AAPA Code of Ethics

 

Introduction

The physician assistant profession has revised its code of ethics several times since the profession began. Although the fundamental principles underlying the ethical care of patients have not changed, the societal framework in which those principles are applied has. Economic pressures of the health care system, social pressures of church and state, technological advances, and changing patient demographics continually transform the landscape in which PAs practice.

Previous codes of the profession were brief lists of tenets for PAs to live by in their professional lives. This document departs from that format by attempting to describe ways in which those tenets apply. Each situation is unique. Individual PAs must use their best judgment in a given situation while considering the preferences of the patient and the supervising physician, clinical information, ethical concepts, and legal obligations.

Four main bioethical principles broadly guided the development of these guidelines: autonomy, bene­ficence, nonmaleficence, and justice.

Autonomy, strictly speaking, means self-rule. Patients have the right to make autonomous decisions and choices, and physician assistants should respect these decisions and choices.

Beneficence means that PAs should act in the patient's best interest. In certain cases, respecting the patient's autonomy and acting in their best interests maybe difficult to balance.

Nonmaleficence means to do no harm, to impose no unnecessary or unacceptable burden upon the patient.

Justice means that patients in similar circumstances should receive similar care. Justice also applies to norms for the fair distribution of resources, risks, and costs.

Physician assistants are expected to behave both legally and morally. They should know and understand the laws governing their practice. Likewise, they should understand the ethical responsibilities of being a health care professional. Legal requirements and ethical expectations will not always be in agreement. Generally speaking, the law describes minimum standards of acceptable behavior, and ethical principles delineate the highest moral standards of behavior.

When faced with an ethical dilemma, PAs may find the guidance they need in this document. If not, they may wish to seek guidance elsewhere  possibly from a supervising physician, a hospital ethics committee, an ethicist, trusted colleagues, or other AAPA policies. PAs should seek legal counsel when they are concerned about the potential legal consequences of their decisions.

The following sections discuss ethical conduct of PAs in their professional interactions with patients, physicians, colleagues, other health professionals, and the public. The "Statement of Values" within this document defines the fundamental values that the PA profession strives to uphold. These values provide the foundation upon which the guidelines rest. The guidelines were written with the understanding the no document can encompass all actual and potential ethical responsibilities, and PAs should not regard them as comprehensive.

Statement of Values of the Physician Assistant Profession

  • Physician assistant hold as their primary responsibility the health, safety, welfare, and dignity of all human beings.
  • Physician assistants uphold the tenets of patient autonomy, beneficence, nonmaleficence, and justice.
  • Physician assistants recognize and promote the value of diversity.
  • Physician assistants treat equally all persons who seek their care.
  • Physician assistants assess their personal capabilities and limitations, striving always to improve their medical practice.
  • Physician assistants actively seek to expand their knowledge and skills, keeping abreast of advances in medicine.
  • Physician assistants work with other members of the health care team to provide compassionate and effective care of patients.
  • Physician assistants respect their professional relationship with physicians.
  • Physician assistants share and expand knowledge within the profession.

The PA and Patient

PA Role and Responsibilities

Physician assistant practice flows out of a unique relationship that involves the PA, the physician, and the patient. The individual patient-PA relationship is based on mutual respect and an agreement to work together regarding medical care. In addition, PAs practice medicine physician supervision; therefore, the care that a PA provides is an extension of the care of the supervising physician. The patient-PA relationship is also a patient-PA-physician relationship.

The principal value of the physician assistant profession is to respect the health, safety, welfare, and dignity of all human beings. This concept is the foundation of the patient-PA relationship. Physician assistants have an ethical obligation to see that each of their patients receives appropriate care. PAs should recognize that each patient is unique and has an ethical right to self-determination. PAs should be sensitive to the beliefs and expectations of the patient, but are not expected to ignore their own personal values, scientific or ethical standards, or the law.

A PA has an ethical duty to offer each patient the full range of information on relevant options for their health care. If personal moral, religious, or ethical beliefs prevent a PA from offering the full range of treatments available or care the patient desires, the PA has an ethical duty to refer an established patient to another qualified provider. PAs are obligated to care for patients in emergency situations and to responsibly transfer established patients if they cannot care for them.<

The PA and Diversity

The physician assistant should respect the culture, values, beliefs, and expectations of the patient.

Discrimination

Physician assistants should not discriminate against classes or categories of patients in the delivery of needed health care. Such classes and categories include gender, color, creed, race, religion, age, ethnic or national origin, political beliefs, nature of illness, disability, socio­economic status, or sexual orientation.

Initiation and Discontinuation of Care

In the absence of a preexisting patient-PA relationship, the physician assistant is under no ethical obligation to care for a person unless no other provider is available. A PA is morally bound to provide care in emergency situations and to arrange proper follow-up. PAs should keep in mind that contracts with health insurance plans might define a legal obligation to provide care to certain patients.

A physician assistant and supervising physician may discontinue their professional relationship with an established patient as long as proper procedures are followed. The PA and physician should provide the patient with adequate notice, offer to transfer records, and arrange for continuity of care if the patient has an ongoing medical condition. Discontinuation of the professional relationship should be undertaken only after a serious attempt has been made to clarify and understand the expectations and concerns of all involved parties.

If the patient decides to terminate the relationship, they are entitled to access appropriate information contained within their medical record.

Informed Consent

Physician assistants have a duty to protect and foster an individual patient's free and informed choices. The doctrine of informed consent means that a PA provides adequate information that is comprehendible to a competent patient or patient surrogate. At a minimum, this should include the nature of the medical condition, the objectives of the proposed treatment, treatment options, possible outcomes, and the risks involved. PAs should be committed to the concept of shared decision making, which involves assisting patients in making decisions that account for medical, situational, and personal factors.

In caring for adolescents, the PA should understand all of the laws and regulations in his or her jurisdiction that are related to the ability of minors to consent to or refuse health care. Adolescents should be encouraged to involve their families in health care decision-making. The PA should also understand consent laws pertaining to emancipated or mature minors. (See the section on Confidentially.)

When the person giving consent is a patient's surrogate, a family member, or other legally authorized representative, the PA should take reasonable care to assure that the decisions made are consistent with the patient's best interests and personal preferences, if known. If the PA believes the surrogate's choices do not reflect the patient's wishes or best interests, the PA should work to resolve the conflict. This may require the use of additional resources, such as an ethics committee.

Confidentiality

Physician assistants should maintain confidentiality. By maintaining confidentiality, PAs re­spect patient privacy and help to prevent discrimination based on medical conditions. If patients are confident that their privacy is protected, they are more likely to seek medical care and more likely to discuss their problems candidly.

In cases of adolescent patients, family support is important but should be balanced with the patient's need for confidentiality and the PA's obligation to respect their emerging autonomy. Adolescents may not be of age to make independent decisions about their health, but providers should respect that they soon will be. To the extent they can, PAs should allow these emerging adults to participate as fully as possible in decisions about their care. It is important that PAs be familiar with and understand the laws and regulations in their jurisdictions that relate to the confidentiality rights of adolescent patients. (See the section on Informed Consent.)

Any communication about a patient conducted in a manner that violates confidentiality is unethical. Because written, electronic, and verbal information may be intercepted or overheard, the PA should always be aware of anyone who might be monitoring communication about a patient.

PAs should choose methods of storage and transmission of patient information that minimize the likelihood of data becoming available to unauthorized persons or organizations. Modern technologies such as computerized record keeping and electronic data transmission present unique challenges that can make the maintenance of patient confidentiality difficult. PAs should advocate for policies and procedures that secure the confidentiality of patient information.

The Patient and the Medical Record

Physician assistants have an obligation to keep information in the patient's medical record confidential. Information should be released only with the written permission of the patient or the patient's legally authorized representative. Specific exceptions to this general rule may exist (e.g., workers compensation, communicable diseases, HIV, knife/gunshot wounds, abuse, substance abuse). It is important that a PA be familiar with and understand the laws and regulations in his or her jurisdiction that relate to the release of information. For example, stringent legal restrictions on release of genetic test results and mental health records often exist.

Both ethically and legally, a patient has certain rights to know the information contained in his or her medical record. While the chart is legally the property of the practice or the institution, the information in the chart is the property of the patient. Most states have laws that provide patients access to their medical records. The PA should know the laws and facilitate patient access to the information.

Disclosure

A physician assistant should disclose to his or her supervising physician information about errors made in the course of caring for a patient. The supervising physician and PA should disclose the error to the patient if such information is significant to the patient's interests and well-being. Errors do not always constitute improper, negligent or unethical behavior, but failure to disclose them may.

Care of Family Members and Co-workers

Treating oneself, co-workers, close friends, family members, or learners whom the physician assistant supervises or teaches my be unethical or create conflicts of interest. PAs should be aware that their judgment might be less than objective in cases involving friends, family members, learners, and colleagues and that providing "curbside" care might sway the individual from establishing an ongoing relationship with a provider. If it becomes necessary to treat a family member or close associate, a formal patient-provider relationship should be established, and the PA should be should consider transferring the patient's care to another provider as soon as it is practical. If a close associate requests care, the PA may with to assist by helping them find an appropriate provider.

There may be exceptions to this guideline, for example, when a PA runs an employee health center or works in occupational medicine. Even in those situations, PAs should be sure they do not provide informal treatment, but provide appropriate medical care in a formally established patient-provider relationship.

Genetic Testing

Evaluating the risk of disease and performing diagnostic genetic tests raise significant ethical concerns. Physician assistants should be knowledgeable about the benefits and risks of genetic tests. Testing should be undertaken only after the patients informed consent is obtained. If PAs order or conduct the tests, they should assure that appropriate pre- and post-test counseling is provided.

PAs should be sure that patients understand the potential consequences of undergoing genetic tests - from impact on patients themselves, possible implications for other family members, and potential use of the information by insurance companies or others who might have access to the information. Because of the potential for discrimination by insurers, employers, or others, PAs should be particularly aware of the need for confidentiality concerning genetic test results.

Reproductive Decision Making

Patients have a right to access the full range of reproductive health care services, including fertility treatments, contraception, sterilization, and abortion. Physician assistants have an ethical obligation to provide balanced and unbiased clinical information about reproductive health care.

When the PA's personal values conflict with providing full disclosure or providing certain services such as sterilization or abortion, the PA need not become involved in that aspect of the patient's care. By referring the patient to a qualified provider, the PA fulfills their ethical obligation to ensure the patient access to all legal options.

End of Life

Physician assistants have an obligation to optimize care and maximize quality of life for patients at the end of life. PAs are encouraged to facilitate open discussion with patients and their family members concerning end of life treatment choices.

PAs should involve the physician in all near-death planning. The PA should only withdraw life support with the supervising physician's agreement and in accordance with the policies of the health care institution.

PAs should be aware of the medical, legal, social, and ethical issues in end of life decision-making. Advance directives, living wills, and organ donation should be discussed during routine patient visits.

The PA and Individual Professionalism

Conflict of Interest

Physician assistants should place service to patients before personal material gain and should avoid undue influence on their clinical judgment. Trust can be undermined by even the appearance of improper influence. Examples of excessive or undue influence on clinical judgment can take several forms. These may include financial incentives, pharmaceutical or other industry gifts, and business arrangements involving referrals. PAs should disclose any actual or potential conflict of interest to their patients.

Acceptance of gifts, trips, hospitality, or other items is discouraged. Before accepting a gift or financial arrangement, PAs might consider the guidelines of the Royal College of Physicians, "Would I be willing to have this arrangement generally known?" or of the American College of Physicians-American Society of Internal Medicine, "What would the public or my patients think of this arrangement?"

Professional Identity

Physician assistants should not misrepresent directly or indirectly, their skills, training, professional credentials, or identity. Physician assistants should uphold the dignity of the PA profession and accept its ethical values.

Competency

Physician assistants should commit themselves to providing competent medical care and extend to each patient the full measure of their professional ability as dedicated, empathetic health care providers. PAs should also strive to maintain and increase the quality of their health care knowledge, cultural sensitivity, and cultural competence through individual study and continuing education.

Sexual Relationships

It is unethical for physician assistants to become sexually involved with patients. It also may be unethical for PAs to become sexually involved with former patients or key third parties. Key third parties are individuals who have influence over the patient. These might include spouses or partners, parents, guardians, or surrogates.

Such relationships generally are unethical because of the PA's position of authority and the inherent imbalance of knowledge, expertise, and status. Issues such as dependence, trust, transference, and inequalities of power may lead to increased vulnerability on the part of the current or former patients or key third parties.

Gender Discrimination and Sexual Harassment

It is unethical for physician assistants to engage in or condone any form of gender dis­crim­ination. Gender discrimination is defined as any behavior, action, or policy that adversely affects an individual or group of individuals due to disparate treatment, disparate impact, or the creation of a hostile or intimidating work or learning environment.

It is unethical for PAs to engage in or condone any form of sexual harassment. Sexual harassment is defined as unwelcome sexual advances, requests for sexual favors, or other verbal or physical conduct of a sexual nature when:

Such conduct has the purpose or effect of interfering with an individual's work or academic performance or creating an intimidating, hostile or offensive work or academic environment, or

Accepting or rejecting such conduct affects or may be perceived to affect professional decisions concerning an individual, or

Submission to such conduct is made either explicitly or implicitly a term or condition of an individual's training or professional position.

The PA and Other Professionals

Team Practice

Physician assistants should be committed to working collegially with other members of the health care team to assure integrated, well-managed, and effective care of patients. PAs should strive to maintain a spirit of cooperation with other health care professionals, their organi­zations, and the general public.

Illegal and Unethical Conduct

Physician assistants should not participate in or conceal any activity that will bring discredit or dishonor to the PA profession. They should report illegal or unethical conduct by health care professionals to the appropriate authorities.

Impairment

Physician assistants have an ethical responsibility to protect patients and the public by identifying and assisting impaired colleagues. "Impaired" means being unable to practice medicine with reasonable skill and safety because of physical or mental illness, loss of motor skills, or excessive use or abuse of drugs and alcohol.

PAs should be able to recognize impairment in physician supervisors, PAs, and other health care providers and should seek assistance from appropriate resources to encourage these individuals to obtain treatment.

PA-Physician Relationship

Supervision should include ongoing communication between the physician and the physician assistant regarding patient care. The PA should consult the supervising physician whenever it will safeguard or advance the welfare of the patient. This includes seeking assistance in situations of conflict with a patient or another health care professional.

Complementary and Alternative Medicine

A patient's request for alternative therapy may create conflict between the physician assistant and the patient. Though physician assistants are under no obligation to provide an alternative therapy, they do have a responsibility to be sensitive to the patient's needs and beliefs and to help the patient understand their medical condition. The PA should gain an understanding of the alternative therapy being considered or being used, the expected outcome, and whether the treatment would clearly be harmful to the patient. If the treatment would harm the patient, the PA should work diligently to dissuade the patient from using it and advise other treatment.

The PA and the Health Care System

Workplace Actions

Physician assistants may face difficult personal decisions to withhold medical services when workplace actions (e.g., strikes, sick-outs, slowdowns, etc.) occur. The potential harm to patients should be carefully weighed against the potential improvements to working conditions and, ultimately, patient care that could result. In general, PAs should individually and collectively work to find alternatives to such actions in addressing workplace concerns.

Managed Care

The focus of managed care organizations on cost containment and resource allocation can present particular ethical challenges to clinicians. When practicing in managed care systems, physician assistants should always act in the best interests of their patients and as an advocate when necessary. PAs should actively resist managed care policies that restrict free exchange of medical information. For example, a PA should not withhold information about treatment options simply because the option is not covered by a particular managed care organization.

PAs should inform patients of financial incentives to limit care, use resources in a fair and efficient way, and avoid arrangements or financial incentives that conflict with the patient's best interests.

PAs as Educators

All physician assistants have a responsibility to share knowledge and information with patients, other health professionals, learners, and the public. The ethical duty to teach includes effective communication with patients so that they will have the information necessary to participate in their health care and wellness.

PAs and Research

The most important ethical principle in research is honesty. This includes assuring subjects' informed consent, following treatment protocols, and accurately reporting findings. Fraud and dishonesty in research should be reported so that the appropriate authorities can take action.

Physician assistants involved in research must be aware of potential conflicts of interest. The patient's welfare takes precedence over the desired research outcome. Any conflict of interest should be disclosed.

In scientific writing, PAs should report information honestly and accurately. Sources of funding for the research must be included in the published reports.

Plagiarism is unethical. Incorporating the words of others, either verbatim or by paraphrasing, without appropriate attribution is unethical and may have legal consequences. When submitting a document for publication, any previous publication of any portion of the document must be fully disclosed.

PAs as Expert Witnesses

The physician assistant expert witness should testify to what he or she believes to be the truth. The PA's review of medical facts should be thorough, fair, and impartial.

The PA expert witness should be fairly compensated for time spent preparing, appearing, and testifying. The PA should not accept a contingency fee based on the outcome of a case in which testimony is given or derive personal, financial, or professional favor in addition to compensation.

The PA and Society

Lawfulness

Physician assistants have the dual duty to respect the law and to work for positive change to laws that will enhance the health and well being of the community.

Executions

Physician assistants, as health care professionals, should not participate in executions because to do so would violate the ethical principle of beneficence.

Access to Care/Resource Allocation

Physician assistants have a responsibility to use health care resources in an appropriate and efficient manner so that all patients have access to needed health care. Resource allocation should be based on societal needs and policies, not the circumstances of an individual patient- PA encounter. PAs participating in policy decisions about resource allocation should consider medical need, cost-effectiveness, efficacy, and equitable distribution of benefits and burdens in society.

Community Well Being

Physician assistants should work for the health, well-being, and the best interest of both the patient and the community. Sometimes there is a dynamic moral tension between the well being of the community in general and the individual patient. Conflict between an individual patient's best interest and the common good is not always easily resolved. In general, PAs should be committed to upholding and enhancing community values, be aware of the needs of the community, and use the knowledge and experience acquired as professionals to contribute to an improved community.

Conclusion

The American Academy of Physician Assistants recognizes its responsibility to aid the PA profession as it strives to provide high quality, accessible health care. Physician assistants wrote these guidelines for themselves and other physician assistants. The ultimate goal is to honor patients and earn their trust while providing the best and most appropriate care possible. At the same time, PAs must understand their personal values and beliefs and recognize the ways in which those values and beliefs can impact the care they provide.

Page last modified November 21, 2014