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The Best Practices in Medical Ethics

What is Ethical Behavior for a Medical Assistant? 

In medicine, a body of guidelines rooted in the Hippocratic Oath serves as the foundation for a code of ethics, including a medical assistant code of ethics. Because care providers often make difficult clinical decisions quickly, it is critical for physicians, nurses, and medical assistants (MAs) to follow the code of ethics as set forth by their professional boards of licensing. Professional conduct that disregards these standards is considered unethical and can result in suspension.


I. Code of Ethics for Medical Assistants: What are Medical Ethics?

The American Medical Association (AMA) was established in 1847 and was the first professional organization of its kind. One of the earliest tasks undertaken by its members was the development of professional standards for education, training and conduct. Its Code of Medical Ethics, a living document that undergoes regular revision, remains the most comprehensive authority on ethical practices in healthcare today.

The AMA Code of Ethics

The Code of Ethics is composed of guidelines designed for optimum patient benefit. Physicians are expected to exercise conduct that honors the professional's responsibility to patients, society, colleagues and self. The guidelines are not enforceable in court, but instead are a collection of professional expectations of an honorable medical practitioner. Set forth by the AMA as the Principles of Medical Ethics, these guidelines are as follows:

  1. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.
  2. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.
  3. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.
  4. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.
  5. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.
  6. 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 care.
  7. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.
  8. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
  9. A physician shall support access to medical care for all people.

The AAMA Code of Ethics for Medical Assistants

The AMA code of ethics is the universal standard for U.S. physicians, but medical assistants must take their own oath in order to join the American Association of Medical Assistants (AAMA). The AAMA maintains this living medical assistant code of ethics document in order to help MAs best evolve with the changing landscape of healthcare.

The AAMA Creed states "I am true to the ethics of my profession." As such, the document sets forth the highest principles considered to universally apply across different types of medical assisting. You'll find that the core values of the AAMA document are very similar to the AMA's. When it comes down to ethical medical practice, the code of ethics for medical assistants are the same as for any professional providing medical services.

Members of AAMA dedicated to the conscientious pursuit of their profession, and thus desiring to merit the high regard of the entire medical profession and the respect of the general public which they serve, do pledge themselves to strive always to:

  • Render service with full respect for the dignity of humanity.
  • Respect confidential information obtained through employment unless legally authorized or required by responsible performance of duty to divulge such information.
  • Uphold the honor and high principles of the profession and accept its disciplines.
  • Seek to continually improve the knowledge and skills of medical assistants for the benefit of patients and professional colleagues.
  • Participate in additional service activities aimed toward improving the health and well-being of the community.

Additional Medical Codes of Ethics

Numerous other professional organizations catering to healthcare workers also promote ethical behavior in the workplace by publishing standards of behavior, including a medical assistant code of ethics. Among them are:

Established standards in medical ethics can help working professionals manage any number of thorny issues. For instance, patients are vulnerable by definition, and this can create an imbalance of power in the physician-patient relationship. Advances in medical science continually pose ethical questions, such as the morality of stem cell research.

Life expectancies have increased by decades over the past century, raising moral dilemmas about end-of-life care and euthanasia. In the U.S., the passage of the Health Insurance Portability and Accountability Act (HIPAA) brought legal ramifications to healthcare professionals who are in a position to see and share confidential patient information.

These professional guidelines may seem to address larger moral issues, but they are also helpful on a case-by-case basis. Healthcare practitioners must continually strive for balance between the needs of an individual patient and the greater needs of a medical facility or community. This can include factoring in available resources, be they medications or empty hospital beds.

Costs should never impact a medical professional's decision about patient care, but doctors face pressure from facilities and health insurance companies to minimize expenses. A worried mother may insist on antibiotics for her child's mild bacterial infection, but her pediatrician has a responsibility to the global community to reduce antibiotic resistance.

Perhaps the family of an elderly cancer patient demands aggressive chemotherapy, while a professional assessment deems it unlikely to help. In these scenarios, and many more, physicians may find a code of ethics to be a helpful guiding light.

While an MA may not be making such impactful decisions, a medical assistant code of ethics is equally as important.

II. Key Principles and Concepts

Beyond the organization-specific guidelines, there are four distinct principles relevant to all patient-physician interaction which extends to the medical assistant code of ethics.

  • Autonomy: Patients have ultimate control over their own bodies. Refusal or acceptance of treatments rests with the patient, even if it is contrary to your professional opinion. The physician's responsibility is to provide patients with the information necessary to make an informed decision, even though it may not be a medically sound one.
  • Beneficence: Physicians must improve each patient's health to the best of their ability, recognizing that what is good for one patient may not be good for another. This means cultivating an awareness of each individual's ability to manage pain, illness, and suffering, and, with that, comprehending the impact their decisions may have on the patient's quality of life.
  • Nonmaleficence: An extension of the 'do no harm' exhortation in the Hippocratic Oath, nonmaleficence requires that physicians consider any unintentional harm that could result from your good intentions. An honest assessment of risks and benefits should be a part of every treatment decision.
  • Justice: All physicians must be fair in their dispensation of resources and treatments. Time, which is considered by many medical professionals as their most valuable commodity, must be allocated in an ethically sound manner.

Informed Consent

The concept of informed consent is another part of patient-physician interaction that must be approached ethically. This can be tricky to manage given the constraints on physicians' time, but medical professionals have an ethical duty to allow patients autonomy in healthcare.

The responsibility lies fully with professionals to communicate diagnoses, treatment options, risks and benefits; physicians must also ensure that their patients completely grasp what is being discussed. A carefully worded conversation that allows time for questions is best. Diagrams and printed materials can help patients better understand their situation and treatment scenarios; and an appreciation of cultural or religious differences could help a physician anticipate a patient's reaction.

Informed consent in the case of a minor carries the same ethical obligations to physicians, even though a minor may not legally consent to medical treatment. State laws vary on the particulars, but parents or authorized caregivers must give consent. The American Academy of Pediatrics (AAP) recommends that minors participate in healthcare decisions where it is age-appropriate; in these cases, older teens are able to question and consent to treatment, while a parent supplies informed permission for a doctor to proceed.

In other patients, the capacity to give informed consent is questionable because age, illness, or other factors prohibit the patient's total understanding of all the variables in play. It's important to recognize differences in individuals when making this assessment; a patient with a neurological disorder may be unable to comprehend treatment details, while another with the same diagnosis could readily give consent.

Elderly patients with dementia, or any other patient in cognitive decline, present a unique ethical dilemma. The principle of autonomy demands that the patient be afforded all decision-making authority. When the patient's competence to make choices falls into question, a surrogate decision-maker may step in to help. Whether this individual is a worried family member, a friend designated by the patient, or even an appointed public guardian, it's crucial this surrogate only acts when the patient is truly unable to. Identifying this moment is time can be difficult for caregivers and medical professionals, which is why medical assistant ethics are so important for aspiring MAs.

Confidentiality

Newer laws that resulted from the passage of HIPAA are designed to ensure that conversations between a physician and a patient remain confidential. While these laws are comprehensive, they can make it more difficult for doctors to decide when confidentiality should be breached. In some cases, a medical professional may have a moral obligation to violate confidentiality, such as when an elderly patient's capacity for decision-making is doubtful, a psychiatrically unbalanced person poses a physical threat, a valid public health issue is risked or a minor is being abused.

A number of other scenarios could trigger an ethical dilemma for practicing medical professionals. For example, a physician who performs abortions or assisted suicide, or perhaps one who manages surrogate pregnancies, may struggle with the development of an appropriate treatment plan for a patient. Other professionals may find that contact with patients carrying virulent communicable diseases makes them uneasy about personal risk. Another still may have a personal diagnosis that endangers his or her ability to provide healthcare. Regardless of the ethical questions keeping today's medical professionals awake at night, patient needs must always come first. Every ethical decision must be approached with an eye to providing the most advantageous outcome for each patient, despite doubts of the practicing physician or medical assistant.

III. Real-World Examples: Describe the Behavior of an Ethical Medical Assistant

Practicing medicine ethically is complex by its very nature. The task of fine-tuning our own internal code of ethics is lifelong. To continue developing an ethically responsible reaction to scenarios you may encounter in the workplace, read on for a sampling of case studies. Think about how you would respond in these scenarios and explore alternative ideas about how to approach them reasonably, considering the certified medical assistant code of ethics.

Euthanasia in the Severely Ill Patient

A young man in your practice lost his mother to Huntington's Chorea, an incurable neurological disorder that carries a 50% risk of transmission to children. Although he has no other physical complaints, he struggles with depression and anxiety and self-medicates with alcohol. He has made it known that should he be diagnosed with Huntington's, he prefers to die immediately rather than live with the diagnosis.

The patient's worst fears came true when two neurologists independently confirmed the diagnosis of Huntington's. His next step was to visit a psychiatrist to request assistance with suicide. The physician refused, after which the patient convinced the physician that he had no plans to commit suicide by himself. At home, the young man wrote a suicide note explaining his choice, pinned it to his shirt and deliberately overdosed on antidepressants. When his wife discovered him unconscious she had him rushed to the hospital, the note still pinned to his shirt.

Questions to consider

  • Treatment of the overdose can be effectively managed with a number of options, after which the patient's antidepressant medications could be adjusted. The root cause of the suicide attempt, however, was knowledge of a diagnosis with an unpleasant prognosis. Of the dual diagnoses of Huntington's and overdose, do either take precedence when choosing a treatment plan?
  • Did the patient make an informed decision when refusing all medical treatment? In this case, the answer is unknowable because the patient is unconscious upon arrival to the hospital. Furthermore, one can postulate that his entire experience with Huntington's is anecdotal and perhaps inaccurate.
  • Due to his incurable diagnosis, the patient is facing severely diminished quality of life. Should this fact affect emergency room physicians' response to his overdose?
  • Because he is unconscious, the patient's wife may legally act as a surrogate and request treatment. Is there a moral obligation for physicians to honor the wishes stated in the patient's note? If so, does it trump the legal requirement that the emergency room treat every patient?

Secret Tubal Ligation

A 33-year-old woman in your obstetrical practice is pregnant with her second child. She has requested tubal ligation at the time of delivery, which is not unusual. After you agree to the procedure, she asks you not to disclose her choice to her husband. He has made it clear he wants more children and is likely to ask for assurance about his wife's future fertility.

Questions to consider

  • Given that your patient is the wife, not the husband, should you honor her wishes and lie to her husband? There is no expectation of confidentiality except to your patient.
  • Is her choice informed? If she is reacting to coercion to have more children, it may color her ability to properly assess risks and benefits.
  • Some practitioners may see a red flag in the husband's insistence on controlling what happens to his wife's body. You are being asked to create a barrier between your patient and her husband. Do you question whether she is being abused?
  • If your patient carries out this plan, her husband will most likely question her inability to conceive in the future, and it's not unreasonable to expect that he will raise the idea of infertility treatment. Is your patient prepared to execute this ruse for the rest of her marriage? Is it morally questionable to administer infertility treatment to a patient you have previously sterilized?
  • Do you have a moral obligation to point out that the serious communication problems this couple have aren't conducive to a long, happy marriage? Your patient may feel differently about sterilization if she were to divorce and remarry.

Severe Fetal Abnormality, Teen Pregnancy, and Religion

Your patient, age 18, is six months pregnant and has no other children. A standard ultrasound revealed severe physical defects that, while not technically incompatible with life, are very unlikely to be survived by the infant. After confirming this diagnosis via amniocentesis, you offer your patient the choice of termination or palliative care for the infant.

Your patient lives with her parents, who are taking an active role in their daughter's pregnancy and health. After some consideration, the parents have chosen to honor their religious beliefs by continuing the pregnancy and caring for the baby when she is born. Your patient agrees with her parents. You suggest conservative measures in managing the remainder of the pregnancy and the birth, and schedule a joint meeting with a neonatologist. The family attends this meeting with a priest who urges that all standard attempts to save the baby should be conducted.

Questions to consider

  • Is the family fully aware of the physical realities the baby will face once she is born? Her diagnosis, trisomy 13, brings with it an extremely difficult infancy; if she beats the odds and survives she will likely have severe neurological impairment and difficulty thriving. Informed consent requires that all possible outcomes are known.
  • Do you have a moral obligation to ameliorate the young mother's grief and trauma by steering her toward termination? Research has not shown this course of action to consistently ease grief.
  • After the child's birth, should aggressive measures be taken to keep her alive? History has demonstrated that a fraction of trisomy 13 babies can survive for up to a year.
  • Does the patient's desire to carry the baby to term require you to provide more aggressive treatment measures than you believe should be taken? Regardless of the age of the patient and the severity of the fetus's diagnosis, the young mother still has the right to autonomy.

Secondary Harm from Pain Management

Your patient, age 85, has lived in a long-term care facility for six months. Her two children chose to place her in this facility because she lived alone and tended to overmedicate and eat poorly. She has considerable pain from osteoarthritis and osteoporosis. Her children have expressed the desire that their mother not be given pain medication that has significant cognitive side effects. They have also shared their perception that their mother is a chronic complainer.

The patient's pain is uncontrolled despite regular doses of Tylenol, and she cannot walk. Her pain is further demonstrated by her inability to achieve a comfortable position in bed or in a wheelchair. Nursing home staff find it difficult to tend to her as often as she requests assistance, and are rarely able to make her comfortable. Her daughter, who lives out of town, reports the nursing home staff to a state agency for inadequate pain management. In response, you attempt a trial of a new anti-inflammatory medication. Two weeks later your patient is hospitalized with a severe gastric bleed.

Questions to consider

  • Your primary patient is the 85-year-old widow, though you have tried to respect her children's requests. Are you fully honoring her right to autonomy in decision-making?
  • The decision-making process is somewhat murky and is complicated by two children, one of whom lives out of state. Is it appropriate to request that the family meet with you and the patient so you can all reach an agreement about a treatment plan?
  • Overworked nursing facility staff members have attempted to respond to your patient's demands, but are only able to help her within your prescribed treatment plan. At what point should a staff member step in and report uncontrolled pain to you? Does a nurse have a moral obligation to intervene on behalf of your patient?
  • Do you have a moral obligation to make your patient comfortable in her declining years, despite her children's wishes that you restrict her pain medication?

Chronic Illness in an Uninsured Patient

Your patient is a 26-year-old girl who was diagnosed with Crohn's disease in her early teens. Crohn's is incurable, but can be managed with medication and good lifestyle choices. Untreated Crohn's can lead to permanent damage that requires surgical intervention, so it is in the patient's best interest to keep the illness in remission. Your patient's symptoms have been controlled until recently. Having graduated from college, she has lost the insurance coverage on her parents' policy that was afforded to her as an undergraduate.

A busy schedule has made it difficult for your patient to manage her illness with diet and exercise, and financial constraints have limited her access to medication. Her symptoms have worsened significantly within the last year, and most recently she has developed kidney stones so large that she is unable to pass them independently. When she stopped eating and drinking, her friends stepped in and delivered her to the emergency room. Her poor health required five days of inpatient treatment to stabilize. Your next best step is to surgically remove the kidney stones; however, your patient lacks the funds to pay for surgery and additional hospitalization. She leaves the hospital against medical advice.

Questions to consider

  • The principle of beneficence demands that you give the best care possible to your patient, regardless of her health insurance or lack thereof. Given that you were aware of her worsening health, could you have done more to follow this patient?
  • Were her most recent healthcare needs truly emergent? You have an obligation to thoughtfully dispense resources to all patients. Is her case one that was so urgent she should have received emergency care that is illegal to deny? Or is her existing health status a natural result of her own inability to manage her illness?
  • Because your patient's friends ultimately intervened in her life so she could get adequate medical care, their actions must be evaluated from an ethical standpoint. Are they morally obligated to continue monitoring your patient's day-to-day health and stepping in when necessary?
  • The patient's parents are unaware of her troubles, due to either embarrassment over her inability to care for herself or a desire not to worry them. Whatever the reason for her silence, do her friends have a moral obligation to inform her family? Having treated her previously as a minor, do you?
  • When a patient opts to disregard medical advice, what is the most ethical role the hospital can play? Should hospital staff have discussed payment options with your patient when she refused surgery? Should they have underwritten the cost anyway?

Dishonesty from an Injured Patient

A patient in your physical therapy practice has come to you via a referral from his primary care physician (PCP). Having injured his back at work, he has taken time off to recover and has been directed to complete a short course of physical therapy. At the end of his treatment his PCP deemed his progress in physical therapy adequate even though he was not yet ready to return to work. However, he told the patient that if he wanted more therapy he need only ask.

After a month passed, the patient reported a flare-up of his back troubles to his PCP. He was prescribed another course of physical therapy. During a session, he confessed to you that he had fallen at his daughter's soccer game and reinjured his back. Though you encouraged him to share this information with his PCP, he did not. As his therapy progressed, his condition worsened significantly. You re-evaluated and determined that his pain actually stems from the second fall, which resulted in an entirely new injury. Once again, your suggestion that he speak to his PCP was rejected. At his most recent therapy session the patient reported the potentially serious symptoms of numbness and weakness in one leg. He is adamant that his PCP "not be bothered" with these details.

Questions to consider

  • The nature of ethical healthcare allows for patients' autonomy in treatment decisions. Does this extend to the right to misrepresent an injury in order to receive care?
  • Theoretically, the patient's employer covered his physical therapy under worker's compensation. Your assessment of his current health, however, indicates that a different injury is likely being treated on the employer's dime. Are you morally obligated to report your suspicions?
  • Medical professionals must also treat patients to their fullest ability according to the principle of beneficence. Given that your patient is worsening rather than responding to treatment that was prescribed for a different injury, are you treating this man to the best of your ability?
  • Confidentiality between patient and professional is always expected. However, your patient refuses to share crucial information with other healthcare professionals who direct his treatment. Are you morally obligated to inform his PCP of the facts as you know them?
  • Medical professionals are responsible to society for allocating healthcare resources to patients. By continuing to treat a patient who has misrepresented the facts of his injury, are you improperly dispensing physical therapy that could be better delivered to another patient?

IV. Further Reading

Almost all major health organizations, be they nonprofits, government branches or private advocates, dedicate a sizable amount of their research and resources to medical ethics, including a code of ethics for medical assistants. Below we've identified a few of the most prominent so that, as a medical professional, you can better consider the foundational ethics informing modern practice.

  • HHS's Understanding Health Information Privacy: The Department of Health and Human Services provides the most comprehensive analysis of the HIPAA Privacy Rule. Its site covers HIPAA enforcements, steps consumers and businesses need to take when HIPAA violations are formally called into question, and the training materials and news related to HIPAA that is disseminated to both professionals and the public.
  • AMA's Medical Ethics: The American Medical Association maintain the Ethics Group, a body that puts forth policies, educational materials and research that reflect the AMA's commitment to bring medical ethics to the forefront of all forms of professional care, including a medical assistant code of ethics. Visitors to the site will find a code of ethics, a forum for ongoing ethical discussions and a wealth of links to research and professional opportunities that deal with medical ethics.
  • ACP Ethics Manual Sixth Edition: This manual put forth by the American College of Physicians is simply one of the most authoritative and conclusive treatises on ethics. The publication, which is entirely online, looks at virtually all major ethical issues physicians face today. Beyond the manual, the ACP also maintains a body of case studies and ethical complaints, which can help to ground a professional's ethical dilemma.
  • Center for Medical Ethics and Health Policy: Part of the Baylor College of Medicine, perhaps no academic body is as wholly focused on how ethics translate to policy than this center. Research, a news blog, educational opportunities and even consultation services can all be found on their website.
  • MedlinePlus's Medical Ethics Portal: MedlinePlus, "a service of the US National Library of Medicine," maintains a robust collection of resources dealing with medical ethics. The portal is segmented into areas like articles, organizations, law and policy and news.
  • American Society of Law, Medicine and Ethics: The ASLME is a society invested in furthering ethical practice as it applies to medicine and the law for an audience of "physicians, nurses, ethicists, educators, students, administrators and other professionals shaping health care for the 21st century."

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