Resident Ethics Series: Issues and Scenarios for Discussion and Guidance

Welcome to the "Resident Ethics Series: Issues and Scenarios for Discussion and Guidance." The AAOS Ethics Committee has created this series to provide orthopaedic surgery residency programs with discussion material to use in training programs across the country. The discussion scenarios are designed to stimulate discussion via changing scenarios and familiarize the surgeon with guidelines, legalities, and resources to utilize when considering ethical issues.

Ethics in Orthopaedic Surgery

Ethics is an established system of moral principles that govern the rules of conduct. Medical ethics define what the physician ought to do and how he or she should behave. Professionalism in medicine pertains to accepted standards in the practice of medicine that guide societal and professional responsibility and relationships. Professionalism demands placing the interest of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health.

Medical ethics is similar to orthopaedic surgery in that there may not be one "correct" answer for every situation. Further, because of various state laws, what is acceptable in one location may not be appropriate in another location. An orthopaedic surgeon has an obligation to know and to follow the law in his or her community.

The PowerPoint slides in this series are designed to foster an understanding of medical ethics, to stimulate discussion and to encourage further exploration of the common ethical dilemmas encountered during the practice of orthopaedic surgery. Please review this series, discuss the scenarios, and read the AAOS Principles, Code of Medical Ethics and Professionalism, the Standards of Professionalism, and the Opinions on Ethics and Professionalism. We hope you enjoy using this series and learning about important ethical and professionalism issues currently facing orthopaedic surgeons.

Thank you,

The AAOS Ethics Committee welcomes your feedback. Email us at residentethicsseries@aaos.org

Issues and Scenarios for Discussion and Guidance:
Powerpoints and Discussion Guides

Resident Supervision

Samuel Crosby, MD; Daniel J. Fuchs, MD

The involvement of residents in surgical procedures has the potential to result in problems including inadequate supervision, misrepresentation of roles, and adverse events. Adequate supervision of residents and accurate representations of their roles are both ethical and necessary. Patient autonomy should be respected, and patients should be able to choose not to have residents participate in their care. While all person involved in the medical team can be found liable for medical errors, the person of ultimate responsibility is the attending surgeon.

Social Media

Lisa Taitsman, MD

Social Media is an ever growing presence in the personal and professional lives of physicians and patients. While social media offers new opportunities, it also poses new challenges to professionalism. Physicians must be aware of the intended benefits and unintended consequences related to their online presence, including social media interactions and communications. Many institutions and medical societies have developed guidelines to help physicians navigate in the new world of social media.

Inter-Professional Relations and Communication

Subramanyan (Jay) Jayasankar, MD

Competent orthopaedic care requires effective communication with patients, family members, team members and colleagues. Patient communication entails more than information exchange. It encompasses the skills needed to obtain all the necessary information from patients of diverse backgrounds, habits, cultures, etc., while building understanding, rapport, and trust. Successful communication among team members creates an environment that encourages free and open interactions. Ineffective communication compromises patient care. Effective communication facilitates high quality patient care and is a core competency.

Second Opinions and Independent Medical Examinations

Charles Carroll IV, MD; Joan B. Krajca-Radcliffe, MD

Second opinions and independent medical examinations may be performed as part of a physician's clinical practice and can be sought by many entities, including other physicians, insurance companies, attorneys, and even the involved patient/claimant. The physician performing these examinations must be aware of the ethical obligations and potential conflicts of interest, and maintain an honest and ethical approach in reaching and reporting his/her opinion. In addition, the examining physician must be aware of state and local laws governing specific areas of jurisdiction, such as extent of injury or causality, and must continue to follow local, state, and national rules of protected health information disclosure. This module presents various scenarios allowing for discussion of clinical situations and ethical dilemmas that may arise.

The Surgeon with HBV, HCV, or HIV

Desmond Brown, MD

The surgeon who contracts a blood-borne infection may transmit the infection to a patient during surgery. There is an ethical obligation to refrain from performing surgery until the infection has been adequately treated. Policies regarding return to work and informing patients attempt to balance the rights of the public and the impaired surgeon.

The Impaired Surgeon

Timothy C. Wilson, MD

Physicians have the ethical duty to intervene when a colleague is impaired. Not only may this prevent harm to patients, but colleagues may utilize the resources available to help treat impaired physicians.

"Value" in Health Care Delivery

Paul Levin, MD

Health care expenses in the United States are growing at an unsustainable rate. Achieving value in health care is recognizing that the utilization of health care resources in patient care needs to have demonstrable short and long term benefits as measured by quality of life. Achieving value may actually require an increased short term expenditure to gain long term health benefits and to restore the individual as a productive member of society. Failure to monitor our expenditures can ultimately threaten the successful delivery of health care to the vast majority of Americans.

Patient Abandonment

Paul Levin, MD

Abandonment is considered unprofessional behavior and, if reported to the state office of professional medical conduct, can trigger an investigation. A physician may also be at risk for a medical malpractice claim if the termination of care occurs at a "critical stage" of treatment and an injury results.

Ethical Aspects of Placebo ("Sham") Surgery

Matthew J. Matava, MD

Placebo or sham surgery controls have been used in a limited fashion in randomized trials of surgical interventions in orthopaedic research but are not without controversy. This module focuses on the definition of placebo (“sham”) surgery; the major differences between medical placebos and sham surgical procedures; the ethical implications of sham surgery versus the benefits it may provide in orthopaedic research; and the ethical criticisms against sham surgical procedures.

Just Say No: Ethical Considerations of Patient Care in the Gray Zone

Nancy M. Cummings, MD

"The ethical dimension of medicine is typically noticed only when a physician finds him or herself in a dilemma in which it is not obvious which of two treasured principles of professional ethics should be upheld and which should be sacrificed." In today's practice environment of share decision making and information availability, patients present to the orthopaedist with their own expectations of what their work up or treatment course should include. Gone are the paternalistic days when Marcus Welby, MD, could come into the room and put his hand on the patient's shoulder and tell the patient what should be done.

Patient Autonomy

Paul Levin, MD

The principal of respecting a patient's autonomy has become the cornerstone of modern health care in the United States. In the past, medicine has been practiced in a paternalistic fashion.

Informed Consent

Paul Levin, MD

Obtaining permission to perform a medical intervention is a widely accepted practice in medical care. When done properly it fulfills a core principal in biomedical ethics of respecting a patient's autonomy and allowing each individual patient to decide how they wish to be cared for.

Confidentiality

Joan Krajca-Radcliffe, MD

Confidentiality refers to limits placed on releasing information disclosed by a person within the patient-physician relationship. It is a long-standing, timehonored tradition in medicine that encompasses standards from the Hippocratic Oath to professional codes to HIPAA regulations. Upholding confidentiality shows respect for patients. It encourages them to seek medical care and divulge sensitive information to enable appropriate medical treatment.

Surrogate Decision Making

Joan Krajca-Radcliffe, MD

When patients lose their decision-making capacity, surrogates are utilized to make health-care decisions on their behalf. The patient may designate a health-care proxy through a Durable Power of Attorney (DPOA). Otherwise, health-care decisions may be made by surrogates through a hierarchy of levels and limitations governed by legal statutes primarily at the state level. This ethics module on Surrogate Decision-Making is designed to stimulate discussion via a changing scenario and familiarize the surgeon with guidelines, resources, and legalities to consider when faced with such clinical situations.

Disclosure with Adverse Outcomes

Kyle J. Jeray, MD

Regardless of the error and its consequences, the IOM states that the standard of care is full disclosure. The Joint Commission requires hospitals to tell patients when adverse outcomes occur. The National Quality Forum requires hospitals to have safe practice guidelines on disclosure of serious errors. Several states have laws requiring disclosure of adverse outcomes.

Paying to Play

Matthew J. Matava, MD

The topic of "playing to play", in terms of a medical provider paying a financial incentive to gain the right to provide medical care to an amateur, collegiate, or professional sports team, has been recognized with increasing frequency. This topic has been brought to light both in the lay media as well as in various legal and medical writings dealing with medicolegal issues unique to the team physician.

Put Me Back in the Game, Doc

Nancy M. Cummings, MD

Sports Medicine can be a "perfect storm" of ethical issues. An athlete gets hurt at a critical time for a team. This is not the simple office-based doctorpatient relationship. There are many other influences on the most fundamental relationship in medicine, and in the 21st century, Hippocrates' basic tenet - "Do no harm" - can be subject to interpretation.

Relationships with Industry

Kenneth C. Thomas, MD

Collaboration between orthopaedic surgeons and industry is essential for the advancement of orthopaedic technology. Numerous advances in patient care have been accomplished through proper relationships. The primary goal of the profession of orthopaedic surgery is caring for the patient. Relationships with industry must be conducted in an ethical manner and not distract from our primary goal. The relationships with industry across all fields of medicine have recently changed with the institution of the PhRMA and AdvaMed Codes of Ethics.

Expert Witness Testimony

Charles Carroll IV, MD

The presented scenario may in fact never happen, but the issue of medical expert testimony is a significant issue related to health care and orthopedic surgery. Professional liability is a major concern and problem for the resident and practicing physician. The purpose of this module is to introduce the concept of expert witness testimony and stimulate discussion on the topic.

The Older Surgeon

Stuart A. Green, MD

The proportion of medical doctors over the age of 65 is increasing. There has been much concern lately about subtle diminution in capacity displayed by such practitioners. While it was hoped that the board recertification process would somehow identify practitioners who are losing their skills, many physicians are outside the reach of the specialty boards. Some never passed the examinations in the first place, and others can simply continue practicing even if their certification is not renewed.

AAOS Code and Principles of Medical Ethics and Professionalism

The Code of Medical Ethics and Professionalism for Orthopaedic Surgeons and the Principles of Medical Ethics and Professionalism in Orthopaedic Surgery provide standards of conduct that define the essentials of honorable behavior for the orthopaedic surgeon. They are aspirational. The basic tenet is that, within orthopaedic surgery, the orthopaedic surgeon must develop and maintain a deeply ingrained moral commitment to the patient’s best interest.

Code of Medical Ethics and Professionalism for Orthopaedic Surgeons (pdf)
Adopted 1988; revised 1991, 1995, 2001, 2002, 2004, 2005, 2009

The Principles represent a distillation of the ten most important aspects of the Code in a simple one-page document.

Principles of Medical Ethics and Professionalism in Orthopaedic Surgery (pdf)
Adopted 1991; revised 1995, 2002

Standards of Professionalism

The Standards of Professionalism (SOPs) play a different role in guiding behavior for orthopaedic surgeons. While drawing from the aspirational Code and Principles, the Standards of Professionalism establish mandatory levels of professional conduct. Alleged violations of the Standards of Professionalism may lead to professional compliance actions, such as censure, suspension, or expulsion from the AAOS.

Advertising by Orthopaedic Surgeons (pdf)
Adopted 2007.

Orthopaedic Expert Opinion and Testimony (pdf)
Adopted 2005; amended 2010

Orthopaedist-Industry Conflicts of Interest (pdf)
Adopted 2007

Professional Relationships (pdf)
Adopted 2005

Providing Musculoskeletal Services to Patients (pdf)
Adopted 2008

Research and Academic Responsibilities (pdf)
Adopted 2006

Opinions on Ethics and Professionalism

The Opinions on Ethics and Professionalism amplify the Code and Principles and apply their tenets to practical situations.

Adopted 1992; revised 1995, 1997, 2002, 2009

Adopted 1998; revised 2002

Adopted 1992; revised 1995, 1997, 2002, 2009

Adopted 1994; revised 1995, 2002, 2003, 2005

Adopted 1995; revised 2002, 2009

Adopted 1994; revised 2002, 2009

Adopted 1992; revised 2004, 2005

Adopted 1992; revised 2002, 2009

Adopted 1993; revised 1997, 2002, 2005

Guide to Professionalism and Ethics in the Practice of Orthopaedic Surgery

January 2012 version

The Guide contains all of the documents listed here, plus relevant AAOS Information and Position Statements.

Ethical Issues in Orthopaedic Surgery

Neil S. Wenger, MD, MDP and Jay R. Lieberman, MD, 1993.

The development of these video cases and discussion guides was a project undertaken by the University of California, Los Angeles; American Academy of Orthopaedic Surgeons; American Orthopaedic Association; and Academic Orthopaedic Society.

Gifts From Industry
View Case Discussion PDF

The Impaired Physician
View Case Discussion PDF

Informed Consent and Research
View Case Discussion PDF

Practicing Under the Pressures of Managed Care
View Case Discussion PDF

Maintaining Confidentiality
View Case Discussion PDF

End-of-life Decisions, DNR Orders and Surgery
View Case Discussion PDF

Advertising
View Case Discussion PDF

Medical Decision-making and Cross-cultural Issues
View Case Discussion PDF

Power Abuse
View Case Discussion PDF

Performing Newly Learned Procedures
View Case Discussion PDF

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