The Code of Medical Ethics of the American Medical Association (AMA) consists of three components:
The Principles of Medical Ethics Ethical Opinions of the Council on Ethical and Judicial Affairs Reports of the Council on Ethical and Judicial Affairs.The first two of these are contained in the Code of Medical Ethics – Current Opinions published biennially (1). New Opinions, issued twice annually at meetings of the AMA's House of Delegates, are available through the Council on Ethical and Judicial Affairs (CEJA)'s website (www.ama-assn.org/go/ceja) and through AMA's electronic database Policy Finder. Reports are available separately.
The Oath of Hippocrates, a brief exposition of principles for physicians' conduct, dates from the fifth century BCE. Its statements protect the rights of the patient and oblige the physician voluntarily to behave in an altruistic manner towards patients. It was modified in the 10th or 11th century AD to eliminate reference to pagan deities and is used widely in a variety of forms to mark entry into the medical profession early in medical school or upon graduation to serve as a guide to ideal conduct for physicians.
In 1803, Thomas Percival, an English physician and philosopher, published a Code of Medical Ethics describing professional duties and ideal behavior relative to hospitals and other charities (2). At the initial meeting of the AMA in Philadelphia, PA in 1847, the two major items on the agenda were the establishment of a code of ethics and the enumeration of minimum requirements for medical education and training (3). The Code of Ethics adopted at that meeting drew heavily on Percival's Medical Ethics.
The original 1847 Code retained its form, content, and principles through revisions in 1903, 1912, and 1947. A major change, with the intent of distinguishing between medical etiquette and medical ethics, appeared in the Principles of Medical Ethics adopted by AMA in 1957. This document contained only 10 short sections intended to provide a succinct expression of the basic concepts of its predecessor (Appendix A) (4).
The 1980 revision of the Principles represented an attempt to balance the dynamic tension between professional standards and legal requirements (5). It occurred in the milieu of legal actions ultimately adverse to the AMA, with judgments that its policies and acts in excluding associations between physicians and chiropractors constituted anticompetitive behavior (6). Section 3 of the 1957 Principles stated, “A physician should practice a method of healing founded on a scientific basis; and he should not voluntarily associate professionally with anyone who violates this principle.” This was replaced in the 1980 Principles by Principle V, “A physician shall continue to study, apply and advance scientific knowledge, make relevant information available to patients, colleagues and the public, obtain consultations, and use the talents of other health professionals when indicated” (5). And in Principle VI the statement “A physician shall…be free to choose …with whom to associate…” appears. The 1980 Principles also introduced gender neutrality, replacing “he” and “his” with “the physician” and “the physician's” (Appendix B) (5).
The 2001 revision of Principles of Medical Ethics added two new principles. One emphasizes that a physician, while caring for a patient, regard responsibility to the patient as paramount. The other asserts that physicians should support access to medical care for all people (7). The 2001 Principles appear as Appendix C.
The Principles of Medical Ethics are intended to address the elements of ethical behavior broadly and to be subject to alteration only infrequently; “(they) are not laws, but standards of conduct which define the essentials of honorable behavior for the physician” (1). Ethical Opinions issued by CEJA represent application of the Principles to specific issues and areas of professional activity. The environment of medical practice is ever changing and CEJA's Ethical Opinions are often revisited in light of new professional activities, new technology and procedures, and socioeconomic changes in the organization of medical practice.The Opinions are organized in the following sections:
1.0 Introduction 2.0 Opinions on Social Policy Issues 3.0 Opinions on Interprofessional Relations 4.0 Opinions on Hospital Relations 5.0 Opinions on Confidentiality, Advertising, and Communications Media Relations 6.0 Opinions on Fees and Charges 7.0 Opinions on Physician Records 8.0 Opinions on Practice Matters 9.0 Opinions on Professional Rights and Responsibilities 10.0 Opinions on the Patient-Physician RelationshipReports of the CEJA provide discussion of and recommend ethical policies concerning the specific issue targeted by the report. They are initiated when new questions or issues are not covered adequately by existing Ethical Opinions, e.g. cloning; when there is non-clarity about how existing ethical policy should be applied to new situations, e.g. managed care; when existing policy is questioned by the profession; or when changes in the environment of practice require revisiting previous opinions.
Typically, topics under consideration for study by CEJA are presented at an Open Forum at the biannual meetings of AMA's House of Delegates with the agenda circulated in advance. Interested individuals are afforded the opportunity to provide input and advice on the topics. Those items that stimulate interest or controversy are selected for study.
Other issues stimulating study and issuance of a Report are those referred from the House of Delegates or Board of Trustees. CEJA Reports include in-depth study of the elements of the issue in question. Drafts of proposed Reports are often reviewed by ethical or technical consultants or by other AMA Councils for comment from their area of expertise. Reports of CEJA are discussed before Reference Committees of the House of Delegates before presentation to the House of Delegates. The House may accept a CEJA Report, reject it, or refer it back for additional study and revision, but it may not amend the Report. Upon adoption of a Report, the recommendations of the Report form the basis for an Ethical Opinion of CEJA which is issued at the succeeding meeting of the House of Delegates.
In a rough analogy between the structure of AMA and that of the Federal Government, the Officers and the Board of Trustees constitute the Executive Branch; the House of Delegates the Legislative Branch; and CEJA the Judicial Branch. Oversight of the Code of Medical Ethics resides with CEJA, which is charged with interpretation of the Principles of Medical Ethics and issuing and promulgating Opinions on ethical matters. Its opinions are not subject to approval by popular vote of the House of Delegates. In addition, CEJA is charged with interpretation of the AMA's constitution and bylaws. It has original jurisdiction in all questions regarding membership, on controversies under the constitution and bylaws and under the Principles of Medical Ethics in which AMA is a party, and in controversies between two or more state medical associations or their members. It has appellate jurisdiction in questions of law and procedure but not of fact in controversies between a constituent association and one or more of its component societies and between a member or members of a component society and that society.
Annually, each incoming President of the AMA presents a nominee for membership on CEJA to the House of Delegates, which may accept or reject, but not offer other candidates. Members serve a 7-year term and may not hold other offices within AMA during their terms. Membership, in addition to the seven senior physician members, includes a Resident Member and a Medical Student member, each eligible to serve a 3-year term so long as they are in the category of Resident or Medical Student. The prohibition against holding office, serving on other AMA Councils or Committees, or representing any association in the House of Delegates is intended to depoliticize CEJA and to help assure that AMA Ethical Policy is not subject to changes in the tide of popular vote. The Council elects its own Chair and Vice Chair.
CEJA limits its ethical pronouncements to physician activities and behavior, and AMA's Code of Medical Ethics does not purport to set standards or provide guidelines for ethical behavior for other health professions, health care institutions, purchasers or purveyors of insurance products, or those who manufacture drugs or medical equipment. This gives some limitations in this era in which forces affecting patient care are increasingly influenced by the government, complex health care organizations, insurers, and industry. It is clear that ethical precepts for physician activities and behavior apply equally to a single physician and to a practice composed of two or three physicians. It is much less clear that these precepts apply to 500 physicians in a practice governed under a corporate structure, and the interaction between expectation for physician behavior and organizational behavior remains a challenge to be addressed in future revisions of AMA's Code of Medical Ethics.
Issues addressed in recent years by CEJA Reports and subsequent Ethical Opinions include genetic testing, aspects of human cloning, conflicts of interest in clinical trials, ethical considerations in encouragement of donation of cadaveric organs for transplantation, interactions with and inducements from the pharmaceutical and medical device industry, electronic communication with patients, and issues of privacy and confidentiality of patients' personal medical information. AMA ethical policies on these topics may be referenced on CEJA's website or through AMA's Policy Finder.
A recent activity is the drafting, approval, and promulgation of the Declaration of Professional Responsibility (Appendix D) (8). This document, conceived in the wake of concerns following the disaster of September 11, 2001, offers to patients a pledge that the medical profession will be available to them in their times of need. The Declaration has been ratified by almost 100 state and specialty medical associations. AMA is in the process of presenting it to organizations representing physicians in other nations for their consideration and support.
These principles are intended to aid physicians individually and collectively in maintaining a high level of ethical conduct. They are not laws but standards by which a physician may determine the propriety of his conduct in his relationship with patients, with colleagues, with members of allied professions, and with the public.
Section 1. The principle objective of the medical profession is to render service to humanity with full respect for the dignity of man. Physicians should merit the confidence of patients entrusted to their care, rendering to each a full measure of service and devotion.
Section 2. Physicians should strive continually to improve medical knowledge and skill, and should make available to their patients and colleagues the benefits of their professional attainments.
Section 3. A physician should practice a method of healing founded on a scientific basis; and he should not voluntarily associate professionally with anyone who violates this principle.
Section 4.The medical professional should safeguard the public and itself against physicians deficient in moral character or professional competence. Physicians should observe all laws, uphold the dignity and honor of the profession and accept its self-imposed disciplines. They should expose, without hesitation, illegal or unethical conduct of fellow members of the profession.
Section 5. A physician may choose whom he will serve. In an emergency, however, he should render service to the best of his ability. Having undertaken the care of a patient, he may not neglect him; and unless he has been discharged he may discontinue his services only after giving adequate notice. He should not solicit patients.
Section 6. A physician should not dispose of his services under terms of conditions which tend to interfere with or impair the free and complete exercise of his medical judgment and skill or tend to cause deterioration of the quality of medical care.
Section 7. In the practice of medicine a physician should limit the source of his professional income to medical services actually rendered by him, or under his supervision, to his patients. His fee should be commensurate with services rendered and the patient's ability to pay. He should neither pay nor receive a commission for referral of patients. Drugs, remedies or appliances may be dispensed or supplied by the physician provided it is in the best interests of the patients.
Section 8. A physician should seek consultation upon request; in doubtful or difficult cases; or whenever it appears that the quality of medical service may be enhanced thereby.
Section 9. A physician may not reveal the confidences entrusted to him in the course of medical attendance, or the deficiencies he may observe in the character of patients, unless he is required to do so by law or unless it becomes necessary in order to protect the welfare of the individual or of the community.
Section 10. The honored ideals of the medical profession imply that the responsibilities of the physician extend not only to the individual, but also to society where these responsibilities deserve his interest and participation in activities which have the purpose of improving both the health and the well-being of the individual and the community.
The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility not only to patients, but also to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.
I. A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity.
II. A physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception.
III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.
IV. A physician shall respect the rights of patients, colleagues, and of other health professionals, and shall safeguard patient confidences within the constraints of the law.
V. A physician shall continue to study, apply and advance scientific knowledge, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.
VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical services.
VIII. A physician shall recognize a responsibility to participate in activities contributing to an improved community.
The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.
I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.
II. A physician shall uphold standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.
III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.
IV. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.
V. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.
VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.
VII. A physician shall, recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.
VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
IX. A physician shall support access to medical care for all people.Never in the history of human civilization has the well-being of each individual been so inextricably linked to that of every other. Plagues and pandemics respect no national borders in a world of global commerce and travel. Wars and acts of terrorism enlist innocents as combatants and mark civilians as targets. Advances in medical science and genetics, while promising great good, may also be harnessed as agents of evil. The unprecedented scope and immediacy of these universal challenges demand concerted action and response by all. As physicians, we are bound in our response by a common heritage of caring for the sick and the suffering. Through the centuries, individual physicians have fulfilled this obligation by applying their skills and knowledge competently, selflessly, and at times heroically. Today, our profession must reaffirm its historical commitment to combat natural and man-made assaults on the health and well-being of humankind. Only by acting together across geographic and ideological divides can we overcome such powerful threats. Humanity is our patient.
We, the members of the world community of physicians, solemnly commit ourselves to:
Respect human life and the dignity of every individual. Refrain from supporting or committing crimes against humanity and condemn all such acts. Treat the sick and injured with competence and compassion and without prejudice. Apply our knowledge and skills when needed, though doing so may put us at risk.Protect the privacy and confidentiality of those for whom we care and breach that confidence only when keeping it would seriously threaten their health and safety or that of others.
Work freely with colleagues to discover, develop, and promote advances in medicine and public health that ameliorate suffering and contribute to human well-being.
Educate the public polity about present and future threats to the health of humanity.Advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.
Teach and mentor those who follow us for they are the future of our caring profession.We make these promises solemnly, freely, and upon our personal and professional honor.
Dr. Riddick is Chief Executive Officer Emeritus of the Ochsner Clinic Foundation. He was a member of the American Medical Association's Council on Ethical and Judicial Affairs 1995–2002 and served as its Vice Chair 1999–2001 and Chair 2001–2002
