A Professional Response to Demands for Accountability: Practical Recommendations Regarding Ethical Aspects of Patient Care

Demands for accountability in medicine are increasing. Accountability generally refers to the obligation of one party to provide a justification and to be held responsible for its actions by another interested party [1, 2]. Previously accountable to their patients and to their colleagues, physicians now face a new rendition of accountability. Citizens, politicians, insurance agencies, and employers are also demanding that their voices be heeded [3, 4]. Similarly, managed care, with its use of provider assessments, provider incentives, and marketing activities, requires clinicians to be accountable to diverse bodies, on diverse matters, and in diverse ways. In this new environment, physicians must develop a practical sense about what accountability is desirable and what is not; they must take the initiative in identifying norms that characterize the essence of health care and in delineating the procedures by which fulfillment of these norms will be assessed. To safeguard and foster their professionalism, physicians must substantively and promptly respond to these challenges. Our goal is to offer, by way of a test case, tangible recommendations for accountability. We focus on a domain that is often ignored in discussions of accountability, namely, the ethical dimensions of medical carepractices, such as informed consent, that are distinct from diagnostic and procedural skills. Of all the possible domains of accountability, we concentrate on ethics because it is among the most challenging to evaluate and because it is crucial if the medical profession is to maintain the trust of patients and the public [5, 6]. In the absence of a national body, the Working Group on Accountability convened to identify the norms of ethical medical practice and to delineate desirable methods of assessment. It is an ad hoc working group of clinician ethicists; most members and consultants are practicing clinicians, and each has a specialty focus in professional ethics, medical assessment, organization, or policy. We start by summarizing a guiding model of stratified accountability, which is described in the accompanying article [7], and we then develop the model in the specific domain of ethical practice. We conclude by suggesting specific initiatives with which to implement the recommendations. A Guiding Model of Accountability Accountability consists of three main parts: the loci or accountable parties, the domains or subject matter for which these parties are accountable, and the procedures by which these parties are assessed and held accountable. Modern medicine consists of many accountable parties, and each can hold the other accountable over many different domains; this leads to what might be called a complex reciprocating matrix of accountability. For example, physicians are accountable to patients, hospitals, employers, the government, and others, and in turn they can hold hospitals, insurers, the government, and others accountable. Models of accountability differ in the domains that are considered to be primary, the specific content areas within each domain that are to be assessed, and the procedures by which different parties will be held accountable. In the accompanying article [7], we argue that no single model of accountability is appropriate to the complexities of modern medicine. Instead, we endorse a stratified model of accountability. At the core is the traditional professional model, which applies to individual physicianpatient interactions and to some institutional matters. Surrounding this core are other institutional matters and interactions among health care institutions in which political and economic mechanisms of accountability, such as public forums to evaluate and approve policies and financial accountability, seem appropriate. In such a stratified model, physicians have primary responsibility for characterizing the content areas in which they will be held accountable, the mechanisms for assessment, and the processes for explanation and action. In this view, professional values remain central but are not sovereign; through the political and economic models of accountability, patients, employers, and others participate in approving and evaluating domains and mechanisms of accountability. By using medical values along with structures of continuously adjustable and testable fairness, the model can combat both public cynicism about medicine's self-interest and the profession's annoyance with ill-informed intrusive outsiders. Thus, in the next three sections, we begin the professionals' process of delineating the core content areas, the assessment procedures, and the mechanisms for response for medical ethics. We identify eight content areas for accountability in medical ethics; because this list is for accountability mechanisms, each area is subdivided into assessable items, numbered to match items in Table 1. Two principles inform this list. First, the content areas are culled from traditional codes [8], from recent statements by medical bodies [9, 10], and from consensus among the members of the Working Group on Accountability. Each area can be derived from fundamental ethical principles; references are provided. Our selection criteria, in keeping with the stratified model of accountability, were to cover professionally endorsed medical values for which patients and other parties may legitimately request accountability. Second, this list is necessary but may not be sufficient; it may be modified as the deliberative process of accountability evolves. We do not propose that professionals establish a rigid, unchanging list to which they hold themselves accountable or that nonprofessionals blindly accept and use such a list. Rather, we propose that professionals create a list that other groups can modify and that professionals and other groups hold themselves and one another to these deliberated standards. Table 1. Information for Use in Physician, Group, and Institutional Report Cards* Core Content Areas of Accountability in Medical Ethics Medical Decision Making Medical decision making is a pre-eminent area of desirable accountability in medical ethics. Patients have well-recognized rights to be informed of their health status and to share in decisions about their care [11-14]. For assessing physicians, we propose that medical decisions be considered in the following contexts of care: noninvasive tests or therapy decisions (item Ia, Table 1); invasive tests or intervention decisions (Ib); life-sustaining intervention decisions (Ic); decisions on participation in clinical research (Id); and decisions in any of the above categories for patients not competent to make their own decisions (Ie). The Joint Commission on the Accreditation of Healthcare Organizations has articulated counterpart standards for institutions [15]. Confidentiality Another well-recognized duty of the medical profession is to maintain patient confidentiality to the greatest possible degree, yielding only to the most pressing and direct interests of others, such as in cases of threats to life [8-10, 16]. Physicians should be accountable for their assessed knowledge of and adherence to standards of confidentiality (IIa). Institutional record-keeping practice is especially vulnerable in the current era of electronic records. Use of medical data for utilization review and patient targeting, such as screening-test eligibility, is widespread, and the sharing of information in integrated health networks may bring further possibilities for breaches of confidentiality [17]. Institutions should therefore be specifically accountable for the following: precautions taken to protect confidentiality (IIb); the policy for release of person-identified informationwhat, to whom, under what circumstances, and when it is legally required (IIc); the regulations for use of medical record data for research, both private and governmental (IId); and the type of information accessible to third-party payers (IIe). Fiduciary Obligations and Conflicts of Interest Physicians and institutions deal with many forces that may compromise the fundamental mission of patient care [18-28]. That physicians must act for the patient's good in preference to their own is widely accepted [29, 30]. For accountability, it is possible to focus on five types of approaches to limit the negative effect of conflicting interests. The following three approaches are for physicians and institutions: documented education of physicians and managers about conflicting interests (IIIa); required disclosure to the institution or patient and institutional review of specified types of conflicts by physicians and managers (IIIb); and physician or institutional disclosure with patient informed consent whenever appropriate (IIIc). Two further approaches apply to institutions: prohibition of physician conflicts that undermine the fiduciary relationship (IIId); and policy safeguards that limit conflicting incentives for institutions (IIIe). Responsibilities Arising from Patient Vulnerability Much of medical ethics rests on the injunction to avoid exploitation of patient vulnerability, but some matters deserve particular concern. Serious boundary violations, such as sexual relations with patients, risk egregious patient harm. Physicians should be clear about the basis for the profession's categorical ban on sexual relations with patients (IVa) [31, 32]. Awareness of sometimes less obvious violations, such as inappropriate touching, gift giving, and socializing, can be helpful toward this end. Because boundary violations are difficult to discuss, institutions should ensure that ethical standards on the matter are explicitly expressed during physician training and continuing education (IVb) [33]; they should also have a policy statement, which should be publicly available and readily accessible through patient representatives, ombudspersons, or other patient resources (IVc). Patient vulnerability can also be an is