For psychiatrist Jim Sabin, M.D., consideration of ethics in the practice of medicine has propelled a fruitful career of thinking, writing, and teaching, while also informing a clinical practice of psychiatry in a variety of settings for more than 40 years.
His special interest has been the ethical allocation of medical resources across a population. As director of the Harvard Pilgrim Health Care Ethics Program and cofounder of the Center for Ethics in Managed Care, sponsored by the Department of Population Medicine and the Division of Medical Ethics at Harvard University, Sabin has been responsible for a nationally recognized organizational ethics program.
Last year Sabin was appointed by AMA President Jeremy Lazarus, M.D., to serve on the AMA’s Council on Ethical and Judicial Affairs (CEJA), which maintains and updates the AMA’s 165-year-old “Code of Medical Ethics.” And CEJA’s opinions and policies are used around the country and the world in ethical decision making, medical licensing board–determinations, and public policy.
In comments to Psychiatric News, Lazarus cited Sabin’s “extraordinary involvement in medical ethics related to many of the pressing issues facing physicians and the health care system.”
Lazarus added, “Jim’s research focus on the clinical and theoretical aspects of resource allocation is extremely timely as our health care system is undergoing a major transformation in delivery and payment reform.”
Lazarus, a psychiatrist who is a past speaker of the APA Assembly, recalled working with Sabin on numerous projects when Lazarus was chair of APA’s Committee on Ethics and Managed Care.
In an interview with Psychiatric News, Sabin acknowledged that he had been inclined to regard the AMA by the light of an older stereotype—as a fairly conservative organization dedicated largely to preservation of traditional private practice and fee-for-service medicine.
But his appointment to what is one of the AMA’s most prestigious councils would seem to underscore the sea change that has happened in organized medicine and at the AMA. And it’s a change that Sabin said he has witnessed.
“During my attendance at the annual meeting last year of the AMA House of Delegates and again last November, I was impressed by the thoughtfulness and robustness of debate and the exchange of opinions,” he said. “There’s an effort to integrate a wide range of views in their consideration of policy initiatives, and it’s clear that the AMA is a ‘big tent.’ ”
Sabin also hailed as “excellent” CEJA’s 2012 report titled “Physician Stewardship of Health Care Resources.”
That report recommended, among other things, that “[m]edicine as a profession must create conditions for practice that make it feasible for individual physicians to be prudent stewards by encouraging health care administrators and organizations to make cost data transparent…so that physicians can exercise well-informed stewardship; ensuring that physicians have the training they need to be informed about health care costs and how their decisions affect overall health care spending; and advocating for policy changes…that promote professional judgment and address systemic barriers that impede responsible stewardship.”
Sabin, who is coauthor of two books, Setting Limits Fairly, written with Norman Daniels and published by Oxford University Press in 2002, and No Margin, No Mission: Health Care Organizations and the Quest for Ethical Excellence, written with Steven Pearson and Ezekiel Emanuel and published by Oxford University Press in 2003, said the entire subject of resource allocation and physician shepherding of resources has become detoxified.
“I’ve noticed in my contact with first-year medical students as a teacher in our seminar-based classes on ethics at Harvard a real evolution in how students think about these issues,” he said. “One of the cases we use to trigger discussion is to have students imagine working for a capitated health care system, with very explicit attention to a budget for a population. The question is—Is this an ethical arrangement?
“In years past you could count on a lot of heated opinion,” Sabin said. “But at this point, it has almost stopped being an interesting discussion.”
Sabin told Psychiatric News that a priority for CEJA this year will be going through the hefty Code of Medical Ethics section by section to modernize it.
“The Code of Medical Ethics is viewed as a living document, not set in stone,” Sabin explained. “That’s a good thing, because while basic principles haven’t changed, the environment in which those principles are practiced by physicians has changed. And items in the code that were enacted in 1985 may not be consistent with policies enacted in 2013.” ■