Ethical Issues in Clinical Medicine

67CHAPTER 11

■ IMPLICATIONS FOR CLINICAL PRACTICE

Individual health care providers can do several things in the clinical

encounter to address racial and ethnic disparities in health care.

Be Aware That Disparities Exist Increasing awareness of racial

and ethnic disparities among health care professionals is an important

first step in addressing disparities in health care. Only with greater

awareness can care providers be attuned to their behavior in clinical

practice and thus monitor that behavior and ensure that all patients

receive the highest quality of care, regardless of race, ethnicity, or

culture.

Practice Culturally Competent Care Previous efforts have

been made to teach clinicians about the attitudes, values, beliefs, and

behaviors of certain cultural groups—the key practice “dos and don’ts”

in caring for “the Hispanic patient” or the “Asian patient,” for example.

In certain situations, learning about a particular local community or

cultural group, with a goal of following the principles of communityoriented primary care, can be helpful; when broadly and uncritically

applied, however, this approach can actually lead to stereotyping and

oversimplification of culture, without respect for its complexity.

Cultural competence has thus evolved from merely learning information and making assumptions about patients on the basis of their

backgrounds to focusing on the development of skills that follow the

principles of patient-centered care. Patient-centeredness encompasses

the qualities of compassion, empathy, and responsiveness to the needs,

values, and expressed preferences of the individual patient. Cultural

competence aims to take things a step further by expanding the repertoire of knowledge and skills classically defined as “patient-centered”

to include those that are especially useful in cross-cultural interactions

(and that, in fact, are vital in all clinical encounters). This repertoire

includes effectively using interpreter services, eliciting the patient’s

understanding of his or her condition, assessing decision-making

preferences and the role of family, determining the patient’s views

about biomedicine versus complementary and alternative medicine,

recognizing sexual and gender issues, and building trust. For example,

while it is important to understand all patients’ beliefs about health, it

may be particularly crucial to understand the health beliefs of patients

who come from a different culture or have a different health care experience. With the individual patient as teacher, the physician can adjust

his or her practice style to meet the patient’s specific needs.

Avoid Stereotyping Several strategies can allow health care providers to counteract, both systemically and individually, the normal

tendency to stereotype. For example, when racially/ethnically/culturally/

socially diverse teams in which each member is given equal power

are assembled and are tasked to achieve a common goal, a sense of

camaraderie develops and prevents the development of stereotypes

based on race/ethnicity, gender, culture, or class. Thus, health care

providers should aim to gain experiences working with and learning

from a diverse set of colleagues. In addition, simply being aware of the

operation of social cognitive factors allows providers to actively check

up on or monitor their behavior. Physicians can constantly reevaluate

to ensure that they are offering the same things, in the same ways, to

all patients. Understanding one’s own susceptibility to stereotyping—

and how disparities may result—is essential in providing equitable,

high-quality care to all patients.

Work to Build Trust Patients’ mistrust of the health care system

and of health care providers impacts multiple facets of the medical

encounter, with effects ranging from decreased patient satisfaction to

delayed care. Although the historic legacy of discrimination can never

be erased, several steps can be taken to build trust with patients and to

address disparities. First, providers must be aware that mistrust exists

and is more prevalent among minority populations, given the history

of discrimination in the United States and other countries. Second,

providers must reassure patients that they come first, that everything

possible will be done to ensure that they always get the best care

available, and that their caregivers will serve as their advocates. Third,

interpersonal skills and communication techniques that demonstrate

honesty, openness, compassion, and respect on the part of the health

care provider are essential tools in dismantling mistrust. Finally,

patients indicate that trust is built when there is shared, participatory

decision-making and the provider makes a concerted effort to understand the patient’s background. When the doctor–patient relationship

is reframed as one of solidarity, the patient’s sense of vulnerability

can be transformed into one of trust. The successful elimination of

disparities requires trust-building interventions and strengthening of

this relationship.

■ CONCLUSION

The issue of racial and ethnic disparities in health care has gained

national prominence, both with the release of the IOM report Unequal

Treatment and with more recent articles that have confirmed their

persistence and explored their root causes. Furthermore, another

influential IOM report, Crossing the Quality Chasm, has highlighted

the importance of equity—i.e., no variations in quality of care due to

personal characteristics, including race and ethnicity—as a central

principle of quality. Current efforts in health care reform and transformation, including a greater focus on value (high-quality care and

cost-control), will sharpen the nation’s focus on the care of populations

who experience low-quality, costly care. Addressing disparities will

become a major focus, and there will be many obvious opportunities

for interventions to eliminate them. Greater attention to addressing the

root causes of disparities will improve the care provided to all patients,

not just those who belong to racial and ethnic minorities.

■ FURTHER READING

Buchmueller TC et al: The ACA’s impact on racial and ethnic disparities in health insurance coverage and access to care. Health Aff

(Millwood) 39:395, 2020.

Carnethon MR et al: Cardiovascular health in African Americans: A

scientific statement from the American Heart Association. Circulation 136:e393, 2017.

Dwyer-lindgren L et al: Inequalities in life expectancy among us

counties, 1980 to 2014: Temporal trends and key drivers. JAMA

Intern Med 177:1003, 2017.

Kreuter MW et al: Addressing social needs in health care settings:

Evidence, challenges and opportunities for public health. Annu Rev

Public Health 42:11, 2021.

Krieger N: Measures of racism, sexism, heterosexism, and gender

binarism for health equity research: from structural injustice to

embodied harm: An ecosocial analysis. Annu Rev Public Health

41:37, 2020.

Medscape: Medscape Lifestyle Report 2016: Bias and burnout. http://

www.medscape.com/features/slideshow/lifestyle/2016/public/overview.

Vyas DA et al: Hidden in plain sight: Reconsidering the use of race

correction in clinical algorithms. N Engl J Med 383:874, 2020.

Williams DR et al: Racism and health: Evidence and needed research.

Annu Rev Public Health 40:105, 2019.

Physicians face novel ethical dilemmas that can be perplexing and

emotionally draining. For example, telemedicine, artificial intelligence,

handheld personal devices, and learning health care systems all hold

the promise of more coordinated and comprehensive care, but also

raise concerns about confidentiality, the doctor–patient relationship,

and responsibility. This chapter presents approaches and principles

that physicians can use to address important vexing ethical issues they

11 Ethical Issues in Clinical

Medicine

Christine Grady, Bernard Lo

68PART 1 The Profession of Medicine

encounter in their work. Physicians make ethical judgments about

clinical situations every day. They should prepare for lifelong learning

about ethical issues so they can respond appropriately. Traditional

professional codes and ethical principles provide instructive guidance

for physicians but need to be interpreted and applied to each situation.

When facing or struggling with a challenging ethical issue, physicians

may need to reevaluate their basic convictions, tolerate uncertainty,

and maintain their integrity while respecting the opinions of others.

Physicians should articulate their concerns and reasoning, discuss and

listen to the views of others involved in the case, and utilize available

resources, including other health care team members, palliative care,

social work, and spiritual care. Moreover, ethics consultation services

or a hospital ethics committee can help to clarify issues and identify

strategies for resolution, including improving communication and

dealing with strong or conflicting emotions. Through these efforts,

physicians can gain deeper insight into the ethical issues they face and

usually reach mutually acceptable resolutions to complex problems.

APPROACHES TO ETHICAL PROBLEMS

Several approaches are useful for resolving ethical issues, including

approaches based on ethical principles, virtue ethics, professional oaths,

and personal values. These various sources of guidance may seem to

conflict in a particular case, leaving the physician in a quandary. In a

diverse society, different individuals may turn to different sources of

moral guidance. In addition, general moral precepts often need to be

interpreted and applied to a particular clinical situation.

■ ETHICAL PRINCIPLES

Ethical principles can serve as general guidelines to help physicians

determine the right thing to do.

Respecting Patients Physicians should always treat patients with

respect, which entails understanding patients’ goals, providing information, communicating effectively, obtaining informed and voluntary

consent, respecting informed refusals, and protecting confidentiality.

Different clinical goals and approaches are often feasible, and interventions can result in both benefit and harm. Individuals differ in how

they value health and medical care and how they weigh the benefits

and risks of medical interventions. Generally, physicians should respect

patients’ values and informed choices. Treating patients with respect is

especially important when patients are responding to experiences of, or

fears about, disrespect and discrimination.

GOALS AND TREATMENT DECISIONS Physicians should provide relevant and accurate information for patients about diagnoses, current

clinical circumstances, expected future course, prognosis, treatment

options, and uncertainties, and discuss patients’ goals of care. Physicians may be tempted to withhold a serious diagnosis, misrepresent it

by using ambiguous terms, or limit discussions of prognosis or risks for

fear that patients will become anxious or depressed. Providing honest

information about clinical situations promotes patients’ autonomy and

trust as well as sound communication with patients and colleagues.

When physicians have to share bad news with patients, they should

adjust the pace of disclosure, offer empathy and hope, provide emotional support, and call on other resources such as spiritual care or

social work to help patients cope. Some patients may choose not to

receive such information or may ask surrogates to make decisions on

their behalf, as is common with serious diagnoses in some traditional

cultures.

SHARED DECISION-MAKING AND OBTAINING INFORMED CONSENT

Physicians should engage their patients in shared decision-making

about their health and their care, whenever appropriate. Physicians

should discuss with patients the nature, risks, and benefits of proposed

care; any alternative; and the likely consequences of each option. Physicians promote shared decision-making by informing and educating

patients, answering their questions, checking that they understand

key issues, making recommendations, and helping them to deliberate.

Medical jargon, needlessly complicated explanations, or the provision

of too much information at once may overwhelm patients. Increasingly, decision aids can assist patients in playing a more active role in

decision-making, improving the accuracy of their perception of risk

and benefit, and helping them feel better informed and clearer about

their values. Informed consent is more than obtaining signatures on

consent forms and involves disclosure of honest and understandable information to promote understanding and choice. Competent,

informed patients may refuse recommended interventions and choose

among reasonable alternatives. In an emergency, treatment can be

given without informed consent if patients cannot give their own

consent and delaying treatment while surrogates are contacted would

jeopardize patients’ lives or health. People are presumed to want such

emergency care unless they have previously indicated otherwise.

Respect for patients does not entitle patients to insist on any care or

treatment that they want. Physicians are not obligated to provide interventions that have no physiologic rationale, that have already failed,

or that are contrary to evidence-based practice recommendations or

good clinical judgment. Public policies and laws also dictate certain

decisions—e.g., allocation of scarce medical resources during a public

health crisis such as the COVID-19 pandemic, use of cadaveric organs

for transplantation, and requests for physician aid in dying.

CARING FOR PATIENTS WHO LACK DECISION-MAKING CAPACITY Some

patients are unable to make informed decisions because of unconsciousness, advanced dementia, delirium, or other medical conditions.

Courts have the legal authority to determine that a patient is legally

incompetent, but in practice, physicians usually determine when

patients lack the capacity to make particular health care decisions and

arrange for authorized surrogates to make decisions, without involving

the courts. Patients with decision-making capacity can express a choice

and appreciate their medical situation; the nature, risks, and benefits of

proposed care; and the consequences of each alternative. Patient choices

should be consistent with their values and not the result of delusions,

hallucinations, or misinformation. Physicians should use available

and validated assessment tools, resources such as psychiatry or ethics

consultation, and clinical judgment to ascertain whether individuals

have the capacity to make decisions for themselves. Patients should not

be assumed to lack capacity if they disagree with recommendations or

refuse treatment. Such decisions should be probed, however, to ensure

the patient is not deciding based on misunderstandings and has the

capacity to make an informed decision. When impairments are fluctuating or reversible, decisions should be postponed if possible until the

patient recovers decision-making capacity.

When a patient lacks decision-making capacity, physicians seek

an appropriate surrogate. Patients may designate a health care proxy

through an advance directive or on a Physician Orders for LifeSustaining Treatment form; such choices should be respected (see

Chap. 12). For patients who lack decision-making capacity and have

not previously designated a health care proxy, family members usually

serve as surrogates. Statutes in most U.S. states delineate a prioritized

list of relatives to make medical decisions. Patients’ values, goals, and

previously expressed preferences guide surrogate decisions. However,

the patient’s current best interests may sometimes justify overriding

earlier preferences if an intervention is likely to provide significant

benefit, previous statements do not fit the situation well, or the patient

gave the surrogate leeway in decisions.

MAINTAINING CONFIDENTIALITY Maintaining confidentiality is

essential to respecting patients’ autonomy and privacy; it encourages

patients to seek treatment and to discuss problems candidly. However,

confidentiality may be overridden to prevent serious harm to third

parties or the patient. Exceptions to confidentiality are justified when

the risk to others is serious and probable, no less restrictive measures

can avert risk, and the adverse effects of overriding confidentiality

are minimized and deemed acceptable by society. For example, laws

require physicians to report cases of tuberculosis, sexually transmitted

infection, elder or child abuse, and domestic violence.

Beneficence or Acting in Patients’ Best Interests The principle of beneficence requires physicians to act for the patient’s benefit.

Patients typically lack medical expertise, and illness may make them

vulnerable. Patients rely on and trust physicians to treat them with

Ethical Issues in Clinical Medicine

69CHAPTER 11

compassion and provide sound recommendations and treatments

aimed to promote their well-being. Physicians encourage such trust

and have a fiduciary duty to act in the best interests of patients, which

should prevail over physicians’ self-interest or the interests of third

parties such as hospitals or insurers. A principle related to beneficence,

“first do no harm,” obliges physicians to prevent unnecessary harm

by recommending interventions that maximize benefit and minimize

harm and forbids physicians from providing known ineffective interventions or acting without due care. Although often cited, this precept

alone provides limited guidance because many beneficial interventions

also pose serious risks.

Physicians increasingly provide care within interdisciplinary teams

and rely on consultation with or referral to specialists. Team members

and consultants contribute different types of expertise to the provision

of comprehensive, high-quality care for patients. Physicians should

collaborate with and respect the contributions of the various interdisciplinary team members and should initiate and participate in regular

communication and planning to avoid diffusion of responsibility and

ensure accountability for quality patient care.

INFLUENCES ON PATIENTS’ BEST INTERESTS Conflicts arise when

patients’ refusal or request of interventions thwarts their own goals for

care, causes serious harm, or conflicts with their best medical interests.

For example, simply accepting a young asthmatic adult’s refusal of

mechanical ventilation for reversible respiratory failure, in the name

of respecting autonomy, is morally constricted. Physicians should elicit

patients’ expectations and concerns, correct their misunderstandings,

and try to persuade them to accept beneficial therapies. If disagreements persist after such efforts, physicians should call on institutional

resources for assistance, but patients’ informed choices and views of

their own best interests should prevail.

Drug prices and out-of-pocket expenses for patients have been escalating in many parts of the world and may compromise care that is in

the patients’ best interests. Physicians should recognize that patients,

especially those with high copayments or inadequate insurance, may

not be able to afford prescribed tests and interventions. Physicians

should strive to prescribe medications that are affordable and acceptable to the patient. Knowing what kind of insurance, if any, the patient

has and whether certain medications are likely to be covered may help

in determining appropriate prescriptions. Available alternatives should

be considered and discussed. Physicians should follow up with patients

who don’t fill prescriptions, don’t take their medications, or skip doses

to explore whether cost and affordability are obstacles. It may be

reasonable for physicians to advocate for coverage of nonformulary

products for sound reasons, such as when the formulary drugs are less

effective or not tolerated or are too costly for the patient to pay for out

of pocket. These should be shared decisions with the patient to the

extent possible.

Organizational policies and workplace conditions may sometimes

conflict with patients’ best interests. Physicians’ focus and dedication to

the well-being and interests of patients may be negatively influenced by

perceived or actual staffing inadequacies, unfair wages, infrastructural

deficiencies or lack of equipment, work-hour limitations, corporate

culture, and threats to personal security in the workplace. Physicians

should work with institutional leaders to ensure that policies and practices support their ability to provide quality care focused on patients’

best interests.

Patients’ interests are served by improvements in overall quality

of care and the increasing use of evidence-based practice guidelines

and performance benchmarking. However, practice guideline recommendations may not serve the interests of each individual patient,

especially when another plan of care may provide substantially greater

benefits. In prioritizing their duty to act in the patient’s best interests,

physicians should be familiar with relevant practice guidelines, be able

to recognize situations that might justify exceptions, and advocate for

reasonable exceptions.

Acting Justly The principle of justice provides guidance to physicians about how to ethically treat patients and make decisions about

allocating important resources, including their own time. Justice in a

general sense means fairness: people should receive what they deserve.

In addition, it is important to act consistently in cases that are similar

in ethically relevant ways, in order to avoid arbitrary, biased, and unfair

decisions. Justice forbids discrimination in health care based on race,

religion, gender, sexual orientation, disability, age, or other personal

characteristics (Chap. 10).

ALLOCATION OF RESOURCES Justice also requires fair allocation of

limited health care resources. Universal access to medically needed

health care remains an unrealized moral aspiration in the United States

and many countries around the world. Patients with no or inadequate

health insurance often cannot afford health care and lack access to

safety-net services. Even among insured patients, insurers may deny

coverage for interventions recommended by their physician. In this

situation, physicians should advocate for patients’ affordable access

to indicated care, try to help patients obtain needed care, and work

with institutions and policies to promote wider access. Doctors might

consider—or patients might request—the use of lies or deception to

obtain such benefits, for example, signing a disability form for a patient

who does not meet disability criteria. Although motivated by a desire to

help the patient, such deception breaches basic ethical guidelines and

undermines physicians’ credibility and trustworthiness.

Allocation of health care resources is unavoidable when resources

are limited. Allocation policies should be fair, transparent, accountable,

responsive to the concerns of those affected, and proportionate to the

situation, including the supply relative to the need. In the 2019–2020

SARS-CoV-2/COVID-19 pandemic, some epicenters anticipated or

faced shortages of staff, protective equipment, hospital and critical care

beds, and ventilators, even after increasing supplies and modifying

usual clinical procedures. Many jurisdictions developed guidelines for

implementing crisis standards of care to allocate limited interventions

and services. Under crisis standards of care, some aspects of conventional care are not possible and interventions may not be provided to

all who might benefit or wish to receive them. Crisis standards of care

aim to promote the good of the community by saving the most lives in

the short term, using evidence-based criteria.

When demand for medications or other interventions exceeds

the supply, allocation should be fair, strive to avoid discrimination,

and mitigate health disparities. First-come, first-served allocation is

not fair, because it disadvantages patients who experience barriers to

accessing care. To avoid discrimination, allocation decisions should

not consider personal social characteristics such as race, gender, or disability, nor consider insurance status or wealth. Allocation policies also

should aspire to reduce health care disparities. U.S. African-American,

Latino-American, and Native-American patients suffered a disproportionate number of COVID-19 cases and deaths, likely due in part to

being employed in jobs that cannot be done remotely or with physical

distancing, crowded housing, lack of health benefits, and poor access

to health care.

Fair and well-considered guidelines help mitigate any emotional

and moral distress that clinicians may experience making difficult

allocation decisions. Authorizing triage officers or committees to make

allocation decisions according to policies determined with public

input allows treating physicians and nurses to dedicate their efforts to

their patients. Ad hoc resource allocation by physicians at the bedside

may be inconsistent, unfair, and ineffective. At the bedside, physicians

should act as patient advocates within constraints set by society, reasonable insurance policies, and evidence-based practice. Many allocation decisions are made at the level of public policy, with physician

and public input. For example, the United Network for Organ Sharing

(www.unos.org) provides criteria for allocating scarce organs.

■ VIRTUE ETHICS

Virtue ethics focuses on physicians’ character and qualities, with the

expectation that doctors will cultivate virtues such as compassion,

trustworthiness, intellectual honesty, humility, and integrity. Proponents argue that, if such characteristics become ingrained, they help

guide physicians in unforeseen situations. Moreover, following ethical

precepts or principles without any of these virtues could lead to uncaring doctor–patient relationships.

70PART 1 The Profession of Medicine

■ PROFESSIONAL OATHS AND CODES

Professional oaths and codes are useful guides for physicians. Most

physicians take oaths during their medical training, and many are

members of professional societies that have professional codes. Physicians pledge to the public and to their patients that they will be guided

by the principles and values in these oaths or codes and commit to the

spirit of the ethical ideals and precepts represented in oaths and professional codes of ethics.

■ PERSONAL VALUES

Personal values, cultural traditions, and religious beliefs are important

sources of personal morality that help physicians address ethical issues

and cope with any moral distress they may experience in practice.

While essential, personal morality alone is a limited ethical guide

in clinical practice. Physicians have role-specific ethical obligations

that go beyond their obligations as good people, including the duties

to obtain informed consent and maintain confidentiality discussed

earlier. Furthermore, in a culturally and religiously diverse world,

physicians should expect that some patients and colleagues will have

personal moral beliefs that differ from their own.

ETHICALLY COMPLEX PROFESSIONAL

ISSUES FOR PHYSICIANS

■ CLAIMS OF CONSCIENCE

Some physicians, based on their personal values, have conscientious

objections to providing, or referring patients for, certain treatments such

as contraception or physician aid in dying. Although physicians should

not be asked to violate deeply held moral beliefs or religious convictions,

patients need medically appropriate, timely care and should always be

treated with respect. Institutions such as clinics and hospitals have a

collective ethical duty to provide care that patients need while making

reasonable attempts to accommodate health care workers’ conscientious objections—for example, when possible by arranging for another

professional to provide the service in question. Patients seeking a

relationship with a doctor or health care institution should be notified

in advance of any conscientious objections to the provision of specific

interventions. Since insurance often constrains patients’ selection of

physicians or health care facilities, switching providers can be burdensome. There are also important limits on claims of conscience. Health

care workers may not insist that patients receive unwanted medical

interventions. They also may not refuse to treat or discriminate against

patients because of their race, ethnicity, disability, genetic information,

or diagnosis. Such discrimination is illegal and violates physicians’

duties to respect patients. Refusal to treat patients for other reasons

such as sexual orientation, gender identity, or other personal characteristics is legally more controversial, yet ethically inappropriate because it

falls short of helping patients in need and respecting them as persons.

■ PHYSICIAN AS GATEKEEPER

In some cases, patients may ask their physicians to facilitate access

to services that the physician has ethical qualms about providing.

For example, a patient might request a prescription for a cognitively

enhancing medication to temporarily augment his cognitive abilities in

order to take an exam or apply for employment. Patients may request

more pain medication than the physician believes is warranted for

the given situation or marijuana to facilitate sleep. Patients may ask

their physician to sign a waiver to avoid vaccines for reasons that

are not included in state exceptions (see Chap. 3). A physician may

feel uncomfortable prescribing attention-deficit/hyperactivity disorder medications to a young child because she is not convinced that

the possible benefit justifies the risks to the child despite the parent’s

request. In these circumstances, the physician should work with the

patient or parent to understand the reasons for their requests, some

of which might be legitimate. In addition to considering possible risks

and benefits to the patient, the physician should consider how meeting

the request might affect other patients, societal values, and public trust

in the medical profession. If the physician determines that fulfilling

the request requires deception, is unfair, jeopardizes her professional

responsibilities, or is inconsistent with the patient’s best medical

interests, the physician should decline and explain the reasons to the

patient.

■ MORAL DISTRESS

Health care providers, including residents, medical students, and

experienced physicians, may experience moral distress when they feel

that ethically appropriate action is hindered by institutional policies

or culture, decision-making hierarchies, limited resources, or other

reasons. Moral distress can lead to anger, anxiety, depression, frustration, fatigue, work dissatisfaction, and burnout. A physician’s health

and well-being can affect how he or she cares for patients. Discussing

complex or unfamiliar clinical situations with colleagues and seeking

assistance with difficult decisions can help alleviate moral distress, as

can a healthy work environment characterized by open communication, mutual respect, and emphasis on the common goal of good

patient care. In addition, physicians should take good care of their own

well-being and be aware of the personal and system factors associated

with stress, burnout, and depression. Health care organizations should

provide a supportive work environment, counseling, and other support

services when needed.

■ OCCUPATIONAL RISKS AND BURDENS

Physicians accept some physical risk in fulfilling their professional

responsibilities, including exposure to infectious agents or toxic

substances, violence in the workplace, and musculoskeletal injury.

Nonetheless, most physicians, nurses, and other hospital staff willingly

care for patients, despite personal risk and fear, grueling hours, and

sometimes inadequate personal protective equipment or information.

During the COVID-19 pandemic, many communities honored clinicians’ dedication to professional ideals, and some medical students who

were relieved from in-person patient care responsibilities volunteered

to support front-line workers in other ways. The burdens of navigating

professional and personal responsibilities fall more heavily on women

health care providers. Health care institutions are responsible for

reducing occupational risk and burden by providing proper information, training and supervision, protective equipment, infrastructure

and workflow modifications, and emotional and psychological support

to physicians. Clinical leaders need to acknowledge fears about personal safety and take steps to mitigate the impact of work on family

responsibilities, moral distress, and burnout.

■ USE OF SOCIAL MEDIA AND PATIENT PORTALS

Increasingly, physicians use social and electronic media to share information and advice with patients and other providers. Social networking

may be especially useful in reaching young or otherwise hard-to-access

patients. Patients increasingly access their physicians’ notes through

patient portals, which aim to transparently share information, promote patient engagement, and increase adherence. Physicians should

be professional and respectful and consider patient confidentiality,

professional boundaries, and therapeutic relationships when posting to

social media or writing notes for the portal. Overall, appropriate use of

these platforms can enhance communication and transparency while

avoiding misunderstandings or harmful consequences for patients,

physicians, or their colleagues. Unprofessional or careless posts that

express frustration or anger over work incidents, disparage patients or

colleagues, use offensive or discriminatory language, or reveal inappropriate personal information about the physician can have negative

consequences. Physicians should separate professional from personal

websites and accounts and follow institutional and professional society

guidelines when communicating with patients.

CONFLICTS OF INTEREST

Acting in patients’ best interests may sometimes conflict with a physician’s self-interest or the interests of third parties such as insurers or

hospitals. From an ethical viewpoint, patients’ interests are paramount.

Transparency, appropriate disclosure, and management of conflicts of

interest are essential to maintain the trust of colleagues and the public.

Disclosure requirements vary for different purposes, and software has