By training, I am a philosopher, specializing in ethics. For nearly 30 years I have been thinking and writing about the ethical dimensions of professional life. How does it happen that professionals are subject to special ethical obligations? So when the American Medical Association's Institute for Ethics opened a slot for a "Visiting Senior Scholar," I submitted an application. Now, a year later, at the end of a sabbatical, I am returning to my academic position at the University of Hawaii and reflecting on my experience. Here are some thoughts on ethics at the AMA.
Representing almost 300,000 physician-members and, arguably, the American medical profession as a whole, the AMA struggles with 3 distinct identities. In the first place, it is a corporation. It has its varied clients and a range of profit centers, and there is a relentless focus on the bottom line.
Secondly the AMA is a trade association for doctors. The vectored interests of the profession are authoritatively resolved in its House of Delegates, which meets twice a year. The House includes representatives from the state medical associations as well as from various specialty societies. Accordingly, there is some basis for the AMA's claim to be the voice of American medicine. Working through its Washington, DC offices, the AMA is a powerful advocate on behalf of medicine's interests.
In the third place, the AMA is a professional association with a selfless commitment to medicine's distinctive goods. This last claim is made completely non-ironically. Within the Chicago offices there is a broad and intense concern with the professional values that ought to inform medical practice. The staff of the Professional Standards Group, where I had my cubicle, displays knowledgeability and dedication that could credit any university. Visiting speakers offer differing ethical perspectives to the staff. The half-dozen formal presentations I gave during the year—some of them critical—were treated with nothing less than respectful interest, and a few of my suggestions found their way into policy initiatives.
Apart from these divergent orientations, the AMA is an ongoing argument about how these 3 quite different roles ought to fill out the organization's identity. In its 155-year history, the balance has constantly shifted.
I spent my year at the AMA headquarters in Chicago along with about 1000 other employees. A few feet from my eighth-floor cubicle was the office of the Council for Ethical and Judicial Affairs (CEJA), the body that now issues the AMA's ethical opinions and codes. The Council itself consists of 9 AMA members, mostly practicing physicians, who are elected to 7-year terms following nomination by incoming AMA presidents. One Council member is a medical student, another, a medical resident. CEJA's canonical ethics texts include a 1-page AMA "Principles of Medical Ethics"—a set of 9 exhortations to virtue—and a slightly longer "Fundamental Elements of the Patient-Physician Relationship"—a set of 6 fairly specific norms. There are also approximately 180 discrete CEJA "Opinions" that treat a range of questions pertaining to professional practice. Issues include the reporting of spouse abuse, genetic counseling, organ procurement, sports medicine, advertising, fee splitting, gifts from industry, caring for the poor, and so on. Finally, there are the "reports and recommendations" that lay out justifications for many of the opinions. Taken together, these 4 components—the principles, elements of the patient-physician relationship, opinions, and reports—are the AMA Code. The first 3 are easily obtained in an AMA publication entitled Code of Medical Ethics: Current Opinions that is revised every 2 years.
As it happens, I have never used the Code in teaching medical ethics nor do I know more than a handful of professors who do. Despite much excellent analysis in these materials, there are some good reasons for passing on pedagogical use. First, the Code is often inconsistent. While the Council and its staff do conscientious work on the opinions, each is drafted separately. What is said this year can conflict with language drafted years ago. Second, the opinions are narrowly focused: they are not intended as a comprehensive set of norms nor are they accompanied by a background conception of the profession's responsibility to society. There is no big picture. Third, some of the opinions—especially the older ones—fail to reflect the best thinking in the current medical ethics literature. These deficits are not the result of carelessness. Rather, each is a consequence of the way CEJA and the AMA conceive the task of developing ethical standards.
Though CEJA members know much more about medical ethics than the representative physician does, it is rare for them to be "specialists" in medical ethics. While staff are knowledgeable, they can only do so much to bring the council members up to speed during their 2-day meetings every other month. In my opinion, CEJA functions, in part, as what advertisers call a "focus group." Its processes generate what may be a fairly accurate reflection of the collective moral judgments of America's better-informed physicians; judgments that are, because of CEJA's role, authoritative within medicine despite dozens of other less-prominent codes governing medical practice in the United States. (See, for example, Medical Ethics: Analysis of the Issues Raised by the Codes, Opinions, and Statements by Brody, Rothstein, McCullough and Bobinski ). What CEJA has not done is to restate and systematize the elements of its work into a single comprehensive document that could be owned by the profession as a whole.
I believe that, at the most fundamental level, the medical profession suffers from a damaging disconnect between the processes by which it articulates what authoritative ethical standards it has, and the processes by which it inculcates ethical standards in its novices and initiates. In the legal profession, for example, there are formal codes developed by the American Bar Association and mandatory courses on professional responsibility taught at every law school. Both the law professors who teach the legal ethics courses and the authors of the ABA's Model Rules of Professional Conduct are singing from the same hymnal. But in remarkable contrast, those who are teaching medical ethics in colleges and universities—who are closely following and carefully contributing to the pertinent literatures—are both distinct and distant from the CEJA members who hammer out authoritative professional guidelines for practitioners. This reflects a traditional split between the private practice doctors, who have historically guided the AMA, and the academic physicians, who have tended to take leadership roles in the specialty societies and the Association of American Medical Colleges. While the academic physicians do not take on the practical task of securing broad practitioner ownership of clear professional standards, the doctors of CEJA have not felt the need to systematize their opinions into pedagogically useful materials. This disconnect is not a problem for the AMA so much as it is a problem for the profession of medicine in the broadest sense.
It is, I believe, essential that these 2 stakeholders be brought together. The medical profession needs to generate consistent, responsible, usable ethical guidance that is incorporated into medical pedagogy even as it is authoritatively endorsed by the leading professional organizations. It is high time for those whose job it is to articulate medicine's most authoritative ethical standards To join forces with those whose job it is to inculcate a distinct sense of professional responsibility in medicine's initiates. It is a dangerous error to see the 2 tasks as so distinct that each can be assigned to separate agencies that do not pay much attention to each other. It is far better to conceive the combined task as constitutive of ethical competency in a mature profession.
If medicine's practitioners and professors are ever to sing from the same hymnal, there will have to be a hymnal.
Brody BA, Rothstein MA, McCollough LB, Bobinski MA. Medical Ethics: Analysis of the Issues Raised by the Codes, Opinions, and Statements. Washington DC: The Bureau of National Affairs, Inc., 2001.