Medical Ethics

Principles of Medical Ethics of the Idaho Medical Association

Members of the IMA must subscribe to the Principles of Medical Ethics of the Idaho Medical Association (see IMA Bylaws Chapter III Membership, Section 3). That document is here reprinted for members in its entirety.

PREAMBLE

This set of statements represents the position of the Idaho Medical Association regarding the ethical duty of its member physicians. They are guidelines for conduct which define the basis for honorable behavior within the medical profession.

1. A physician's highest duty is to seek the relief of consequences of accident and illness, and, where possible, to assure the maintenance of health and the prevention of injury and disease.
2. A physician shall maintain adequate medical records to allow continuity of patient care. He should keep in confidence the statements and clinical condition of his patients, releasing such information only with the patient's consent, or if it becomes necessary in order to protect the welfare of the individual or of the community, or where otherwise required by law.
3. A physician shall demonstrate a continuing commitment to the maintenance and advancement of his professional skills.
4. A physician shall obtain consultation and assistance from other physicians or recognized medical professionals where, in his judgment, it best serves the medical needs of his patient.
5. A physician may choose to serve or not to serve as consultant to another health practitioner.
6. A physician may choose the patients whom he will serve. In an emergency, 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.
7. A physician shall respect the desire of his patient to participate in decisions relating to therapy. This includes informing his patients of the rationale for and probable consequences of his treatment.
8. In his representation to the public a physician shall not engage in exaggeration, distortion or misrepresentation regarding himself or his practice.
9. A physician's fee should be set fairly, based on the services rendered by him or under his supervision.
10. A physician shall safeguard the public and the profession by following these principles. Professional incompetence and unethical behavior shall be reported to the appropriate medical authorities.

JUDICIAL COMMISSION
OPINIONS AND REPORTS

1. Charges for Completion of Insurance Forms:
The physician should, without additional charge to the patient, complete, or provide the information necessary to complete, the standard, simplified insurance forms approved by the AMA and the Health Insurance Council, or other similar simplified health insurance forms; however, due to the proliferation of insurance claims related paper work, more complex forms required by some third party carriers and frequent requests for written reports or other evaluations, it is not unreasonable for a physician to impose a reasonable charge for this extended service to the patient.(Adopted July 1981)

2. Interest Charges and Service Charges:
Excluding charges for Medicare and/or Medicaid patients, it is not unethical for a physician to charge interest on an unpaid bill or note, or to charge a penalty on fees for professional services not paid within a prescribed period of time. The patient must be notified in advance of the existence of this practice.(Adopted July 1981)

3. Lien Against Charges for Medical Services:
It is not unethical for a physician to exercise his right to a lien pursuant to Section 45-704B, Idaho Code.(Adopted July 1981)

4. Records on Termination of Partnership or Professional Affiliation:
When a physician who is presently treating a patient requests records from another physician who has formerly treated the patient, that former physician should promptly make available to the attending physician, when properly authorized by the patient, pertinent information concerning the diagnosis and treatment of that patient. The physician need not necessarily send exact duplicates of all information contained in the clinical record, but may summarize the pertinent clinical aspects of the record, or confer directly with the attending physician.

If the amount of material to be duplicated is unusually large, or the physician is required to spend an inordinate amount of time summarizing the clinical history, dictating or otherwise utilizing his time or that of his office personnel, a reasonable fee may be charged. These anticipated charges, however, should be made known to the patient prior to performing the service.
Under no circumstances, including the disposition of a patient's bill, should a physician refuse to make available his clinical record or summary to a colleague when requested and properly authorized by the patient. (Adopted July 1981)

5. Collection of Accounts:
Before a physician refers a delinquent account to a collection agency, he should first consider the patient's ability to pay and the tactics and methods of the collection agency.
The physician should not sell his delinquent accounts to a collection agency for a flat fee. (Adopted July 1981)

6. Surgical Assistant's Fee:
Each physician engaged in the care of the patient is entitled to compensation commensurate with the value of the services he has personally rendered. No physician should bill in his own name for a service which he does not perform or supervise.
Referral does not constitute a professional service for which a professional charge should be made.
When services are provided by more than one physician, each physician should submit his own bill to the patient to be compensated separately if possible. (Adopted July 1981)

7. Physician Advertising:
It shall be unethical for any physician to disseminate or cause to be disseminated any form of public communication containing a false, fraudulent, misleading, or deceptive statement or claim, for the purpose of or likely to induce, directly or indirectly, the rendering of professional services or furnishing of products in connection with the professional practice for which the physician is licensed. A "public communication" shall include, but not be limited to, communications by means of television, radio, motion picture, newspaper, book or list or directory of physicians. A false, fraudulent, misleading or deceptive statement or claim includes a statement or claim which does any of the following:

(a) Contains a misrepresentation of facts;
(b) Is likely to mislead or deceive because of a failure to disclose material facts;
(c) Is intended or is likely to create false or unjustified expectations of favorable results;
(d) Relates to fees, other than a standard consultation fee or range of fees for specific types of services, without fully disclosing all variables and other material factors;
(e) Contains other representations or implications that in reasonable probabilities will cause an ordinarily prudent person to misunderstand or be deceived.,

Any price advertisement shall be exact, without the use of such phrases as "as low as," "and up," "lowest prices" or words or phrases of similar import. Any advertisement which refers to services, or costs for such services, and which used words of comparison must be based on verifiable data substantiating the comparison. Any person so advertising shall be prepared to provide information sufficient to establish the accuracy of such comparison. Price advertising shall not be fraudulent, deceitful, or misleading. In connection with price advertising, the price for each product or service shall be clearly identifiable. The price advertised for products shall include charges for any related professional services, including dispensing and fitting services, unless the advertisement specifically and clearly indicates otherwise.

No physician shall compensate or give anything of value to a representative of the press, radio, television or other communications medium in anticipation of, or in return for, professional publicity unless the fact of compensation is made known in such publicity.
A physician may not use any professional card, professional announcement card, office sign, letterhead, telephone directory listing, medical list, medical directory listing, or a similar professional notice or device if it includes a statement or claim that is false, fraudulent, misleading or deceptive as previously defined.
Advertising by any physician may include but not be limited to the following:

(a) A statement of the name of the physician, and the addresses and telephone numbers of the offices maintained by the physician.
(b) A statement of office hours regularly maintained by the physician.
(c) A statement of language, other than English, fluently spoken by the physician or a person in the physician's office.
(d) A statement that the physician is board certified or eligible, or a statement that the physician limits his practice to specific fields.
(e) A statement that the physician provides services under a specified private or public insurance plan or health care plan.
(f) A statement of names of schools and postgraduate clinical training programs from which the physician has graduated, together with the degrees received.
(g) A statement of publications authored by the practitioner.
(h) A statement of teaching positions currently or formerly held by the physician, together with pertinent dates.
(i) A statement of his or her affiliations with hospitals or clinics.
(j) A statement of the charges or fees for services offered by the physician.
(k) A statement that the physician regularly accepts installment payment of fees.
(l) Otherwise lawful images of a physician, his or physical facilities, or a commodity to be advertised, but not of persons or parts of persons or facsimiles thereof for the purpose of demonstrating a medical condition, injury, disease, including obesity, or recovery or relief therefrom. (Except that eyeglasses, contact lenses, hearing aids, dentures and orthopedic devices may be advertised on the person.)(Adopted July 1982)

8. Physician Sale of Medically Related Products:
It is unethical for a physician to promote the sale of drugs, devices, appliances or goods (hereinafter "medical products") to a patient that are unnecessary and not medically indicated. If a physician offers medical products to his patients in connection with his practice, the physician must not exercise any undue influence over the patient regarding the selection of medical products from other sources. Patients are entitled to the same freedom of choice in selecting medical products distributed by a physician as they have in the choice of a physician. (Adopted July 1983)

9. Fee Splitting and Rebates:
It is unethical for a physician to participate in fee splitting or receive or give rebates, either directly or indirectly. Consideration in the form of any kind of valuable property solely for the referral of a patient constitutes fee splitting or a rebate and is improper both for the physician paying the consideration and the physician receiving the consideration. The patient relies on the judgment of the physician in all matters of referrals, and the sole criteria of a physician in making the referral must be based on the medical skills of the person to whom the patient is referred. Laboratories that provide consideration to physicians solely based on the number of referrals are engaged in fee splitting or rebates, which is unethical.(Adopted July 1983)

10. Medical Communications:
Physicians should cooperate with the press to insure that medical news is made available more accurately than would be possible without their assistance. News of general interest to the public that falls within this category includes births, deaths, accidents and police cases. The following information is considered to be in the public domain and can be made available without the specific consent of a patient:

(a) Patient's name, address, age.
(b) Nature of accident: general information regarding the injuries, such as "mild," "moderate," or "severe" may be released, but there should be no discussion of the specific injury or the circumstances surrounding the accident.
(c) Patient's condition: a general statement may be made regarding the patient using classifications of minor injuries and general diagnosis of good, fair, serious or critical. A physician shall not disclose any specific information regarding the patient without the consent of the patient. The decision of the patient regarding disclosure of specific information is controlling. (Adopted July 1983)

11. Ownership of Health Facility by Physician:
It is not unethical for a physician to own or have a financial interest in a for profit hospital, nursing home or other health facility, such as an emergency clinic, free-standing surgical center or diagnostic facility. But the physician has an ethical obligation to disclose his ownership of such a health care facility to his patients in making a referral or prior to admission or utilization. The cardinal rule is that the physician not place his or her own financial interest above the welfare of the patient under any circumstances. Financial gain should at all times be subordinate to the patient's interest.(Adopted July, 1985)

12. Capital Punishment:
As a member of a profession dedicated to preserving life, the physician should not be a participant in legally authorized execution. A physician may make a determination or certification of death as provided by law. individual's opinion on capital punishment is a personal, moral decision of the physician, and should not be a determinant in fulfilling of one's professional role. (Adopted July 1985)

13. Abuse of Children:
Idaho law requires the reporting of suspected abuse of children, and this can be a problem for the physician who may be the object of pleadings from both offenders and victims to keep the matter confidential. Physicians should keep in mind that failure to comply with the laws requiring reporting of suspected cases of child abuse and others at risk may result in later severe abuse which may result in permanent bodily or brain injury or even death. A person who is brought to a physician with a suspicious injury is the patient whose interests require the protection of law in a particular situation, even though the physician may also provide services from time to time to parents or other members of the family. There is an ethical obligation for the physician to comply with the statutory requirements for reporting suspected abuse. (Adopted July 1985)

14. Contingent Physician Fees:
If a physician's fee for medical service is contingent on the successful outcome of a claim, there is the ever-present danger that the physician may become less of a healer and more of an advocate. Accordingly, a physician's fee for medical services should be based on the value of the service provided by the physician to the patient and not on the uncertain outcome of a contingency that does not in any way relate to the value of the medical service.(Adopted July 1985)

15. Records of Physicians on Retirement:
A patient's records may be necessary to the patient in the future not only for medical care, but also for employment, insurance, litigation or other reason. When a physician retires or dies, patients should be notified and urged to find a new physician and should be informed that, upon authorization, records will be sent to the new physician. Records which may be of value to a patient and which are not forwarded to a new physician should be retained, either by the physician himself, another physician, or such other person lawfully permitted to act as a custodian of the records.(Adopted July 1985)

16. Drugs and Devices/Prescribing:
(a) A physician should not be influenced in the prescribing of drugs, devices or appliances by a direct or indirect financial interest in a pharmaceutical firm or other supplier. Whether the firm is a manufacturer, distributor, wholesaler or repackager of the products involved is immaterial. Reputable firms rely on quality and efficacy to sell their products under competitive circumstances and do not appeal to physicians to have financial involvements with the firm in order to influence their prescribing.
(b) A physician may own or operate a pharmacy if there is no resulting exploitation of patients.
(c) A physician should not give patients prescription in code or enter into agreement with pharmacies or other suppliers regarding the filling of prescriptions by code.
(d) Patients are entitled to the same freedom in selecting who will fill their prescription needs as they are in the choice of a physician. The prescription is a written direction for a therapeutic or corrective agent. A patient is entitled to a copy of the physician's prescription for drugs, eyeglasses, contact lenses, or other devices as required by law. The patient has the right to have the prescription filled wherever the patient wishes.
(e) Patients have a right to prompt access to the information contained in their individual medical records. The prescription is an essential part of the patient's medical record. Physicians should not discourage patients from requesting a written prescription or urge them to fill prescriptions at an establishment which has a direct telephone line or which has entered into a business or other preferential arrangement with the physician with respect to the filling of the physician's prescription. Adopted July 1985)

17. Incentives to Limit Care:
Consistent with IMA ethical requirements of disclosure to the patient of ownership or financial interest in drugs, devices and health care facilities, the physician who has a financial incentive to limit access to care should disclose this fact to the patient before such limitation is imposed.(Adopted July 1985)

18. Sale of Donor Organs for Transplant:
It is unethical for any physician to be involved in the purchase or sale of non-renewable transplantable organs.(Adopted July 1985)

19. Withholding or Withdrawing Life-Prolonging Medical Treatment:
The social commitment of the physician is to sustain life and relieve suffering. Where the performance of one duty conflicts with the other, the choice of the patient, or his family or legal representative if the patient is incompetent to act on his own behalf, should prevail. In the absence of the patient's choice or an authorized proxy, the physician must act in the best interests of the patient.
For humane reasons, with informed consent, a physician may do what is medically necessary to alleviate severe pain, or cease or omit treatment to permit a terminally ill patient whose death is imminent to die. However, he should not intentionally cause death. In deciding whether the administration of potentially life-prolonging medical treatment is in the best interest of the patient who is incompetent to act in his own behalf, the physician should determine what the possibility is for extending life under humane and comfortable conditions and what are the prior expressed wishes of the patient and attitudes of the family or those who have responsibility for the custody of the patient.
Even if death is not imminent but a patient's coma is beyond doubt irreversible and there are adequate safeguards to confirm the accuracy of the diagnosis, and with the concurrence of those who have responsibility for the care of the patient, it is not unethical to discontinue all means of life-prolonging medical treatment.

Life-prolonging medical treatment includes medication and artificially or technologically supplied respiration, nutrition or hydration. In treating a terminally ill or irreversibly comatose patient, the physician should determine whether the benefits of treatment outweigh its burdens. At all times, the dignity of the patient should be maintained. (Adopted July 1987)

20. Corporate Practice of Medicine:
The contractual relationships that physicians assume when they join or affiliate with group practices or agree to provide services to the patients of an insurance plan are varied.
Income arrangements may include hourly wages for physicians working part time, annual salaries for those working full time, and share of group income for physicians who are partners in groups that are somewhat autonomous and contract with plans to provide the required medical care. Arrangements also usually include a range of fringe benefits, such as paid vacations, insurance, and pension plans.
Physicians may work directly for plans or may be employed by the medical group or the hospital that has contracted with the plan to provide services. In the operation of such plans, physicians should not be subjected to lay interference in professional medical matters and their primary responsibility should be to the patients they serve. (Adopted February 1998)

21. Guidelines for Expert Medical Witnesses:

1. Recommended Qualifications for the Physician Expert Witness

a. The physician expert witness must have a current, valid, and unrestricted license to practice medicine in the state in which he or she practices.
b. The physician expert witness shall be a diplomate of or have satisfactorily completed the certification requirements of a specialty board recognized by the American Board of Medical Specialties or the American Board of Osteopathic Specialties as well as be qualified by experience or demonstrated competence in the subject of the case. The specialty certification of that physician shall be appropriate to the subject matter of the case.
c. The physician expert witness shall be familiar with the clinical practice of the specialty or the subject matter of the case at the time of the occurrence and shall be actively involved in the clinical practice of the specialty or the subject matter of the case for three of the previous five years at the time of the occurrence.
d. The physician expert witness shall affirm and be prepared to document the percentage of time that is involved in serving as an expert witness.

2. Recommended Guidelines for Behavior of the Physician Expert Witness - Physicians have an obligation to testify in court as expert witnesses when appropriate. Physician expert witnesses are expected to be impartial and shall not adopt a position as an advocate or partisan in the legal proceedings.

a. The physician expert witness shall review the medical information in the case and testify to its content fairly and impartially. The physician's review of medical facts shall be thorough, fair and impartial and shall not exclude any relevant information in order to create a view favoring either the plaintiff or the defendant.
b. The physician expert witness shall review and be familiar with the standards of practice prevailing in the applicable community at the time of occurrence.
c. The physician expert witness shall be prepared to state the basis of the testimony presented and whether it is based on personal experience, specific clinical references, or generally accepted opinion in the specialty field. Important alternate methods and views shall be fairly presented and discussed.
d. Compensation of the physician expert witness shall be reasonable and commensurate with the time and effort given to preparing for deposition and court appearance. It is unethical for a physician expert witness to link compensation to the outcome of the case.
e. The physician expert witness shall be aware that transcripts of depositions and courtroom testimony are public records, subject to independent peer review. (Adopted October 1998)