Just another day in your busy emergency department, except that today one of your patients ended up having a lumbar puncture positive for bacterial meningitis. You intubated the patient and were well within the three-foot radius for droplet exposure. You know that you need a single dose of ciprofloxacin and then you can safely go home to your family and friends. You could halt your work flow and get seen in your ED as a patient, but you could also just order that single dose of Cipro for the patient you’re currently treating and then take it yourself. The patient has Medicare; they are never going to pay for it. What’s standing in your way? Ethics!

We practice in high-stress environments, and are asked to make serious ethical decisions surrounding patient care and dispositions multiple times throughout each shift. We all have an individual moral compass to help us navigate, but we are also ethically guided and held accountable by an overarching document called the American Medical Association (AMA) Code of Medical Ethics.

History of the AMA Code of Medical Ethics

The first version of the Code of Medical Ethics was written in 1847, and the initial members of the AMA unanimously adopted it. Over the past 167 years, the Code has been through multiple revisions with amendments and additions as the health care arena has changed. The Code currently consists of a general preamble and the nine principles of medical ethics followed by 10 chapters of ethical policy. The Code is considered the real-world application of ethical principles to the modern practice of medicine.¹

I am not an AMA member, so how can the code apply to me?
The AMA Code of Medical Ethics is applied to all practicing physicians in the United States and is used as a template for medical ethics in most other industrialized nations. Your membership status in the AMA does not determine whether or not you are governed by the Code, and if you are called into question in a court of law, the Code can and will be used to both defend and attack the decisions you have made. The AMA Code of Medical Ethics is a measuring stick that is applied to all physicians.

Who makes the code and maintains its accuracy?
The AMA Code of Medical Ethics is written and maintained by the Council on Ethical and Judicial Affairs. The council is composed of eight physicians and one medical student. One of the physician seats is reserved for a resident or fellow physician. The President of the AMA nominates all of the members of the Council. The medical student serves a two-year term, the resident/fellow physician serves a three-year term, and the other seven members serve seven-year terms. The Council writes the reports and ethical policy, and these reports are then proffered to the House of Delegates (HOD) of the AMA. The reports and new policy are debated in reference committee and on the floor of the HOD. The reference committee and the Delegates of the HOD vote to pass the new policy and file the report, to refer the report back to the Council, or to vote down the report and policy. Due to the sensitive nature of many of the reports and policies, it is not unusual for reports to be referred back to the Council multiple times before being adopted by the HOD.

In the last six years, the Council has been working on a code modernization project. Modernizing the Code has highlighted gaps in the current Code and illuminated policies that can be withdrawn because they are no longer applicable to the contemporary practice of medicine. The proffered Code modernization can be viewed by AMA members, and once finalized will be viewable by the public via the AMA website. The new Code will be composed of 12 chapters and is streamlined and efficient.

Case Resolution

Let’s return to our case. First, we will use our moral compass. Arguments to use the patient to order the prophylaxis are: 1) the patient will not pay for the medication out of pocket; 2) you won’t need to mess up the workflow of the ED; and 3) this is the easiest way you can think of to get the prophylaxis. Reasons against would be: 1) it is now putting a medication on the patient’s chart that was not received and may confuse future treatment decisions; 2) Medicare is being charged for a medication that was not given to the patient, and this may be considered fraud; and 3) you have an alternative way of getting the prophylaxis via paperwork and some additional time.

Principle III states, “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.”

Now, let’s see what the Code has to say on this matter. Principle II of the Code states, “A physician shall uphold the 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.” Principle III states, “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.”²

It does appear quite clear. The ethical choice is to go through the hassle of the paperwork and have the medication ordered under your name and recorded for the appropriate use (postexposure prophylaxis).

I encourage you to familiarize yourself with the principles of the AMA Code of Medical Ethics and to use the Code to practically apply ethical principles to your current practice.

If you would like to get more involved in the AMA and setting ethical policy for our profession, please contact Dr. Fairbrother at Hilary.Fairbrother@nyumc.org.

Dr. Fairbrother is assistant director of undergraduate medical education at the Ronald O. Perelman Department of Emergency Medicine at New York University School of Medicine in New York.

References

1. American Medical Association. History of AMA ethics. Available at http://www.ama-assn.org/ama/pub/about-ama/our-history/history-ama-ethics.page. Accessed January 5, 2015.
2. American Medical Association. Principles of medical ethics. Available at http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/principles-medical-ethics.page. Accessed January 5, 2015.