eStudy and Resident Center

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,

AAOS Ethics Committee

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

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

Patient Autonomy

Powerpoint Slideshow (ppt)

Discussion Guide (pdf)

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.

Confidentiality

Powerpoint Slideshow (ppt)

Discussion Guide (pdf)

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.

Disclosure with Adverse Outcomes

Powerpoint Slideshow (ppt)

Discussion Guide (pdf)

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.

Put Me Back in the Game, Doc

Powerpoint Slideshow (ppt)

Discussion Guide (pdf)

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.

Expert Witness Testimony

Powerpoint Slideshow

Discussion Guide

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.

Informed Consent

Powerpoint Slideshow (ppt)

Discussion Guide (pdf)

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.

Surrogate Decision Making

Powerpoint Slideshow (ppt)

Discussion Guide (pdf)

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.

Paying to Play

Powerpoint Slideshow (ppt)

Discussion Guide (pdf)

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.

Relationships with Industry

Powerpoint Slideshow (ppt)

Discussion Guide (pdf)

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.

The Older Surgeon

Powerpoint Slideshow (ppt)

Discussion Guide (pdf)

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

Adopted 2007.

Orthopaedic Expert Opinion and Testimony

Adopted 2005; amended 2010

Orthopaedist-Industry Conflicts of Interest

Adopted 2007

Professional Relationships

Adopted 2005

Providing Musculoskeletal Services to Patients

Adopted 2008

Research and Academic Responsibilities

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.

Advertising by Orthopaedic Surgeons (pdf)

Adopted 1992; revised 1995, 1997, 2002, 2009

Care and Treatment of the Medically Underserved (pdf)

Adopted 1998; revised 2002

Continuing Medical Education (pdf)

Adopted 1992; revised 1995, 1997, 2002, 2009

Ethics in Health Research in Orthopaedic Surgery (pdf)

Adopted 1994; revised 1995, 2002, 2003, 2005

Medical and Surgical Procedure Patents (pdf)

Adopted 1995; revised 2002, 2009

The Orthopaedic Surgeon in the Managed Care Setting (pdf)

Adopted 1994; revised 2002, 2009

The Orthopaedic Surgeon's Relationship with Industry (pdf)

Adopted 1992; revised 2004, 2005

Second or Additional Medical Opinions in Orthopaedic Surgery (pdf)

Adopted 1992; revised 2002, 2009

Sexual Harassment and Exploitation (pdf)

Adopted 1993; revised 1997, 2002, 2005

Sexual Misconduct in the Physician-Patient Relationship (pdf)

Adopted 1993; revised 2002, 2009

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.