Professional Medical Associations: Title and subTitle BreakEthical and Practical Guidelines

Medicine is, in essence, a moral enterprise, and its professional associations should therefore be built on ethically sound foundations. At the very least, when physicians form associations, such associations should promote the interests of those they serve. This, sadly, has not always been the case, when economic, commercial, and political agendas so often take precedence over ethical obligations.

The history of professional medical associations reflects a constant tension between self-interest and ethical ideals that has never been resolved. This tension is the result of the mixed origins and aims of the social institutions from which professional associations arose. For example, some associations originated in the Renaissance from groups of scholars whose aim was the exchange of knowledge and ideas about natural science, medicine, and philosophy. Other associations were founded by royal fiat to set standards of education and practice in the public interest. Still others were inspired by the elitist ethos of the medieval guilds. Today, the dominant influence on professional associations is economic, and the tension between self-interest and ethical principles is greater than ever. This conflict is eroding the moral foundations of all professional associations, not only in medicine, but in law, education, and even the ministry.

Physicians must now choose more definitively than ever whether their professional associations will assert the primacy of ethical commitment or shed any pretense of being moral enterprises and, instead, allow economic considerations to dominate their policies. The time is propitious for the medical profession to act responsibly to reaffirm the ethical commitment that grounds physicians' authenticity. Only then can physicians justify the claim to the moral integrity that patients expect. The present dilemma provides an opportunity for professional medical associations to shift the balance from self-interest to the interests of patients, thereby regaining public support and influence. Judging from recent trends, it is an opportunity that may not come again.

The current challenge therefore impels us to offer these reflections on the ethics of professional medical associations. We believe that such associations must be committed, first of all, to the welfare of the sick, even at some risk to the profession's collective pride and profit. We also believe that a multitude of physicians would endorse membership in professional associations that demonstrate this kind of moral leadership.

For centuries, a commitment to the effacement of self-interest has been embedded in traditional codes of medical ethics but has never been actualized as the vital spirit of professional organizations. Too often, ethical goals have been commingled with protection of self-interest, privilege, and prerogative. Yet, effacement of self-interest is the distinguishing feature of a true profession that sets it apart from other occupations. It is the heart of the professing of medicine, ie, the public declaration and promise that physicians can be trusted to use their skills for something other than their own benefit. Individual physicians privately make this promise whenever they invite trust by offering their skills to help someone who is ill.

When physicians form professional associations, they should make this promise collectively. They become members of a moral community dedicated to the primacy of those who need their help. That is why the ethical principles that medical associations ought to follow are so similar to those guiding the behavior of individual physicians. Professional associations exist to proclaim, protect, refine, teach, and enforce that behavior. Without such a commitment, they easily degenerate into self-serving trade associations, lobbies, or unions.

Sadly, this is the direction in which, to varying degrees, some professional medical associations seem to be drifting. Too many have already become corporatized entities in pursuit of profit to finance bulky administrative staffs or to lobby for the protection of privileges and the benefit of their members. Some associations have come to resemble guilds or mutual benefit societies. Clearly, the public has perceived this trend and no longer trusts those associations to act on its behalf.

In a properly conceived professional medical organization, physicians should associate to improve the care of the sick, to advance the health of the public, and to ensure that their fellow associates are faithful to that mission. Professional associations should try to ensure that physicians are competent practitioners, have good character, and provide mutual professional support for their colleagues. Associations should help to advance medical knowledge. They should help to establish and maintain standards of performance and education. They must speak out clearly whenever medicine is of dubious quality, unequally distributed, or inaccessible. They should provide leadership in confronting the broader issues of public health. They should be critics of those aspects of culture and lifestyle that are injurious to human health, and they should seek to improve community health and promote public information about health. They should defend the health of the most vulnerable members of society and advocate access to quality health care for all.

Today, when virtually all aspects of society are commercialized, there is an increasing deprofessionalization of all professions. The public yearns for professionals and professional associations devoted to something beyond self-interest. In no endeavor, except possibly the ministry and education, is this need more urgently felt by the American public than in medicine. That is why any scandal or perceived defect of virtue so seriously undermines public confidence in the integrity of the entire profession and its official organizations.

Medicine now has the chance to establish its ethical integrity convincingly, through responsible and constructive participation in the next round of public debate on health care reform. However, this can only be accomplished by professional organizations that take seriously their roles as moral communities. This means that, in public discourse or in policy debate, these organizations should not be champions of professional prerogatives, power, or profit. They will be believable only when they speak from the viewpoint of those they serve. Such a professional voice was notably absent in the last national debate about health care reform.

If physicians were to provide this kind of leadership, the medical profession could energize all the other health professions—even those professions outside the health field. Were they to take the ethical high ground, professional medical associations could provide the reassurances the public needs today. Without ethical commitment by the medical profession, however, the public has no defense against exploitation by the health care industry other than the law. The protection of patients, like the advancement of health care reform, needs the commitment of professional medical organizations, and these organizations must be seen as trustworthy.

There is an abundant literature on the ethical behavior of physicians as independent solo practitioners or members of medical group practices. There is also a growing literature on the ethics governing medical practice when physicians are employees or contractors for health care companies, both for-profit and not-for-profit. By contrast, there is virtually no writing on the ethics of professional medical membership associations (eg, national or state medical societies and specialty societies). What follows, based on the preceding discussion, is an attempt at outlining some guidelines that ought to govern these organizations.

First, the mission of professional medical associations ought to be consistent with that of the medical profession itself and should include all those public and professional goals mentioned above. The extent to which professional medical associations should attempt to protect the economic interests of their members or represent their members in negotiations with government regulators, insurers, and other third parties is debatable, but some such activity may well be unavoidable. However, associations should be aware of the dangers of focusing too much attention on the economic concerns of their members at the expense of their many—and more important—public and professional responsibilities. A reasonable compromise should be struck between the legitimate economic concerns of a professional facing an increasingly hostile workplace and the ethical obligations of a profession that wishes to be trusted and hopes to continue to hold a privileged place in US society. These latter obligations should prevail. As a practical matter, medical associations should recognize that their power and influence in effecting almost any change in the health care system will increasingly depend on public trust and support, which, in turn, will depend on whether the associations are seen to be working for the public interest.

Second, in our opinion, medical associations should not embrace unions or try to become unions. Physicians' unions, even those limited to fully salaried physicians, are, in essence, economic bargaining instruments for which the ultimate power is the threat of withholding services. Public renunciation of that power and promises to use the union only in defense of patients' rights and the improvement of medical care are not likely to dispel the public suspicion that physicians' unions would inevitably become self-serving. In the competitive market that health care has become, physicians' unions are bound to be seen as economic power tools, and physicians will almost certainly come to use them as such. It would be far better, we believe, for physicians to promote patients' interests on ethical and medical grounds as members of medical associations than to seek confrontations as union members. In our view, unions and truly professional associations are simply incompatible.

Third, the financial support of a professional medical organization should properly be derived from its membership dues, from such income as it may receive through the performance of the various functions mentioned earlier, and from grants and contracts awarded by government or charitable foundations. For-profit business ventures unrelated to the central purposes of the organization should be avoided, and even those that are related should be strictly limited to ventures with clear public benefits that can be openly discussed and fully disclosed. Whatever their nature, all income-generating ventures should be managed on a cost-plus basis, with a modest profit margin that would be perceived as appropriate for a professional organization primarily dedicated to public service and the improvement of medical care.

To avoid conflicts of interest, the professional medical association should not seek or accept support from companies that sell health care products or services. Neither should the association make deals with companies that involve co-branding, the use of the organization's name in the public marketing of goods and services. However, there would usually be no problem with selling certain professional goods and services to members only. Investment income from funds accumulated through ethical means also would not be problematic, but medical associations should not invest in enterprises related to medical care. Full disclosure and public accountability are essential in all cases.

Fourth, the ownership and publication of journals and other sources of medical information pose special ethical problems for professional medical associations and societies. When these publications claim simply to be house organs, there is little or no ethical problem with the control of editorial content and policies by the organization, provided there is full disclosure to readers. However, if the publication claims to be an impartial scholarly or scientific journal, it is important that the relationship between the medical association and the editorial staff of the journal ensures the editorial independence of the journal. Ideally, a journal should be able to survive entirely by means of subscriptions or, when necessary, through subsidy by the organization. Support from page charges or from charitable grants-in-aid are also permissible, but income from advertising could be problematic. Professional association journals that are too dependent on advertising income risk vulnerability to influence by advertisers and thereby jeopardize their independence and credibility. Firm policies are needed to protect journals from such influence, and to monitor the number and quality of the advertisements.

Fifth, meetings sponsored by professional medical associations and organizations should be consistent with all the above guidelines. In particular, support or sponsorship of the meeting as a whole or in part by manufacturers of products and services used or prescribed by physician-members of the organization should be avoided, even when such support is unrestricted or for general education purposes only. However, there is no ethical objection to charging manufacturers for the privilege of exhibiting their products at a meeting, provided all exhibitors are treated equally and without favor and provided the exhibit and meeting areas are appropriately separated. Professional meetings should not become medical bazaars.

Finally, governance of professional medical associations will vary, but certain general principles should prevail. Governance through bylaws adopted by the members, equal voting rights for all members (or, at least, representative democracy), and full accountability of elected officers to the members are among the most important principles. All policies and actions adopted by professional medical associations should be publicly disclosed.

The moral choices physicians and their professional associations face today are not unique to our times. Temptations to use medical power for personal, commercial, or organizational advantage have always existed. What is unique today is the unprecedented power of medical knowledge and the enormity of the potential profit to be made through its use. Given the pervasive spread of commercialism throughout the health care system, the obligation to use medical power with ethical constraint is more urgent than ever.

Professional medical associations have a great opportunity for leadership as moral agents since they can unite physicians in a community dedicated to the welfare of patients. Were medical associations to use that opportunity for the common good, they could help bring about the health care reform for which the public yearns and our country needs. The public would respond to such leadership, and it would accord to the profession the trust and respect that ethically motivated physicians deserve.