CLINICAL ETHICS Gaps, conflicts, and consensus in the ethics statements of professional associations, medical groups, and health plans

Background: Patients today interact with physicians, physician groups, and health plans, each of which may follow distinct ethical guidelines. Method: We systematically compared physician codes of ethics with ethics policies at physician group practices and health plans, using the 1998–99 policies of 38 organisations—18 medical associations (associations), nine physician group practices (groups), and 12 health plans (plans)—selected using random and stratified purposive sampling. A clinician and a social scientist independently abstracted each document, using a 397-item health care ethics taxonomy; a reconciled abstraction form was used for analysis. This study focuses on ethics policies regarding professional obligation towards patients, resource allocation, and care for the vulnerable in society. Results: A majority in all three groups mention ‘‘fiduciary obligations’’ of one sort or another, but associations generally address physician/patient relations but not health plan obligations, while plans rarely endorse physicians’ obligations of advocacy, beneficence, and non-maleficence. Except for occasional mentions of cost effectiveness or efficiency, ethical considerations in resource allocation rarely arise in the ethics policies of all three organisational types. Very few associations, groups, or plans specifically endorse obligations to vulnerable populations. Conclusions: With some important exceptions, we found that the ethics policies of associations, groups, and plans are narrowly focused and often ignore important ethical concerns for society, such as resource allocation and care for vulnerable populations. More collaborative work is needed to build integrated sets of ethical standards that address the aims and responsibilities of the major stakeholders in health care delivery.