A Must Read: Clinical and Professional Ethics Guidelines for the Practice of Thyroidology

I n our roles as physicians and/or investigators, we encounter ethical issues and dilemmas on a daily basis. These may arise in our relationships with individual patients and colleagues, as well as in our interactions with the healthcare system and society more broadly. Scientific advances, major restructuring of healthcare systems, and increasing globalization, have added 21st century twists to universal and timeless ethical challenges. It is, therefore, with gratitude to members of the Ethics Committee (EC) of the American Thyroid Association (ATA) for developing a document, “Clinical and Professional Ethics Guidelines for the Practice of Thyroidology,” to help guide us through the challenging and sometimes trying times that arise in the practice and research of thyroidology. The guidelines were subsequently approved by the ATA Board of Directors, and are presented in this issue of Thyroid (1).

What I find most appealing about these Guidelines is their accessibility. Written in a thoughtful and thought-provoking manner by an interdisciplinary group of scholars (comprised of ethicists, endocrinologists/thyroidologists, and a thyroid surgeon), they offer practical guidance for addressing issues related to professional, clinical, and research ethics, as well as conflicts of interest, and ethical considerations with respect to resource allocations, and serve as an example for sister societies. By using illustrations from the real-life experiences of the practicing clinical thyroidologist and investigator throughout the document, the authors succeed in their goal of providing an informative document modeled after the Endocrine Society's trailblazing 2001 “Code of Ethics” (2) and informed by its 2003 “Ethical Aspects of Conflicts of Interest” (3) that is timely and directly relevant to thyroidologists.

In addition to a succinct review of the ethical underpinnings of biomedical care and research, several novel, and (dare I say) brave issues are addressed. Management of the fertile female patient and discussion of the “fetus as a patient” are handled very well, as is the discussion of end-of-life decision making (familiar territory to bioethicists, but less frequently encountered by thyroidologists). Inclusion of discussion of the ethical responsibility to patients during transitions of care is also apt in our current healthcare environment. There are a few areas I found particularly bold. I hope that we embrace the challenge to maintain “ethical integrity in unethical environments or cultures,” and unite as a community to address and rectify any questionable practices that exist in healthcare and research. Likewise, the admonition to be “mindful of unnecessary or excessive testing” rings especially true. While difficult in the current climate, this topic deserves further discussion, as well as outcomes/effectiveness studies. The section on conflicts of interest, including criteria for ATA committee membership, will likely be controversial, and may generate discussion. I am already looking forward to the next iteration of the guidelines. I hope it will include additional exploration of ethical considerations of “equipoise” and placebo-controlled trials as related to unresolved questions in thyroidology, perhaps adapting discussions from the metabolic bone disease field (4,5). Ethical input may also help guide appropriate use of new testing modalities as they are introduced. Expanded commentary on resource allocation and how to live (ethically) in a “global village” is also welcome. Balancing the needs of an individual patient with that of the multitude can be troubling; there is tension inherent in the knowledge that many children in the Himalayas might evade the fate of life-long cretinism for the cost of one ultrasound-guided fine-needle aspiration in New York.

Because addressing ethical issues is so much a part of our daily lives, many of us feel it is not necessary to take time out from our too busy schedules to read an “ethics” treatise. I urge you to reconsider. Just as we spend years studying “science,” we must also systematically become informed about key aspects of the “art” of our profession. These Guidelines provide just such a foundation and framework. Indeed, I propose that an ethics assessment should be consciously included in every patient care encounter, along with history, physical, and laboratory evaluation, and considered with the same import as choice of a specific aim in research. I encourage you to review these Guidelines and consider how to integrate some of the lessons learned into your daily professional activities. In addition, I hope they foster an environment in which overtly controversial issues in thyroidology are brought into the light of day, and stimulate an open dialogue on “thorny” topics on which reasonable and well-intentioned people might disagree. It would be wonderful if it also serves as the first step toward creating a forum promoting a free and respectful exchange of ideas about ethical issues that concern members of the thyroid community, so that we can gently support and remind each other of the oath we took on graduation day, maintain a moral compass in a difficult environment, and provide the highest quality care and research for the patients we serve.