For more than 175 years, the AMA Code of Medical Ethics has been the leading source of ethical guidance to physicians on the provision of patient care. But as an increasing number of physicians are employed by health systems, those doctors’ ability to uphold ethical commitments to patient well-being are coming into conflict with the goals and demands of hospital administrators.
“Should the AMA Code of Medical Ethics speak to health care systems?” asked Michael Suk, MD, JD, MPH, MBA during an education session at the most recent AMA Interim Meeting.
The answer is “a resounding yes,” said Dr. Suk, who took part with other AMA leaders in an open forum hosted by the AMA Council of Ethical and Judicial Affairs regarding the role of the AMA Code of Medical Ethics in shaping health system ethics.
That answer is meaningful coming from Dr. Suk. In addition to serving on the AMA Board of Trustees, he is professor and chair of the Musculoskeletal Institute and the Department of Orthopaedic Surgery at Geisinger health system. Also, he serves as chief physician officer of Geisinger System Services, the health system’s enterprise supply chain and pharmacy division.
Geisinger is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
“I'm a board-certified practicing orthopedic surgeon. I have to wear several hats within a large integrated health care system,” Dr. Suk said, noting that besides regularly operating on patients, he supervises more than 40 residents, has responsibilities at the medical school and chairs a large musculoskeletal institute with over 700 staff members in 10 hospitals.
“Further complicating things is I'm also a health system operations executive who helps oversee a $1.5 billion supply chain, pharmacy and master facility planning unit within a $10 billion organization,” he added. “So, as you go through these three different particular hats that I have to wear on a regular basis, it often times can underscore levels of tension that exist between all of them.”
It’s more than theoretical
Geisinger is an integrated health system with more than 500,000 members in its health plan, and one of the ethical issues its administrators face is whether—or, maybe more to the point, how best —the plan should cover certain medications.
Case in point: semaglutide (marketed as Wegovy for weight loss, and as Ozempic to treat type 2 diabetes).
“We know that obesity is a medical condition that has a strong correlation to subsequent chronic disease,” Dr. Suk said. The ethical dilemma is that it can play a substantial role in value-based care, “but it costs a lot of money. So that's upfront cost associated with a preventive measure that is not directly linked to a traditional payment model.”
Without a value-based model in place for sharing the risk between payers, physicians and hospitals in order to improve population based outcomes, Dr. Suk noted, health systems are forced to balance upfront costs with a potential for decreased revenue on acute exacerbations of chronic disease.
“Those things are inherently in conflict,” he said.
How the Code can lead
Among the topics the AMA Code of Medical Ethics addresses is unionization and other "Political Action by Physicians," Opinion 1.2.10.
Included in that is the question of whether physicians should be allowed to own hospitals.
“We have an obligation that under no circumstances may a physician put their financial interest above that of a patient. That is an ethical requirement,” said AMA President Jesse Ehrenfeld, MD, MPH, who also served as a panelist at the open forum.
Still, physicians at some health systems sense that their professional values—and the patients they are designed to serve—don’t always come first.
“That lack of a voice is driving people towards having a renewed interest in collective action and unionization, which can create some inherent struggles,” he said.
The new AMA Code of Medical Ethics website makes ethics guidance available free of charge in an easy-to-use, searchable format with oodles of related content to help physicians, medical students and other stakeholders navigate thorny ethical issues.
