healthcare ethics essay

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Medical Ethics Issues: Position Papers & Resources

In addition to the ACP Ethics Manual, ACP publishes ethics position papers on a broad range of health care ethics issues including clinical ethics, professionalism, the delivery of health care, teaching, medical research, human rights and other topics. ACP ethics policy is approved by the Board of Regents and serves as the basis for the development of ACP ethics education and practice resources and legislative, regulatory and policy implementation activities.

Current ACP Ethics Policies and Resources

New determination of death and organ transplantation, position papers.

• Standards and Ethics Issues in the Determination of Death: A Position Paper From the American College of Physicians (September 4, 2023)
• Ethics, Determination of Death, and Organ Transplantation in Normothermic Regional Perfusion (NRP) with Controlled Donation after Circulatory Determination of Death (cDCD): American College of Physicians Statement of Concern (April 17, 2021)

Comments and Letters

• ACP letter to the Uniform Law Commission Committee about updating the Uniform Determination of Death Act (UDDA) (June 7, 2023)
• Does Normothermic Regional Perfusion Violate the Ethical Principles Underlying Organ Procurement? Yes. (Chest. 2022;162(2):288-90)
• Rebuttal From Dr. DeCamp et al. (Chest. 2022;162(2):292-3)

NEW Disability

• ACP Letter Regarding Discrimination on Basis of Disability in Health and Human Service Programs Proposed Rule 2023 (November 13, 2023)

NEW Electronic and Online Professionalism

Ethics manual, electronic patient-physician communication, electronic health records, telemedicine, and online professionalism.

• Initiating and Discontinuing the Patient–Physician Relationship
• The Medical Record
• Boundaries and Privacy

Case Studies

• Lab Results Reporting, Ethics, and the 21st Century Cures Act Rule on Information Blocking CME/MOC

Ethics, Electronic Health Record Integrity and the Patient-Physician Relationship CME/MOC (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2021)

Ethics, Professionalism, and the Physician Social Media Influencer CME/MOC (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

”Doctor, Can’t You Just Phone a Prescription In?” and Other Ethical Challenges of Telemedicine Encounters CME/MOC (ACP Ethics Case Studies Series. MOC and CME by Medscape. 2019)

Maintaining Medical Professionalism Online: Posting of Patient Information CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Addressing a Colleague's Sexually Explicit Facebook Post CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Copied and Pasted and Misdiagnosed (or Cloned Notes and Blind Alleys) CME (ACP Ethics Case Studies Series. CME by Medscape. 2015)

American College of Physicians Ethical Guidance for Electronic Patient-Physician Communication: Aligning Expectations (J Gen Intern Med. published online 22 June 2020)

Ethical Implications of the Electronic Health Record: In the Service of the Patient (J Gen Intern Med. 2017;32:935-9)

Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings (Ann Intern Med. 2015;163:787-9)

Online Medical Professionalism: Patient and Public Relationships (Ann Intern Med. 2013;158:620-7)

NEW End-of-Life Care

• Care of Patients Near the End of Life
• Show Codes, Slow Codes, Full Codes, or No Codes: What Is a Doctor to Do? CME/MOC (ACP Ethic Case Studies Series, MOC and CME by Medsape. 2023)

2011 Letter and 2009 letter to Congressman Blumenauer regarding ACP’s support for legislation to pay for voluntary end-of-life care consultations (see H.R. 1898, the Life Sustaining Treatment Preferences Act of 2009).

• Ethics, Determination of Death, and Organ Transplantation in Normothermic Regional Perfusion (NRP) with Controlled Donation after Circulatory Determination of Death (cDCD): American College of Physicians Statement of Concern

End-of-Life (PEACE) Brochures (ACP. 2014) The PEACE brochures were developed by the Patient Education Work Group, which was convened in conjunction with the Consensus Panel project. Order copies of printed brochures

• Improving Your End-of-Life Care Practice
• Living with a Serious Illness: Talking with Your Doctor When the Future is Uncertain
• When You Have Pain at the End of Life
• Making Medical Decisions for a Loved One at the End of Life

ACP-ASIM End-of-Life Care Consensus Panel Papers (1999-2001) ACP convened this Greenwall Foundation supported consensus panel to develop ethical, policy, and clinical recommendations for physicians and other clinicians on end-of-life decisions.

Physician's Guide to End-of-Life Care Edited by Lois Snyder, JD, and Timothy Quill, MD, FACP (ACP Books. 2001)

Advance Directive Forms for Your State Contact Caring Connections, a program of the National Hospice and Palliative Care Organization (NHPCO).

National Healthcare Decisions Day, April 16 Details and resources on NHDD and the importance of advance care planning.

• Expert Witnesses

To Be or Not to Be: Should I Serve as an Expert Witness? CME (ACP Ethics Case Studies Series. CME by Medscape. 2014)

Guidelines for the Physician Expert Witness (Ann Intern Med. 1990;113:789)

NEW Family Caregivers

Ethical Guidance on Family Caregiving, Support, and Visitation in Hospitals and Residential Health Care Facilities, Including During Public Health Emergencies (J Gen Intern Med. 2023 Mar 20:1–8)

Family Caregivers, Patients and Physicians: Ethical Guidance to Optimize Relationships (J Gen Intern Med. 2010;25:255-60)

Family Caregivers, Patients and Physicians: Ethical Guidance to Optimize Relationships (ACP. 2009) (This publication is a longer version of the position paper above.)

Information Resources for Physicians Supporting Family Caregivers (ACP. 2010) This appendix of resources was developed in conjunction with the ACP position paper to help physicians manage relationships with patients and caregivers.

When the Family Caregiver Is a Physician: Negotiating the Ethical Boundaries CME/MOC (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

Genetic Testing and Precision Medicine

• Precision Medicine, Genetic Testing, Privacy, and Confidentiality

ACP Comments on privacy protection and human genome sequencing (May 24, 2012) ACP provided comments to the Presidential Commission for the Study of Bioethical Issues regarding the ethical implications of evolving notions of privacy and access in relation to the integration of large-scale human genome sequencing into research and clinical care.

Position Papers and Statements

Ethical Considerations in Precision Medicine and Genetic Testing in Internal Medicine Practice Ann Intern Med.2022;175:1322-1323

Genetic Testing and Reuniting Families (July 10, 2018)

Global Health Clinical Experiences

• Cultural Humility and Volunteerism

Ethical Obligations Regarding Short-Term Global Health Clinical Experiences (Ann Intern Med. 2018;168:651-7)

NEW Health and Human Rights

"Health and human rights are interrelated. When human rights are promoted, health is promoted ... Physicians have important roles in promoting health and human rights and addressing social inequities." (Ethics Manual, seventh edition).

• Obligations of the Physician to Society

Health as a Human Right (Ann Intern Med. doi:10.7326/M23-1900)

ACP's Human Rights Page : ACP policy statements and letters of support, as well as documents related to College advocacy for the humane treatment of prisoners and detainees.

NEW Health Information Privacy, Protection, and Use

• Confidentiality
• Research Sections within the Research chapter include “Use of Human Biological Materials in Research” and “Internet and Social Media Research”.

Maintaining Medical Professionalism Online: Posting of Patient Information (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Confidentiality and Privacy: Beyond HIPAA to Honey, Can We Talk? (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Ethical Guidance for Physicians and Health Care Institutions on Grateful Patient Fundraising: A Position Paper From the American College of Physicians (Ann Intern Med.doi:10.7326/M23-1691)

Health Information Privacy, Protection, and Use in the Expanding Digital Health Ecosystem: A Position Paper of the American College of Physicians (Ann Intern Med.2021;174:994-998)

NEW Pandemics and Ethics -->

Health care system catastrophes.

• The Patient-Physician Relationship and Health Care System Catastrophes
• Medical Risk to Physician and Patient

When Resources Are Limited During a Public Health Catastrophe: Nondiscrimination and Ethical Allocation Guidance CME/MOC (ACP Ethics Case Studies Series. MOC and CME by Medscape. 2023)

Pandemic Treatment Resource Allocation Ethics and Nondiscrimination (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

Stewardship of Health Care Resources: Allocating Mechanical Ventilators During Pandemic Influenza (ACP Ethics Case Studies Series. 2017)

ACP supports ACIP recommendation for additional mRNA COVID-19 vaccine dose and WHO call for equitable global vaccine distribution (August 17, 2021)

ACP Statement on Global COVID-19 Vaccine Distribution and Allocation: On Being Ethical and Practical (June 8, 2021)

ACP's Policy Statement on the Ethical Allocation of Vaccines During Pandemics Including COVID-19 (November 23, 2020)

A Wake-up Call for Healthcare Emerging Ethical Lessons from Covid-19 (Modern Healthcare, June 16, 2020)

Non-Discrimination in the Stewardship of Healthcare Resources in Health System Catastrophes, including COVID-19 Pandemic (March 26, 2020)

Internists Say Harassment Based on Race or Ethnic Origin is Never Okay (March 31, 2020)

Universal Do-Not-Resuscitate Orders, Social Worth, and Life-Years: Opposing Discriminatory Approaches to the Allocation of Resources During the COVID-19 Pandemic and Other Health System Catastrophes (Ann Intern Med.2020;173:230-232)

NEW Patient–Physician Relationship

Patient-physician relationship.

• The Physician and the Patient
• Initiating and Discontinuing the Patient-Physician Relationship
• Third-Party Evaluations
• Providing Medical Care to One’s Self; Persons With Whom the Physician has a Preexisting Close Nonprofessional Relationship or a Reporting Relationship; and VIPs
• Sexual Contact between Physician and Patient
• Gifts from Patients

Confidentiality and privacy, disclosure of medical errors, and informed and surrogate decision making

• Informed Decision Making and Consent
• Making Decisions Near the End of Life

The Doctor Will See You Shortly. The Ethical Significance of Time for the Patient–Physician Relationship (J Gen Intern Med. 2005;20:1057-62)

Ethics and Time, Time Perception, and the Patient–Physician Relationship (ACP. March 2003) (This publication is a longer version of the position paper above.)

• Patient Prejudice? The Patient Said What?... and What Comes Next CME (ACP Ethics Case Studies Series. CME by Medscape. 2022)

Confidentiality and Privacy: Beyond HIPAA to Honey, Can We Talk? CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Preventive Health Screening, Ethics, and the Cognitively Impaired Patient CME (ACP Ethics Case Studies Series. CME by Medscape. 2015)

The Difficult Patient: Should You End the Relationship? What Now? An Ethics Case Study CME (ACP Ethics Case Studies Series. CME by Medscape. 2014)

Must You Disclose Mistakes Made by Other Physicians? CME (ACP Observer. November 2003)

Physicians and Society

• Relation of the Physician to Government
• Strikes and Other Joint Actions by Physicians

Physician Work Stoppages and Political Demonstrations—Economic Self-Interest or Patient Advocacy? Where Is the Line? CME (ACP Ethics Case Studies Series. CME by Medscape. 2010)

• Physician-Assisted Suicide and Euthanasia
• Toolkit on Issues in Delivering Patient-Centered End-of-Life Care and Responding to a Request for Physician-Assisted Suicide (Member login)

Ethics and the Legalization of Physician-Assisted Suicide (Ann Intern Med. 2017;167:576-8)

Physician–Industry Relations

• Conflicts of Interest
• Sponsored Research

Physician Open Payments (Sunshine Rule) This ACP webpage provides guidance and related tools for physicians on the Physician Payment Sunshine Rule (also referred to as the National Physician Payment Transparency Program, or Open Payments). The Open Payments system, implemented by the Centers for Medicare and Medicaid Services (CMS) in 2015, provides a mechanism for the public reporting of physician and teaching hospital financial relationships with industry.

Physician–Industry Relations. Part 1: Individual Physicians (Ann Intern Med. 2002;136:396-402)

Physician–Industry Relations. Part 2: Organizational Issues (Ann Intern Med. 2002;136:403-6)

NEW Practice Models, the Business of Medicine and the Changing Practice Environment

• The Changing Practice Environment
• Financial Arrangements

Ethics, Professionalism, Physician Employment and Health Care Business Practices CME/MOC

Banning Harmful Health Behaviors as a Condition of Employment: Where There's Smoke There's Fired? CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Wellness Programs and Patient Goals of Care CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Obligations and Opportunities: The Role of Clinical Societies in the Ethics of Managed Care (J Am Geriatr Soc. 1998;46:378-80)

Ethical and Professionalism Implications of Physician Employment and Health Care Business Practices CME (Ann Intern Med. published online 15 March 2021)

Assessing the Patient Care Implications of “Concierge” and Other Direct Patient Contracting Practices (Ann Intern Med. 2015;163:949-52)

The Patient-Centered Medical Home: An Ethical Analysis of Principles and Practice (J Gen Intern Med. 2013;28:141-6)

Ethical Considerations for the Use of Patient Incentives to Promote Personal Responsibility for Health: West Virginia Medicaid and Beyond (ACP. 2010)

Pay-for-Performance Principles That Promote Patient-Centered Care: An Ethics Manifesto (Ann Intern Med. 2007;147:792-4)

Pay-for-Performance Principles that Ensure the Promotion of Patient Centered Care—An Ethics Manifesto (ACP. 2007) (This publication is a longer version of the position paper above.)

Medical Professionalism in the Changing Health Care Environment: Revitalizing Internal Medicine by Focusing on the Patient–Physician Relationship (ACP. 2005)

Ethics in Practice: Managed Care and the Changing Health Care Environment (Ann Intern Med. 2004;141:131-6)

Selling Products Out of the Office (Ann Intern Med. 1999;131:863-4)

Prescription Drug Abuse

Prescription Drug Abuse (Ann Intern Med. 2014;160:198-200)

NEW Professionalism

American College of Physicians Pledge (ACP. 1982 [updated; original 1924]) The ACP Pledge is taken by new Fellows at Convocation at each Internal Medicine annual meeting. The Pledge affirms the physician’s membership in an ethical and moral community dedicated to healing, comfort, and altruism.

Physician Charter on Professionalism

Medical Professionalism in the New Millennium: A Physician Charter (Ann Intern Med. 2002;136:243-6)

• Professionalism

Ethical and Professionalism Implications of Physician Employment and Health Care Business Practices (Ann Intern Med. published online 15 March 2021)

• ACP Professional Accountability Principles (ACP. March 2018)

Professional Attire and the Patient-Physician Relationship CME/MOC (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

Addressing a Colleague's Unprofessional Behavior During Sign-Out CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Dealing with the "Disruptive" Physician Colleague CME (ACP Ethics Case Studies Series. CME by Medscape. 2009)

Professional Well-being and Ethics

• The Impaired Physician

Physician Suicide Prevention: The Ethics and Role of the Physician Colleague and the Healing Community CME/MOC

When an Aging Colleague Seems Impaired CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Physician Suicide Prevention and the Ethics and Role of a Healing Community: An American College of Physicians Policy Paper (J Gen Intern Med. 2021 Sep;36(9):2829-2835)

Physician Impairment and Rehabilitation: Reintegration Into Medical Practice While Ensuring Patient Safety (Ann Intern Med. 2019;170(12):871-879.)

ACP’s Physician Well-being and Professional Satisfaction initiative aims to foster a culture of wellness, reduce administrative burdens on physicians, improve practice efficiency and enhance individual physician well-being. The project website includes tools and programs for individual members, their practices, and ACP Chapters.

Research Ethics and Human Subjects

Research Sections within the chapter include “Protection of Human Subjects,” “Use of Human Biological Materials in Research,” “Placebo Controls,” “Innovative Medical Therapies,” “Scientific Publication,” “Sponsored Research” and “Public Announcement of Research Discoveries.”

Responsible Conduct of Research (RCR) Project

Under a grant from the Association of American Medical Colleges and the DHHS Office of Research Integrity, ACP Ethics staff has implemented member education and support programs on the responsible conduct of office-based research. Workshops have been presented at ACP's annual meeting as well as at several ACP chapter meetings.

Research in the Physician's Office: Navigating the Ethical Minefield (Hastings Cent Rep. 2008)

Volunteering for a Research Study? Talk with Your Doctor About What You Should Know This patient education brochure provides information and guidance to patients who are considering volunteering for a research study. The brochures are designed to facilitate conversations between doctors and their patients. They are intended for distribution in doctors’ offices and come in packages of 50. Access the brochure order form .

Author! Author! Who Should Be Named in a Published Study? An Ethics Case Study CME (ACP Ethics Case Studies Series. CME by Medscape. 2014)

When are Industry-Sponsored Trials a Good Match for Community Doctors? CME (ACP-ASIM Observer. 2001)

Research Ethics Training Resources

• Revised Common Rule Educational Materials , Department of Health and Human Services
• The Research Clinic , Office of Research Integrity, Department of Health and Human Services
• Responsible Conduct of Research (RCR) , Research Ethics and Compliance Training, CITI Program
• Responsible Conduct of Research Training , Office of Intramural Research, National Institutes of Health
• HIPAA Training and Resources , Department of Health and Human Services
• Online Ethics Center for Engineering and Science , Center for Engineering Ethics and Society, National Academy of Engineering
• World Association of Medical Editors (WAME)
• Council of Science Editors (CSE)
• European Association of Science Editors (EASE)

ACP supports National Academies’ call for withdrawal of Notice of Proposed Rulemaking (NPRM) for ‘Common Rule’ and for appointing a new commission (Dec. 31, 2015) ACP issued a statement in support of the National Academies' call for withdrawal of the Common Rule NPRM and for appointing a new research ethics commission.

ACP Comments on Notice of Proposed Rule Making (NPRM) (Dec. 31, 2015) ACP submitted comments to the Office for Human Research Protections of the U.S. Department of Health and Human Services on the Notice of Proposed Rule Making, "Federal Policy for the Protection of Human Subjects," also known as the Common Rule. ACP also submitted an earlier round of comments on the proposed rule making on Oct. 25, 2011.

Stewardship of Health Care Resources

"Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly in practicing high-value care. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient puts the patient first but also respects the need to use resources wisely and to help ensure that resources are equitably available" (Ethics Manual, seventh edition).

Conflicting duties? The physician's primary duty, first and foremost, is to the individual patient. She or he must advocate for the patient—in a health care system that grows more and more complex by the year—based on the best interests of the patient. But the physician also should use health care resources responsibly and efficiently. Are these duties in conflict? The Ethics Manual and ethics case studies explore these issues and provide help in sorting them out.

Is it rationing? Parsimonious care is not rationing. The goal of medical parsimony is to provide the care necessary for the patient's good on the basis primarily of evidence-based medicine. Although this may have the welcome side effect of preserving resources, reducing resource use is not the intent. It is this difference in intent and action that helps provide a foundation for the ethical distinction between parsimonious medicine and rationing.

• Resource Allocation

ACP’s High Value Care Project aims to improve health, avoid harms, and eliminate wasteful practices. The project website offers learning resources for clinicians and medical educators, clinical guidelines, best practice advice, case studies and patient resources on a wide variety of related topics.

Patient Requests for Specific Care: 'Surely You Can Explain to My Insurer That I Need Boniva?' CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Who Should Get What? Mammography and the Stewardship of Health Care Resources CME (ACP Ethics Case Studies Series. CME by Medscape. 2012)

The following ethics case studies were developed through an award from the ABIM Foundation's Putting the Charter into Practice project. Watch a video report of the ACP's work on this project presented by Dr. David Fleming, former President of the College.

Stewardship of Health Care Resources: Allocating Mechanical Ventilators During Pandemic Influenza CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Stewardship of Health Care Resources: Responding to a Patient's Request for Antibiotics (ACP Ethics Case Studies Series. CME by Medscape. 2014)

Teaching, Training and the Hidden Curriculum

• Attending Physicians and Physicians-in-Training

Resident Duty Hours: To Hand Over or Gloss Over? CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Hidden Curricula, Ethics, and Professionalism: Optimizing Clinical Learning Environments in Becoming and Being a Physician (Ann Intern Med. 2018;168:506-8)

CME/MOC activities based on this ACP position paper are available:

Annals offers two CME/MOC activities:

Ethics, Professionalism, and the Hidden Curriculum (Click on “CME/MOC” on the left sidebar.)

Annals On Call – Hidden Curriculum

In this Curbsiders Podcast , Sanjay Desai, MD, coauthor of ACP’s position paper and Internal Medicine program director at Johns Hopkins, reviews several cases that illustrate how institutional norms can shape the practice of medicine. Detailed summaries of the cases discussed are available here .

Archived Ethics Position Papers

Health Information Technology & Privacy (July 2011)

Cognitively Impaired Subjects (November 1989)

• Ethics Position Papers by Publication Date

The American College of Healthcare Executives Code of Ethics

This essay about the American College of Healthcare Executives (ACHE) Code of Ethics discusses how the ethical standards set for healthcare management can be applied to broader life lessons and societal values. It explores the principles of excellence, integrity, inclusivity, and stewardship outlined by the ACHE, and imagines a world where these values guide not only healthcare leaders but also other professional and personal realms. The essay emphasizes the importance of respect for individual dignity, lifelong learning, ethical leadership, and organizational excellence. It also considers the broader implications of these principles, suggesting they provide a blueprint for a fair, equitable, and compassionate society. The text ultimately serves as a call to action, urging readers to lead with integrity and compassion in all aspects of life.

How it works

In an era where the compass of morality often spins wildly, the ethical framework established by the American College of Healthcare Executives (ACHE) emerges as a lighthouse for those navigating the complex seas of healthcare management. This isn’t just about rules to follow; it’s a declaration of the values that should underpin the decisions and actions of those at the helm of our healthcare institutions. Let’s dive into a less conventional exploration of how the principles outlined by the ACHE intertwine with broader life lessons, offering insights that resonate far beyond the walls of hospitals and clinics.

At the heart of the ACHE’s Code of Ethics lies a commitment to excellence, integrity, inclusivity, and stewardship. These aren’t just buzzwords; they are the pillars that support the immense responsibility healthcare leaders bear. Imagine a world where these principles guide not only healthcare but every facet of our lives. Such a world would be marked by actions driven by the highest standards, uncompromising honesty, respect for diversity, and a mindful guardianship over the resources entrusted to us.

The ACHE mandates respect for individual rights and dignity. This principle transcends the professional realm, touching the very essence of our social fabric. It’s a reminder that whether in the emergency room, the corporate boardroom, or the dinner table, every interaction is an opportunity to affirm the value and dignity of those around us. It calls for a culture where diverse perspectives aren’t just tolerated but celebrated, where the uniqueness of each individual is recognized as a vital thread in the tapestry of our collective humanity.

Furthermore, the Code emphasizes the advancement of healthcare management as a noble profession. This isn’t merely about climbing the career ladder; it’s a call to arms for lifelong learning, sharing knowledge, and paving the way for those who will follow. Imagine if every professional were as committed to the betterment of their field, dedicated to research, mentorship, and the dissemination of knowledge. Such a commitment could transform industries, leading to unprecedented innovation and growth.

Ethical leadership, as championed by the ACHE, requires more than just making the right decisions. It’s about embodying the virtues of transparency, accountability, and humility. It’s easy to lead when the seas are calm, but true leadership is tested in the storm. It involves admitting when we’re wrong, learning from our mistakes, and always placing the greater good above personal gain. This principle of leadership echoes in every realm of life, challenging us to lead by example, regardless of our position or title.

The Code also stresses the importance of organizational excellence. In healthcare, this means promoting practices that enhance patient care and outcomes. But let’s expand this horizon. Imagine organizations across all sectors adopting a similar commitment to excellence, where ethical practices are ingrained in the organizational DNA, driving not only compliance but innovation and quality service delivery. Such organizations would not only succeed but also set new benchmarks for what it means to do good business.

Moreover, the ACHE’s call for fairness and justice in healthcare—a demand for equitable distribution of resources and impartial decision-making—holds a mirror to society. It reflects a vision where fairness and justice aren’t just legal principles but the foundation of our social contract. In a world often divided by disparities, this principle serves as a reminder of our shared responsibility to strive for a more equitable and just society.

In drawing parallels between the ACHE’s ethical guidelines and broader life lessons, we find that these principles offer a blueprint for a more ethical, inclusive, and compassionate world. They challenge us to rise above the status quo, to not only be better professionals but better humans.

This exploration of the ACHE’s Code of Ethics through a broader lens is more than an academic exercise; it’s a call to action. It invites us to reflect on our values and the impact of our decisions, urging us to lead with integrity and compassion, both in our professional lives and beyond. In doing so, we not only enhance the quality of healthcare but also contribute to the creation of a world marked by fairness, excellence, and respect for all.

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• Volume 44, Issue 12
• How to read an ethics paper
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• http://orcid.org/0000-0002-4609-9179 Melanie Jansen 1 , 2 ,
• Peter Ellerton 3
• 1 Paediatric Intensive Care Unit & Centre for Children’s Health Ethics and Law , Children’s Health Queensland Hospital and Health Service , South Brisbane , Queensland , Australia
• 2 Faculty of Medicine , University of Queensland , Herston , Queensland , Australia
• 3 Faculty of Humanities and Social Sciences , University of Queensland , Brisbane , Queensland , Australia
• Correspondence to Dr Melanie Jansen, Paediatric Intensive Care Unit & Centre for Children’s Health Ethics and Law, Children’s Health Queensland Hospital and Health Service, Brisbane, QLD 4101, Australia; doctormjansen{at}gmail.com

In recent decades, evidence-based medicine has become one of the foundations of clinical practice, making it necessary that healthcare practitioners develop keen critical appraisal skills for scientific papers. Worksheets to guide clinicians through this critical appraisal are often used in journal clubs, a key part of continuing medical education. A similar need is arising for health professionals to develop skills in the critical appraisal of medical ethics papers. Medicine is increasingly ethically complex, and there is a growing medical ethics literature that modern practitioners need to be able to use in their practice. In addition, clinical ethics services are commonplace in healthcare institutions, and the lion’s share of the work done by these services is done by clinicians in addition to their usual roles. Education to support this work is important. In this paper, we present a worksheet designed to help busy healthcare practitioners critically appraise ethics papers relevant to clinical practice. In the first section, we explain what is different about ethics papers. We then describe how to work through the steps in our critical appraisal worksheet: identifying the point at issue; scrutinising definitions; dissecting the arguments presented; considering counterarguments; and finally deciding on relevance. Working through this reflective worksheet will help healthcare practitioners to use the ethics literature effectively in clinical practice. We also intend it to be a shared evaluative tool that can form the basis of professional discussion such as at ethics journal clubs. Practising these critical reasoning skills will also increase practitioners’ capacity to think through difficult ethical decisions in daily clinical practice.

• clinical ethics
• education for health care professionals

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/medethics-2018-104997

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Evidence-based medicine is a foundation of clinical practice, necessitating that healthcare practitioners develop keen critical appraisal skills for scientific papers. Many excellent resources exist, including the paper by Sackett  et al 1 and a reference book by Greenhalgh. 2 In 1992, the Medical Journal of Australia published a paper titled ‘How to read a journal article’ . 3 The authors’ goal was to give a step-by-step guide to critically appraising scientific papers. Journal clubs using this worksheet, or similar, are now commonplace in teaching hospitals and are a key part of medical education. A similar need is arising for health professionals to develop skills in the critical appraisal of ethics papers. The reasons for this are twofold. First, healthcare grows increasingly ethically complex. Just as clinicians must keep abreast of the scientific literature, they should also keep up to date with the ethics literature relevant to their practice. Second, clinical ethics services (CES) have become commonplace in hospitals in developed nations. The lion’s share of the work of these services is done by healthcare professionals in addition to their clinical roles 4–6 and who have highly variable levels of training. 4–8 There is an urgent need to equip these and other clinical staff with skills to appraise papers relevant to these aspects of practice.

In this paper, we present the critical appraisal worksheet developed at the Centre for Children’s Health Ethics and Law (CCHEL), Children’s Health Queensland, Brisbane, Australia ( table 1 ). The worksheet was developed for our ethics journal club and has proved useful both for the critical appraisal of ethics papers and for the development of critical thinking skills that can be applied in clinical practice and in clinical ethics consultation work. The goal of this paper is to provide a tool for clinicians without extensive philosophical training to critically appraise ethics papers relevant to clinical practice. We also intend it to be a shared evaluative tool that can form the basis of professional discussion such as at ethics journal clubs. In the first section, we explain what is different about ethics papers. We then describe the steps in our critical appraisal worksheet.

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Ethics critical appraisal worksheet

What is different about ethics papers? A discussion of arguments, facts and values

It is important to recognise that ethics is a philosophical, not a scientific, discipline. Healthcare professionals are accustomed to critically appraising scientific data, and to constructing an argument based on that data for why a particular clinical decision is justified. Note that we use the word argument in the philosophical sense, meaning a set of reasons that justify a position. For example, if a patient presents with clinical signs consistent with bacterial pneumonia, the doctor will prescribe an antibiotic regimen based on their knowledge of the likely pathogens and the efficacy of particular antibiotics against these. That oral amoxicillin is an effective treatment for mild community-acquired pneumonia is a factual claim supported by scientific evidence. In contrast, ethical claims are claims of value and must be justified with an ethical argument. For example, the claim that life-sustaining therapy (LST) should be withdrawn from a patient with end-stage cancer is a value claim. Prescriptive words such as ‘should’ and ‘ought’ are useful signposts for value claims. An argument that may justify the claim that LST should be withdrawn is that the patient had previously stated that they did not want to be maintained on LST, and therefore to respect their autonomy the treatment should be withdrawn.

Note that matters of fact and matters of value coexist in clinical medicine (as they do in life) and that rationales for ethical and medical decisions are usually made up of both fact and value claims. Take the example just given of the argument that therapy should be stopped to respect the patient’s autonomy. That the patient had previously expressed wishes not to be maintained on life support is a factual claim. The claim that we should respect autonomy is a value claim. Likewise, when deciding on antibiotics for the patient with pneumonia, the claim that amoxicillin is effective is a factual claim. That we should treat the patient with amoxicillin is a value claim—the implicit argument for which is that the right thing to do is to treat patients with the most effective therapy for their disease. This seems so plainly reasonable that it does not need to be stated; however, it is important to recognise implicit value judgements in clinical decisions, as these are often at issue when there is conflict. The important skill is to be able to differentiate fact and value claims and to understand how the two can interact to form a set of reasons that support a particular conclusion. To do this, it is important to understand how arguments are constructed.

Understanding arguments is important for clinical practice, because ethical decision making threads through everything healthcare practitioners do. High-level skills in this area are especially important for those providing clinical ethics consultation. The UK Clinical Ethics Network and the American Society for Bioethics and Humanities have each published core competencies for clinical ethics consultation. 9 10 Both specify the need for consultants to understand ethical theory and reasoning, to analyse ethical conflicts, and to be able to elicit values and assumptions. Understanding argumentation is fundamental to these skills. The ethics critical appraisal worksheet provides a framework through which to appraise arguments and, by guiding practitioners to read ethics papers actively, aims to deepen understanding of ethical argumentation. We acknowledge that there is a growing literature in empirical ethics—this critical appraisal worksheet is not intended for these papers, as they are scientific papers and can be appraised as such. This worksheet is intended for papers that discuss ethical issues, not those that present scientific data relevant to an ethical issue.

The ethics critical appraisal worksheet

We have structured the worksheet in a similar way to the one by Darzins et al , 3 as a matrix of questions arranged in three columns ( table 1 ). In the first column are questions that prompt the reader to look for important types of information in the article. The second column contains questions that help the reader to decide whether there are problems with these. The third column poses questions to help the reader decide if any problems identified threaten the quality of the paper. Using this worksheet should assist clinicians to more rapidly identify problems with the paper, making the reading of ethics papers more time-efficient.

Critical appraisal questions

What is the point at issue.

The point at issue is the ethical question that the paper is addressing. Well-written ethics papers will explicitly state the point, or points, at issue in the introduction and will go on to address them. Poorly written ethics papers will shift between points at issue, which clouds reasoning and precludes systematic appraisal of all the relevant arguments. Shifting the point at issue happens often in ethical discussions. For example, we may be discussing the issue of whether we should continue providing LST to a child with a very poor prognosis. One person believes that the LST is causing suffering to the child, another person questions the truth of this. A third person points out that we cannot over-ride the parents’ autonomy. This third person is shifting the point at issue. The ethicality of over-riding parental autonomy is important, but concerns a different point at issue. Whether the LST is causing suffering or not is a point that needs to be explored and clarified before moving onto the question of whether it is of a magnitude that makes it reasonable to interfere with parental autonomy.

Has the author defined all of the terms they use?

Defining key terms is critical to avoid confusion. For example, in a paper discussing the rights of adolescents to autonomy in medical decision making, the author needs to define what persons they are referring to with the word ‘adolescent’; exactly what range of decisions they are referring to within the phrase ‘medical decision making’; and exactly how autonomy is conceived in this context. Failing to define key terms used in an argument sacrifices clarity, and defining key terms in an unusual or unreasonable way may have implications for the generalisability of the argument.

Dissect the argument: What are the premises of the author’s argument? What is/are the author’s conclusion/s?

This section of the worksheet requires explanation of the anatomy of an argument and clarification of the difference between truth and validity.

Arguments consist of premises and a conclusion, for example:

Premise 1: Human suffering is undesirable.

Premise 2: Medically extending life in case X prolongs human suffering.

Conclusion: Medically extending life in case X is undesirable.

This is a valid argument because the conclusion follows logically from the premises; that is, it is impossible for the premises to be true and the conclusion false. Whether the conclusion (or a premise) is true or not is a separate issue. Refuting this argument requires proving one or both of the premises to be false—finding evidence that suffering is not always undesirable, or making a case that this particular medical intervention does not prolong suffering. There are no errors of reasoning in this argument, but there may be factual errors which will prove the argument to be a bad one. Consider another argument:

Premise 1: Lucy has a chronic cough.

Premise 2: Lung cancer can present with a chronic cough.

Conclusion: Lucy has lung cancer.

In this case, the argument is invalid. The premises are true but the reasoning is flawed. It is true that Lucy has a chronic cough, and that lung cancer can present with a chronic cough, but it does not follow that Lucy necessarily has lung cancer. Her chronic cough may be from asthma or chronic bronchitis. Lucy may even have lung cancer, although it could be of a type that would not usually cause coughing. So, even if all the information given is true, the conclusion that she must have lung cancer does not necessarily follow.

Another important phenomenon to be aware of is the ‘hidden assumption’. A hidden assumption is a premise that is not explicitly stated. For example, a person may claim that homosexuality is morally wrong because it is unnatural. The hidden premise here is that things that are unnatural are morally wrong, as follows:

Premise 1: (Hidden) Things that are unnatural are morally wrong.

Premise 2: Homosexuality is unnatural.

Conclusion: Homosexuality is morally wrong.

To refute this argument one needs to either show the premises are false or that the reasoning is invalid. The reasoning is valid because it is impossible for the premises to be true and the conclusion false. However, even if one were to accept premise 2—in ignorance of the natural occurrence of homosexuality in many animals—the hidden premise 1 ignores that many things that are unnatural are considered morally good (or at least morally neutral), such as medicines, clothing or the telephone. Identifying the hidden premise is necessary to fully represent the argument, and hence to properly evaluate it.

In ethics papers, deciding whether premises are true will often require recourse to the scientific literature. Good ethics papers have well-researched references for factual premises. Appraising the validity of reasoning can be more difficult and requires practice. A full and rich account of logical fallacies is outside the scope of this paper; however, there are excellent, accessible resources available to hone these skills. 11 It is also worth noting that the overall position of an ethics paper is likely to be made up of a complex argument, with the conclusions of initial arguments making up the premises of further arguments. For example, some may claim that premise 1 (above) is a claim about the existence of ethical laws of nature. To support this claim, the person must develop an argument for the existence of ethical laws of nature and the definition of ‘unnatural’, ending with premise 1—things that are unnatural are morally wrong—as the conclusion. The analytical framework we present here is applicable to each constituent argument of a complex argument.

Does the author address all relevant counterarguments?

When making a case for an ethical position, it is imperative that authors address counterarguments to their position. If an author has not addressed relevant counterarguments, or has done so unconvincingly, this significantly decreases the strength of their case, or at least suggests a shallow investigation of the issue.

Is the argument or exploration of the issue relevant to your practice?

Some ethics papers will address a specific ethical question arising in the reader’s own practice and assist them in navigating this scenario. Other papers will change the way practitioners think, affecting practice in myriad but subtle ways. There will be papers that, while of good internal quality, are not relevant to the reader’s practice. Explicitly deciding on the relevance of a paper prompts practitioners to contextualise new ethical information within their own practice.

Working through this reflective worksheet will aid healthcare practitioners in actively reading and critically appraising ethics papers, enabling them to use the ethics literature more effectively. Developing these critical reasoning skills will also increase capacity to think through difficult ethical decisions in day-to-day practice. It is of particular importance that clinicians working within CES develop these skills to a high level. In the future, we hope to empirically evaluate the ethics critical appraisal worksheet.

Key messages

Healthcare is increasingly ethically complex, and so there is a growing need for clinicians to keep up to date with the ethics literature relevant to clinical practice.

Clinical ethics services have become commonplace, and the majority of the work of these services is done by clinicians in addition to their clinical roles.

Ethics papers differ in important ways from scientific papers, requiring a different set of critical appraisal skills.

We have developed a worksheet to assist clinicians in the critical appraisal of ethics papers, which can also be used as a shared evaluative tool, such as at ethics journal clubs.

Acknowledgments

The authors would like to acknowledge all CCHEL Clinical Ethics Response Pool members who have participated in the ethics journal club, and in so doing have helped to refine this critical appraisal worksheet.

• Sackett DL ,
• Rosenberg WM ,
• Gray JA , et al
• Greenhalgh T
• Darzins PJ ,
• Pearlman RA
• Slowther AM ,
• McClimans L ,
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• Godkin MD ,
• Upshur RE , et al
• Kesselheim JC ,
• Johnson J ,
• Larcher V ,
• Richardson J ,
• Meaden S , et al

Contributors MJ conceived the idea of the critical appraisal worksheet for clinicians. PE assisted in developing the idea and refining the worksheet. MJ wrote the initial draft of the manuscript. PE and MJ were both involved in draft review and development of the final version of the manuscript. MJ is the guarantor of this article.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Disclaimer The views expressed in this paper are the authors’ own and do not necessarily reflect the views of their institutions.

Competing interests None declared.

Patient consent Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

Author note MJ is a medical doctor in intensive care medicine and has additional qualifications and experience in clinical ethics. She co-led the working group to establish the Centre for Children’s Health Ethics and Law at Children’s Health Queensland, and was the centre’s inaugural Clinical Ethics Fellow. MJ recently completed a Churchill Fellowship in clinical ethics. She has published both empirical research and analysis pieces on healthcare ethics issues. PE is a science educator and philosopher, and is the Curriculum Director of the University of Queensland Critical Thinking Project. He is an expert in critical thinking and argumentation and has published on these topics in a number of contexts.

Correction notice This article has been made Open Access since it was published Online First.

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“The Doctor as a Humanist”: The Viewpoint of the Students

Conference Report and Reflection by Poposki Ognen (University Pompeu Fabra); Castillo Gualda Paula (University of Balearic Islands); Barbero Pablos Enrique (University Autonoma de Madrid); Pogosyan Mariam (Sechenov University); Yusupova Diana (Sechenov University); and Ahire Akash (Sechenov University)

The practice of Medicine as a profession has become very technical; doctors rely on fancy investigations, treatment algorithms and standardized guidelines in treating patients. In a lot of universities, medical students and residents are trained without appreciating the importance of art and the humanities in delivering good care to patients and their families. Factual knowledge is imposed on us, as students, from scientific evidence delivered by highly specialized professionals: those who know more and more about niche subjects.

As a result, when someone decides to become a doctor , it seems that scientific training is the sole priority, with most attention being given to the disease-treatment model. As medical students, we are taught very specific subjects, leaving little or no space or time for any cultural enrichment programs. And yet, Personal growth as a doctor and a human being cannot be achieved unless one is exposed to the whole range of human experience. Learning from art and artists can be one such means of gaining these enriching experiences. We can learn from historians, and from eminent painters, sculptors, and writers, as well as from great scientists. How do we achieve these ends? The following essay summarizes and reviews one attempt at providing answers. The 2nd “Doctor as a Humanist” Symposium took place at Sechenov University in Moscow from the 1 st to the 3 rd of April, 2019, to explore the holistic perspective of interpersonal treatment.

To begin our essay, we would like to clarify some key concepts, such as culture, humanism and humanities, as they were employed at the conference. Culture is a complex phenomenon that includes knowledge, beliefs, artistic production, morals, customs and skills acquired by being part of a society, which can be transmitted consciously or unconsciously, by individuals to others and through different generations.

The humanities are academic disciplines that study the cultural aspects and frailties of being human, and use methods that are primarily analytical, critical, or speculative, which distinguish them from the approaches of the natural sciences. Humanism is the practice of making the human story central. Consequently, the studies of humanities, so invested in human stories, is one aspect of practicing humanism.

Technological and practical progress in medicine has been impressive in the past fifty years. Nevertheless, patients still suffer from chronic conditions such as heart failure, chronic lung disease, depression, and many others. These are conditions where technology cannot significantly change the outcomes or reverse the underlying condition. One of the ways to alleviate suffering is through compassion and empathy where the doctor is a professional who listens to, understands and comforts the patient, as well as engaging the patient as a fellow human being. We need arts and humanities as doctors’ tools to comfort and, perhaps, even to heal. We also need them to remind us that we are ‘merely human’ ourselves, and that we share our humanity with our patients, as equals.

Unquestionably, there are fundamental requirements that every physician must internalize; the conference goal was to explain that one such requirement is the humanistic view. Opera, poetry, philosophy, history, the study of dialectics, biographical readings, and even volunteering abroad can be means of engaging the world for positive change. Sometimes called  “soft” skills, these are in fact necessary and valuable qualities to empower ourselves as persons, as well as doctors. The 2nd The Doctor as a Humanist Symposium placed the corner stone in a global project that aims to understand medicine as a multidisciplinary subject, and to establish the concept of humanistic medicine both as a science and an art where the patient and the doctor are human beings working together.

STUDENT PARTICIPATION

The event united experts in Medicine and the Humanities from all over the world. The speakers (doctors, nurses and students) were from Russia, the USA, the UK, Spain, Italy, Germany, Mexico and more. Each day’s program was both intense and diverse, and included plenary lectures and panel sessions. Medical students were highly involved in all parts of the conference, offering us a great chance to introduce our projects, share our opinions on various topics, and discuss our questions connected with the role of the humanities in medicine.We participated in roundtable discussions, which were chaired by experts from different countries. Even though this made us nervous, at the same time it was very important for us, as students, to be a part of it. We discussed the future of medical humanities from various perspectives, and above all our thoughts and ideas were listened to and commented on, on an equal basis with the world’s experts. For once, we could see that our views were being taken into consideration, and we hope that in the future this will be the norm and NOT the exception. We are the future of medicine, and our voices should be heard, too.

At the end of the first day there was a students’ session, where we gave our opinions on the relative importance of the medical humanities from a multicultural viewpoint, and on this particular roundtable there were students from Russia, Spain, Iran, Mexico, Italy, as well as a Nursing resident. One of the students during the session shared her view that “I would like to see medicine through the lens of humanism and empathy, and also implement all its principles in my professional life on a daily basis”. All participants agreed, and although we were representing different countries and cultures there was no disagreement about this. Even though we have not yet faced many of the obstacles of the world of medicine, we can see the role of compassion in clinical practice better perhaps than our seniors. We shared our points of view about this question and its relevance in the different countries. It was an incredible moment, as experts and professors demonstrated a great interest in our ideas.

The program was extremely diverse; however, the main idea that most speakers expressed was how to find, sustain and not lose humanist goals. Brandy Schillace gave an impressive presentation entitled “Medical Humanities today: a publisher’s perspective”, which studied the importance of writing and publishing not only clinical trials, but also papers from historians, literary scholars, sociologists, and patients with personal experiences. The nurses Pilar d’Agosto and Maria Arias made a presentation on the topic of the Nursing Perspective that is one of the main pillars of medical practice. Professor Jacek Mostwin (Johns Hopkins University) shared his thoughts on patients’ memoirs. An Italian student, Benedetta Ronchi presented the results of an interview on medical humanities posed to the participants and speakers during the symposium. The plurality of perspectives made this conference an enriching event and showed us how diverse ideas can help us become better doctors. More importantly, it reminded us of our common humanity.

A significant part of the symposium was dedicated to Medicine and Art. Prof Josep Baños and Irene Canbra Badii spoke about the portrayal of physicians in TV medical dramas during the last fifty years. The book “The role of the humanities in the teaching of medical students” was presented by these authors and then given to participants as gifts. Dr Ourania Varsou showed how Poetry can influence human senses through her own experience in communicating with patients. She believed that many of the opinions and knowledge that we have internalized should be unlearned in order to have a better understanding of the human mind. The stimulus of poetry makes this possible. Poetry allows us to find new ways to express ourselves, and thus increase our emotional intelligence and understanding of other people’s feelings.

One of the most impressive lectures was by Dr Joan.B Soriano, who spoke about “Doctors and Patients in Opera” and showed how the leading roles of physicians in opera have changed over the centuries. People used to consider the doctor as the antihero, but with time this view has transformed into a positive one that plays a huge role in history.

It is important to be professional in your medical career, but also to be passionate about the life surrounding you; for instance, Dr Soriano is also a professional baritone singer. For students, this Symposium was full of obvious and hidden messages, which gave us much lot of food for thought. As Edmund Pellegrino, the founding editor of the Journal of Medicine and Philosophy , said: “Medicine is the most humane of sciences, the most empiric of arts, and the most scientific of humanities.”

CHOOSING ONE WORD

To conclude our summary of the students’ viewpoint each of us chose One word to encapsulate our thoughts about the symposium.

The Doctor as a Humanist is a multicultural event where everyone can learn and contribute to this global necessity to put the heart and soul back into medicine. Of course, we are aware and delighted that other organizations are championing the cause of the Humanities in Medicine, and in some cases, such as https://www.dur.ac.uk/imh/ , they have been doing so for many years.

As medical students, we appreciate how we have been placed at the centre of the symposium, which we believe has made this new initiative rather special. We hope that students of Medicine and from other disciplines come and participate in future symposia.

If you want to learn more, and see how you can participate, please contact the International student representatives, Mariam ( [email protected] ) and David ( [email protected] ).

Acknowledgements

Assistance provided by Jonathan McFarland (c) and Joan B. Soriano (University Autonoma de Madrid) was greatly appreciated during the planning and the development of the article.

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Hydroxychloroquine has no effect on SARS-CoV-2 load in nasopharynx of patients with mild form of COVID-19

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Due to the constantly growing numbers of COVID-19 infections and death cases attempts were undertaken to find drugs with anti SARS-CoV-2 activity among ones already approved for other pathologies. In the framework of such attempts, in a number of in vitro, as well as in vivo, models it was shown that hydroxychloroquine (HCQ) has an effect against SARS-CoV-2. While there was not enough clinical data to support the use of HCQ, several countries including Russia have included HCQ in treatment protocols for infected patients and for prophylactic. Here, we evaluated the SARS-CoV-2 RNA in nasopharynx swabs from infected patients in mild conditions and compared the viral RNA load dynamics between patients receiving HCQ and control group without antiviral pharmacological therapy. We found statistically significant relationship between maximal RNA quantity and patients’ deteriorating medical conditions, as well as confirmed the arterial hypertension to be a risk factor for people with COVID-19. However, we showed that HCQ therapy neither shortened the viral shedding period nor reduced the virus RNA load.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

The study was funded by Moscow Department of Healthcare and by the Russian Science Foundation grant, agreement #18-15-00420.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Local ethics committees approved the study protocol and all participants provided their written consent.

All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.

Two patients were additionally included into the Control group. Absolute SARS-CoV-2 RNA copy number was estimated using viral genomic RNA and the results were compared to synthetic DNA standards. Additional statistics were included into the results. Figures were edited. Manuscript text was edited.

Data Availability

All data generated and analysed during the study are included in the article. Any additional information is available from the corresponding author on reasonable request.

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Perspective

When pto stands for 'pretend time off': doctors struggle to take real breaks.

Mara Gordon

A survey shows that doctors have trouble taking full vacations from their high-stress jobs. Even when they do, they often still do work on their time off. Wolfgang Kaehler/LightRocket via Getty Images hide caption

A survey shows that doctors have trouble taking full vacations from their high-stress jobs. Even when they do, they often still do work on their time off.

A few weeks ago, I took a vacation with my family. We went hiking in the national parks of southern Utah, and I was blissfully disconnected from work.

I'm a family physician, so taking a break from my job meant not seeing patients. It also meant not responding to patients' messages or checking my work email. For a full week, I was free.

Taking a real break — with no sneaky computer time to bang out a few prescription refill requests — left me feeling reenergized and ready to take care of my patients when I returned.

But apparently, being a doctor who doesn't work on vacation puts me squarely in the minority of U.S. physicians.

Research published in JAMA Network Open this year set out to quantify exactly how doctors use their vacation time — and what the implications might be for a health care workforce plagued by burnout, dissatisfaction and doctors who are thinking about leaving medicine.

"There is a strong business case for supporting taking real vacation," says Dr. Christine Sinsky , the lead author of the paper. "Burnout is incredibly expensive for organizations."

Shots - Health News

Health workers know what good care is. pandemic burnout is getting in the way.

Researchers surveyed 3,024 doctors, part of an American Medical Association cohort designed to represent the American physician workforce. They found that 59.6% of American physicians took 15 days of vacation or less per year. That's a little more than the average American: Most workers who have been at a job for a year or more get between 10 and 14 days of paid vacation time , according to the U.S. Bureau of Labor Statistics.

However, most doctors don't take real vacation. Over 70% of doctors surveyed said they worked on a typical vacation day.

"I have heard physicians refer to PTO as 'pretend time off,'" Sinsky says, referring to the acronym for "paid time off."

Sinsky and co-authors found that physicians who took more than three weeks of vacation a year had lower rates of burnout than those who took less, since vacation time is linked to well-being and job satisfaction .

And all those doctors toiling away on vacation, sitting poolside with their laptops? Sinsky argues it has serious consequences for health care.

Physician burnout is linked to high job turnover and excess health care costs , among other problems.

Still, it can be hard to change the culture of workaholism in medicine. Even the study authors confessed that they, too, worked on vacation.

"I remember when one of our first well-being papers was published," says Dr. Colin West , a co-author of the new study and a health care workforce researcher at the Mayo Clinic. "I responded to the revisions up at the family cabin in northern Minnesota on vacation."

Sinsky agreed. "I do not take all my vacation, which I recognize as a delicious irony of the whole thing," she says.

She's the American Medical Association's vice president of professional satisfaction. If she can't take a real vacation, is there any hope for the rest of us?

I interviewed a half dozen fellow physicians and chatted off the record with many friends and colleagues to get a sense of why it feels so hard to give ourselves a break. Here, I offer a few theories about why doctors are so terrible at taking time off.

We don't want to make more work for our colleagues

The authors of the study in JAMA Network Open didn't explore exactly what type of work doctors did on vacation, but the physicians I spoke to had some ideas.

"If I am not doing anything, I will triage my email a little bit," says Jocelyn Fitzgerald , a urogynecologist at the University of Pittsburgh who was not involved in the study. "I also find that certain high-priority virtual meetings sometimes find their way into my vacations."

Even if doctors aren't scheduled to see patients, there's almost always plenty of work to be done: dealing with emergencies, medication refills, paperwork. For many of us, the electronic medical record (EMR) is an unrelenting taskmaster , delivering a near-constant flow of bureaucratic to-dos.

When I go on vacation, my fellow primary care doctors handle that work for me, and I do the same for them.

But it can sometimes feel like a lot to ask, especially when colleagues are doing that work on top of their normal workload.

"You end up putting people in kind of a sticky situation, asking for favors, and they [feel they] need to pay it back," says Jay-Sheree Allen , a family physician and fellow in preventive medicine at the Mayo Clinic.

She says her practice has a "doctor of the day" who covers all urgent calls and messages, which helps reduce some of the guilt she feels about taking time off.

Still, non-urgent tasks are left for her to complete when she gets back. She says she usually logs in to the EMR when she's on vacation so the tasks don't pile up upon her return. If she doesn't, Allen estimates there will be about eight hours of paperwork awaiting her after a week or so of vacation.

"My strategy, I absolutely do not recommend," Allen says. But "I would prefer that than coming back to the total storm."

We have too little flexibility about when we take vacation

Lawren Wooten , a resident physician in pediatrics at the University of California San Francisco, says she takes 100% of her vacation time. But there are a lot of stipulations about exactly how she uses it.

She has to take it in two-week blocks — "that's a long time at once," she says — and it's hard to change the schedule once her chief residents assign her dates.

"Sometimes I wish I had vacation in the middle of two really emotionally challenging rotations like an ICU rotation and an oncology rotation," she says, referring to the intensive care unit. "We don't really get to control our schedules at this point in our careers."

Once Wooten finishes residency and becomes an attending physician, it's likely she'll have more autonomy over her vacation time — but not necessarily all that much more.

"We generally have to know when our vacations are far in advance because patients schedule with us far in advance," says Fitzgerald, the gynecologist.

Taking vacation means giving up potential pay

Many physicians are paid based on the number of patients they see or procedures they complete. If they take time off work, they make less money.

"Vacation is money off your table," says West, the physician well-being researcher. "People have a hard time stepping off of the treadmill."

A 2022 research brief from the American Medical Association estimated that over 55% of U.S. physicians were paid at least in part based on "productivity," as opposed to earning a flat amount regardless of patient volume. That means the more patients doctors cram into their schedules, the more money they make. Going on vacation could decrease their take-home pay.

But West says it's important to weigh the financial benefits of skipping vacation against the risk of burnout from working too much.

Physician burnout is linked not only to excess health care costs but also to higher rates of medical errors. In one large survey of American surgeons , for example, surgeons experiencing burnout were more likely to report being involved in a major medical error. (It's unclear to what extent the burnout caused the errors or the errors caused the burnout, however.)

Doctors think they're the only one who can do their jobs

When I go on vacation, my colleagues see my patients for me. I work in a small office, so I know the other doctors well and I trust that my patients are in good hands when I'm away.

Doctors have their own diagnosis: 'Moral distress' from an inhumane health system

But ceding that control to colleagues might be difficult for some doctors, especially when it comes to challenging patients or big research projects.

"I think we need to learn to be better at trusting our colleagues," says Adi Shah , an infectious disease doctor at the Mayo Clinic. "You don't have to micromanage every slide on the PowerPoint — it's OK."

West, the well-being researcher, says health care is moving toward a team-based model and away from a culture where an individual doctor is responsible for everything. Still, he adds, it can be hard for some doctors to accept help.

"You can be a neurosurgeon, you're supposed to go on vacation tomorrow and you operate on a patient. And there are complications or risk of complications, and you're the one who has the relationship with that family," West says. "It is really, really hard for us to say ... 'You're in great hands with the rest of my team.'"

What doctors need, says West, is "a little bit less of the God complex."

We don't have any interests other than medicine

Shah, the infectious disease doctor, frequently posts tongue-in-cheek memes on X (formerly known as Twitter) about the culture of medicine. Unplugging during vacation is one of his favorite topics, despite his struggles to follow his own advice.

His recommendation to doctors is to get a hobby, so we can find something better to do than work all the time.

"Stop taking yourself too seriously," he says. Shah argues that medical training is so busy that many physicians neglect to develop any interests other than medicine. When fully trained doctors are finally finished with their education, he says, they're at a loss for what to do with their newfound freedom.

Since completing his training a few years ago, Shah has committed himself to new hobbies, such as salsa dancing. He has plans to go to a kite festival next year.

Shah has also prioritized making the long trip from Minnesota to see his family in India at least twice a year — a journey that requires significant time off work. He has a trip there planned this month.

"This is the first time in 11 years I'm making it to India in summer so that I can have a mango in May," the peak season for the fruit, Shah says.

Wooten, the pediatrician, agrees. She works hard to develop a full life outside her career.

"Throughout our secondary and medical education, I believe we've really been indoctrinated into putting institutions above ourselves," Wooten adds. "It takes work to overcome that."

Mara Gordon is a family physician in Camden, N.J., and a contributor to NPR. She's on X as @MaraGordonMD .

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The US didn't feel safe enough to raise a kid, so we moved to Japan

• Trevor D. Houchen and his wife were living in Atlanta when they found out they were expecting.
• He and his wife felt it would be unsafe to raise their child there and decided to move to Japan.
• He finds Japan more affordable, safe, and is happy to be living near his wife's family — but he's scared of bullying.

My wife was already six months pregnant when we agreed she would leave the US and have our baby in Japan . I would join a few months later.

We'd been living in Atlanta for about seven years when we found out we were expecting. She's Japanese, I'm American, and we met in LA.

We both started getting nervous about what our life would be like living with a child in our one-bedroom apartment in Atlanta, a city where the crime rate is 122% higher than the national average, according to Gitnux , a market data website.

I had been working two jobs at the time, so it also felt like my wife was going to have to be home alone without any family support for too many hours of the day.

The final decision came at the beginning of her third trimester. Some bleeding led to a one-night stay at a hospital in Atlanta. The shockingly high hospital bill — we're still battling it out with our insurance company — came next.

So, on the last allowable day for a pregnant woman to fly , she got on a plane to Japan.

My pregnant wife flew to Japan on her own to have our baby, I followed

I was in the middle of semesters at two different colleges — Georgia Technical College and Georgia Gwinnett College — as an adjunct professor, and leaving my students right then wasn't an option. We decided I'd finish the semester, close shop on our apartment, and then fly out to Japan to meet my newborn. He'd already be four months old by the time I got there.

After my wife arrived in Japan she texted me from her parents' home in Yokosuka — about an hour south of Tokyo by car— and said she'd made it safely and was glad to be back "home."

But I was "home," or so I thought. I spent the next four months teaching, packing, and selling all the stuff we'd accumulated over the years in Atlanta. I wrapped up the semester, and flew out to meet my son.

Having our baby in Japan was the right decision

When I arrived, my wife was living comfortably with our son at her parents' house. The cost of delivering our baby had been 650,000 yen, or $4,186. Of this amount the Ministry of Health covered 500,000 yen — a government co-pay for babies born to a parent enrolled in the national health insurance. The extra 150,000 yen we covered was for the private room my wife opted for, otherwise, there would have been no out-of-pocket expense.

In Japan, the cost of delivering a baby in a hospital ranges between 400,000 to 600,000 yen, or $2,552 to $3,827, according to the Ministry of Health, Labor, and Welfare . In the US, according to a survey by Perterson-KFF (formerly known as Kaiser Family Foundation) and based on data between 2018 through 2020, the average cost of childbirth for an insured mother is $18,865. While for insured mothers the majority of that is covered, out-of-pocket payments are still $2,852, on average.

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My wife was ecstatic to be back in her country and getting help from her parents and sister with our son.

When we would take our son for walks in his stroller, older Japanese men and women would often smile, bend down low to get a close look at our son, and say, "kawaii ne," "he's cute isn't he," in Japanese. The warmth and feeling of safety on the street made us feel like we'd made the right decision.

Day care is affordable in Japan

Our son is now one and we've started talking about putting him in Houkien, government-subsidized day care for kids 5 and under. Last year, the Japanese government announced that by 2025 day care for all children 6 months to 2 years old will be free, per The Japan Times .

At these day care centers kids receive health checks and they are run by certified caregivers

According to Care.com , the average cost of childcare in Atlanta is $19.56 per hour, adding up to over $3,000 a month. We wouldn't have been able to afford that.

Safety is no longer a concern

I regularly see children no older than five or six taking the subway in Tokyo by themselves, which I find impressive. After 8 months, I still get lost almost every day trying to navigate the busiest subway system in the world .

In Atlanta, we had heard gunshots at least a few times a week and few parents let their kids do anything on their own before turning 12. I wasn't allowed to take the subway by myself in New York City — where I grew up — until I was 15.

The crime, danger, and ruthless nature of the life I had known in the US just doesn't exist to any discernible degree here in Japan , especially in Yokosuka, where we live. By contrast, even though Atlanta's rate has dropped, in 2023, there were 135 homicides recorded . In contrast, I couldn't find a record for a single murder in Yokosuka in 2023.

Even with the US Naval base right in the middle of the city, Yokosuka is low-key, quiet, safe, and family friendly.

When it's time for junior high, I'd prefer my son go to school in the US

I'm all for our son going to elementary school in Japan . I want him to learn to speak Japanese fluently and feel safe enough to enjoy his childhood to its fullest. I'm also happy he's able to spend his formative years near his grandparents.

But beyond elementary school , I'd rather our son go to junior high and high school in the US. As a professor myself and after a 20-year long career in education, I have read studies that note the lack of critical thinking taught in Japanese high schools.

The Japanese proverb " deru kugi wa utareru" means "the nail that sticks up gets hammered down." My interpretation of this is, "don't be an individual," learn to be exactly like everyone else.

And then, there's the bullying. In a 2022 survey by the Japanese government, 681,948 cases of bullying were recorded in Japan's schools, per The Mainichi . As a biracial child in Japan , I would be anxious about the difficulties my son would face.

Like everything in life, there are pros and cons, but for the time being, my wife and I are happy to raise our son here in Japan where it's safe, nurturing, and affordable.

Watch: Why childcare has become so unaffordable

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