Papers
(1999-2001)
ACP convened this Greenwall Foundation supported consensus panel to develop ethical, policy, and clinical recommendations for physicians and other clinicians on end-of-life decisions.

Advance Directive Forms for Your State
Contact Caring Connections, a program of the National Hospice and Palliative Care Organization (NHPCO).

National Healthcare Decisions Day, April 16
Details and resources on NHDD and the importance of advance care planning.

Ethics Manual

• Expert Witnesses

Case Studies

To Be or Not to Be: Should I Serve as an Expert Witness? CME
(ACP Ethics Case Studies Series. CME by Medscape. 2014)

Position Papers

Guidelines for the Physician Expert Witness
(Ann Intern Med. 1990;113:789)

Position Papers

• Ethical Guidance on Family Caregiving, Support, and Visitation in Hospitals and Residential Health Care Facilities, Including During Public Health Emergencies
  (J Gen Intern Med. 2023 Mar 20:1–8)

• Family Caregivers, Patients and Physicians: Ethical Guidance to Optimize Relationships
  (J Gen Intern Med. 2010;25:255-60)

• Family Caregivers, Patients and Physicians: Ethical Guidance to Optimize Relationships
  (ACP. 2009) (This publication is a longer version of the position paper above.)

Resources

Information Resources for Physicians Supporting Family Caregivers
(ACP. 2010)
This appendix of resources was developed in conjunction with the ACP position paper to help physicians manage relationships with patients and caregivers.

Case Studies

When the Family Caregiver Is a Physician: Negotiating the Ethical Boundaries CME/MOC
(ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

Ethics Manual

• Precision Medicine, Genetic Testing, Privacy, and Confidentiality

Comments and Letters

ACP Comments on privacy protection and human genome sequencing
(May 24, 2012)
ACP provided comments to the Presidential Commission for the Study of Bioethical Issues regarding the ethical implications of evolving notions of privacy and access in relation to the integration of large-scale human genome sequencing into research and clinical care.

Position Papers and Statements

Ethical Considerations in Precision Medicine and Genetic Testing in Internal Medicine Practice
Ann Intern Med.2022;175:1322-1323

Genetic Testing and Reuniting Families
(July 10, 2018)

Ethics Manual

• Cultural Humility and Volunteerism

Position Papers

Ethical Obligations Regarding Short-Term Global Health Clinical Experiences
(Ann Intern Med. 2018;168:651-7)

Ethics Manual

• Obligations of the Physician to Society

Position Papers and Statements

Health as a Human Right
(Ann Intern Med. doi:10.7326/M23-1900)

Comments and Letters

ACP's Human Rights Page: ACP policy statements and letters of support, as well as documents related to College advocacy for the humane treatment of prisoners and detainees.

Ethics Manual

• Confidentiality
• The Medical Record
• Boundaries and Privacy
• Research
  Sections within the Research chapter include “Use of Human Biological Materials in Research” and “Internet and Social Media Research”.

Case Studies

• Maintaining Medical Professionalism Online: Posting of Patient Information
  (ACP Ethics Case Studies Series. CME by Medscape. 2018)

• Confidentiality and Privacy: Beyond HIPAA to Honey, Can We Talk?
  (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Position Papers

• Ethical Guidance for Physicians and Health Care Institutions on Grateful Patient Fundraising: A Position Paper From the American College of Physicians (Ann Intern Med.doi:10.7326/M23-1691)

• Health Information Privacy, Protection, and Use in the Expanding Digital Health Ecosystem: A Position Paper of the American College of Physicians
  (Ann Intern Med.2021;174:994-998)

Ethics Manual

health care system catastrophes

• The Patient-Physician Relationship and Health Care System Catastrophes
• Medical Risk to Physician and Patient

Case Studies

• When Resources Are Limited During a Public Health Catastrophe: Nondiscrimination and Ethical Allocation Guidance CME/MOC
  (ACP Ethics Case Studies Series. MOC and CME by Medscape. 2023)

• Pandemic Treatment Resource Allocation Ethics and Nondiscrimination
  (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

• Stewardship of Health Care Resources: Allocating Mechanical Ventilators During Pandemic Influenza
  (ACP Ethics Case Studies Series. 2017)

Position Papers and Statements

• Ethical Guidance on Family Caregiving, Support, and Visitation in Hospitals and Residential Health Care Facilities, Including During Public Health Emergencies
  (J Gen Intern Med. 2023 Mar 20:1–8)

• ACP supports ACIP recommendation for additional mRNA COVID-19 vaccine dose and WHO call for equitable global vaccine distribution
  (August 17, 2021)

• ACP Statement on Global COVID-19 Vaccine Distribution and Allocation: On Being Ethical and Practical
  (June 8, 2021)

• ACP's Policy Statement on the Ethical Allocation of Vaccines During Pandemics Including COVID-19
  (November 23, 2020)

• A Wake-up Call for Healthcare Emerging Ethical Lessons from Covid-19
  (Modern Healthcare, June 16, 2020)

• Non-Discrimination in the Stewardship of Healthcare Resources in Health System Catastrophes, including COVID-19 Pandemic
  (March 26, 2020)

• Internists Say Harassment Based on Race or Ethnic Origin is Never Okay
  (March 31, 2020)

Other

• Universal Do-Not-Resuscitate Orders, Social Worth, and Life-Years: Opposing Discriminatory Approaches to the Allocation of Resources During the COVID-19 Pandemic and Other Health System Catastrophes
  (Ann Intern Med.2020;173:230-232)

Ethics Manual

Patient-physician Relationship

• The Physician and the Patient
• Initiating and Discontinuing the Patient-Physician Relationship
• Third-Party Evaluations
• The Patient-Physician Relationship and Health Care System Catastrophes
• Providing Medical Care to One’s Self; Persons With Whom the Physician has a Preexisting Close Nonprofessional Relationship or a Reporting Relationship; and VIPs
• Sexual Contact between Physician and Patient
• Gifts from Patients

Confidentiality and privacy, disclosure of medical errors, and informed and surrogate decision making

• Confidentiality
• Boundaries and Privacy
• Disclosure
• Informed Decision Making and Consent
• Making Decisions Near the End of Life

Position Papers

• Ethical Guidance for Physicians and Health Care Institutions on Grateful Patient Fundraising: A Position Paper From the American College of Physicians (Ann Intern Med.doi:10.7326/M23-1691)

• The Doctor Will See You Shortly. The Ethical Significance of Time for the Patient–Physician Relationship
  (J Gen Intern Med. 2005;20:1057-62)

• Ethics and Time, Time Perception, and the Patient–Physician Relationship
  (ACP. March 2003) (This publication is a longer version of the position paper above.)

Case Studies

• Chaperones, Professional Boundaries and the Potential for Misunderstandings CME

• Patient Prejudice? The Patient Said What?... and What Comes Next CME
  (ACP Ethics Case Studies Series. CME by Medscape. 2022)

• Confidentiality and Privacy: Beyond HIPAA to Honey, Can We Talk? CME
  (ACP Ethics Case Studies Series. CME by Medscape. 2018)

• Preventive Health Screening, Ethics, and the Cognitively Impaired Patient CME
  (ACP Ethics Case Studies Series. CME by Medscape. 2015)

• The Difficult Patient: Should You End the Relationship? What Now? An Ethics Case Study CME
  (ACP Ethics Case Studies Series. CME by Medscape. 2014)

• Must You Disclose Mistakes Made by Other Physicians? CME
  (ACP Observer. November 2003)

Ethics Manual

• Obligations of the Physician to Society
• Relation of the Physician to Government
• Strikes and Other Joint Actions by Physicians

Case Studies

Physician Work Stoppages and Political Demonstrations—Economic Self-Interest or Patient Advocacy? Where Is the Line? CME
(ACP Ethics Case Studies Series. CME by Medscape. 2010)

Ethics Manual

• Physician-Assisted Suicide and Euthanasia

Resources

• Toolkit on Issues in Delivering Patient-Centered End-of-Life Care and Responding to a Request for Physician-Assisted Suicide (Member login)

Position Papers

Ethics and the Legalization of Physician-Assisted Suicide
(Ann Intern Med. 2017;167:576-8)

Ethics Manual

• Conflicts of Interest
• Sponsored Research

Resources

Physician Open Payments (Sunshine Rule)
This ACP webpage provides guidance and related tools for physicians on the Physician Payment Sunshine Rule (also referred to as the National Physician Payment Transparency Program, or Open Payments). The Open Payments system, implemented by the Centers for Medicare and Medicaid Services (CMS) in 2015, provides a mechanism for the public reporting of physician and teaching hospital financial relationships with industry.

Position Papers

• Physician–Industry Relations. Part 1: Individual Physicians
  (Ann Intern Med. 2002;136:396-402)

• Physician–Industry Relations. Part 2: Organizational Issues
  (Ann Intern Med. 2002;136:403-6)

Ethics Manual

• The Changing Practice Environment
• Conflicts of Interest
• Financial Arrangements

Case Studies

• Ethics, Professionalism, Physician Employment and Health Care Business Practices CME/MOC

• Banning Harmful Health Behaviors as a Condition of Employment: Where There's Smoke There's Fired? CME
  (ACP Ethics Case Studies Series. CME by Medscape. 2018)

• Wellness Programs and Patient Goals of Care CME
  (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Resources

Obligations and Opportunities: The Role of Clinical Societies in the Ethics of Managed Care
(J Am Geriatr Soc. 1998;46:378-80)

Position Papers

• Ethical and Professionalism Implications of Physician Employment and Health Care Business Practices CME
  (Ann Intern Med. published online 15 March 2021)

• Assessing the Patient Care Implications of “Concierge” and Other Direct Patient Contracting Practices
  (Ann Intern Med. 2015;163:949-52)

• The Patient-Centered Medical Home: An Ethical Analysis of Principles and Practice
  (J Gen Intern Med. 2013;28:141-6)

• Ethical Considerations for the Use of Patient Incentives to Promote Personal Responsibility for Health: West Virginia Medicaid and Beyond
  (ACP. 2010)

• Pay-for-Performance Principles That Promote Patient-Centered Care: An Ethics Manifesto
  (Ann Intern Med. 2007;147:792-4)

• Pay-for-Performance Principles that Ensure the Promotion of Patient Centered Care—An Ethics Manifesto
  (ACP. 2007) (This publication is a longer version of the position paper above.)

• Medical Professionalism in the Changing Health Care Environment: Revitalizing Internal Medicine by Focusing on the Patient–Physician Relationship
  (ACP. 2005)

• Ethics in Practice: Managed Care and the Changing Health Care Environment
  (Ann Intern Med. 2004;141:131-6)

• Selling Products Out of the Office
  (Ann Intern Med. 1999;131:863-4)

ACP Pledge

American College of Physicians Pledge
(ACP. 1982 [updated; original 1924])
The ACP Pledge is taken by new Fellows at Convocation at each Internal Medicine annual meeting. The Pledge affirms the physician’s membership in an ethical and moral community dedicated to healing, comfort, and altruism.

Physician Charter on Professionalism

Medical Professionalism in the New Millennium: A Physician Charter
(Ann Intern Med. 2002;136:243-6)

Ethics Manual

• Professionalism

Position Papers and Statements

• Ethical Guidance for Physicians and Health Care Institutions on Grateful Patient Fundraising: A Position Paper From the American College of Physicians (Ann Intern Med.doi:10.7326/M23-1691)

• Ethical and Professionalism Implications of Physician Employment and Health Care Business Practices
  (Ann Intern Med. published online 15 March 2021)

• ACP Professional Accountability Principles
  (ACP. March 2018)

Case Studies

• Professional Attire and the Patient-Physician Relationship CME/MOC
  (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

• Addressing a Colleague's Unprofessional Behavior During Sign-Out CME
  (ACP Ethics Case Studies Series. CME by Medscape. 2018)

• Dealing with the "Disruptive" Physician Colleague CME
  (ACP Ethics Case Studies Series. CME by Medscape. 2009)

Ethics Manual

• The Impaired Physician

Case Studies

Physician Suicide Prevention: The Ethics and Role of the Physician Colleague and the Healing Community CME/MOC

When an Aging Colleague Seems Impaired CME
(ACP Ethics Case Studies Series. CME by Medscape. 2017)

Position Papers

Physician Suicide Prevention and the Ethics and Role of a Healing Community: An American College of Physicians Policy Paper
(J Gen Intern Med. 2021 Sep;36(9):2829-2835)

Physician Impairment and Rehabilitation: Reintegration Into Medical Practice While Ensuring Patient Safety
(Ann Intern Med. 2019;170(12):871-879.)

Resources

ACP’s Physician Well-being and Professional Satisfaction initiative aims to foster a culture of wellness, reduce administrative burdens on physicians, improve practice efficiency and enhance individual physician well-being. The project website includes tools and programs for individual members, their practices, and ACP Chapters.

Ethics Manual

• Research
  Sections within the chapter include “Protection of Human Subjects,” “Use of Human Biological Materials in Research,” “Placebo Controls,” “Innovative Medical Therapies,” “Scientific Publication,” “Sponsored Research” and “Public Announcement of Research Discoveries.”

Responsible Conduct of Research (RCR) Project

Under a grant from the Association of American Medical Colleges and the DHHS Office of Research Integrity, ACP Ethics staff has implemented member education and support programs on the responsible conduct of office-based research. Workshops have been presented at ACP's annual meeting as well as at several ACP chapter meetings.

Resources

• Research in the Physician's Office: Navigating the Ethical Minefield
  (Hastings Cent Rep. 2008)

• Volunteering for a Research Study? Talk with Your Doctor About What You Should Know
  This patient education brochure provides information and guidance to patients who are considering volunteering for a research study. The brochures are designed to facilitate conversations between doctors and their patients. They are intended for distribution in doctors’ offices and come in packages of 50. Access the brochure order form.

Case Studies

• Author! Author! Who Should Be Named in a Published Study? An Ethics Case Study CME
  (ACP Ethics Case Studies Series. CME by Medscape. 2014)

• When are Industry-Sponsored Trials a Good Match for Community Doctors? CME
  (ACP-ASIM Observer. 2001)

Research Ethics Training Resources

• Revised Common Rule Educational Materials, Department of Health and Human Services
• The Research Clinic, Office of Research Integrity, Department of Health and Human Services
• Responsible Conduct of Research (RCR), Research Ethics and Compliance Training, CITI Program
• Responsible Conduct of Research Training, Office of Intramural Research, National Institutes of Health
• HIPAA Training and Resources, Department of Health and Human Services
• Online Ethics Center for Engineering and Science,University of Virginia
• World Association of Medical Editors (WAME)
• Council of Science Editors (CSE)
• European Association of Science Editors (EASE)

Comments and Letters

ACP supports National Academies’ call for withdrawal of Notice of Proposed Rulemaking (NPRM) for ‘Common Rule’ and for appointing a new commission
(Dec. 31, 2015)
ACP issued a statement in support of the National Academies' call for withdrawal of the Common Rule NPRM and for appointing a new research ethics commission.

ACP Comments on Notice of Proposed Rule Making (NPRM)
(Dec. 31, 2015)
ACP submitted comments to the Office for Human Research Protections of the U.S. Department of Health and Human Services on the Notice of Proposed Rule Making, "Federal Policy for the Protection of Human Subjects," also known as the Common Rule. ACP also submitted an earlier round of comments on the proposed rule making on Oct. 25, 2011.

Ethics Manual

• The Changing Practice Environment
• Resource Allocation

Resources

ACP’s High Value Care Project aims to improve health, avoid harms, and eliminate wasteful practices. The project website offers learning resources for clinicians and medical educators, clinical guidelines, best practice advice, case studies and patient resources on a wide variety of related topics.

Case Studies

• Patient Requests for Specific Care: 'Surely You Can Explain to My Insurer That I Need Boniva?' CME
  (ACP Ethics Case Studies Series. CME by Medscape. 2018)

• Who Should Get What? Mammography and the Stewardship of Health Care Resources CME
  (ACP Ethics Case Studies Series. CME by Medscape. 2012)

The following ethics case studies were developed through an award from the ABIM Foundation's Putting the Charter into Practice project. Watch a video report of the ACP's work on this project presented by Dr. David Fleming, former President of the College.

• Stewardship of Health Care Resources: Allocating Mechanical Ventilators During Pandemic Influenza CME
  (ACP Ethics Case Studies Series. CME by Medscape. 2017)

• Stewardship of Health Care Resources: Responding to a Patient's Request for Antibiotics
  (ACP Ethics Case Studies Series. CME by Medscape. 2014)

Ethics Manual

• Attending Physicians and Physicians-in-Training

Case Studies

• Professional Attire and the Patient-Physician Relationship CME/MOC
  (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

• Addressing a Colleague's Unprofessional Behavior During Sign-Out CME
  (ACP Ethics Case Studies Series. CME by Medscape. 2018)

• Resident Duty Hours: To Hand Over or Gloss Over? CME
  (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Position Papers

Hidden Curricula, Ethics, and Professionalism: Optimizing Clinical Learning Environments in Becoming and Being a Physician
(Ann Intern Med. 2018;168:506-8)

Resources

CME/MOC activities based on this ACP position paper are available:

• Annals offers two CME/MOC activities:

  • Ethics, Professionalism, and the Hidden Curriculum (Click on “CME/MOC” on the left sidebar.)

  • Annals On Call – Hidden Curriculum

• In this Curbsiders Podcast, Sanjay Desai, MD, coauthor of ACP’s position paper and Internal Medicine program director at Johns Hopkins, reviews several cases that illustrate how institutional norms can shape the practice of medicine. Detailed summaries of the cases discussed are available here.