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Tricky Decisions: 7 Common Ethical Quandaries

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For young ophthalmologists and members-in-training, a formal discussion of professional ethical responsibilities is not likely to be a high priority. Rather, decisions about buying into a partnership, whether to obtain fellowship subspecialty training and whether or how to co-manage may be primary concerns. However, a successful career requires enhancing your understanding of professionalism and medical ethics. The following snapshots of core ethical issues are critical for ophthalmologists entering practice.

1. Competence
It’s been said that after formal training, you are now fully qualified to begin learning your craft. Ophthalmologists must continuously achieve and maintain competence as new information and technologies become available. After formal training, you remain responsible for seeking educational opportunities, using the resources at your disposal. These may include formal courses, independent study and the assistance of an experienced mentor. Competence requires a lifelong commitment to education. For more information, see Principle 3 and Rule 1 of the Code of Ethics.

2. Informed Consent
Informed consent is not merely a signature on a legal document, it is a process whereby patients are made to comprehend important information, to declare themselves competent to make decisions about their own healthcare and to voluntarily agree to the recommendations for care. Informed consent is the responsibility of the ophthalmologist, though aspects of this process are often inappropriately delegated. Prepared materials can be used in the interests of efficiency, but all informed consent should be individualized to the particular patient. For more details, see Rule 2 of the Code of Ethics and the “Informed Consent” advisory opinion.

3. Delegation and Postoperative Care
While permissible under the law, actual co-management arrangements are widely variable. Your decision on whether to co-manage patients with other health care providers is one that may influence your choice of community or practice group. In addition, defining the roles of your technicians will be necessary and may include respect for the routine practices of the existing office. In all co-management and delegation arrangements, you remain responsible for the welfare of your patients. For clarification, see Rules of Ethics 7 and 8 and the Academy’s compendium on postoperative care.

4. Commercial Relationships
Don’t allow your judgment regarding appropriate patient care to be clouded by appealing offers for commercial relationships. Carefully evaluate these offers and navigate cautiously. Commercial relationships may include relations with industry, ownership of ambulatory surgical centers or lasers, optical shops or even use of equipment for reimbursable diagnostic testing. The existence of a commercial relationship does not necessarily indicate that a conflict of interest exists. Disclosure of commercial relationships that could represent conflicts of interest is required in communications with patients, the public and colleagues. For more information, see Rule 6 of the Code of Ethics and the “Disclosure of Professionally Related Commercial Relationships and Interests” advisory opinion.

5. Advertising
Know what you are doing: medical advertising is a unique class of advertising with special perils. Your advertising must be complaint with federal and particular state laws, depending on where you practice. You are legally and ethically responsible for content, even if the advertising is created by another entity on your behalf. The fact that one’s employer, such as a large group practice, hospital or managed care entity, designed and paid for the advertisement does not discharge the individual physician from responsibility under the Code of Ethics. The ophthalmologist must not permit or cooperate with any misleading communications to the public concerning his/her practice, and must take steps to prevent them. For more information, see the Academy’s compendium on advertising, Rule 13 of the Code of Ethics and the Federal Trade Commission’s advertising guidelines.

6. Conflicts of Interest
A conflict of interest exists when professional judgment concerning the well-being of the patient has a reasonable chance of being influenced by other interests of the provider. Disclosure of a conflict of interest is required in communications to patients, the public and colleagues. Examples of such conflicts include using a particular IOL because it was provided at a discount, preferentially prescribing a drug at the recommendation of a favored industry representative or accepting remuneration that far exceeds the services you provide as an industry consultant. For more clarification, see Rule 15 of the Code of Ethics and the “Disclosure of Professionally Related Commercial Relationships and Interests” advisory opinion.

7. Expert Witness Testimony
If you develop a degree of expertise and recognition within the profession, you may be asked to provide expert testimony on behalf of a plaintiff or defendant in civil litigation. Expert witness testimony is often critical to the medico-legal process, and a true expert may be of great value in this process. Those with true expertise should feel an obligation to provide objective testimony when it is helpful to this process. However, tread with caution. Gaining the substantial financial reward is not without its real perils. There are many pitfalls for the naïve or inadequately prepared practitioner. For further details, see Rule 16 of the Code of Ethics and other Academy resources on expert witness testimony.

Conclusion
For more information on these and other topics or to ask questions of Ethics Committee members in person, sign up to attend Academy-sponsored ethics courses and roundtables at the Joint Meeting in Atlanta. These courses and Breakfast with the Experts roundtables provide an ideal opportunity to hone your knowledge of the ethical practice of ophthalmology.

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About the author: Mara Pearse Burke is the manager of the Academy’s Ethics Program. She can be reached at ethics@aao.org.