CODE OF ETHICS AND GUIDE TO THE ETHICAL BEHAVIOUR OF PHYSICIANS

New Zealand Medical Association

1989, last amended 2002

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The current New Zealand Medical Association (NZMA) Code of Ethics, which includes a Guide to the Ethical Behaviour of Physicians, was adopted in 1989, amended in December 1992, and last amended in March of 2002. There is great similarity, both in structure and content, between the NZMA code and the preceding code and guide of the Canadian Medical Association. The section of the NZMA entitled "Responsibilities to the Profession" and portions of the section entitled "Responsibilities to Society," not printed here, repeat some of the prescriptions of the Canadian code.

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Code of Ethics

All medical practitioners, including those who may not be engaged directly in clinical practice, will acknowledge and accept the following Principles of Ethical Behaviour:

Consider the health and well-being of the patient to be your first priority.
Respect the rights of the patient.
Respect the patient's autonomy and freedom of choice.
Avoid exploiting the patient in any manner.
Protect the patient's private information throughout his/her lifetime and following death, unless there are overriding public interest considerations at stake, or a patient's own safety requires a breach of confidentiality.
Strive to improve your knowledge and skills so that the best possible advice and treatment can be offered to the patient.
Adhere to the scientific basis for medical practice while acknowledging the limits of current knowledge.
Honour the profession and its traditions in the ways that best serve the interests of the patient.
Recognise your own limitations and the special skills of others in the prevention and treatment of disease.
Accept a responsibility for assisting in the allocation of limited resources to maximise medical benefit across the community.
Accept a responsibility for advocating for adequate resourcing of medical services.

Recommendations

Given the complexities of doctor–patient relationships, and the increasing difficulties brought about by the need for rationing of resources and direct intervention of third-party providers of funding, no set of guidelines can cover all situations. The following set of recommendations is designed to convey an overall pattern of professional behaviour consistent with the principles set out above in the Code of Ethics.

Responsibilities to the Patient

1. Doctors should ensure that all conduct in the practice of their profession is above reproach. Exploitation of any patient, whether it be physical, sexual, emotional, or financial, is unacceptable and the trust embodied in the doctor–patient relationship must be respected.
2. Doctors, like a number of other professionals, are involved in relationships in which there is a potential imbalance of power. Sexual relationships between doctors and their patients and students fall within this category. The NZMA is mindful of Medical Council policy in relation to sexual relationships with present and former patients, and expects doctors to be familiar with this. The NZMA considers that a sexual relationship with a current patient is unethical and that, in most instances, sexual relations with a former patient would be regarded as unethical, particularly where exploitation of patient vulnerability occurs. It is acknowledged that in some cases the patient–doctor relationship may be brief, minor in nature, or in the distant past. In such circumstances and where the sexual relationship has developed from social contact away from the professional environment, impropriety would not necessarily be inferred. Any complaints about a sexual relationship with a former patient need to be considered on an individual basis before being condemned as unethical.
3. Doctors should practise the science and art of medicine to the best of their ability in full moral independence, with compassion and respect for human dignity.
4. Doctors should ensure that every patient receives appropriate investigation into their complaint or condition, including adequate collation of information for optimal management.
5. Doctors should ensure that information is recorded accurately and is securely maintained.
6. Doctors should seek to improve their standards of medical care through continuing self education and thoughtful interaction with appropriate colleagues.
7. Doctors have the right, except in an emergency, to refuse to care for a particular patient. In any situation which is not an emergency, doctors may withdraw from or decline to provide care as long as an alternative source of care is available and that the appropriate avenue for securing this is known to the patient. Where a doctor does withdraw care from a patient, reasonable notice should be given.
8. When a patient is accepted for care, doctors will render medical service to that person without discrimination (as defined by the Human Rights Act).9. Doctors should ensure that continuity of care is available in relation to all patients, whether seen urgently or unexpectedly, or within a long-term contractual setting, and should establish appropriate arrangements to cover absence from practice or hours off duty, informing patients of these.
10. Doctors should ensure that patients are involved, within the limits of their capacities, in understanding the nature of their problems, the range of possible solutions, as well as the likely benefits, risks, and costs, and shall assist them in making informed choices.
11. Doctors should recognise the right of patients to choose their doctors freely.
12. Doctors should recognise their own professional limitations and, when indicated, recommend to patients that additional opinions and services be obtained, and accept a patient's right to request other opinions. In making a referral to another health professional, so far as practical, the doctor shall have a basis for confidence in the competence of that practitioner.
13. Doctors should accept the right of a patient to be referred for further management in situations where there is a moral or clinical disagreement about the most appropriate course to take.
14. Doctors should keep in confidence information derived from a patient, or from a colleague regarding a patient, and divulge it only with the permission of the patient except when the law requires otherwise, or in those unusual circumstances when it is clearly in the patient's best interests or there is an overriding public good. Patients should be made aware of the information sharing which enables the delivery of good quality medical care. Where a patient expressly limits possession of particular information to one practitioner, this must ordinarily be respected. Patients should be made aware in advance, if possible, where there are limits to the confidentiality which can be provided. When it is necessary to divulge confidential patient information this must be done only to the proper authorities, and a record kept of when reporting occurred and its significance.
15. Doctors should recommend only those diagnostic procedures which seem necessary to assist in the care of the patient and only that treatment which seems necessary for the well-being of the patient.
16. When requested or when need is apparent, doctors should provide patients with information required to enable them to receive benefits to which they may be entitled.
17. Doctors shall accept those obligations to patients which are imposed by statutory provisions and the codes of the Privacy Commissioner, the Human Rights Commissioner and the Health and Disability Commissioner, and the requirements of the Medical Council of New Zealand.
18. Doctors have a duty to explain to patients the role of doctors, patients and citizens generally in advancing medical knowledge, given that medical knowledge evolves in the light of ongoing research.
19. Doctors should accept that autonomy of patients remains important in childhood, chronic illness, ageing, and in the process of dying.
20. Doctors should bear in mind always the obligation of preserving life wherever possible and justifiable, while allowing death to occur with dignity and comfort when it appears to be inevitable. Doctors should be prepared to discuss and contribute to the content of advance directives and give effect to them. In the case of conflicts concerning management, doctors should consult widely within the profession and, if indicated, with ethicists and legal authorities.
21. In relation to transplantation and requests for organ donation, doctors should accept that when death of the brain has occurred, the cellular life of the body may be supported if some parts of the body might be used to prolong or improve the health of others. They shall recognise their responsibilities to the donor of organs that will be transplanted by disclosing fully to the donor or relatives the intent and purpose of the procedure. In the case of a living donor, the risks of the donation procedures must be fully explained. Doctors will ensure that the determination of the time of death of any donor patient is made by doctors who are in no way concerned with the transplant procedure or associated with the proposed recipient in a way that might exert any influence upon any decisions made.
22. Doctors have a responsibility to ensure that all people in their employ are fully aware of the appropriate actions to be taken in cases of medical emergency. It is strongly recommended that these procedures be included in a written policy document.

Professional Responsibilities

23. Doctors have both a right and a responsibility to maintain their own health and well-being at a standard that ensures that they are fit to practise.
24. Doctors should seek guidance and assistance from colleagues and professional or healthcare organisations whenever they are unable to function in a competent, safe and ethical manner.25. Doctors have a general responsibility for the safety of patients and shall therefore take appropriate steps to ensure unsafe or unethical practices on the part of colleagues are curtailed and/or reported to relevant authorities without delay.
26. Doctors should make available to their colleagues, on the request of patients, a report or summary of their findings and treatment relating to that patient.
27. Doctors should recognise that an established relationship between doctor and patient has a value which dictates that this should not be disturbed without compelling reasons. Disruption of such a relationship should, wherever possible, be discussed in advance with an independent colleague.
28. Doctors should avoid impugning the reputations of other doctors with colleagues, patients or other persons.
29. Doctors should accept a share of the profession's responsibility toward society in matters relating to the health and safety of the public, health promotion and education, and legislation affecting the health or well-being of the community.
30. Doctors should not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman, or degrading procedures, whatever the offence of which the victim of such procedures is suspected, accused or guilty.
31. Doctors should recognise the responsibility to assist courts, commissioners, commissions, and disciplinary bodies, in arriving at just decisions. In all circumstances doctors shall certify only that which has been personally verified when they are testifying as to circumstances of fact.
32. Doctors should not allow their standing as medical professionals to be used inappropriately in the endorsement of commercial products. When doctors are acting as agents for, or have a financial or other interest in, commercial organisations, their interest must be declared to patients.
33. Doctors should not use secret remedies.
34. Advances and innovative approaches to medical practice should be subject to review and promulgation through professional channels and medical scientific literature. Doctors should accept responsibility for providing the public with carefully considered, generally accepted opinions when presenting scientific knowledge. In presenting any personal opinion contrary to a generally held viewpoint of the profession, doctors must indicate that such is the case, and present information fairly.
35. Doctors should accept that their professional reputation must be based upon their ability, technical skills and integrity. Doctors should advertise professional services or make professional announcements only in circumstances where the primary purpose of any notification is factual presentation of information reasonably needed by any person wishing to make an informed decision about the appropriateness and availability of services that may meet his or her medical needs. Any such announcement or advertisement must be demonstrably true in all respects and contain no testimonial material or endorsement of clinical skills. Qualifications not recognised by appropriate New Zealand statutory bodies should not be quoted.
36. Doctors should exercise careful judgement before accepting any gift, hospitality or gratuity which could be interpreted as an inducement to use or endorse any product, equipment or policy. In all cases of doubt, advice should be sought from relevant professional organisations.

Research

37. Before initiating or participating in any clinical research, doctors must assure themselves that the particular investigation is justified in the light of previous research and knowledge. Any proposed study should reasonably be expected to provide the answers to the questions raised. All studies involving patients should be subject to the scrutiny of an Ethics Committee before initiation. It is often appropriate to establish a committee independent of the primary investigators, initiators and funders of a trial to oversee ongoing ethical issues, including the evaluation of emerging results according to stated clinical, ethical and scientific criteria.
38. Doctors must be assured that the planning and conduct of any particular study is such that it minimises the risk of harm to participants. In comparative studies, the patient and control groups must receive the best available treatment.
39. Patient consent for participating in clinical research (or permission of those authorised to act on their behalf) should be obtained in writing only after a full written explanation of the purpose of that research has been made, and any foreseeable health hazards outlined. Opportunity must be given for questioning and withdrawal. When indicated, an explanation of the theory and justification for double-blind procedures should be given. Acceptance or refusal to participate in a clinical study must never interfere with the doctor–patient relationship or access to appropriate treatment. No degree of coercion is acceptable.
40. Boundaries between formalised clinical research and various types of innovation have become blurred to an increasing extent. Doctors retain the right to recommend, and any patient has the right to receive, any new drug or treatment which, in the doctor's considered judgement, offers hope of saving life, re-establishing health or alleviating suffering. Doctors are advised to document carefully the basis for any such decisions and also record the patient's perception and basis for a decision. In all such cases the doctors must fully inform the patient about the drug or treatment, including the fact that such treatment is new or unorthodox, if that is so.
41. In situations where a doctor is undertaking an innovative or unusual procedure on his or her own initiative, it is wise to consult colleagues. This recommendation applies particularly in relation to care of the dying.
42. It is the duty of doctors to ensure that the first communication of research results be through recognised scientific channels, including journals and meetings of professional bodies, to ensure appropriate peer review. Participants in the research should also be informed of the results as soon as is practicable after completion.
43. Doctors should not participate in clinical research involving control by the funder over the release of information or results, and must retain the right to publish or otherwise release any findings they have made. Any dispute or ethical issue which may arise in the course of research should be considered openly, e.g. by consultation with the Ethics Committee of the NZMA and/or Regional Ethics Committees.

Teaching

44. Clinical teaching is the basis on which sound clinical practice is based. It is the duty of doctors to share information and promote education within the profession. Education of colleagues and medical students should be regarded as a responsibility for all doctors.
45. Teaching involving direct patient contact must be undertaken with sensitivity, compassion, respect for privacy, and, whenever possible, with the consent of the patient, guardian or appropriate agent. Particular sensitivity is required when patients are disabled or disempowered, e.g. children. If teaching involves a patient in a permanent vegetative state, the teacher should, if at all possible, consult with a nursing or medical colleague and a relative before commencing the session.
46. Wherever possible, patients should be given sufficient information on the form and content of the teaching, and adequate time for consideration, before consenting or declining to participate in clinical teaching. Refusal by a patient to participate in a study or teaching session must not interfere with other aspects of the doctor–patient relationship or access to appropriate treatment.
47. Patients' understanding of, or perspective on, their medical problems may be influenced by involvement in clinical teaching. Doctors must be sensitive to this possibility and ensure that information is provided in an unbiased manner, and that any questions receive adequate answers. It may be appropriate for the doctor to return later to address these issues.

Medicine and Commerce

48. Commercial interests of an employer, health provider, or doctor must not interfere with the free exercise of clinical judgement in determining the best ways of meeting the needs of individual patients or the community, nor with the capacities of individual doctors to co-operate with other health providers in the interests of their patients, nor compromise standards of care in order to meet financial or commercial targets.
49. Where potential conflict arises between the best interests of particular patients and commercial or rationing prerogatives, doctors have a duty to explain the issues and dilemmas to their patients. Doctors shall state quite clearly what their intentions are and why they advocate particular patterns of diagnosis, treatment or resource use. Rationing of resources must be open to public scrutiny and points of conflict identified and presented in a rational, non-biased manner to the public.
50. Doctors who provide capital towards health services in the private sector are entitled to expect a reasonable return on investment. Where there may be a conflict of interests, the circumstances should be disclosed and open to scrutiny.
51. Like all professionals, doctors have the right to fair recompense for the use of their skills and experience. However, motives of profit must not be permitted to influence professional judgement on behalf of patients.
52. Doctors should insist that any contracts into which they enter, including those involving patients, be written in clear language such that all parties have a clear understanding of the intentions and rules.
53. Doctors who find themselves in a potentially controversial contractual or commercial situation should seek the advice of a suitable colleague or organisation.

Code of Ethics and Guide to the Ethical Behaviour of Physicians

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