Journal of the American Medical Informatics Association, 25(11), 2018, 1579–1582
doi: 10.1093/jamia/ocy092
Advance Access Publication Date: 17 October 2018
Messages from AMIA
Messages from AMIA
AMIA’s code of professional and ethical conduct 2018
1
Global Business Solutions, Mayo Clinic, Rochester, Minnesota, USA, 2Department of Health Services Administration, University
of Alabama at Birmingham, Birmingham, Alabama, USA, 3The Regenstrief Institute, Indianapolis, Indiana, USA, 4Department of
Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA, 5Department of Philosophy, Institute for Bioethics and Health Policy, University of Miami Miller School of Medicine, Miami, Florida, USA, 6Department of Health Informatics, Institute for Bioethics and Health Policy, University of Miami Miller School of Medicine, Miami,
Florida, USA, 7Department of Public Health Sciences, Institute for Bioethics and Health Policy, University of Miami Miller School
of Medicine, Miami, Florida, USA, 8Department of Electrical and Computer Engineering, Institute for Bioethics and Health Policy,
University of Miami Miller School of Medicine, Miami, Florida, USA, 9Department of Anesthesiology, Institute for Bioethics and
Health Policy, University of Miami Miller School of Medicine, Miami, Florida, USA, 10School of Nursing and Health Studies, Institute for Bioethics and Health Policy, University of Miami Miller School of Medicine, Miami, Florida, USA, 11Department of Sociology, Center for Clinical Epidemiology & Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA, 12Department
of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, USA, 13Department of Pediatrics, Vanderbilt University,
Nashville, Tennessee, USA, 14Division of Health Services Informatics, Johns Hopkins University, Baltimore, Maryland, USA, 15Department of Veterans Affairs, Salt Lake City, Utah, USA, 16Department of Child and Adolescent Psychiatry, New York University
School of Medicine, New York, New York, USA, 17Department of Population Health, New York University School of Medicine,
New York, New York, USA, 18Department of Family Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA, 19Department of Biomedical Engineering, The University of Arizona, Tucson, Arizona, USA, 20Department of Systems & Industrial Engineering, The University of Arizona, Tucson, Arizona, USA, 21Quest Diagnostics, West Hills, California, USA, and 22Institute for
Healthcare Informatics, Center of Excellence in Bioinformatics and Life Sciences, University at Buffalo, Buffalo, New York, USA
Corresponding Author: Carolyn Petersen, MS, MBI, Global Business Solutions, Mayo Clinic, 200 First St. SW, Rochester,
MN 55905, USA (petersen.carolyn@mayo.edu)
Received 30 May 2018; Revised 8 June 2018; Editorial Decision 15 June 2018; Accepted 18 June 2018
Key words: codes of ethics, professional ethics, institutional ethics, professional-patient relations, delivery of health care
INTRODUCTION
AMIA has a longstanding interest in and a professional obligation to
promote a strong ethical framework for the field of biomedical and
health informatics. This white paper presents the latest AMIA Code
of Professional and Ethical Conduct. The original Code was approved in 20071 by the AMIA Board of Directors. Recognizing the
need to update the Code to ensure that it remains current and relevant, this document constitutes a revision of and update to the second
code, approved in 2012 and published in the Journal of the American
Medical Informatics Association in 2013.2 The code presented here
remains an evolving document, with modifications expected as the in-
formation technology, informatics, and healthcare environments
change over time. AMIA will publish on its web site the most recent
version of the Code of Ethics as part of a process that seeks ongoing
response from and involvement by AMIA members.
Because the Code is meant to be practical, applicable in real life,
and easily understood, it is compact and uses general language.
The AMIA Code of Ethics is not intended to be prescriptive or legislative; it is aspirational and extends beyond regulatory and legal obligations to provide the broad strokes of a set of important ethical
principles pertinent to the field of biomedical and health informatics.
The Code is organized around the common roles of AMIA members and the constituents they serve, including patients, caregivers,
C The Author(s) 2018. Published by Oxford University Press on behalf of the American Medical Informatics Association.
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All rights reserved. For permissions, please email: journals.permissions@oup.com
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Carolyn Petersen,1 Eta S Berner,2 Peter J Embi,3 Kate Fultz Hollis,4
Kenneth W Goodman,5,6,7,8,9,10 Ross Koppel,11 Christoph U Lehmann,12,13 Harold
Lehmann,14 Sarah A Maulden,15 Kyle A McGregor,16,17 Anthony Solomonides,18
Vignesh Subbian,19,20 Enrique Terrazas,21 and Peter Winkelstein22
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AMIA’s “Conflict of Interest Policy,” which governs the organization’s employees and leaders in regard to some of their financial and other interactions with outside entities.14
AMIA’s “Meeting Anti-Harassment Policy,” which describes
AMIA’s commitment to providing an atmosphere that is welcoming
to all members and supports learning and professional growth.15
The International Committee of Medical Journal Editors’
“Recommendations for the Conduct, Reporting, Editing, and
Publication of Scholarly Work in Medical Journals.”16 This document is widely accepted as identifying standards for publication
and authorship, and is paralleled by the editorial policies for the
past17 and current18 publishers of the Journal of the American
Medical Informatics Association, as well as the publisher of
Applied Clinical Informatics.19
Privacy laws. Several sections herein address patient privacy or
the rights of patients to view and control access to their health information. These sections are intended to parallel and make explicit duties under the law. In the United States, for instance, the
Privacy Rule under the Health Insurance Portability and Accountability Act20 lays out many duties for those who are entrusted with
health information. Many other countries have similar laws to
protect patient data. Informatics professionals are expected to be
familiar with and follow the laws governing their practice.
Members of the Ethics Committee are unanimous in their view
that those who work in informatics, much as in other health professions, are duty-bound to embrace a patient-centered approach to
their work, even if that work does not involve direct patient care or
human subjects research. As elsewhere in the health professions, vulnerable populations or those with special needs may be entitled to
additional considerations.
The importance of professionalism and ethics has been recognized for millennia by health professionals and organizations,21 now
including information technology professionals. This code of ethics
emphasizes AMIA’s commitment to adhere to and promote the
highest standard of ethical and professional behavior.
PRINCIPLES OF PROFESSIONAL AND ETHICAL
CONDUCT FOR AMIA MEMBERS
AMIA members acknowledge as their professional duty to uphold
the following principles of and guidelines for ethical conduct. AMIA
members are expected to know to seek the advice of institutional
ethics committees, AMIA’s Ethics Committee, or appropriate institutional review boards, as necessary. The following code details
address patient care, interactions with colleagues, responsibilities to
employers, and roles regarding society and research.
I. Key ethical guidelines regarding patients, guardians, and their
authorized representatives (called here collectively “patients”)
AMIA members involved in patient care should:
A. Recognize that patients and their loved ones and caregivers
have the right to know about the existence and use of electronic
records containing their personal healthcare information, and
have the right to create and maintain their own personal health
records and manage personal health information using a variety
of platforms including mobile devices. In this context AMIA
members should:
1. Not mislead patients about the collection, use, or communication of their healthcare information.
2. Enable and — as appropriate, within reason and the scope
of their position and in accord with independent ethical
and legal standards — facilitate patients’ rights and ability
to access, review, and correct their electronic health information.
3. Recognize that patient-provided/generated health data,
such as those collected on mobile devices, deserve the same
diligence and protection as biomedical and health data
gathered in the process of providing health care.
B. Advocate and work as appropriate to ensure that protected
health information (PHI),20 personally identifiable information
(PII), and other biomedical data are transmitted, acquired,
recorded, stored, maintained, analyzed, and communicated in an
appropriately safe, reliable, secure, and confidential manner, and
that such data management is consistent with applicable laws, local
privacy and security policies, and accepted informatics standards.
C. Never knowingly disclose PHI, PII, or biomedical or health data
in violation of legal requirements or accepted local confidentiality
practices, or in ways that are inconsistent with the explanation
of data disclosure and use to the patient. AMIA members
should understand that inappropriate disclosure of biomedical
information can cause harm, and so should work to prevent
such disclosures. AMIA members should avoid acquiring data
through means that run the risk of, or fail to prevent, inappropriate disclosure. Likewise, even if an action does not involve
disclosure, one should not use — or through negligence permit
the use of — patient information and data in ways inconsistent
with the stated purposes, goals, or intentions of the patient or
organization responsible for these data, except as appropriate
for public health, previously approved and communicated research uses, or reporting as required under the law.
II. Key ethical guidelines regarding colleagues
AMIA members should:
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clinicians, researchers, students, agencies, hospitals and practices,
medical organizations, vendors, insurance companies, and others
with whom they interact. The AMIA Board and the AMIA Ethics
Committee encourage members to offer suggestions for improvements and changes. In this way, the Code will continue to evolve to
best serve AMIA and the larger informatics community.
The Code’s authors are aware that all professionals will, from
time to time, find themselves in situations shaped by what has been
called “dual agency” or “multiple agency.” In these circumstances,
a professional encounters conflicting commitments, duties, or loyalties. An informatics professional may have conflicting duties to
patients, to colleagues, to society, and to an employer. Few, if any,
codes of ethics are nimble enough to provide guidance in such situations. Further, AMIA’s Ethics Committee is a resource to members
who find themselves in ethically unclear or challenging situations.
AMIA members may contact the AMIA Ethics Committee,
which can provide guidance in some circumstances. AMIA members
are professionally diverse,3,4 and include those who are, or are in
training to be, nurses, physicians, pharmacists, dentists, informaticians, computer scientists, and others. In many cases, these professions have their own codes of ethics.5–12 The International Medical
Informatics Association, an international federation for which
AMIA serves as the U.S. membership organization, also has a revised “Code of Ethics for Health Information Professionals.”13
This document incorporates issues covered by other documents
and laws bearing on ethics and professional conduct:
Journal of the American Medical Informatics Association, 2018, Vol. 25, No. 11
A. Endeavor, as appropriate, to support and foster colleagues’
and/or team members’ work, in a timely, respectful, and conscientious way to support their roles in healthcare and/or research
and education.
B. Support and foster the efforts of patients to be actively involved in the collection, management, and curation of their
health data.
D. If a leader, an AMIA member should:
1. Be familiar with these guidelines and their applicability to
their practice, unit, or organization.
2. Communicate as appropriate about these ethical guidelines
to those they lead.
3. Strive to promote familiarity with, and use of, these ethical
guidelines.
III. Key ethical guidelines regarding institutions, employers, business partners, and clients (called here collectively “employers”)
AMIA members should:
A. Understand their duties and obligations to current and former
employers and fulfill them to the best of their abilities within the
bounds of ethical and legal norms.
B. Understand and appreciate that employers have legal and ethical rights and obligations, including those related to intellectual
property. Understand and respect the obligations of their
employers, and comply with local policies and procedures to the
extent that they do not violate ethical and legal norms. Consider
the tradeoffs that occur with the configuration and use of technologies (eg, decision support systems) before implementation,
and monitor and manage results when the optimal approach is
unclear.
C. Inform the employer and act in accordance with ethico-legal
mandates and patient rights when employer actions, policies,
or procedures would violate ethical or legal obligations, contracts, or other agreements made with patients. Maintain a safe
and high-quality environment even while implementing innovation, recognizing that all changes in a complex adaptive environment generate unanticipated consequences and potential
harm.
D. Disseminate new knowledge — both positive and negative —
expeditiously, to allow the field to advance and to permit others
to take advantage of novel discoveries to improve patient care.
E. Strive as appropriate in the context of one’s position to foster
the generation of knowledge and biomedical advances through
appropriate support for ethical and institutionally approved research efforts facilitated through informed consent and disclosure
processes and procedures, particularly when third-party entities
not meeting the definition of business associates are involved.
F. Know and abide by the applicable governmental regulations
and local policies that define ethical research in their professional
environment.
V. General professional and ethical guidelines
AMIA members should:
A. Maintain competence as informatics professionals:
1. Obtain applicable continuing education and be dedicated
to a culture of lifelong learning and improvement;
2. Recognize technical and ethical limitations and seek consultation when needed, particularly in ethically conflicting
situations;
3. Contribute to the education and mentoring of students, junior members, and others, as appropriate;
4. Promote a culture of inclusivity in their work and professional conduct.
B. Strive to encourage the adoption of informatics approaches
supported by adequate evidence to improve health and healthcare; and to encourage and support efforts to improve the
amount and quality of such evidence.
C. Be mindful that their work and actions reflect on the profession and on AMIA.
CONCLUSION
As a matter of personal and professional integrity, adherence to the
principles laid out here is expected of all who have the privilege of
serving in the field of biomedical and health informatics. Those
whose skills allow them to contribute in one way or another to the
health of individuals and populations carry important responsibilities, and this Code of Ethics delineates how informaticians may best
do so.
FUNDING
IV. Key ethical guidelines regarding society and regarding
research
AMIA members involved in research should:
A. Be aware of the Declaration of Helsinki (Ethical Principles for
Medical Research Involving Human Subjects), which should
guide all human subject research, including research that involves
users of informatics tools and interventions as human subjects
(eg, workflow analysis studies, clinical decision support systems
analysis, patient care innovations, analysis, etc.).22,23 Recognize
that duty and care to colleagues exist regardless of whether such
responsibilities are acknowledged by institutional review boards,
vendors, and others involved in informatics activities.
B. Be mindful and respectful of the social or public health implications of their work, ensuring that the greatest good for society
is balanced by ethical obligations to individual patients.
C. Avoid any plagiarism or self-plagiarism or other misrepresentations of the truth in the publication of research and other work.
None.
PROVENANCE AND PEER REVIEW
Not commissioned; not peer reviewed.
Conflict of interest statement. None.
ACKNOWLEDGMENTS
The authors and the AMIA Ethics Committee would like to thank the AMIA
Board of Directors for its continuing interest in refining and publishing these
guidelines. Phyllis Burchman, AMIA’s Director of Office Operations and Human Resources, provided invaluable support to the Ethics Committee in its
work. Members of the AMIA Ethics Committee who contributed to the second version of the code in 2012 and are not otherwise listed here include
Samantha Adams, Robert Hsiung, John Hurdle, and Dixie A. Jones. This
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C. Advise colleagues and others, as appropriate, about actual or
potential information or systems issues (including system flaws,
bugs, usability issues, etc.) that negatively affect patient safety,
privacy, data security, or outcomes or could hinder colleagues’
ability to delegate responsibilities to patients, other colleagues,
involved institutions, or other stakeholders.
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version of the code also owes much to the members of AMIA’s Ethical, Legal,
and Social Issues (ELSI) Working Group.
REFERENCES
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1. Hurdle JF, Adams S, Brokel J, et al. American Medical Informatics Association. A code of professional ethical conduct for the American Medical Informatics Association: an AMIA Board of Directors approved white
paper. J Am Med Inform Assoc 2007; 14 (4): 391–3.
2. Goodman KW, Adams S, Berner ES, et al. AMIA’s code of professional
and ethical conduct. J Am Med Inform Assoc 2013; 20 (1): 141–3.
3. Hersh W. Viewpoint paper: who are the informaticians? What we know
and should know. J Am Med Inform Assoc 2006; 13 (2): 166.
4. Kannry J, Sengstack P, Thyvalikakath TP, et al. The chief clinical informatics officer (CCIO): AMIA task force report on CCIO knowledge, education,
and skillset requirements. Appl Clin Inform 2016; 07 (01): 143–76.
5. American Nurses Association. Code of ethics for nurses. 2001. http://
www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses.aspx Accessed January 14, 2018.
6. American College of Physicians. ACP ethics manual, 6th ed: a comprehensive medical ethics resource. 2012. https://www.acponline.org/clinical-information/ethics-and-professionalism/acp-ethics-manual-sixth-edition
Accessed January 14, 2018.
7. American Health Information Management Association. American
Health Information Management Association code of ethics. 2011. http://
library.ahima.org/doc?oid¼105098#.WDiEgLIrKM8 Accessed January
14, 2018.
8. Association of Computing Machinery. ACM code of ethics. 1992. https://
www.acm.org/about-acm/code-of-ethics Accessed January 14, 2018.
9. Healthcare Information and Management Systems Society Electronic
Health Record Association. EHR developer code of conduct. 2016. http://
www.ehra.org/sites/ehra.org/files/ehr-code-of-conduct-v2.pdf Accessed
January 14, 2018.
10. Association of Internet Researchers. Ethical decision-making and internet
research: recommendations from the AoIR ethics working committee (version 2.0). http://aoir.org/reports/ethics2.pdf Accessed January 14, 2018.
11. Medical Library Association. Code of ethics for health sciences librarianship. 2010. http://www.mlanet.org/p/cm/ld/fid¼160 Accessed January 14,
2018.
12. Illinois Institute of Technology. Ethic codes collections. http://ethics.iit.
edu/ecodes/ Accessed January 14, 2018.
13. International Medical Informatics Association. IMIA code of ethics for
health information professionals. 2016. http://imia-medinfo.org/wp/wpcontent/uploads/2015/07/IMIA-Code-of-Ethics-2016.pdf Accessed January 14, 2018.
14. AMIA. Conflict of interest policy. 2016. https://www.amia.org/aboutamia/ethics/conflict-interest Accessed January 14, 2018.
15. AMIA. Meeting anti-harassment policy. https://www.amia.org/amiameeting-anti-harassment-policy Accessed February 17, 2018.
16. International Committee of Medical Journal Editors. Recommendations
for the conduct, reporting, editing, and publication of scholarly work in
medical journals. 2017. http://www.icmje.org/icmje-recommendations.
pdf Accessed January 14, 2018.
17. BMJ Group. Editorial policies. http://authors.bmj.com/policies/ Accessed
January 14, 2018.
18. Oxford University Press. Publication rights. https://academic.oup.com/
journals/pages/access_purchase/rights_and_permissions/publication_
rights Accessed January 14, 2018.
19. Thieme Medical Publishers. Authors & reviewers. https://www.thieme.
com/resources/87-resources-for-authors Accessed January 14, 2018.
20. Health Insurance Portability and Accountability Act of 1996 (Public Law
104e191). https://aspe.hhs.gov/report/health-insurance-portability-andaccountability-act-1996 Accessed January 14, 2018.
21. Wikipedia. Hippocratic oath. https://en.wikipedia.org/wiki/Hippocratic_
Oath Accessed January 14, 2018.
22. WMA General Assembly WMA Declaration of Helsinki – Ethical Principles
for Medical Research Involving Human Subjects. https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/ Accessed January 14, 2018.
23. Federal Policy for the Protection of Human Subjects (‘Common Rule’).
https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr-46/
index.html Accessed March 20, 2018.
Excerpt from:
Swirsky, ES. (2020). Chapter 27: Ethical Issues of Health Information Management. In P. Oachs and A.
Watters (eds), Health Information Management: Concepts, Principles and Practice, 6th ed. Chicago:
AHIMA Press.
27
Ethical Issues in Health Information Management
Eric S. Swirsky, JD, MA
Learning Objectives
• Differentiate fundamental bioethical theories and principles related to healthcare and biomedical sciences
• Evaluate and respond to ethical issues that arise in HIM practice
• Evaluate personal values and ethical duties of HIM professionals
• Assess the AHIMA Code of Ethics to evaluate essential ethical skills and standards of professional
practice
• Utilize an ethical decision-making tool to analyze complex ethical issues and make reasoned decisions
• Determine areas of personal and professional bias that inform HIM practice, including the influence of
culture and diversity
Through the millennia, the science and practice of medicine have evolved alongside the moral relationship
that exists between caregivers and patients. The movement towards professionalization of medicine,
essentially beginning with the work of Hippocrates, served as the vanguard for the subsequent
transformation of the healing arts and sciences into a $3 trillion healthcare industry in the US (CMS 2019).
Of course, the Hippocratic sect was not a professional organization; however, it did try to codify the moral
relationship between physicians and their patients that is still recognized to this day. The ancient ethical
principles of refraining from harm and protecting patient confidentiality stand among the traditional clinical
values that have withstood time, but they have been weathered and worn through the ages.
In modern times, technology has expanded and challenged the provider-patient relationship in many
ways. Traditional values have given way to a new set of societal interests in the wake of technological
innovation and implementation; in the age of the electronic health record (EHR), for example, the
Hippocratic notion of confidentiality has been labeled a “decrepit concept” due to information sharing and
the number of clinicians and administrators who access patient records (Siegler 1982, 1518). The
widespread implementation of information technologies and novel uses of data have resulted in further
challenges to the concept of confidentiality. While the sharing of information may be for the benefit of the
patient, there is also sharing that is for the benefit of the healthcare provider or third-party payers—the
provider-patient relationship is very crowded. Yet, information technologies may have a more profound
impact from an ethical standpoint. Consider this quote by medical historian Stanley Joel Reiser:
Technologies can develop identities of their own…. Machines inexorably direct the attention of both the
doctor and patient to the measurable aspects of illness, but away from the “human” factors that are at least
equally important. Insofar as technological evidence occupies the time and commands the chief allegiance of
both doctor and patient, it diminishes the possibility that a close personal relationship will develop between
the two. So, without realizing what has happened, the physician in the last two centuries has gradually
relinquished his unsatisfactory attachment to subjective evidence – what the patient says – only to substitute a
devotion to technological evidence – what the machine says. He has thus exchanged one partial view of
disease for another. As the physician makes greater use of the technology of diagnosis, he perceives the
patient more and more indirectly through a screen of machines and specialists; he also relinquishes his control
over more and more diagnostic processes. These circumstances tend to estrange him from his patient and
from his own judgment. (1978, 229)
Health information technology (HIT) and attendant professions serve a wide variety of stakeholders in
the healthcare system—from patients, to healthcare providers, to third-party payers, state and federal
agencies, accrediting organizations, and an array of others. Due to the ubiquity of HIT in clinical
environments, health information management (HIM) and health informatics (HI) stand at the crux of
communication in a complex and multidisciplinary health system; as such, these disciplines form the mortar
that binds together the bricks of team-based healthcare as information is exchanged to coordinate care of
patients. The importance of ethical standards in HIM and HI should not be minimized; communication
issues are among the most common root causes of sentinel events, which are defined by the Joint
Commission as unanticipated “patient safety events (not primarily related to the natural course of the
patient’s illness or underlying condition) that reach a patient and result in death, permanent harm, or severe
temporary harm” (Joint Commission 2015, 1). Therefore, professionals working in these fields must abide
by their respective ethical codes and standards of professional conduct to avoid medical errors, malpractice,
and other risks to patient safety that are related to the use of HIT and communication of health information
and data.
In general, healthcare technology has the potential to improve the quality of human life and introduce
efficient means to achieve that goal; however, technology must be wielded with care. Sir William Osler, the
so-called father of modern medicine, recognized this over 100 years ago when he wrote, “The old art cannot
be replaced by, but must be absorbed in, the new science” (1907, 96). Technological advancement does not
guarantee improved patient outcomes or relations and may serve to interfere with both at any given time
along the continuum of care. Because of this, HIM professionals are guided to attend to these issues through
the American Health Information Management Association (AHIMA) Code of Ethics so that they may
serve as stewards of the profession. Ethical problems arise in scenarios that make us question, “What should
I do?” Ethical principles, theories, and codes are tools that help us understand the issues, possibly resolve
them, or justify a chosen course of action. The study of ethics can help HIM professionals in a number of
ways: it prepares them for situations they may not have considered or know how to resolve, it provides tools
for making difficult decisions, and it offers a way to reflect upon our own sense of professionalism—the
knowledge, skills, and attitudes required to meet the expected standards of deliberate professional practice
and excellence through lifelong learning.
[A] Morality and Ethics in Health Information Management
The phrase “first do no harm” is well known in healthcare as a long-standing code of conduct for medical
professionals; for thousands of years, this goal has ushered providers to refrain from intentionally harming
patients. Like others in healthcare disciplines, HIM professionals must adhere to a code of ethics, which is
a set of standards regarding business practices and professional behavior. Health information managers may
not have direct patient care contact, but they do interact with patients in terms of coding, release of
information (ROI), data quality, and so forth; while they many never touch a person physically, work of
HIM professionals can affect every life in a health system. Moreover, healthcare workers are frequently
called to make decisions in situations where there are conflicting standards or values among stakeholders
and understanding one’s professional role and responsibilities will help the decision-making process. To
fully comprehend the expectations set out in the AHIMA Code of Ethics, it is necessary to understand the
theories and principles that provide its moral foundations.
[B] Morality
Morality is the general term used to describe norms, duties, manners, or customs that people use to
distinguish between right and wrong; it is the human activity where communal standards of conduct and
character are created. There are numerous sources of moral standards; for example, they can be derived
from an individual’s self-conception or sense of integrity, societal cultural beliefs and customs, or from
other groups like professional organizations or institutional policies.
Although they may be related, morals are not the same thing as laws. Laws are formal rules that are
defined and uniformly enforced by the government and determine what is legally right and wrong based on
concepts of justice and equity; morality is a set of informal personal, group, organizational, or societal
norms that are based in communal ideals of goodness. There are many issues in healthcare that have both
legal and moral implications. Consider an act of deception. It may not be illegal to lie to a classmate
regarding an exam grade; however, it could be argued that the same is an immoral act, even if it is harmless.
At the same time, one may feel morally compelled or justified in lying to a third-party payer so a patient can
get treatment they cannot afford; however, falsification of medical records or lying to insurance companies
can have legal and professional ramifications.
A moral dilemma is a situation in which there is a decision to be made, but any choice may violate
some other duty or standard because the right thing to do may be hard to choose or be unknown. It can be
difficult to identify moral dilemmas when they arise; they are frequently embedded in complex situations,
especially in healthcare. Issues may arise among conflicting moral obligations, between moral standards
and laws, when there is a barrier that prevents doing the right thing, or when we have a gut feeling that
something is wrong but it is unclear what it is. A mistake or error in judgment that results in harmful effects
relative to ethical standards is referred to as an ethical lapse. For an ethical lapse to occur, one does not
have to have a bad intention or deliberately choose to deviate from that standard; all that matters is that one
intended the action that resulted in harm. In these situations, we usually begin by asking, “What is the right
thing to do? What should I (or someone) do? What ought they do?” Sentences with should or ought are
clues—if you are asking these questions, there is probably an unresolved moral issue at hand. These moral
dilemmas have three common structural features:
●
A moral agent—a person responsible for making a decision for themselves or others
●
A course of action—the decision that needs to be made, and the decision-making process that was
used to reach it
●
An outcome—the result of taking a particular course of action (Doherty and Purtilo 2016, 56)
For example, George Washington chopped down a cherry tree, as the story goes. When his father asked him
if he had done it, he answered, “Yes, I did; I cannot tell a lie.” In this scenario the moral dilemma is related
to truth telling or veracity, the agent is young George Washington, the course of action is George’s decision
whether or not to tell the truth, and the outcome is George telling the truth, thus earning the respect of his
father. Dilemmas can arise from any of these structural features individually or in concert. In other words,
problems arise for healthcare providers with regard to moral agents and their agency (who should make a
decision?), the course of action (what should be done?), and the outcome (were the patients’ goals of care
met?).
Situations involving moral dilemmas or lapses can result in moral distress for healthcare professionals.
Moral distress, defined as “the experience of cognitive-emotional dissonance that arises when one feels
compelled to act contrary to one’s moral requirements,” is common in clinical environments; however, it
receives relatively little attention in health professions education (Berger 2013, 395). Situations that evoke
moral distress include negative role modeling, witnessing the immoral acts of colleagues and mentors, and
participating in substandard patient care; it has been associated with burnout and cynicism when it
manifests as humiliation, dehumanization of patients, and witnessing unethical acts, such as blatant
falsification of patient medical records (Billings et al. 2011, 504). Figure 27.1 illustrates some sources of
moral distress. Moreover, the effects may be cumulative as learners do not uniformly receive adequate
training to deal with their moral distress and therefore lack the agency to participate in controversial cases
or report wrongdoing as they progress through training and move into practice (Berger 2013, 395). Moral
distress is an affront to the moral agency of providers because cognitive-emotional dissonance can prevent
them from responding appropriately when they suspect something is wrong. In the face of these distressing
moral dilemmas, health information managers are expected to uphold professional responsibilities,
standards, and values. This is referred to as moral courage, defined as the personal trait of individuals who
act upon their ethical values to help others despite personal risk, adversity, and professional isolation;
despite the consequences, morally courageous people are prepared to do the right thing when others are not
(Murray 2010).
Figure 27.1.
Sources and examples of moral distress
Sources and Examples of Moral Distress
• There are multiple options known, but the right action is not clear.
e.g., conflicting policies create a situation in which the professional does not know the proper protocol.
• There are multiple options known, but none of the actions feel “right” or they lead to undesirable
outcomes.
e.g., professional is hesitant to be a whistleblower due to fears of reprisal.
• Something does not feel right, but we do not know what it is.
e.g., colleague appears to nervously close a patient record and blush when you appear unexpectedly.
• Something does not feel right, but we do not know what our options are.
e.g., professional witnesses unethical behavior but does not know applicable policies and procedures.
• We cannot do what we know to be “right.”
e.g., professional policy dictates action or inaction that conflicts with personal values.
[B] Ethical Theories, Principles, and Concepts
Morality is closely related to the field of ethics, which is the study of morality using the principles, theories,
and decision-making frameworks of philosophy. Morality refers to standards of conduct and right and
wrong, whereas ethics provides structure to analyze those standards within a particular context. In
healthcare, ethics involves formal decision-making needed when dealing with diverse and competing
perspectives, values, and obligations of stakeholders who have interests in a common problem. An ethical
approach to decision-making poses questions about how we ought to act in relationships with one another,
asks us to consider whether our actions are right or wrong, and identifies how character traits may help or
hinder us in day-to-day life. Different ethical theories approach moral questions in different ways; some
take a case-based approach, others only look at outcomes, while some may be concerned with the character
traits of the people involved. There is no pure ethical theory that controls the others, and there is no
hierarchy to settle disputes when theories conflict; each one has its strengths and weaknesses, and
healthcare professionals’ ability to understand them will enhance their decision-making toolbox.
Medicine is a fundamentally moral endeavor in which healthcare providers and staff frequently navigate
patient, professional, and personal values that come into conflict with a host of ethical, legal, and prudential
considerations; therefore, the continuing moral development of trainees and practitioners should be a high
priority in the health professions (Wiggleton et al. 2010, 111). The moral relationship between providers
and their patients has been studied by philosophers for thousands of years, and as a result there are a variety
of ethical theories, principles, and concepts that have been developed; what follows below is a review of
some that are regularly applied in healthcare.
[C] Virtue Ethics
Different approaches to clinical ethics trace their origins to the Hippocratic tradition that emerged from
ancient Greek medicine around the fifth century BC—the Age of Virtue Ethics. In determining what is
good or right in terms of conduct, the virtue ethics approach considers the character of the moral agent who
performs the action. How the virtues work is described most thoroughly by Aristotle in his work entitled
Nicomachean Ethics, which provides an account of the gradual progression of human excellence (figure
27.2). Moral excellence begins with having the predisposition and capacity to progress in that way, and the
person must work hard to attain virtue of character. Aristotle explains that this sort of virtue is not
something that people are born with. Rather, it results in the cultivation of habits over a lifetime of training
in the practical application of theoretical knowledge, which leads to character development and expertise,
and ultimately mastery in adult life (Aristotle and Irwin 1999, 18). These virtues include things such as
courage, honesty, generosity, and temperance, and in order to determine if a particular act is right or wrong,
virtue ethics asks, “What would a moral agent with a virtuous character do?” The virtuous moral agent does
not act because of a rule or obligation or to achieve a good result; rather, the virtuous person acts because
they are the type of person who behaves in a way that reflects the excellence of character to make proper
moral decisions. In other words, good acts are the expression of a good life or a life well lived. Although
this line of philosophical reasoning is thousands of years old, there are modern philosophers who assert that
the Aristotelian framework is essential to the philosophy of technology. As we will see in the pages to
follow, these types of professional virtues may be derived from the guidelines established by the AHIMA
Code of Ethics.
Figure 27.2.
The progression of excellence
Wisdom
Virtue
Habits
Predisposition
• Potential
• Theoretical
• Practical
application
• Training
• Repetition
• Effective practice
• Expertise
• Character
• Actualization
• Mastery
• Human flourishing
development
knowledge
• Capacity
[C]Deontology
Deontology, or Kantianism, is a theory developed by German philosopher Immanuel Kant in the late 18th
century that studies the nature of moral obligations. For Kant, the essential element of ethical inquiry is not
character, but rather it is the content of moral principles that determine rational action. Deontology holds
that what is right and good in terms of morality is determined by a moral agent’s actions and intentions
relative to their duties and obligations. Actions are judged good or bad by the nature of the act itself and the
moral agent’s intentional will to do the act. According to Kant, true happiness is found by leading this sort
of principled life, and to choose any other way of life is irrational; there is no good act without good will,
and a virtuous act must be done not out of a sense of duty or ego but because it is the right thing to do. This
is rational behavior in Kant's philosophy—to act immorally is to behave irrationally because it is irrational
to pursue something of lesser value at the risk of the greater (that is, bodily pleasure versus human dignity).
So, if a person has the means to make the moral choice and does not, then not only are they being immoral
but also irrational (Kant and Gregor 1998, 37). Moral laws are not supposed to be moral constraints; rather,
they are natural behavior of rational beings. There may be duties and obligations, but when the rational
moral agent acts, they do so because they believe that what they are doing is the right thing to do and not
because they have to comply with the rules—following rules is not the same as acting morally because
moral action flows from free will.
Kant believed in a right way of living and acting, and that was determined a priori. That means
human knowledge of right and wrong comes through deduction beforehand rather than
observation after the fact; a thing is morally right or wrong based upon reason and not
consequences. But that is not all: Kant believed that a person should always act in a way that they
hope all people would act in the same situation—what Kant called the categorical imperative. In
essence, the categorical imperative states that moral actions are universalizable laws of nature,
meaning that an act is always either moral or immoral as determined by rational analysis of the
act and the intention of the person doing the action. One such universizable law dictates that
people may not be used as a means towards an end; rather, all people are ends in themselves and
deserve to be treated with dignity. That means an action that treats people badly to achieve a
positive result is immoral—we cannot use one person to benefit another person or thing (Kant
and Gregor 1998, 31–42).
To demonstrate this, consider the act of lying, which for Kant was morally prohibited (see figure 27.3).
Remember that for an act to be moral it always must be the right thing to do. If lying is moral, then it must
always be morally correct to lie, which leads to an absurd result that strains rationality: if lying were to be
the moral standard, then there never would be a reason to believe anything that anyone said. This would
defeat a fundamental purpose of communication, which is to convey information. To the contrary, if truth
telling is the standard, then we can expect the truth to be told, and we can rely on the information we
receive. But, veracity is not enough; it must be done with the intention of doing the right thing. Making
truth telling a categorical imperative does not belie the fact that people regularly deceive one another; it
merely sets a universal standard for morality in the area of truth telling. Kant believed in a right way of
living and acting, and that way was determined a priori, “where we have to do not with assuming grounds
for what happens but rather laws for what ought to happen even if it never does” (Kant and Gregor 1998,
36). One can see how deontology applies to HIM in that health information managers have a number of
duties that they are expected to follow, including duties to patients, the organizations they work for, and the
community at large.
Figure 27.3.
Kant decision matrix—honesty
Should I lie
or tell the
truth?
Ethical Dilemma
Action
Lie
Tell the truth
Intention
For personal
benefit
It's the right
thing to do
For personal
benefit
It's the right
thing to do
Imperative?
No
No
No
Yes
[C]Utilitarianism
Utilitarianism is one of the most influential approaches to modern medical ethics and in healthcare in
general. It provides a basic model for preserving healthcare resources, triage, and disaster response. The
general view of classical utilitarianism is the greatest happiness principle, which proposes that to
determine the greatest good we look to the consequences of action; that is, “actions are right in proportion
as they tend to promote happiness, wrong as they tend to produce the reverse of happiness. By happiness is
intended pleasure, and the absence of pain” (Mill 2007, 6). So, according to utilitarian theory, an act is
moral to the extent that it produces happiness, and the morally correct action is that which creates the
greatest and most good for the greatest number of people.
Although there is a sense of hedonism in this pursuit of happiness, it should not descend into base
physical pleasures because of the focus on consequences and obtaining the greatest benefit for the greatest
number of people and not just oneself. Some kinds of pleasures are more desirable and valuable as
outcomes. In other words, determining the greatest good is a matter of quality as well as quantity, and the
standard is not individual happiness but what is best for the collective (Mill 2007, 7–10). Of course, there
are many ways to calculate the greatest good, and determinations of utility can lead to all sorts of results.
Cost–benefit analyses, for example, can be troubling. For instance, in the 1970s, Ford Motor Company put a
value of around $200,000 per life based on deferred future earnings (DFE). It was widely reported that they
did not recall their Ford Pinto, which had gas tanks that caught afire after traffic accidents, because the cost
of the recall was more than the DFE. This led to public outrage.
Utilitarianism requires moral agents to consider outcomes in making the determination whether an act is
moral or not. In doing so, HIM professionals must consider several different courses of action, their
possible outcomes, and which of those results brings about the greatest balance of benefit over harm. This is
an essential task in a utilitarian approach, and predicting the future is not easily done. Frequently,
utilitarianism requires a balancing act of hypothetical benefits and burdens of the outcomes, and when we
look to the greatest benefit for the greatest number of people, the minority can lose out. Still, utility plays an
important role in the formulation and assessment of institutional and public policies such as data sharing
and interoperability; however, in maximizing good outcomes one must be careful to avoid unjust
distributions of benefits and burdens (Beauchamp and Childress 2013, 360). For example, utility may
support confidentiality as it fosters trust in the provider-patient relationship; if patients do not trust their
clinicians, then they may not seek care and suffer poor outcomes and health. In this scenario, the health of
the community may suffer, and so we can say that greater good is upheld when health records are kept
confidential. However, there are situations in which the public welfare would not be upheld by maintaining
confidentiality, such as preventing an outbreak of a particularly virulent contagion such as Ebola or
tuberculosis, where it might be important to know who came into contact with those diagnosed with the
disease.
[C] Principlism
Despite centuries of philosophical thought in clinical ethics, providers were ill-equipped to face the
challenges presented by innovation in the health sciences and biomedical technology in the 20th century.
The Hippocratic tradition, for example, was not suited to deal with modern issues related to public health,
informed consent, privacy, and access to care in modern pluralistic societies (Beauchamp and Childress
2013, 1). Principlism, also known as The Four Principles of Biomedical Ethics, arose in this context as
societies became more diverse and required guidelines that provided comprehensive ethical direction while
allowing for patient-centered decision-making. This set of guidelines was popularized in the 1970s and is
upheld by the AHIMA Code of Ethics:
●
Autonomy—Often referred to as the right to self-determination, autonomy refers to an individual’s
right to determine what does or does not happen to him or her in terms of healthcare. Autonomy is a
core ethical principle of modern medicine, meaning a patient has the right to rule themselves and
choose their course of treatment within the standard of care. There are two conditions that are
essential for a person to exercise their autonomy: liberty and agency. That means that to make
decisions one must be free from controlling influences, such as coercion, and have the capacity to
make an intentional choice; these are the same conditions that are necessary for patients to provide
informed consent, defined as a person’s “autonomous authorization of a medical intervention or of
participation in research” (Beauchamp and Childress 2013, 122). The principle of autonomy
promotes truth telling, or veracity, as patients cannot make meaningful decisions unless they have
accurate information. At the same time, patients who are deemed to lack decision-making capacity,
such as children under the age of 18 years of age, do not have the required agency to decide for
themselves and must have someone else make decisions for them. This sort of interference with the
actions and decision-making of others, when it is done for their benefit, is referred to as
paternalism and can be ethically controversial.
●
Beneficence—A term that refers to the moral obligation of promoting good for or providing
services that benefit others, such as releasing health information that will help a patient receive care
or ensure payment of services received. Beneficence creates a variety of duties for healthcare
providers, including duties to prevent harm, promote rights of patients, and remove conditions that
will cause harm to others. Altruism, the belief that one must make personal sacrifice and benefit
other people before oneself, is a related ethical concept. The principle of beneficence holds that
good outcomes are determined by balancing benefits with risk for harm or cost so that benefits can
be maximized to yield a greater good. Beneficence has two distinct aspects: first, positive
beneficence requires that we promote the good for others; and second, utility requires that we seek
the best possible result. However, utilitarianism and beneficence are different and should not be
conflated. For utilitarians, the balance of harms and goods to maximize beneficial outcomes is the
primary determinant of ethics; in principlism, the balancing of harm and good is just one of the
factors to be weighed in the balance (Beauchamp and Childress 2013, 203).
●
Nonmaleficence—Whereas beneficence requires us to promote good, prevent harm, and remove
harm, nonmaleficence requires us to refrain from actions that cause harm and refrain from inflicting
harm—it calls for the “intentional avoidance of actions that cause harm” (Beauchamp and Childress
2013, 152). This is not easily done in clinical environments where we must harm people in order to
heal through invasive medical interventions such as surgery or physical therapy; however, the
principle of nonmaleficence requires that we justify the harmful actions. These actions are not only
related to physical harms, but also harms to individual autonomy, such as the disclosure of
protected health information (PHI) and other breaches of professional obligations. This is related to
the ethical concept of least harm, which applies to situations where two choices may both present
necessary, justifiable harms. One should choose the situation that will do the least amount of harm
to the fewest number of people. For example, in disclosing health information, a health information
manager is required by The Health Insurance Portability and Accountability Act of 1996
(HIPAA) to abide by the minimum necessary standard and disclose only that information needed to
accomplish the task to those who need to know.
●
Justice—The principle of justice refers to the fair and equitable treatment of persons considering
what is owed to them; the term distributive justice refers to the fair and equitable allocation of
goods and harms according to social norms, while procedural justice addresses the fairness of
policies, processes, and strategies for setting priorities and resolving disputes. There are many
theories of justice, and common to all of them is the notion that “equals must be treated equally,
and unequals must be treated unequally” (Beauchamp and Childress 2013, 250). This aspect of the
principle of justice does not parse out what is equal or unequal, but there are a variety of theories
that include distribution according to need, equal shares, effort, or contribution, or to address past
injustice. Naturally, this creates problems in the creation of policy due to disagreements that arise in
the conception of justice and fairness in distribution; however, as discussed earlier in this chapter,
no one theory or principle controls. In a principlism analysis we look at all the factors that arise to
determine which of the options are best to fit the situation. Distributive and procedural justice apply
to the work of HIM professionals in relation to the way information is shared with patients and
healthcare providers for certain purposes and the policies and protocols that must be followed in
making such disclosures.
The four principles of autonomy, beneficence, nonmaleficence, and justice work in concert, and there is
no formal hierarchy or priority, but they can be useful in situations where there are conflicting duties or
responsibilities and only one can be satisfied. When faced with a moral dilemma, the principles are meant to
be considered and balanced to determine the right course of action. The principles frequently come into
conflict as they compete in the balance; for example, there are times when healthcare providers override
autonomy to provide for the welfare of the patient. As discussed later in this chapter, ethical decisionmaking tools are useful in managing the various theories, principles, values, and interests that come
attendant to morally charged healthcare decisions. See figure 27.4 for a summary of ethical thinking.
Figure 27.4.
Thinking ethically
Thinking Ethically
Virtue ethics
What would a virtuous or wise person do in this situation?
Deontology
Are the action and intention in accord with moral duties and obligations?
Utilitarianism
Does the outcome lead to the greatest good for the greatest number of people?
Autonomy
Are individuals allowed voluntary self-determination?
Justice
Are people being treated fairly?
[B] Professional Code of Ethics
A code of ethics is a set of standards and rules adopted by an organization to establish minimum
expectations for professional responsibility and guide its members in determining right and wrong conduct
when performing their job duties. The AHIMA Code of Ethics applies to all AHIMA members and is based
on the core values of the association. The preamble to the AHIMA Code of Ethics states the following:
The ethical obligations of the HIM professional include the safeguarding of privacy and security of health
information; disclosure of health information; development, use, and maintenance of health information
systems and health information; and ensuring the accessibility and integrity of health information. (AHIMA
2019a)
The code acknowledges healthcare consumers’ concern about security, the risks to personal privacy, and
their inability to control how their health information is used and disclosed in a fragmented health system.
This includes considerations of what and how information should be collected and handled, control of
access to the information, the conditions through which information should be disclosed, how long the
information must be retained, and how is it disposed of (AHIMA 2019a). HIM professionals have ethical
and legal responsibilities as professionals to perform their duties in compliance with state and federal
regulations and employer policies and procedures; these professional obligations are central to the health
information manager’s role across employment sites and methods of professional practice. In addition,
some information, such as genetic, drug, alcohol, and mental health information, requires additional
safeguards to protect vulnerable patients. The protection of the information is a core function of the
business of healthcare and is essential for interactions with patient populations (AHIMA 2019a). HIM
professionals have access to sensitive information contained within the health record. Patients trust that the
information they share with their healthcare provider will be protected.
The professional working in the field of HIM is obligated to demonstrate knowledge, skills, and attitudes
that reflect the values and ethical code maintained by the discipline. The six purposes listed in the AHIMA
Code of Ethics are descriptions of the values and principles used to guide the conduct of HIM professionals.
(See figure 27.5.)
Figure 27.5.
Overview of the AHIMA Code of Ethics
The AHIMA Code of Ethics serves six purposes:
● Promotes high standards of HIM practice
● Summarizes broad ethical principles that reflect the profession’s core values
● Establishes a set of ethical principles to be used to guide decision-making and actions
● Establishes a framework for professional behavior and responsibilities when professional
obligations conflict or ethical uncertainties arise
● Provides ethical principles by which the general public can hold the HIM professional
accountable
● Mentors practitioners new to the field to HIM’s mission, values, and ethical principles
Principles
The following ethical principles are based on the core values of the American Health
Information Management Association and apply to all AHIMA members, nonmembers with
CCHIIM certifications, and students. Guidelines included for each ethical principle are a
noninclusive list of behaviors and situations that can help to clarify the principle. They are not
meant to be a comprehensive list of all situations that can occur.
Principle
Example
● Advocate, uphold, and defend the consumer’s
Safeguard all confidential patient
right to privacy and the doctrine of
information to include, but not limited to,
confidentiality in the use and disclosure of
personal, health, financial, genetic, and
information.
outcome information.
● Put service and the health and welfare of
●
●
Act with integrity, behave in a
persons before self-interest and conduct
trustworthy manner, elevate service to
oneself in the practice of the profession so as
others above self-interest, and promote
to bring honor to oneself, to peers, and to the
high standards of practice in every
health information management profession.
setting.
Preserve, protect, and secure personal health
Take precautions to ensure and maintain
information in any form or medium and hold
the confidentiality of information
in the highest regard health information and
transmitted, transferred, or disposed of in
other information of a confidential nature
the event of termination, incapacitation,
obtained in an official capacity, taking into
or death of a healthcare provider to other
account the applicable statutes and regulations.
parties through the use of any media.
Refuse to participate in or conceal unethical
Act in a professional and ethical manner
practices or procedures and report such
at all times.
practices.
●
●
Use technology, data, and information
Use healthcare employer technology
resources in the way they are intended to be
resources within the confines of
used.
organizational policies.
Advocate for appropriate uses of information
Educate stakeholders about the need to
resources across the healthcare ecosystem.
maintain data integrity and the potential
impacts should data integrity not be
maintained.
●
Recruit and mentor students, staff, peers, and
Be responsible for setting clear,
colleagues to develop and strengthen the
appropriate, and culturally sensitive
professional workforce.
boundaries for students, staff, peers,
colleagues, and members within
professional organizations.
●
Represent the profession to the public in a
Be an advocate for the profession in all
positive manner.
settings and participate in activities that
promote and explain the mission, values,
and principles of the profession to the
public.
●
Advance health information management
Develop and enhance continually
knowledge and practice through continuing
professional expertise, knowledge, and
education, research, publications, and
skills (including appropriate education,
presentations.
research, training, consultation, and
supervision).
●
●
Perform honorably health information
Perform responsibly all duties as
management association responsibilities,
assigned by the professional association
either appointed or elected, and preserve the
operating within bylaws and policies and
confidentiality of any privileged information
procedures of the association and any
made known in any official capacity.
pertinent laws.
State truthfully and accurately one’s
Claim only those relevant professional
credentials, professional education, and
credentials actually possessed and correct
experiences.
any inaccuracies occurring regarding
credentials.
●
●
Facilitate interdisciplinary collaboration in
Foster trust among group members and
situations supporting health information
adjust behavior in order to establish
practice.
relationships with teams.
Respect the inherent dignity and worth of
Treat each person in a respectful fashion,
every person.
being mindful of individual differences
and cultural and ethnic diversity.
Source: Adapted from AHIMA 2019a, 2019b.
The code includes core principles and guidelines that are aspirational and enforceable. Alleged violations
of ethical principles are taken seriously by AHIMA and reviewed by a team dedicated to that purpose. It is
the duty of HIM professionals to maintain professional integrity, not only in performing their own jobrelated tasks but also in reporting suspected violations of these ethical principles. For example, AHIMA
provides the Standards of Ethical Coding to assist coding professionals and managers more specifically in
decision-making when it comes to coding situations. It outlines expectations for making ethical decisions in
the workplace and demonstrates coding professionals’ commitment to integrity during the coding process
(AHIMA 2016). The principles and guidelines contained in the code reflect ethical theories and principles
discussed earlier:
●
Virtue ethics: The Code reflects character traits that should be instilled in the professional,
including integrity, advocacy, trustworthiness, altruism, veracity, expertise, life-long learning,
reflective practice, loyalty, and being honorable, respectable, competent, and service-minded.
●
Deontology: The Code states clearly that “professional responsibilities often require an individual
to move beyond personal values. For example, an individual might demonstrate behaviors that are
based on the values of honesty, providing service to others, or demonstrating loyalty” (AHIMA
2019b). These expected behaviors result in specific duties, such as safeguarding patient
information, taking actions against the unethical conduct of colleagues, and cooperation with lawful
authorities as appropriate.
●
Utilitarianism: The very existence of the Code is an expression of utilitarianism in that one of its
intended purposes is to provide for the common good by providing “ethical principles by which the
general public can hold the HIM professional accountable” (AHIMA 2019a).
●
Autonomy: HIM professionals are expected to promote the value of self-determination for all
patients. That includes the duty to protect the patient’s right to privacy and the duty to maintain
confidentiality flow from this ethical principle.
●
Beneficence: There are many places in the Code in which we can appreciate the HIM professional’s
duties to act for the benefit of others and prevent harmful effects. The first two guidelines reflect
this where they call for advocacy in the protection of patient rights and altruism by putting service
to others before self-interest.
●
Nonmaleficence: Health information managers not only have to work for the benefit of others, but
they are also expected to refrain from acts of dishonesty, fraud, and deception.
●
Justice: Respecting the inherent dignity of every person requires that HIM professionals “value all
kinds and classes of people equitably...[and] ensure all voices are listened to and respected”
(AHIMA 2019b).
[B] Professional Values and Obligations
HIM professionals are ethically responsible for preserving, protecting, and securing health information in
all mediums. This responsibility should be what the HIM professional values as part of his or her duties.
The professional values AHIMA identifies as essential are respect, excellence, leadership, and integrity and
are demonstrated as follows:
•
Respect: appreciation of the value of differing perspectives, enjoyable experiences, courteous
interaction, and celebration of achievements that advance our common cause
•
Excellence: advancement of the profession through distinction in professional practice, HIM
education, and meritorious service
•
Leadership: visionary thinking, decisions responsive to membership and mission, and
accountability for actions and outcomes
•
Integrity: openness in decision-making, honesty in communication and activity, and ethical
practices that command trust and support collaboration. (AHIMA 2017a)
An HIM professional’s ethical obligations include the duty to the patient and the healthcare team to
protect health information, provide service to those who seek access to their information, preserve and
secure health information, promote the quality and advancement of healthcare, function within the scope of
responsibility, and refrain from passing clinical judgment. Obligations also include those to the employer
such as loyalty; protection of committee deliberations (for example, a committee may involve decisions
related to who will receive an organ donation from a donation list, and those deliberations are protected
much like patient information); compliance with all laws, regulations, and policies that govern the health
information system (HIS); recognition of the authority and power of the job responsibilities; and acceptance
of compensation only in relationship to work responsibilities. Ethical obligations to the public include
advocating change when patterns or system problems are not in the best interest of the patients, as follows:
●
Reporting violations of practice standards to the proper authorities
●
Promoting interdisciplinary cooperation and collaboration
●
Ethical obligations to self, peers, and professional associations, including being honest about
degrees, credentials, and work experiences
●
Bringing honor to oneself by committing to lifelong learning
●
Strengthening HIM membership in AHIMA and state associations
●
Representing the HIM profession to the public
●
Promoting and participating in HIM research. (Harman, Mullen, and Cornelius 2017, 3–31)
HIM professionals are ethically obligated to give back to the HIM community by providing practice
opportunities for students, such as being involved in student professional practice experience opportunities.
HIM professionals also have a responsibility to maintain their skills through continued learning and to pass
on knowledge to new HIM professionals and students.
[B] Ethical Decision-Making
There are numerous roles, responsibilities, and expectations set upon health information managers, and in
practice they may come into conflict. Even if they do not, there could be a conflict between professional
duties and patient expectations or between personal and professional values. When a healthcare professional
is faced with ethical decisions and dilemmas, there are many factors to be considered in the decisionmaking process; these include patient preferences; cost; technological feasibility; federal and state laws;
medical staff bylaws; accreditation and licensing standards; and employer policies, rules, and regulations.
Decision-making in ethically charged situations requires thoughtful reflection and informed professional
judgement. This chapter has described theories and principles of ethics that result in even more duties and
obligations to act or refrain from action; however, tools are needed to provide a framework for decisionmaking to keep things in order and ensure that nothing gets missed. There are a variety of such tools
available, and it is recommended that HIM professionals use a formal ethical decision-making process to
encourage reliable moral judgements in professional practice.
An example of an ethical dilemma for a healthcare organization that would benefit from a decisionmaking process would be a case involving the handling of advance directives for healthcare, such as living
wills and powers of attorney, in the EHR. Advance directives are important documents that state patients’
wishes for treatment in the event they lose decision-making capacity and are not able to make their own
healthcare decisions. Despite good intentions, it is well established in case law and the experiences of
clinicians and patients and families across the country that the inability to locate advance directives within
the EHR has led to violations of patient wishes, including resuscitating patients who have expressed the
wish not to be resuscitated in the case of cardiac arrest. In such cases, decision-making frameworks help
care teams identify the various issues, parties, policies, and interests that need to be considered and
addressed.
Health information managers should be guided by the AHIMA Code of Ethics in making ethical
decisions, and an ethical decision-making tool can help to provide order to the process. Figure 27.6 shows
seven considerations that should be asked by HIM professionals faced with an ethical decision.
Figure 27.6
Ethical decision-making process
What is the moral
dilemma?
What are my
assumptions,
biases, emotions,
and values?
What are the
facts?
What are the
stakeholder
values?
What are the
options?
What is the
chosen course of
action?
What policy can
mitigate or
preempt this
issue?
Source: Adapted from Doherty and Purtilo 2016; Glover 2017.
Decisions made to resolve an ethical dilemma should go through a process such as the one identified in
figure 27.6. Step one prompts us to ask, “What is the ethical problem I am facing?” Frequently, ethically
charged scenarios create multiple problems simultaneously, and asking this question at the outset will allow
one to parse the problems out and deal with each individually. Applying the example of advance directives
in the EHR discussed above, there are multiple problems that arise, including insults to the agency and
autonomy of patients and their families, possible issues in institutional policy and protocol in handling this
documentation, and moral distress of healthcare providers and staff that can result from poor outcomes.
There are many duties that HIM professionals are responsible for, and identifying the question at hand
allows the professional to determine which apply to the particular ethical issue.
Step two of this process involves the HIM professional’s gut reaction to the situation. This is a critical
step that allows the decision maker to identify personal assumptions, biases, emotions, and values that may
interfere with the decision-making process. Doing this helps us to understand not only our own feelings, but
also the distinctions and differences from the other values that need to be considered (Glover 2017, 54).
Considering advance directives in the EHR, health information managers may identify with a patient’s right
to autonomy to make end-of-life decisions in advance; however, they may very well have personal
reservations about an individual’s ability to make future medical decisions in the present for health
conditions they have not experienced, or otherwise question whether advance directives can accurately
reflect a patient’s wishes. Explicitly identifying these biases up front will help prevent them to
inappropriately affect the decision-making process and outcome.
In the third step in the process, we are guided to gather relevant information. In doing so, one must
consider facts that are known and work to identify and obtain facts that are necessary to make a decision. At
times there will be facts that remain unknown, and in those situations we can proceed with our assumptions
duly noted while keeping an eye on how those assumptions impact the analysis (Glover 2017, 54–55). In
our ongoing analysis of the issue involving advance directives, there may be few facts that are known;
suppose that all we know is that the patient has a living will that was given to someone on the care team
upon admission, it is not in the EHR, and the patient’s wishes were not followed as a result. Among the
facts to be gathered might be as follows: What does the patient or family want now? Has this happened
before? Does the hospital have policies and protocols for handling advance directives, and if so what are
they? If there is a policy, was it followed? If there is no policy, why not? Did the physicians know about the
living will and have a legitimate reason for disregarding it? There are many facts to be gathered in
situations such as this, and as they are collected, other questions may arise.
Step four asks us to identify the relevant stakeholders—meaning the respective the individuals,
institutions, and communities whose values and interests are affected and will be impacted by the decision.
Ethical issues frequently impact patients and their families, the clinical care team and other healthcare
professionals, HIM professionals and departments, institutions and their administrators, and society as a
whole (Glover 2017, 55). In our advance directives case, consider the following:
●
The patient—not just this patient but all patients in the facility have an interest in self-determination
(autonomy) and making healthcare decisions at the end of life.
●
The care team and other healthcare professionals—the standard of care should be followed using
the best available evidence, and the paradigm of patient-centered care requires that patients be
respected when they are known (deontology). Healthcare providers have duties to benefit their
patients (beneficence) and avoid harming them (nonmaleficence), and failing to abide by the terms
of a lawfully executed advance directive may violate both. Other providers and staff may be
implicated by the outcome as well, including those working on the pastoral service, social workers,
house staff, and palliative care and hospice staff. The immediate care team are not the only ones
with interests in the well-being of patients at the end of life (beneficence and nonmaleficence).
●
The family—end-of-life scenarios are complex events that have wide-ranging impacts with diverse
and sometimes incompatible perspectives. In this case, the family may agree with the patient and
desire that their wishes be honored. But, as is sometimes the case, families may disagree with
patient wishes and may have divergent interests and needs that should be accounted for and
addressed. If the advance directive cannot be found, a family member may be called upon to serve
as a decision-maker for the patient (autonomy).
●
HIM professionals—health information managers share professional duties and values with other
members of the care team and have some unique to the discipline (professional autonomy).
Moreover, as described in step two, HIM professionals and everyone else impacting the decision
should come to terms with personal interests and biases that may inform the outcome. In this case,
the HIM department has an obligation to handle advance directives according to law and
professional standards expressed in the AHIMA Code of Ethics (deontology), respect a patient’s
right to choose (autonomy), shield patients from preventable harm, and allocate resources in an
equitable manner. Of particular importance are the duties to maintain accuracy, fidelity, and
accessibility of information in the EHR (Glover 2017, 55).
●
Hospital administrators—these professionals share many of the same values in providing for the
welfare of patients as other healthcare providers and staff discussed above, but they also must keep
an eye on matters related to risk management and liability of the institution. There are a number of
policies and protocols implicated in this case, and the parties who are responsible for them should
be involved in the process so they can meet the needs of the community the institution serves
(utility).
●
Society—many jurisdictions provide for advance directives by state law to allow the community at
large to make healthcare decisions in the absence of decision-making capacity (utility). As a matter
of fairness, the benefits of such laws should be extended to all of those who are supposed to receive
them (justice).
After accounting for the information that needs to be collected, step five asks us to identify the options
for resolution that are available and how those actions are justified or not justified in terms of professional
obligations and legal requirements. The options will flow from the question being considered. Suppose the
question at hand is the ethical status of the institutional policy on handling advance directives in the EHR.
Options might include doing nothing at all, providing training for staff for entering this sensitive
information in the record, and making wholesale changes to the policy if it is inadequate. Each option
should be considered on its own merits with regard to how it may be justified or not based on the facts of
the case and stakeholder interests that have been uncovered.
The sixth step asks us to make a choice and complete the chosen course of action based on its ethical
justification. In so doing, HIM managers should pay careful attention to the impacts and outcomes that
result from the action because institutional policies should reflect diverse professional values and
stakeholder interests. Professionals are responsible for their own behavior, and the standards they set should
not be contrary to the values of the institutions and communities they serve (Glover 2017, 56).
Finally, the seventh step of the ethical decision-making process calls for reflection on the decisionmaking process, outcome, and policy for future occurrences. Reflecting can help the HIM professional to
mitigate the occurrence of the problem in the future, determine if additional action is necessary to achieve
the desired outcome, or develop new or amended policies and procedures for the handling of advance
directives in the institution so these types of problems do not arise. This is a complex set of issues that
requires addressing the needs of patients, families, healthcare providers and staff, the institution, and the
community at large. Many different needs and values must be considered and attended to, and in some cases
the work of a health information manager may affect them all. See figure 27.7 for an illustration of this
process.
Figure 27.7
Ethical decision-making breakdown
Case: Living will in the EHR
• What is the moral dilemma?
What should I do about my institution's policies and protocols on handling advance directives in the EHR?
• What are my assumptions, biases, emotions, and values?
This is personally and professionally disturbing. Patients have an ethical and legal right to make healthcare
decisions, and providers have corresponding duties to respect patient requests to withhold life support.
• What are the facts?
Known: patient has a living will that was given to someone on the care team upon admission, it is not in the
EHR, and the patient was resuscitated.
Unknown: What does the patient or family want now? Has this happened before? What are the policies and
protocols for entering advance directives into the EHR, and were they followed? Are advance directives easily
accessible in the EHR? Did the doctors have clinical or other reasons for ignoring the living will?
• What are the stakeholder values?
Patients: vulnerable at the end of life; want their wishes met when making healthcare decisions in advance
directives.
Care teams: meet the standard of care and abide by patient requests to withhold treatment when appropriate;
EHRs that meet the demands for usability in clinical environments.
Family: want competent care for their loved ones; have healthcare decisions honored.
HIM professionals: prevent harm; maintain accuracy and accessibility of information in the EHR; maintain the
trust of institutional and local community.
Hospital administrators: welfare of the community; risk management and liability; maintenance of policies;
EHRs that meet needs of the system.
• What are the options?
1) Do nothing; 2) train staff on timely recording of advance directives; 3) research the problem and make
changes to policy to meet the needs of patients and providers.
• What is the chosen course of action?
Assuming there are appropriate policies in place, it will be important to investigate the issue to see exactly what
happened in this case. If this is a matter of training, that can be facilitated in a number of ways. It may be
advisable to perform a needs assessment to see if this is a larger problem than this case.
• What policy can mitigate or preempt this issue?
If this happens to be a recurring issue it may be necessary to make changes to policy. This is a complex set of
issues that requires addressing the needs of patients, families, healthcare providers and staff, the institution, and
the community at large.
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Purpose
This unit provides an in-depth study of AMIA's Code of Professional Ethics
and its relation to the ethical principles of autonomy, beneficence, and
justice. After providing a foundation for informatics ethics, we move into the
realm of ethical decision-making and the justification of moral actions and
intended
outcomes.
Objectives
At the completion of this unit, students will be able to
1.
apply ethical principles to problems in health informatics,
analyze ethical issues and options using a decision-making
framework, and
3. evaluate the ethical status of health information technology
implementations.
Assignment
2.
This is a two-week unit that will be completed through the modules below. Within each
learning module you will find the instructions and materials that you need to complete
the
assignment. See
the
calendar
for
all
due
dates.
•
Module 1 -- Individual/Group discussion assignment in which students will
respond to discovery questions in an interactive discusson board.
•
Module 2 -- Group assignment in which you will analyze an informatics
•
case study using an ethical decision-making matrix.
Readings -- The required readings are offered inside their respective
units; however, I have another attached here that I offer as optional
recommended reading. I wrote a book chapter on informatics ethics
that covers both units nicely. It was commissioned by AHIMA and
analyzes the AHIMA code of ethics, so I think it will serve as a good
reference for the unit. You can find that here -Unit 2 Ethical Issues in HIM_excerpt.pdf
See attachment for reading:
Peterson, C., et al. (2018). AMIA’s code of professional and ethical conduct
2018. Journal of the American Medical Informatics Association, 25(11): 15791582.
2. Beauchamp, T. L., and Kahn, J. P. (2014). Ethical theory and
Bioethics. In T. L. Beauchamp, et al. (eds) Contemporary Issues in
Bioethics, 8th ed. Boston: Cengage.
1.
Ethical Theories and Principles
https://youtu.be/L-rR99EaEFg
Assignment:
300 – 600 Words for both
1.
Describe ethical theories/principles that are reflected in AMIA's
Code of Professional Conduct.
2.
Considering your response to Unit 1 Module 2 that described
character traits of a good informatician, is AMIA's Code of
Professional Conduct adequate or does it need to be amended?
22
ETHlCAL THEORY AND :RIO.ETHICS
authoritative sources for reflection and decision making. Cases such as the so-called
Tuskegee :iyphilis study (in which syphilis treatment was intentionally withheld from a
group of African-American men in rural Alabama without their knowledge or consent in
a government-sponsored experiment to follow the course of the disease) are rou1im:ly in
voked to illustrate unjustified biomedical experimentation. Decisions reached ahom morn!
wrongs in this case serve as a form of authority for decisions in new cases. These cases
profoundly influence our standards of fairness, negligence, paternalism, aad the like.
Just as case law (legal rules) develops incrementally from legal decisions in cases, so the
moral law (moral rules) develops incrementally. J-irom this perspective, principles are less
important for moral reasoning than cases.
At first :iight, casuistry seems strongly opposed to the frameworks of principles in
traditional duty-based theory.However, closer inspection of casuistry shows that its pri
mary concern (like the ethics of care) is with an excessive reliance in recent philosophy
on impartial, universal action guides. Two casuistc;, Albert Jonsen and Stephen Toulmin,
write that "good casuistry ... applies general principles to particular cases with
discernment." As a history of similar cases and similar judgments mounts, we become
more confident in our general judgments.A "locus of moral certitude" arises in the
judgments, and the stable elements crystallize into tentative principles. As confidence in
these generalizations increases, they are accepted less tentatively and mornl knowledge
devel...
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