Ethical conduct is the cornerstone of any professional organization, particularly when its decisions have an impact on public health. The ACR recognizes the importance of upholding ethical standards and has established a Code of Ethics to guide its members. Here we explore the practical application of the ACR’s Code of Ethics.1
Manage Potential Conflicts
Central to the ACR’s Disclosure Policy is the identification of relationships that pose actual or potential conflicts of interest (COI).1 This policy helps maintain transparency and integrity within the organization’s decision-making processes.
As part of the procedure, Dr. Smith abstains from participating in discussions or decisions directly related to policies that could impact the market for diagnostic imaging equipment, ensuring his personal interests do not compromise the integrity of the committee’s recommendations. The committee records Dr. Smith’s abstention using the designated “Record of Abstention During a Meeting,” providing transparent documentation of his adherence to ethical guidelines.
By implementing and adhering to COI procedures, the ACR committee helps safeguard the integrity of its decision-making processes. This not only strengthens the credibility of the organization, but also ensures policies are formulated in the best interest of patients and the broader healthcare community.
Volunteer members and staff should endeavor to avoid both actual COI and the appearance of COI. This policy could have broad implications and different interpretations.1
“Conflicts of interest are circumstances that create a risk that professional judgments or actions regarding a primary interest will be unduly influenced by a secondary interest,” states Basil Varkey in “Principles of Clinical Ethics and Their Application to Practice,” Medical Principles and Practice.2
Scenario (gifts of food and beverages): Stopping at an elegant booth at ACR Convergence for an espresso or gelato could pose a conflict for ACR volunteer members and staff. It is also common for office staff of clinicians to be offered beverages or food by a pharmaceutical representative. Even if clinicians do not meet a representative nor personally partake in the food, their staff partaking in such gifts could also constitute a COI for them.
Scenario (gifts of drug samples): A more challenging example regards the acceptance of drug samples from pharmaceutical representatives, which is a widespread practice.2 Many patients struggle to obtain their medications due to delays or rejections in the prior authorization process.3 Some patients experience worsening of their rheumatic disease, sometimes having to resort to glucocorticoids while a prolonged appeals process is underway.4 Drug samples can help these patients who cannot otherwise afford the medications. However, the availability of drug samples may be associated with the prescription of brand name drugs when less expensive options are available. Some research also indicates that low-income patients are not the primary recipients of drug samples.4 A counterargument to this is that it is increasingly common for copays and other out-of-pocket expenditures for advanced therapies to be prohibitive for most patients, including those with higher incomes.
The principle of proportionality serves as a valuable tool for assessing COI in this context.3 Is our decision being directed to the most important conflicts? Would our policy and implementation be overly scrupulous and interfere with the conduct of reasonable clinical practice? Notably, the National Academy of Medicine has advocated that clinicians in academic medical centers and teaching hospitals adopt policies that prohibit the use of drug samples except in specified situations for patients who lack financial access to medications.3 Although the ACR Code of Ethics does not prescribe specific recommendations, it encourages practitioners to consider the issue in the context of overarching principles. This enables us to tailor our policies to individual circumstances.
Report Misconduct
At the ACR, members are obligated to uphold professionalism, honesty and transparency, and to report any instances of misconduct that compromise patient care or professional ethics.1
Scenario: Consider Dr. Williams, an oncologist serving on a committee tasked with evaluating cancer treatment protocols. Among his colleagues is Ms. Thompson, employed by a pharmaceutical company specializing in cancer medications. Throughout committee meetings, Dr. Williams observes her subtly attempting to influence decisions in favor of her company’s products, despite limited evidence supporting their efficacy.
Dr. Williams recognizes the COI inherent in Ms. Thompson’s affiliation. He documents instances of her attempts to sway committee decisions and reports her behavior to relevant regulatory bodies. The committee addresses the issue, emphasizing the importance of maintaining impartiality. Ms. Thompson is reminded of her obligation to uphold professional standards, and measures are implemented to prevent future incidents.
By reporting misconduct, Dr. Williams ensures decisions within the committee are made in the best interests of patients, rather than influenced by commercial motives. He sets a positive example for his colleagues, reinforcing the integrity of the medical profession.
Demonstrate Concern for Research Subjects
The ACR’s Code of Ethics requires demonstration of the same care and concern for the well-being of research subjects as for patients with whom we provide clinical care in a therapeutic relationship.1
Scenario: As an investigator in a study of patients with rheumatoid arthritis (RA), Dr. Lee is sometimes called on to perform a joint count on a study subject. This occurs during her clinic time. She is often faced with having both a study subject and her clinic patient waiting to see her at the same time. Dr. Lee faces a difficult decision: Whom should she prioritize? The patient she knows well, whom she will see again in the future and who was scheduled to see her? Or the study participant who took time out of their day to volunteer for the study and is now waiting for her in a cramped research room?
It is often easier to first attend to the patient we know and have an ongoing therapeutic relationship with. However, according to the principles underlying the Code of Ethics, we ought to provide the same beneficence (i.e., acting for the benefit of the patient), nonmaleficence (i.e., not harming the patient—in this case by not wasting the commodity of their time and possibly money) and justice (i.e., providing fair, equitable and appropriate treatment) to both individuals.2 They each have equal claim on us, as the Code of Ethics reminds us.
In Conclusion
The application of the ACR Code of Ethics to day-to-day practice underscores the organization’s commitment to ethical conduct and accountability. Through case scenarios we demonstrate how the code aids us in managing COI, fostering transparency and promoting ethical, equitable treatment of research participants and patients. In this way, the ACR upholds ethical leadership within the field, contributing to the goal of advancing patient care and bolstering public trust in our profession.
Prajakta Masurkar, PhD, MPharm, is a health economics and outcomes research (HEOR) senior manager at Amgen, specializing in evidence generation for payers in inflammation and rare diseases (lupus, atopic dermatitis, prurigo nodularis and alopecia areata). She is a member of the ACR Committee on Ethics and COI.
Charis Meng, MD, is a clinical rheumatologist at the Hospital for Special Surgery, New York, whose research interests include tapering rheumatoid arthritis therapies and different pain patterns of rheumatoid arthritis. She is a member of the ACR Committee on Ethics and COI.
Disclosures
Prajakta Masurkar, PhD, MPharm, is an employee and stockholder of Amgen.
References
- Code of Ethics of the American College of Rheumatology, Inc. American College of Rheumatology. 2017 Aug. https://tinyurl.com/54xkyxbe.
- Varkey B. Principles of clinical ethics and their application to practice. Med Princ Pract. 2021;30(1):17–28.
- Wallace ZS, Harkness T, Fu X, et al. Treatment delays associated with prior authorization for infusible medications: A cohort study. Arthritis Care Res (Hoboken). 2020 Nov;72(11):1543–1549.
- Lo B, Field MJ, editors. Conflict of Interest in Medical Research, Education, and Practice. Washington, D.C.: National Academies Press; 2009. https://www.ncbi.nlm.nih.gov/books/NBK22926.
*These scenarios are fictional. Any resemblance to any real-life persons is purely coincidental.
Question? Email the editor at [email protected].
