The moral obligations of physician executives

Physician Executive, Nov-Dec, 2004 by Arthur Lazarus

A problem has developed for increasing numbers of physicians who assumed executive roles, especially physicians in nontraditional settings. Medical codes of ethics have generally failed to recognize competing values and moral conflicts inherent in health care rendered in different organizational settings, including private practice.

For example, the American Medical Association (AMA) Principles of Medical Ethics provides norms for treating patients, but provides little guidance for physician executives in terms of helping their organizations comply with legal and regulatory requirements, avoiding litigation, improving productivity and quality and building organizational trust and integrity.

When conflict exists between the needs of the organization or society and the needs of patients, the physician executive is left in a lurch, compelled only by an ongoing commitment to the needs of patients.

Using myself as an example--a psychiatrist employed in the pharmaceutical industry--there are at least five distinct sets of ethical principles I could follow:

1. AMA Principles of Medical Ethics

2. AMA Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry

3. AMA Principles of Medical Ethics With Annotations Especially Applicable to Psychiatric Administrators

4. American College of Healthcare Executives (ACHE) Code of Ethics

5. American Academy of Pharmaceutical Physicians (AAPP) Code of Ethics for the Practice of Pharmaceutical Medicine

The smorgasbord of offerings places physician executives squarely at the crossroads of ethical uncertainty. On one hand, an organization's code of ethics may be irrelevant to a physician executive's job or work setting. Again, using the pharmaceutical industry as an example, many pharmaceutical physicians adhere to the AAPP code of ethics, which basically guides ethical decision making related to patients (subjects) in clinical trials, but not to patients seen in clinical practice.

On the other hand, some codes of conduct may conflict with one other, making it impossible for a physician executive to choose a proper course of action when faced with an ethical dilemma or, worse yet, forcing him or her to resign from the job (or from the professional organization whose ethical principles can no longer be followed in good faith).

When a physician's organizational role collides with the ethical tenets of a professional society, a problem may also occur for ethics committees whose job is to adjudicate complaints of unethical behavior.

APA code

For example, many years ago, a district branch of the American Psychiatric Association (APA) struggled to reach a decision in a case brought against two psychiatrists.

The complaint alleged that, by conducting insurance reviews with the attending physician without the patient's written consent, the psychiatrists were behaving unethically.

The committee was uncertain whether the APA code of ethics even applied to the psychiatrists, as the code was originally written for practicing psychiatrists and predated the era of managed care. (Indeed, it remains controversial whether physicians working in an administrative capacity for managed care organizations are practicing medicine and liable for their decisions.)

The psychiatrists were exonerated, and later an addendum to the APA's code of ethics was incorporated to clarify existing standards for psychiatrists practicing in "organized settings."

The addendum stated: "A psychiatrist shall not conduct reviews or participate in reviews in a manner likely to demean the dignity of the patient by asking for highly personal material not necessary for the conduct of the review. A reviewing psychiatrist shall strive as hard for a patient he or she reviews as for one he or she treats to prevent the disclosure of sensitive patient material to anyone other than for clear, clinical necessity." The APA's philosophy is consistent with its overall approach to resolving ethical conflicts, that is, to resolve conflicts in a manner that results in the greatest benefit to the patient.

In a second addendum to the principles, the APA opined that various specialty groups within psychiatry can develop their own code of ethics "as long as it is additive to the principles ... and does not subtract or change any elements of the [code]."

It was in this spirit that the American Association of Psychiatric Administrators (AAPA) developed its own principles for psychiatrists working in all types of organizations, not only in managed care. The AAPA code of ethics stipulates that psychiatric administrators are responsible for the well being of the organization that is being administered, in addition to the welfare of patients.

ACHE code

The ACHE code of ethics is even broader. It contains standards of ethical behavior for health care executives in virtually all professional relationships--colleagues, patients, members of the health care executive's organization and other organizations, the community, and society as a whole.

The code also incorporates standards of ethical behavior governing personal behavior, particularly when that conduct directly relates to the role and identity of the health care executive. It is expected that health care executives will lead exemplary lives as moral advocates for the "rights, interests, and prerogatives of others served."