After 4 years' work, revised Code of Ethics goes to General Council for decision

Douglas M. Sawyer, MD; John R. Williams, PhD

Canadian Medical Association Journal 1996; 155: 314-315

Douglas Sawyer, a Red Deer, Alta., pathologist, chairs the CMA's Committee on Ethics. John Williams is director of ethics at the CMA.

In Brief

The CMA's Committee on Ethics will present a revised Code of Ethics for consideration by General Council during the annual meeting in Sydney, NS, later this month. This article outlines the reasons for updating the current (1990) version of the code and explains some of the significant changes and omissions. If approved by General Council, the revised code will take effect immediately.

En bref

Le Comité de l'éthique de l'AMC soumettra une version révisée du Code de déontologie au Conseil général au cours de l'assemblée annuelle qui se tiendra à Sydney (Nouvelle-Écosse) plus tard au cours du mois. Cet article décrit pourquoi on a mis à jour la version actuelle (1990) du Code et explique certains des changements importants. Si elle est approuvée par le Conseil général, la version révisée du Code entrera en vigueur sur-le-champ.

Almost 4 years after it began a major review of the Code of Ethics, the CMA Committee on Ethics will present its proposed revised code to General Council for approval later this month.

The committee spent the first 2 years deciding what type of code would suit the medical profession at this time and preparing the first draft of a revised code.[1] It and a subsequent draft were circulated widely to the Board of Directors and to CMA councils, committees, provincial and territorial divisions and affiliated societies, as well as to numerous other individuals and groups. This resulted in many comments and suggested changes that were examined closely and taken into account in subsequent revisions. The version being presented to General Council this year is accompanied by a set of annotations explaining the reasons for the committee's recommendations.

Reasons for change

The review of the current (1990) code found that much revision was needed.

The division between the seven principles of ethical behaviour at the beginning -- the code proper -- and the guide to the ethical behaviour of physicians, which accounts for the bulk of the document, is confusing.
The seven principles can no longer be considered the fundamental principles of medical ethics.
Other numbered sections are inadequate, especially those dealing with confidentiality (6), treatment recommendations (8), proxy decision making (14), contracts and advertising (30, 31, 33 and 36) and professional courtesy (43).
The current code is weak with respect to responsibilities to society (47-49) and in the lack of any reference to responsibilities to oneself.
It contains no recognition of the conflict physicians face between their responsibilities to the individual patient and to others.

Each of these issues has been addressed in the revised code. In determining the extent and nature of the revisions to be undertaken, the committee had to decide what a Code of Ethics can do. A code can provide a basic statement of principles and values and a set of guidelines for physician behaviour, but it cannot serve as a legal code, a bill of rights or a mission statement.[2] The Committee on Ethics resisted calls from various sources to reduce the code to a set of legal requirements. The practice of medicine has always required more of physicians than simple conformity to the law.[3]

Values

Another challenge was choosing the values on which to ground the code. Comments on the drafts revealed two very different understandings of ethics. According to one, the basic principles of medical ethics are unchangeable -- they just have to be applied in new situations. The other view considers that these principles are subject to change because of, for example, the emergence of patient autonomy and informed consent in opposition to the tradition of medical paternalism. The committee attempted to accommodate both views by basing its revised code on the enduring ethical principles of medicine, especially compassion, beneficence, nonmaleficence, respect for persons and justice.

One of the values incorporated in the revised code is the primacy of individual conscience in moral decision making. The code is a guide for physicians who have to decide for themselves how to behave in specific situations; it should be followed unless a physician has good reasons not to, and then the physician should be prepared to justify the contrary decision. Other values reflected in the format are brevity and usefulness; the code is long enough to provide practical advice on the major ethical issues of medical practice, but not too lengthy to hinder quick and easy use.

Outcomes

The time and effort spent revising the code will be justified if it produces better outcomes than the current version. What are these desired outcomes? First and foremost is an improvement in the quality of the patient-physician relationship, which will be achieved if physicians understand and implement their responsibilities to patients as outlined in the revised code. Many of these responsibilities, such as the prohibition against discrimination, the need for good communication and the limits to confidentiality, have been made more explicit.

Another desired outcome is an improvement in physician behaviour and decision making. The code can play but a small role in achieving this goal, and to do so it must be included in educational programs at the undergraduate, postgraduate and continuing-education levels. Despite these limitations, it can be a useful guide by helping physicians determine what is expected of them.

A third goal is improvement in the quality and efficiency of health care. The revised code addresses in some detail physicians' responsibilities for the health and well-being of all members of society, not just for their own patients. Quality and efficiency of care are important considerations to ensure that limited medical resources produce maximum benefits for all in need.

The final desired outcome is an improvement in professional and interprofessional collegiality. The revised code retains the section on responsibilities to the profession with its requirement that all physicians share the privilege and responsibility of maintaining medicine as a self-regulating profession. It also encourages cooperation with other health professionals in the interests of individual patients and society.

Omissions

The revised code reflects the committee's view that the Code of Ethics should enunciate physicians' responsibilities. Numerous articles have been deleted. Some (18-23) were cut because the code is not the place to deal with specific bioethical topics such as transplantation, abortion and euthanasia; others (30-33 and 36) were deleted because they are peripheral to ethics and better treated in regulations by the appropriate authorities, and one (12) because it deals with physicians' rights rather than responsibilities. The right in question -- to refuse a patient except in emergencies -- is one of a number of rights that could be claimed by physicians. The committee felt that these should be dealt with in a separate document, and it has already begun work on this project.

The revised code is also silent on patients' rights. If a declaration of such rights is considered desirable, it should be developed by patients or their representatives, not by physicians and the CMA. The Committee on Ethics would be more than willing to participate in such a project in an advisory capacity.

Conclusion

The revised code represents a consensus of the medical profession of Canada and is in accord with other national and international codes of medical ethics and with current ethical and legal thinking on the nature and goals of medicine.

The Committee on Ethics is satisfied that it has completed the revision to the best of its ability. It has tried hard to accommodate the points raised by members, divisions and licensing bodies, while maintaining a firm, consistent and ethical stance. The long process of consultation has shown that any further changes at the request of one group are likely to be opposed by others. On balance, the committee feels that the proposed new code is a definite improvement over the current version.

The Committee on Ethics awaits with great interest the debate at General Council.

References

Williams JR. Revision of the Code of Ethics: a backgrounder for the CMA annual meeting. CMAJ 1994; 151: 209-10.
Joseph K. Codes of ethics. Bioethics Outlook 1995; 6: 9-11.
Spicer CM. Nature and role of codes and other ethics directives. In: Reich WT, editor. Encyclopedia of Bioethics. Rev ed. vol 5. New York: Simon & Schuster Macmillan, 1995: 2605-12

| CMAJ August 1, 1996 (vol 155, no 3) / CMAJ le 1er août 1996 (vol 155, no 3) |