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American College of Physicians (ACP) PDF

Some aspects of medicine, like the patient-physician relationship, are fundamental and timeless. Medicine, however, does not stand still-it evolves. Physicians must be prepared to deal with changes and reaffirm what is fundamental. This sixth edition of the Ethics Manual examines emerging issues in medical ethics and professionalism and revisits older issues that are still very pertinent. Changes to the Manual since the 2005 (fifth) edition include new or expanded sections on treatment without
interpersonal contact; confidentiality and electronic health records; therapeutic nondisclosure; genetic testing; health system catastrophes; caring for oneself, persons with whom the physician has a prior nonprofessional relationship, and very important persons (VIPs); boundaries and privacy; social media and online professionalism; surrogate decision making and end-of-life care; pay-for-performance and professionalism; physician-industry relations; interrogation; cross-cultural efficacy, cultural humility, and physician volunteerism; attending physicians and physicians-in-training; consultation, shared care, and the patient-centered medical home; protection of human subjects; use of human biological materials and research; placebo controls; scientific publication; and sponsored research. A case method for ethics decision making is included (Appendix).

The Manual is intended to facilitate the process of making ethical decisions in clinical practice, teaching, and medical research and to describe and explain underlying ethics principles, as well as the physician's role in society and with colleagues. Because ethics and professionalism must be understood within a historical and cultural context, the second edition of the Manual included a brief overview of the cultural, philosophical, and religious underpinnings of medical ethics in Western cultures. In this edition, we refer the reader to that overview (2, 3) and to other sources (4, 5) that more fully explore this rich heritage.

The Manual raises issues and presents general guidelines. In applying these guidelines, physicians should consider the circumstances of the individual patient and use their best judgment. Physicians have moral and legal obligations, and the two may not be concordant. Physician participation in torture is legal in some countries but is never morally defensible. Physicians must keep in mind the distinctions and potential conflicts between legal and ethical obligations and seek counsel when concerned about the potential legal consequences of decisions. We refer to the law in this Manual for illustrative purposes only; this should not be taken as a statement of the law or the legal consequences of actions, which can vary by state and country. Physicians must develop and maintain an adequate knowledge of key components of the laws and regulations that affect their patients and practices.
Medical and professional ethics often establish positive duties (that is, what one should do) to a greater extent than the law. Current understanding of medical ethics is based on the principles from which positive duties emerge. These principles include beneficence (a duty to promote good and act in the best interest of the patient and the health of society) and nonmaleficence (the duty to do no harm to patients). Also included is respect for patient autonomy-the duty to protect and foster a patient's free, uncoerced choices (6). From the principle of respect for autonomy are derived the rules for truth-telling. The relative weight granted to these principles and the conflicts among them often account for the ethical dilemmas that physicians face. Physicians who will be challenged to resolve those dilemmas must have such virtues as compassion, courage, and patience.

In addition, considerations of justice must inform the physician's role as citizen and clinical decisions about resource allocation. The principle of distributive justice requires that we seek to equitably distribute the life-enhancing opportunities afforded by health care. How to accomplish this distribution is the focus of intense debate. More than ever, concerns about justice challenge the traditional role of physician as patient advocate.
The environment for the delivery of health care continues to change. Sites of care are shifting, with more care provided in ambulatory settings while the intensity of inpatient care increases. The U.S. health care system does not serve all of its citizens well, and major reform has been needed. Health care financing is a serious concern, and society's values will be tested in decisions about resource allocation.

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