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Sade shares AMA ethical challenges for millennium

by Cindy A. Abole
Public Relations
Ask MUSC cardiothoracic surgeon Robert Sade, M.D., about his new role with the American Medical Association's Council on Ethical and Judicial Affairs (CEJA) and chances are he will break out into an easy smile and invite you to pull up a chair. 

After all, Sade who serves as the South Carolina Medical Association (SCMA) Speaker of the House, has been squaring off on ethical and moral medical issues for 13 years on behalf of Palmetto State physicians as a founding member of the SCMA bioethics committee. He's familiar with statewide and national AMA issues and its effects on fellow colleagues, the medical industry and most importantly, patients.

In June, Sade was named to the AMA council post which acts as the judicial body that  sets and establishes professional standards through a constitution and bylaws. Sade joins Orangeburg physician Randolph D. Smoak Jr., M.D., new AMA president, and South Carolina delegates J. Chris Hawk, III, M.D., Daniel W. Brake, M.D., and fourth-year MUSC medical student Kris Crawford, as part of the Palmetto State's working contingent in medicine's largest professional organization. 

For Sade, the move is a step forward working on behalf of its 300,000-plus members and peers.

CEJA's duty is to help set professional standards for physicians nationally, which also includes ethical behavior. AMA's own principles of medical ethics outlines rules for physicians and the behaviors and codes of professional conduct.

“These principles are the guts of what shapes a physician's view on ethics and principles,” Sade said. “Applying them under specific instances and with the profession is CEJA's role.”

The group issues reports on a variety of today's most pressing and controversial medical ethics issues. Once approved by the AMA's House of Delegates, the reports are formally established into AMA policy. The group also issues opinions based upon recommendations at the end of each of their reports which automatically become part of the organization's Code of Medical Ethics.

While Sade begins a seven-year term on the council, Hawk, a Charleston surgeon, begins his role on the AMA's scientific committee. Brake, also from Charleston, is a member of the association's legislation committee while Crawford finishes his term as student representative on the American Medical Political Action Committee.

“There are a lot of states who want this opportunity of having a seat at the table,” said William F. Mahon, chief executive officer of the SCMA. “South Carolina happens to be one of three states who are in such an enviable position. Our representation may not all be leadership roles, but I feel that South Carolina physicians are certainly well-represented.”

For 153 years, the Code of Medical Ethics has managed to change and shape the nature of healthcare delivery in the United States. Although there have been heated debates waged over issues and conflicts of interest, CEJA's opinions have helped guide the profession to where it is today. 

As a council member, Sade joins a team of nine members—seven physicians, one resident and a medical student—in debating some of medicine's hottest issues. Among issues currently in the spotlight questions the profession's stand on cost versus profit in medicine. 

Professionalism versus commercialism in medicine
 How ethical is it for physicians to sell health-related products or services within their own offices or practice sites? Sade asks, is it morally proper for a plastic surgeon or dermatologist to use their own reputations as experienced professionals to endorse or sell a retail line of cosmetics to a patient following surgery or treatment without conflict of interest?

“There's a number of medical specialists who find prohibition of office sales totally  objectionable,” Sade said.  He gives the example of orthopaedists who regularly sell specialty-related items like crutches, canes and other medical items directly through their offices.

On the other hand, “It's no secret that some physicians, working within professional office settings, are making huge profits by running a non-medical business behind their medical degrees,” Sade said. “If a doctor provides a product for sale, for example, a week in his personally-owned resort-style spa, will it actually improve their recovery and health? What we don't know is how much of it will actually help the patient's health versus profiting from an individual's desire for comfort or luxury.”

According to Mahon, many of the issues that are being discussed and resolved by CEJA are not only making an impact locally and nationally, but internationally. Years ago in South Carolina, physicians and pharmacists battled over the issue of who could
legally dispense and sell prescriptive drugs, Mahon recalled. The issue was later resolved in favor of pharmacists through the S.C. General Assembly. 

Today, CEJA and state medical organizations worry about the popularity of natural and alternative medicines, especially in the sale of vitamins, minerals and other non-prescription drugs to patients through physician practices. 

“No one really has a handle on it,” Mahon said. “For years, the only time there were any complaints was when certain issues were challenged and raised through SCMA. It's always been known that some physicians have supplemented their income this way.”

But CEJA is carefully looking at how these practices conform to professional standards set by the AMA's codes and principles of medical ethics.

“Business is prominent and pervasive throughout healthcare,” Sade said. “Physicians possess and sell goods unrelated to health within their offices. In some cases, the physician is becoming more of a distributor than healer. CEJA's role is to protect professionalism and excellence during changing times. It's a challenge for physicians to balance both professionalism and economic interests, in that order. What's even more difficult for physicians is sustaining this role of professionalism as their most important guideline throughout their entire careers.”

In 1997, SCMA and CEJA completed a report on this issue which helped the SCMA to investigate the impact of business and medicine practices within South Carolina. This effort  received mixed reviews
from statewide physicians, especially ophthalmologists, dermatologists and some medical specialty organizations, who disagreed with CEJA's stringent stance. For now, the issue continues to draw open debate among state medical and specialty societies.

Disclosure of training and level of expertise
Other areas of interest revolve around AMA's policy for specifically identifying medical students to patients who are receiving part of their care from them.

The issue hit home recently when a court case raised questions about medical care between managed care giant Blue Cross/Blue Shield of South Carolina and the family of a Greenville patient. The dispute challenged the specifics of a patient's contract with the level of medical care received from a resident versus a board-certified physician. In the end, the court ruled in favor of the plaintiff.

According to Mahon, it's common for people to assume that white cloaked professionals are physicians. The issue has caused medical schools to re-evaluate the formalities of introduction of medical students at all levels and the proper monitoring of work once they begin contact with any patient. 

“In most cases, medical schools have not welcomed changes in the way students are required to interact with patients,” Sade said.

“Yet on the whole, schools have done well in providing very good supervision in the training of their medical students, residents and interns.” He continued, “Above all things, students, like all physicians, should always be truthful in disclosing who they are and what their roles are.”

CEJA also recommends that patients even become more proactive throughout their own care. “It's up to the patient how they accept and adjust to their care, including complying with the treatment plan they have agreed to,” Sade said. 
 How does Sade view the drift away from professionalism toward commercialism in medicine?

“My concern is that there's already so much commercialism in medicine, that new guidelines may be ignored, undermining the credibility of CEJA,” Sade said. 

In short, he worries that by creating and imposing rules, laws and ethical guidelines for the profession, there's a chance that few people will pay attention and follow them.

“As you attempt to control an increasingly widespread behavior, you may undermine the respect for authority of whoever makes the guidelines for creating the balancing act,” Sade said. “It will be interesting to see and be involved in how CEJA manages to weigh the issues of business, professionalism, current and ideal practice.”

Other interests for Sade includes the ability to learn, listen and contribute to council and deliberations. Sade's schedule will be hard-pressed. His role calls for him to attend six formal meetings per year, plus continuous communication with CEJA members through online debates and discussions courtesy of the World Wide Web and e-mail.

“I've been thinking about ethical issues for quite some time and have some opinions about the way things ought to be,” he said. “However, there are lots of issues that I don't know enough about the history of how an idea or standard was developed and how we got to where we are today.”

Other ethical concerns
Other areas of controversy being addressed by CEJA include the provision of gifts to physicians by medical industries and purposeful deceit by physicians regarding a patient diagnoses and their HMO contracts.

“People are clever and learn how to get around problems that stand in the way of getting an insurance company to pay for a desirable treatment,“ Sade said. “To me, lying to anyone—the patient, the medical staff, even the healthcare provider—undermines the integrity of the physician and of the medical profession as a whole.” 

Among the most important of CEJA's activities is its current proposal to update and revise the AMA's Principles of Medical Ethics, the core rules for medicine established and first set by the organization in 1847. 

“There's been a number of important changes that have taken place since the last revision of the Principles in 1980,” Sade said.

“This would include for example, the rise of managed care, the anticipated huge impact of gene technology, geriatric medicine and end-of life care issues.”

Above all, Sade feels confident about his participation and potential for establishing positive change. “How CEJA and the AMA goes about doing this, while creating reasonable policies given the realities of the profession and economic life of Americans at the beginning of the 21st century will be the challenge,” he said.
 

Principles of Medical Ethics 

Preamble 
The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility not only to patients, but also to society, to other health professionals, and to self.

The following principles adopted by the American Medical Association are not laws, but standards of conduct that define the essentials of honorable behavior for the physician. 

Principles of Medical Ethics 
I. A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity. 

II. A physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception. 

III. A physician shall respect the law and recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. 

IV. A physician shall respect the rights of patients, of colleagues, and of other health professionals, and shall safeguard patient confidences within the constraints of the law. 

V. A physician shall continue to study, apply, and advance scientific knowledge, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talent of other health professionals when indicated. 

VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical services. 

VII. A physician shall recognize a responsibility to participate in activities contributing to an improved  community. 

Source: Code of Medical Ethics: Current Opinions With Annotations © 1996 American Medical Association. Content provided by the Ethics Standards Division