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Ethics of Clinician Communication in a Changing Communication Landscape: Guidance From Professional Societies

Ethics of Clinician Communication in a Changing Communication Landscape: Guidance From... Abstract Background Cancer experts engage in public communication whenever they promote their research or practice, respond to media inquiries, or use social media. In a changing communication landscape characterized by new technologies and heightened attention to cancer controversies, these activities may pose ethical challenges. This study was designed to evaluate existing resources to help clinicians navigate their public communication activities. Methods We conducted a systematic, qualitative content analysis of codes of ethics, policy statements, and similar documents disseminated by professional medical and nursing societies for their members. We examined these documents for four types of content related to public communication: communication via traditional media; communication via social media; other communication to the public, policy, and legal spheres; and nonspecific language regarding public communication. Results We identified 46 documents from 23 professional societies for analysis. Five societies had language about traditional news media communication, five had guidance about social media, 11 had guidance about other communication domains, and 15 societies offered general language about public communication. The limited existing guidance focused on ethical issues related to patients (such as privacy violations) or clinicians (such as accuracy and professional boundaries), with less attention to population or policy impact of communication. Conclusions Cancer-related professional societies might consider establishing more specific guidance for clinicians concerning their communication activities in light of changes to the communication landscape. Additional research is warranted to understand the extent to which clinicians face ethical challenges in public communication. The changing communication landscape imposes new challenges for clinicians. For instance, as new communication technologies like social media and blogs become more popular, clinicians confront dilemmas regarding use of these tools in their personal and professional lives and as vehicles to reach the public. The risks of such communication include potential harms to patients (eg, patient privacy and/or confidentiality), potential harms to experts’ professional integrity (eg, inappropriate information sharing), and challenges to the sanctity of the doctor–patient relationship (eg, preserving boundaries) (1–6). Communication also imposes population-level ethical concerns. As scientific issues become increasingly politically charged, clinicians may face dilemmas around whether and how to communicate their perspectives to their patients and the broader public, navigating morally ambiguous terrain between education and persuasion (7), and balancing their competing roles and responsibilities to patients and the larger public. These communication challenges may be particularly pronounced for cancer-related issues. The mass media often feature controversies surrounding cancer prevention (eg, the human papillomavirus vaccine) (8) and screening (eg, the US Preventive Services Task Force mammography screening guidelines) (9). Cancer scientists and clinicians compete for scarce mass media space to express their views alongside politicians, advocates, patients, and cancer survivors (10). In the face of controversy and public uncertainty, cancer experts may face heightened pressure to use mass or social media to shape the public’s evolving views and decisions related to cancer screening and treatment. Clinicians engage in public communication whenever they promote their research or practice, respond to media inquiries, use social networking sites, blog, or testify in policy arenas. Yet, it is not clear whether clinicians navigate these potentially ethically challenging communications with sufficient guidance. Our research sought to fill this gap, asking: To what extent do clinical professional societies provide guidance on public communication in traditional media, social media, or other communication venues? Our objective was to analyze professional codes of ethics and similar guidance for the types of ethical issues they describe and the recommendations they offer. Methods Included Professional Societies We used existing references (11–13) to create a comprehensive list of nurse and physician professional societies, including primary care providers, and excluding societies that serve international clinicians or clinicians-in-training. We then selected all medical and nursing societies with more than 20 000 members (14). This criterion allowed us to include the major oncology specialty society (American Society of Clinical Oncology, membership 25 000) and its peer specialties for comparison, due to our interest in cancer-related communication. We also included one society of technicians who perform cancer-related procedures (American Society of Radiologic Technologists, membership 129 000) and three cancer-specific medical societies that had membership below 20 000 (American Society for Therapeutic Radiology, membership 9000; American Society for Therapeutic Radiology and Oncology, membership 9000; and American Roentgen Ray Society, membership 14 000). These selection criteria resulted in 28 societies. To identify documents for analysis, we searched each society’s Web site for 1) publically available codes of ethics or conduct for members and 2) professional guidelines, policy statements, or opinions related to member communication with the public. We then contacted the communications or membership person at each organization to solicit those materials. If there was no response to our initial and follow-up contacts, we sent a final e-mail describing the publically available materials identified on the organization’s Web site and asking for verification that no additional materials fit the study criteria. This two-phased strategy yielded materials or a response confirming no materials for 27 of the 28 organizations (we neither identified materials nor received a response from the American Society for Radiation Oncology). All searches and contacts were performed between October 1 and October 31, 2012. Coding Scheme We developed a coding scheme to examine collected materials (see Supplementary Materials, available online), focusing on those documents that were explicitly advisory in intent (eg, codes of ethics, conduct, and policy statements), excluding less formal documents like member newsletters. In addition to capturing descriptive information (ie, name of society, document type, length, and date), the instrument covered four communication-related domains: 1) references to communication to the public via traditional media; 2) references to communication using electronic or social media; 3) references to other forms of communication to the public, policy, and legal spheres; and 4) references to general language about public communication. The coder indicated whether the information was present or absent and noted the document section for qualitative analysis. One author examined all documents, with a sample of documents double coded by the second author and disagreements resolved via deliberation. Analysis In the first stage of the analysis (led by one author), we characterized the collected documents and indicated which types of public communication language were present or absent. The next stage of the analysis (led by the other author) consisted of a qualitative examination of the relevant documents. We used matrix presentations of the data to facilitate comparisons of major themes (15). The qualitative analysis focused on two types of content identified a priori: description of concerns (ethical or practical) related to communication and type of guidance offered. We assessed what types of issues or recommendations relevant to the changing communication landscape were missing and whether there were any tensions or competing principles in the guidance. Results The total sample comprised 46 documents; the median document length was four pages, and the dates of publication (where available) ranged from 1977 to 2012. The documents included 12 codes of ethics, one code of conduct, two mission and/or values statements, four manual or procedures guides, nine policy statements, four advisory opinions, two peer-reviewed journal articles, and 12 combinations (eg, an ethics code that included a policy statement). Table 1 displays the 23 societies that contributed the 46 documents, indicating whether the documents included content related to the four communication domains (news media, social media, other communication, and general). Only the American Medical Association (AMA) included language about all four domains in its guidance. No cancer-related clinical societies offered information about communication via traditional or social media; one society (American College of Radiology) mentioned expert testimony, and the Oncology Nursing Society and American College of Radiology included general language about communication. In total, five of the 23 societies presented guidance about public communication via traditional news media, five presented guidance about public communication via blogs and social media, 11 included language about other types of communication, and 15 offered general public communication language. Table 1. Mention of public communication issues in medical and nursing societies’ professional guidance documents, October 2012 (N = 46 documents) Professional societies* [No. of documents analyzed]  Membership†  Type of public communication discussed in document  Traditional news media  Blogs and social media  Other‡  General  General clinical societies   American Medical Association (AMA) [7]  297000  Y  Y  Y  Y   American Nurses Association (ANA) [5]  165000  N  Y  N  Y   American Academy of Family Physicians (AAFP) [1]  94600  N  N  N  N   American College of Physicians (ACP) [2]  85000  Y  N  Y  Y  Cancer-related clinical societies§   American Society for Clinical Pathology (ASCP) [1]  130000  N  N  N  N   American Society of Radiologic Technologists (ASRT) [2]  129000  N  N  N  N   Oncology Nurses Society (ONS) [2]  35000  N  N  N  Y   American College of Radiology (ACR) [1]  32000  N  N  Y  Y   American Society of Clinical Oncology (ASCO) [1]  25000  N  N  N  N  All other clinical societies   American College of Surgeons (ACS) [1]  70000  Y  N  Y  Y   American Association of Critical Care Nurses (AACN) [1]  65000  N  N  N  N   American Congress of Obstetricians and Gynecologists (ACOG) [3]  41000  N  N  Y  Y   Association of periOperative Registered Nurses (AORN) [1]  41000  N  N  N  N   American Association of Nurse Anesthetists (AANA) [1]  39086  N  N  N  Y   American Psychiatric Association (APA) [3]  38000  Y  N  Y  Y   American Society of Anesthesiologists (ASA) [2]  38000  N  Y  Y  Y   American College of Cardiology (ACC) [1]  37000  N  N  Y  Y   American Academy of Orthopedic Surgeons (AAOS) [1]  35000  N  N  N  Y   Emergency Nurses Association (ENA) [2]  33000  N  Y  N  N   American Academy of Ophthalmology (AAO) [3]  27000  Y  N  Y  Y   American College of Emergency Physicians (ACEP) [3]  26000  N  N  Y  Y   Association of Women’s Health, Obstetric and Neonatal Nursing (AWHONN) [1]  22000  N  Y  N  N   American Academy of Neurology (AAN) [1]  21000  N  N  Y  Y  Total number of societies that discussed communication    5  5  11  15  Professional societies* [No. of documents analyzed]  Membership†  Type of public communication discussed in document  Traditional news media  Blogs and social media  Other‡  General  General clinical societies   American Medical Association (AMA) [7]  297000  Y  Y  Y  Y   American Nurses Association (ANA) [5]  165000  N  Y  N  Y   American Academy of Family Physicians (AAFP) [1]  94600  N  N  N  N   American College of Physicians (ACP) [2]  85000  Y  N  Y  Y  Cancer-related clinical societies§   American Society for Clinical Pathology (ASCP) [1]  130000  N  N  N  N   American Society of Radiologic Technologists (ASRT) [2]  129000  N  N  N  N   Oncology Nurses Society (ONS) [2]  35000  N  N  N  Y   American College of Radiology (ACR) [1]  32000  N  N  Y  Y   American Society of Clinical Oncology (ASCO) [1]  25000  N  N  N  N  All other clinical societies   American College of Surgeons (ACS) [1]  70000  Y  N  Y  Y   American Association of Critical Care Nurses (AACN) [1]  65000  N  N  N  N   American Congress of Obstetricians and Gynecologists (ACOG) [3]  41000  N  N  Y  Y   Association of periOperative Registered Nurses (AORN) [1]  41000  N  N  N  N   American Association of Nurse Anesthetists (AANA) [1]  39086  N  N  N  Y   American Psychiatric Association (APA) [3]  38000  Y  N  Y  Y   American Society of Anesthesiologists (ASA) [2]  38000  N  Y  Y  Y   American College of Cardiology (ACC) [1]  37000  N  N  Y  Y   American Academy of Orthopedic Surgeons (AAOS) [1]  35000  N  N  N  Y   Emergency Nurses Association (ENA) [2]  33000  N  Y  N  N   American Academy of Ophthalmology (AAO) [3]  27000  Y  N  Y  Y   American College of Emergency Physicians (ACEP) [3]  26000  N  N  Y  Y   Association of Women’s Health, Obstetric and Neonatal Nursing (AWHONN) [1]  22000  N  Y  N  N   American Academy of Neurology (AAN) [1]  21000  N  N  Y  Y  Total number of societies that discussed communication    5  5  11  15  * Excluded from this list are medical societies that confirmed there were no documents relevant to our inquiry (Radiological Society of North America, American Academy of Nurse Practitioners, American Roentgen Ray Society) and medical societies that only offered newsletters-type documents (American Academy of Pediatrics). † Membership numbers from Gale Medical and Health Information Directory (2010 edition). ‡ Includes references to political communication, testimony in legal or policy venues, or advertising. § Refers to societies of clinicians that engage significantly with cancer prevention, detection, treatment, and research. View Large Table 2 presents a synthesis of the qualitative analysis. Among the five societies that offered language about news media, ethical concerns were grounded in ensuring that information communicated was accurate and respected patient privacy and/or confidentiality. Three societies (AMA, American College of Physicians, and American Psychiatric Association) asserted a positive duty or obligation to work with the news media. One society’s guidance (American Psychiatric Association, in a 1977 document) was distinguished by its strong emphasis on the importance of working with the media as an opportunity to establish public trust. Table 2. Qualitative analysis of ethical concerns and recommendations offered in clinical society guidance, October 2012 (N = 46 documents)* Public communication domain  Society type  Ethical or practical concerns identified (Society)  Guidance or recommendations offered (Society)  Traditional news media  General  Patients’ privacy, legal rights (AMA) Confidentiality of patient information (ACP) and of patient–physician relationship (AMA) Limiting authority to provide diagnosis or prognosis to attending physician (AMA) Accuracy of information (ACP)  Physicians should cooperate with media and provide them information, ensuring medical news is available promptly, accurately (AMA) Physicians should provide the news media with accurate information; an obligation to society and an extension of practice (ACP)    Cancer-specific  None  None    Other specialty  Public trust (APA) Privacy, confidentiality (APA) Accuracy, avoiding unjustified expectations, avoiding deception (ACS, AAO)  Obligation to work with media, importance of good media relations for establishing public trust and credibility (APA) Avoid exaggeration and claims without evidence (APA) Provide accurate information, represent clinical credentials, and identify any sponsors of communication (ACS)  Blogs and social media  General  Accuracy of online information (AMA, ANA) Patient privacy and confidentiality (AMA, ANA) Potential for commercial or other conflicts of interest (AMA) Consequences on individual careers or public trust in nursing or medical profession (AMA, ANA) Professional/personal boundaries, inappropriate (ANA)  When providing individual medical information via online sites, be consistent with other ethical standards, like truthfulness, privacy protection, informed consent (AMA) Information should be accurate, timely, reliable, scientifically sound (AMA) Minimize conflicts of interest or commercial biases (AMA) Physicians should routinely monitor their online presence, maintain appropriate boundaries with patients, consider separating personal and professional content online, bring unprofessional content to attention of colleagues (AMA) Avoid individually identifiable information about patients; observe ethically prescribed boundaries with patients; use privacy settings and separate personal and professional content; bring potentially harmful content to attention of authorities; participate in developing institutional policies (from ANA Principles for Social Networking)    Cancer-specific  None  None    Other specialty†  Privacy, confidentiality (ASA, ENA) Reputational risks to individuals and the specialty as a whole (ASA)  Need greater awareness and guidelines regarding use of social media (ASA) Use safeguards for online profiles; observe ethical and professional clinician–patient boundaries (ENA) Consistently evaluate communications using social media and report any breaches among colleagues (ENA)  Other policy or public communication (eg, advertising, legal testimony  General  Physicians have political rights (like all citizens) to influence government, free speech (AMA) Misleading or deceptive information, unjustified expectations, honesty, accuracy (AMA) Confidentiality (AMA) Patient consent (AMA)  Obligation to assist in administration of justice (AMA); ethical duty to assist patients and society in resolving disputes (ACP) Physicians involved in testimony must have appropriate expertise and honestly and objectively interpret medical facts (ACP, AMA) Testimony must be accurate, reflect current scientific thought and standards of care (AMA) Compensation must be reasonable and noncontingent upon outcome (ACP)    Cancer-specific  Accuracy, scientifically correct testimony (ACR)  Expert testimony should be nonpartisan, scientifically correct, and clinically accurate (ACR)    Other specialty  Accuracy and objectivity of information communicated; avoidance of conflict of interest/appropriate compensation for testimony (ASA, ACC, ACEP, AAN, ACOG, APA, ACS, AAO) Importance of testimony in legal/policy venues to assure availability of unbiased expertise (ACEP) Misleading, false, or deceptive testimony or advertising is unethical (AAO) Ethical and legal obligations for truth-telling (ACS)  Expert testimony should be objective, fair, accurate, thorough; cannot misrepresent credentials; may not give false testimony; compensation must be reasonable (all) Must identify if personal opinions are not generally accepted by other cardiologists (ACC) Expert witnesses should not act as an advocate or partisan but as a genuine expert and educator (ACC, ACS) Encourages psychiatrists to serve society by consulting with executive, legislative, and judiciary branches of government (APA)  Public communication domain  Society type  Ethical or practical concerns identified (Society)  Guidance or recommendations offered (Society)  Traditional news media  General  Patients’ privacy, legal rights (AMA) Confidentiality of patient information (ACP) and of patient–physician relationship (AMA) Limiting authority to provide diagnosis or prognosis to attending physician (AMA) Accuracy of information (ACP)  Physicians should cooperate with media and provide them information, ensuring medical news is available promptly, accurately (AMA) Physicians should provide the news media with accurate information; an obligation to society and an extension of practice (ACP)    Cancer-specific  None  None    Other specialty  Public trust (APA) Privacy, confidentiality (APA) Accuracy, avoiding unjustified expectations, avoiding deception (ACS, AAO)  Obligation to work with media, importance of good media relations for establishing public trust and credibility (APA) Avoid exaggeration and claims without evidence (APA) Provide accurate information, represent clinical credentials, and identify any sponsors of communication (ACS)  Blogs and social media  General  Accuracy of online information (AMA, ANA) Patient privacy and confidentiality (AMA, ANA) Potential for commercial or other conflicts of interest (AMA) Consequences on individual careers or public trust in nursing or medical profession (AMA, ANA) Professional/personal boundaries, inappropriate (ANA)  When providing individual medical information via online sites, be consistent with other ethical standards, like truthfulness, privacy protection, informed consent (AMA) Information should be accurate, timely, reliable, scientifically sound (AMA) Minimize conflicts of interest or commercial biases (AMA) Physicians should routinely monitor their online presence, maintain appropriate boundaries with patients, consider separating personal and professional content online, bring unprofessional content to attention of colleagues (AMA) Avoid individually identifiable information about patients; observe ethically prescribed boundaries with patients; use privacy settings and separate personal and professional content; bring potentially harmful content to attention of authorities; participate in developing institutional policies (from ANA Principles for Social Networking)    Cancer-specific  None  None    Other specialty†  Privacy, confidentiality (ASA, ENA) Reputational risks to individuals and the specialty as a whole (ASA)  Need greater awareness and guidelines regarding use of social media (ASA) Use safeguards for online profiles; observe ethical and professional clinician–patient boundaries (ENA) Consistently evaluate communications using social media and report any breaches among colleagues (ENA)  Other policy or public communication (eg, advertising, legal testimony  General  Physicians have political rights (like all citizens) to influence government, free speech (AMA) Misleading or deceptive information, unjustified expectations, honesty, accuracy (AMA) Confidentiality (AMA) Patient consent (AMA)  Obligation to assist in administration of justice (AMA); ethical duty to assist patients and society in resolving disputes (ACP) Physicians involved in testimony must have appropriate expertise and honestly and objectively interpret medical facts (ACP, AMA) Testimony must be accurate, reflect current scientific thought and standards of care (AMA) Compensation must be reasonable and noncontingent upon outcome (ACP)    Cancer-specific  Accuracy, scientifically correct testimony (ACR)  Expert testimony should be nonpartisan, scientifically correct, and clinically accurate (ACR)    Other specialty  Accuracy and objectivity of information communicated; avoidance of conflict of interest/appropriate compensation for testimony (ASA, ACC, ACEP, AAN, ACOG, APA, ACS, AAO) Importance of testimony in legal/policy venues to assure availability of unbiased expertise (ACEP) Misleading, false, or deceptive testimony or advertising is unethical (AAO) Ethical and legal obligations for truth-telling (ACS)  Expert testimony should be objective, fair, accurate, thorough; cannot misrepresent credentials; may not give false testimony; compensation must be reasonable (all) Must identify if personal opinions are not generally accepted by other cardiologists (ACC) Expert witnesses should not act as an advocate or partisan but as a genuine expert and educator (ACC, ACS) Encourages psychiatrists to serve society by consulting with executive, legislative, and judiciary branches of government (APA)  * Excluded from this analysis are societies that confirmed there were no documents relevant to our inquiry (Radiological Society of North America, American Academy of Nurse Practitioners, American Roentgen Ray Society) and medical societies that only offered newsletters-type documents (American Academy of Pediatrics). AAN = American Academy of Neurology; AAO = American Academy of Ophthalmology; ACC = American College of Cardiology; ACEP = American College of Emergency Physicians; ACOG = American Congress of Obstetricians and Gynecologists; ACP = American College of Physicians; ACR = American College of Radiology; ACS = American College of Surgeons; AMA = American Medical Association; ANA = American Nurses Association; APA = American Psychiatric Association; ASA = American Society of Anesthesiologists; ENA = Emergency Nurses Association. † Association of Women’s Health, Obstetric and Neonatal Nursing (AWHONN) issued guidance for use of Facebook, but the document was related only to the AWHONN page and not members’ use, so is not described here. View Large Five societies’ materials presented content related to communication via blogs or social media, describing the value of such communication for clinicians for personal expression, establishing a marketable online presence, networking, disseminating health education, or engaging in policy issues. As with communication via traditional media, ensuring accuracy and protecting patient privacy and/or confidentiality were paramount, but documents also referenced ethical concerns about disrupting the professional or personal boundaries of the clinician–patient relationship, problematic consequences of social media misuse on individual careers, or loss of public trust in the profession (Table 2). The AMA and the American Nurses Association established social media guidelines in 2010 (16) and 2011 (17), respectively. These guidelines offered specific recommendations to providers, such as separating personal and professional social media accounts and regularly reviewing their online presence. The most frequent and comprehensive professional guidelines regarding communication concerned expert witness testimony (Table 2). Although concerns regarding the accuracy of these communications and protection of patient confidentiality were most central, the guidance also offered specific language regarding objectivity and navigating advocacy and expert roles. Most of the expert witness guidelines explicitly encouraged involvement in judicial and other policy domains. Finally, we examined documents for their mention of general language about public communication. Many of the 15 societies that included such language described a general clinician responsibility to participate in activities that improve the health and well-being of the community. Others described a narrower responsibility to make specific information available to the public or advocate through strategic communications to improve public health. Among the cancer-related societies, both the Oncology Nursing Society and the American College of Radiology emphasized the accuracy of information as an important principle, with the Oncology Nursing Society highlighting the importance of timely communication. Although these claims indicated positive responsibilities for clinicians to engage in public communication, they rarely offered specific guidance on how to do so other than to be accurate, truthful, and avoid deception. The AMA guidance offered the most comprehensive language on communication, describing the importance of working to improve Americans’ comprehension of health and science matters as well as physicians’ social responsibility to make their perspectives heard. The AMA was the only society to describe a reactive role, indicating that clinicians should “make timely responses to misleading and inaccurate media releases . . . [to] giv[e] the general public a more accurate and balanced perspective of the medical profession and medical issues.” (18). Discussion We found that clinical societies often provide general language to their members about the ethical importance of public communication as a clinician responsibility, norm, or duty, but few offer specific guidance on how to interact with traditional or social media outlets to exert those responsibilities. Our findings are consistent with a 2001 review of professional ethics codes that identified little content about public communication (19), as well as a recent article observing a lack of scholarship around the ethics of scientists’ public relations activities (20). Cancer-related societies offered even less public communication-related guidance than other societies. This gap is concerning given that cancer issues tend to be viewed as confusing by the public, with cancer communications characterized by mixed messages, hyperbole, and controversy (21–24). Previous research confirms that cancer specialists indeed view communicating to the public as an important responsibility but are not often clear about how to do it or with what objective (25). Our analysis revealed several consistent communication-relevant ethical principles that clinical societies value, including accuracy, avoidance of deception, timeliness, protection of privacy, and objectivity. These principles generally address individual-level patient or provider–patient relationship issues, rather than population- or policy-level considerations. These principles may also compete. For instance, fidelity to truthfulness, accuracy, and use of scientific evidence could conflict with the moral tenet of improving public health. In particular, communication research on framing indicates that communication that engages audience values is particularly effective (26,27). This suggests that clinicians seeking to influence the public to improve public health may want to be strategic in framing controversial cancer-related issues in terms of social values, instead of, or in addition to, communicating accurate scientific evidence. Limited scholarly work has examined the ethics of framing in communication by clinicians or scientists (28). Another source of tension concerns whether the principle of truth-telling extends to a moral responsibility for clinicians to correct others’ misstatements. New research indicates that correcting misunderstandings may make the original misperceptions more entrenched (29), suggesting that clinicians may face a dilemma over whether or not to publically correct misperceptions. More work is needed to analyze the ethics of clinician communication in light of new research on framing, a changing communication landscape with novel opportunities to reach the public, and an increasingly politicized discourse surrounding science. Limitations and Future Directions Our research has some limitations. First, we may not have captured all relevant documents because societies may have other sources of confidential member guidance to which we did not have access; in addition, clinicians may be guided by the policies and procedures of other organizations, such as state medical societies, health-care institutions, or other professional societies (30). Second, we examined documents available at one point in time (October 2012), but heightened attention to social media (3,5) suggests societies may develop new guidance in the future. For example, in April 2013, the American College of Physicians and the Federation of State Medical Boards jointly published new guidelines about online medical professionalism (31). Third, we only examined guidance for clinicians; other types of experts communicate to the public about cancer, including public health professionals, advisory panelists, nonclinician cancer scientists, and health advocates. Finally, our study was not intended to analyze the ethics of one-on-one clinician–patient communication or ethical issues in other forms of health communication, such as strategic campaigns (32). Overall, we found a paucity of existing resources guiding clinicians in their public communications. 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Google Scholar CrossRef Search ADS   27. Nelson TE Garst J . Values-based political messages and persuasion: relationships among speaker, recipient, and evoked values. Polit Psychol . 2005; 26( 4): 489– 515. Google Scholar CrossRef Search ADS   28. Nisbet MC . The ethics of framing science. In: Nerlich B Elliott R Larson B, eds. Communicating Biological Sciences: Ethical and Metaphorical Dimensions . Burlington, VT: Ashgate; 2009: 51– 73. 29. Nyhan B Reifler J Ubel PA . The hazards of correcting myths about health care reform. Med Care . 2013; 51( 2): 127– 132. Google Scholar CrossRef Search ADS PubMed  30. Cain J . Social media in health care: the case for organizational policy and employee education. Am J Health Syst Pharm . 2011; 68( 11): 1036– 1040. Google Scholar CrossRef Search ADS PubMed  31. Farnan JM Snyder Sulmasy L Worster BK Chaudhry HJ Rhyne JA Arora VM . Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med . 2013; 158( 8): 620– 627. Google Scholar CrossRef Search ADS PubMed  32. Guttman N Salmon CT . Guilt, fear, stigma and knowledge gaps: ethical issues in public health communication interventions. Bioethics . 2004; 18( 6): 531– 552. Google Scholar CrossRef Search ADS PubMed  © The Author 2013. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JNCI Monographs Oxford University Press

Ethics of Clinician Communication in a Changing Communication Landscape: Guidance From Professional Societies

Gollust, Sarah E.; Dwyer, Anne M.
JNCI Monographs , Volume 2013 (47) – Dec 26, 2013
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Oxford University Press
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© The Author 2013. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
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Article
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1052-6773
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1745-6614
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10.1093/jncimonographs/lgt028
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24395984
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Abstract

Abstract Background Cancer experts engage in public communication whenever they promote their research or practice, respond to media inquiries, or use social media. In a changing communication landscape characterized by new technologies and heightened attention to cancer controversies, these activities may pose ethical challenges. This study was designed to evaluate existing resources to help clinicians navigate their public communication activities. Methods We conducted a systematic, qualitative content analysis of codes of ethics, policy statements, and similar documents disseminated by professional medical and nursing societies for their members. We examined these documents for four types of content related to public communication: communication via traditional media; communication via social media; other communication to the public, policy, and legal spheres; and nonspecific language regarding public communication. Results We identified 46 documents from 23 professional societies for analysis. Five societies had language about traditional news media communication, five had guidance about social media, 11 had guidance about other communication domains, and 15 societies offered general language about public communication. The limited existing guidance focused on ethical issues related to patients (such as privacy violations) or clinicians (such as accuracy and professional boundaries), with less attention to population or policy impact of communication. Conclusions Cancer-related professional societies might consider establishing more specific guidance for clinicians concerning their communication activities in light of changes to the communication landscape. Additional research is warranted to understand the extent to which clinicians face ethical challenges in public communication. The changing communication landscape imposes new challenges for clinicians. For instance, as new communication technologies like social media and blogs become more popular, clinicians confront dilemmas regarding use of these tools in their personal and professional lives and as vehicles to reach the public. The risks of such communication include potential harms to patients (eg, patient privacy and/or confidentiality), potential harms to experts’ professional integrity (eg, inappropriate information sharing), and challenges to the sanctity of the doctor–patient relationship (eg, preserving boundaries) (1–6). Communication also imposes population-level ethical concerns. As scientific issues become increasingly politically charged, clinicians may face dilemmas around whether and how to communicate their perspectives to their patients and the broader public, navigating morally ambiguous terrain between education and persuasion (7), and balancing their competing roles and responsibilities to patients and the larger public. These communication challenges may be particularly pronounced for cancer-related issues. The mass media often feature controversies surrounding cancer prevention (eg, the human papillomavirus vaccine) (8) and screening (eg, the US Preventive Services Task Force mammography screening guidelines) (9). Cancer scientists and clinicians compete for scarce mass media space to express their views alongside politicians, advocates, patients, and cancer survivors (10). In the face of controversy and public uncertainty, cancer experts may face heightened pressure to use mass or social media to shape the public’s evolving views and decisions related to cancer screening and treatment. Clinicians engage in public communication whenever they promote their research or practice, respond to media inquiries, use social networking sites, blog, or testify in policy arenas. Yet, it is not clear whether clinicians navigate these potentially ethically challenging communications with sufficient guidance. Our research sought to fill this gap, asking: To what extent do clinical professional societies provide guidance on public communication in traditional media, social media, or other communication venues? Our objective was to analyze professional codes of ethics and similar guidance for the types of ethical issues they describe and the recommendations they offer. Methods Included Professional Societies We used existing references (11–13) to create a comprehensive list of nurse and physician professional societies, including primary care providers, and excluding societies that serve international clinicians or clinicians-in-training. We then selected all medical and nursing societies with more than 20 000 members (14). This criterion allowed us to include the major oncology specialty society (American Society of Clinical Oncology, membership 25 000) and its peer specialties for comparison, due to our interest in cancer-related communication. We also included one society of technicians who perform cancer-related procedures (American Society of Radiologic Technologists, membership 129 000) and three cancer-specific medical societies that had membership below 20 000 (American Society for Therapeutic Radiology, membership 9000; American Society for Therapeutic Radiology and Oncology, membership 9000; and American Roentgen Ray Society, membership 14 000). These selection criteria resulted in 28 societies. To identify documents for analysis, we searched each society’s Web site for 1) publically available codes of ethics or conduct for members and 2) professional guidelines, policy statements, or opinions related to member communication with the public. We then contacted the communications or membership person at each organization to solicit those materials. If there was no response to our initial and follow-up contacts, we sent a final e-mail describing the publically available materials identified on the organization’s Web site and asking for verification that no additional materials fit the study criteria. This two-phased strategy yielded materials or a response confirming no materials for 27 of the 28 organizations (we neither identified materials nor received a response from the American Society for Radiation Oncology). All searches and contacts were performed between October 1 and October 31, 2012. Coding Scheme We developed a coding scheme to examine collected materials (see Supplementary Materials, available online), focusing on those documents that were explicitly advisory in intent (eg, codes of ethics, conduct, and policy statements), excluding less formal documents like member newsletters. In addition to capturing descriptive information (ie, name of society, document type, length, and date), the instrument covered four communication-related domains: 1) references to communication to the public via traditional media; 2) references to communication using electronic or social media; 3) references to other forms of communication to the public, policy, and legal spheres; and 4) references to general language about public communication. The coder indicated whether the information was present or absent and noted the document section for qualitative analysis. One author examined all documents, with a sample of documents double coded by the second author and disagreements resolved via deliberation. Analysis In the first stage of the analysis (led by one author), we characterized the collected documents and indicated which types of public communication language were present or absent. The next stage of the analysis (led by the other author) consisted of a qualitative examination of the relevant documents. We used matrix presentations of the data to facilitate comparisons of major themes (15). The qualitative analysis focused on two types of content identified a priori: description of concerns (ethical or practical) related to communication and type of guidance offered. We assessed what types of issues or recommendations relevant to the changing communication landscape were missing and whether there were any tensions or competing principles in the guidance. Results The total sample comprised 46 documents; the median document length was four pages, and the dates of publication (where available) ranged from 1977 to 2012. The documents included 12 codes of ethics, one code of conduct, two mission and/or values statements, four manual or procedures guides, nine policy statements, four advisory opinions, two peer-reviewed journal articles, and 12 combinations (eg, an ethics code that included a policy statement). Table 1 displays the 23 societies that contributed the 46 documents, indicating whether the documents included content related to the four communication domains (news media, social media, other communication, and general). Only the American Medical Association (AMA) included language about all four domains in its guidance. No cancer-related clinical societies offered information about communication via traditional or social media; one society (American College of Radiology) mentioned expert testimony, and the Oncology Nursing Society and American College of Radiology included general language about communication. In total, five of the 23 societies presented guidance about public communication via traditional news media, five presented guidance about public communication via blogs and social media, 11 included language about other types of communication, and 15 offered general public communication language. Table 1. Mention of public communication issues in medical and nursing societies’ professional guidance documents, October 2012 (N = 46 documents) Professional societies* [No. of documents analyzed]  Membership†  Type of public communication discussed in document  Traditional news media  Blogs and social media  Other‡  General  General clinical societies   American Medical Association (AMA) [7]  297000  Y  Y  Y  Y   American Nurses Association (ANA) [5]  165000  N  Y  N  Y   American Academy of Family Physicians (AAFP) [1]  94600  N  N  N  N   American College of Physicians (ACP) [2]  85000  Y  N  Y  Y  Cancer-related clinical societies§   American Society for Clinical Pathology (ASCP) [1]  130000  N  N  N  N   American Society of Radiologic Technologists (ASRT) [2]  129000  N  N  N  N   Oncology Nurses Society (ONS) [2]  35000  N  N  N  Y   American College of Radiology (ACR) [1]  32000  N  N  Y  Y   American Society of Clinical Oncology (ASCO) [1]  25000  N  N  N  N  All other clinical societies   American College of Surgeons (ACS) [1]  70000  Y  N  Y  Y   American Association of Critical Care Nurses (AACN) [1]  65000  N  N  N  N   American Congress of Obstetricians and Gynecologists (ACOG) [3]  41000  N  N  Y  Y   Association of periOperative Registered Nurses (AORN) [1]  41000  N  N  N  N   American Association of Nurse Anesthetists (AANA) [1]  39086  N  N  N  Y   American Psychiatric Association (APA) [3]  38000  Y  N  Y  Y   American Society of Anesthesiologists (ASA) [2]  38000  N  Y  Y  Y   American College of Cardiology (ACC) [1]  37000  N  N  Y  Y   American Academy of Orthopedic Surgeons (AAOS) [1]  35000  N  N  N  Y   Emergency Nurses Association (ENA) [2]  33000  N  Y  N  N   American Academy of Ophthalmology (AAO) [3]  27000  Y  N  Y  Y   American College of Emergency Physicians (ACEP) [3]  26000  N  N  Y  Y   Association of Women’s Health, Obstetric and Neonatal Nursing (AWHONN) [1]  22000  N  Y  N  N   American Academy of Neurology (AAN) [1]  21000  N  N  Y  Y  Total number of societies that discussed communication    5  5  11  15  Professional societies* [No. of documents analyzed]  Membership†  Type of public communication discussed in document  Traditional news media  Blogs and social media  Other‡  General  General clinical societies   American Medical Association (AMA) [7]  297000  Y  Y  Y  Y   American Nurses Association (ANA) [5]  165000  N  Y  N  Y   American Academy of Family Physicians (AAFP) [1]  94600  N  N  N  N   American College of Physicians (ACP) [2]  85000  Y  N  Y  Y  Cancer-related clinical societies§   American Society for Clinical Pathology (ASCP) [1]  130000  N  N  N  N   American Society of Radiologic Technologists (ASRT) [2]  129000  N  N  N  N   Oncology Nurses Society (ONS) [2]  35000  N  N  N  Y   American College of Radiology (ACR) [1]  32000  N  N  Y  Y   American Society of Clinical Oncology (ASCO) [1]  25000  N  N  N  N  All other clinical societies   American College of Surgeons (ACS) [1]  70000  Y  N  Y  Y   American Association of Critical Care Nurses (AACN) [1]  65000  N  N  N  N   American Congress of Obstetricians and Gynecologists (ACOG) [3]  41000  N  N  Y  Y   Association of periOperative Registered Nurses (AORN) [1]  41000  N  N  N  N   American Association of Nurse Anesthetists (AANA) [1]  39086  N  N  N  Y   American Psychiatric Association (APA) [3]  38000  Y  N  Y  Y   American Society of Anesthesiologists (ASA) [2]  38000  N  Y  Y  Y   American College of Cardiology (ACC) [1]  37000  N  N  Y  Y   American Academy of Orthopedic Surgeons (AAOS) [1]  35000  N  N  N  Y   Emergency Nurses Association (ENA) [2]  33000  N  Y  N  N   American Academy of Ophthalmology (AAO) [3]  27000  Y  N  Y  Y   American College of Emergency Physicians (ACEP) [3]  26000  N  N  Y  Y   Association of Women’s Health, Obstetric and Neonatal Nursing (AWHONN) [1]  22000  N  Y  N  N   American Academy of Neurology (AAN) [1]  21000  N  N  Y  Y  Total number of societies that discussed communication    5  5  11  15  * Excluded from this list are medical societies that confirmed there were no documents relevant to our inquiry (Radiological Society of North America, American Academy of Nurse Practitioners, American Roentgen Ray Society) and medical societies that only offered newsletters-type documents (American Academy of Pediatrics). † Membership numbers from Gale Medical and Health Information Directory (2010 edition). ‡ Includes references to political communication, testimony in legal or policy venues, or advertising. § Refers to societies of clinicians that engage significantly with cancer prevention, detection, treatment, and research. View Large Table 2 presents a synthesis of the qualitative analysis. Among the five societies that offered language about news media, ethical concerns were grounded in ensuring that information communicated was accurate and respected patient privacy and/or confidentiality. Three societies (AMA, American College of Physicians, and American Psychiatric Association) asserted a positive duty or obligation to work with the news media. One society’s guidance (American Psychiatric Association, in a 1977 document) was distinguished by its strong emphasis on the importance of working with the media as an opportunity to establish public trust. Table 2. Qualitative analysis of ethical concerns and recommendations offered in clinical society guidance, October 2012 (N = 46 documents)* Public communication domain  Society type  Ethical or practical concerns identified (Society)  Guidance or recommendations offered (Society)  Traditional news media  General  Patients’ privacy, legal rights (AMA) Confidentiality of patient information (ACP) and of patient–physician relationship (AMA) Limiting authority to provide diagnosis or prognosis to attending physician (AMA) Accuracy of information (ACP)  Physicians should cooperate with media and provide them information, ensuring medical news is available promptly, accurately (AMA) Physicians should provide the news media with accurate information; an obligation to society and an extension of practice (ACP)    Cancer-specific  None  None    Other specialty  Public trust (APA) Privacy, confidentiality (APA) Accuracy, avoiding unjustified expectations, avoiding deception (ACS, AAO)  Obligation to work with media, importance of good media relations for establishing public trust and credibility (APA) Avoid exaggeration and claims without evidence (APA) Provide accurate information, represent clinical credentials, and identify any sponsors of communication (ACS)  Blogs and social media  General  Accuracy of online information (AMA, ANA) Patient privacy and confidentiality (AMA, ANA) Potential for commercial or other conflicts of interest (AMA) Consequences on individual careers or public trust in nursing or medical profession (AMA, ANA) Professional/personal boundaries, inappropriate (ANA)  When providing individual medical information via online sites, be consistent with other ethical standards, like truthfulness, privacy protection, informed consent (AMA) Information should be accurate, timely, reliable, scientifically sound (AMA) Minimize conflicts of interest or commercial biases (AMA) Physicians should routinely monitor their online presence, maintain appropriate boundaries with patients, consider separating personal and professional content online, bring unprofessional content to attention of colleagues (AMA) Avoid individually identifiable information about patients; observe ethically prescribed boundaries with patients; use privacy settings and separate personal and professional content; bring potentially harmful content to attention of authorities; participate in developing institutional policies (from ANA Principles for Social Networking)    Cancer-specific  None  None    Other specialty†  Privacy, confidentiality (ASA, ENA) Reputational risks to individuals and the specialty as a whole (ASA)  Need greater awareness and guidelines regarding use of social media (ASA) Use safeguards for online profiles; observe ethical and professional clinician–patient boundaries (ENA) Consistently evaluate communications using social media and report any breaches among colleagues (ENA)  Other policy or public communication (eg, advertising, legal testimony  General  Physicians have political rights (like all citizens) to influence government, free speech (AMA) Misleading or deceptive information, unjustified expectations, honesty, accuracy (AMA) Confidentiality (AMA) Patient consent (AMA)  Obligation to assist in administration of justice (AMA); ethical duty to assist patients and society in resolving disputes (ACP) Physicians involved in testimony must have appropriate expertise and honestly and objectively interpret medical facts (ACP, AMA) Testimony must be accurate, reflect current scientific thought and standards of care (AMA) Compensation must be reasonable and noncontingent upon outcome (ACP)    Cancer-specific  Accuracy, scientifically correct testimony (ACR)  Expert testimony should be nonpartisan, scientifically correct, and clinically accurate (ACR)    Other specialty  Accuracy and objectivity of information communicated; avoidance of conflict of interest/appropriate compensation for testimony (ASA, ACC, ACEP, AAN, ACOG, APA, ACS, AAO) Importance of testimony in legal/policy venues to assure availability of unbiased expertise (ACEP) Misleading, false, or deceptive testimony or advertising is unethical (AAO) Ethical and legal obligations for truth-telling (ACS)  Expert testimony should be objective, fair, accurate, thorough; cannot misrepresent credentials; may not give false testimony; compensation must be reasonable (all) Must identify if personal opinions are not generally accepted by other cardiologists (ACC) Expert witnesses should not act as an advocate or partisan but as a genuine expert and educator (ACC, ACS) Encourages psychiatrists to serve society by consulting with executive, legislative, and judiciary branches of government (APA)  Public communication domain  Society type  Ethical or practical concerns identified (Society)  Guidance or recommendations offered (Society)  Traditional news media  General  Patients’ privacy, legal rights (AMA) Confidentiality of patient information (ACP) and of patient–physician relationship (AMA) Limiting authority to provide diagnosis or prognosis to attending physician (AMA) Accuracy of information (ACP)  Physicians should cooperate with media and provide them information, ensuring medical news is available promptly, accurately (AMA) Physicians should provide the news media with accurate information; an obligation to society and an extension of practice (ACP)    Cancer-specific  None  None    Other specialty  Public trust (APA) Privacy, confidentiality (APA) Accuracy, avoiding unjustified expectations, avoiding deception (ACS, AAO)  Obligation to work with media, importance of good media relations for establishing public trust and credibility (APA) Avoid exaggeration and claims without evidence (APA) Provide accurate information, represent clinical credentials, and identify any sponsors of communication (ACS)  Blogs and social media  General  Accuracy of online information (AMA, ANA) Patient privacy and confidentiality (AMA, ANA) Potential for commercial or other conflicts of interest (AMA) Consequences on individual careers or public trust in nursing or medical profession (AMA, ANA) Professional/personal boundaries, inappropriate (ANA)  When providing individual medical information via online sites, be consistent with other ethical standards, like truthfulness, privacy protection, informed consent (AMA) Information should be accurate, timely, reliable, scientifically sound (AMA) Minimize conflicts of interest or commercial biases (AMA) Physicians should routinely monitor their online presence, maintain appropriate boundaries with patients, consider separating personal and professional content online, bring unprofessional content to attention of colleagues (AMA) Avoid individually identifiable information about patients; observe ethically prescribed boundaries with patients; use privacy settings and separate personal and professional content; bring potentially harmful content to attention of authorities; participate in developing institutional policies (from ANA Principles for Social Networking)    Cancer-specific  None  None    Other specialty†  Privacy, confidentiality (ASA, ENA) Reputational risks to individuals and the specialty as a whole (ASA)  Need greater awareness and guidelines regarding use of social media (ASA) Use safeguards for online profiles; observe ethical and professional clinician–patient boundaries (ENA) Consistently evaluate communications using social media and report any breaches among colleagues (ENA)  Other policy or public communication (eg, advertising, legal testimony  General  Physicians have political rights (like all citizens) to influence government, free speech (AMA) Misleading or deceptive information, unjustified expectations, honesty, accuracy (AMA) Confidentiality (AMA) Patient consent (AMA)  Obligation to assist in administration of justice (AMA); ethical duty to assist patients and society in resolving disputes (ACP) Physicians involved in testimony must have appropriate expertise and honestly and objectively interpret medical facts (ACP, AMA) Testimony must be accurate, reflect current scientific thought and standards of care (AMA) Compensation must be reasonable and noncontingent upon outcome (ACP)    Cancer-specific  Accuracy, scientifically correct testimony (ACR)  Expert testimony should be nonpartisan, scientifically correct, and clinically accurate (ACR)    Other specialty  Accuracy and objectivity of information communicated; avoidance of conflict of interest/appropriate compensation for testimony (ASA, ACC, ACEP, AAN, ACOG, APA, ACS, AAO) Importance of testimony in legal/policy venues to assure availability of unbiased expertise (ACEP) Misleading, false, or deceptive testimony or advertising is unethical (AAO) Ethical and legal obligations for truth-telling (ACS)  Expert testimony should be objective, fair, accurate, thorough; cannot misrepresent credentials; may not give false testimony; compensation must be reasonable (all) Must identify if personal opinions are not generally accepted by other cardiologists (ACC) Expert witnesses should not act as an advocate or partisan but as a genuine expert and educator (ACC, ACS) Encourages psychiatrists to serve society by consulting with executive, legislative, and judiciary branches of government (APA)  * Excluded from this analysis are societies that confirmed there were no documents relevant to our inquiry (Radiological Society of North America, American Academy of Nurse Practitioners, American Roentgen Ray Society) and medical societies that only offered newsletters-type documents (American Academy of Pediatrics). AAN = American Academy of Neurology; AAO = American Academy of Ophthalmology; ACC = American College of Cardiology; ACEP = American College of Emergency Physicians; ACOG = American Congress of Obstetricians and Gynecologists; ACP = American College of Physicians; ACR = American College of Radiology; ACS = American College of Surgeons; AMA = American Medical Association; ANA = American Nurses Association; APA = American Psychiatric Association; ASA = American Society of Anesthesiologists; ENA = Emergency Nurses Association. † Association of Women’s Health, Obstetric and Neonatal Nursing (AWHONN) issued guidance for use of Facebook, but the document was related only to the AWHONN page and not members’ use, so is not described here. View Large Five societies’ materials presented content related to communication via blogs or social media, describing the value of such communication for clinicians for personal expression, establishing a marketable online presence, networking, disseminating health education, or engaging in policy issues. As with communication via traditional media, ensuring accuracy and protecting patient privacy and/or confidentiality were paramount, but documents also referenced ethical concerns about disrupting the professional or personal boundaries of the clinician–patient relationship, problematic consequences of social media misuse on individual careers, or loss of public trust in the profession (Table 2). The AMA and the American Nurses Association established social media guidelines in 2010 (16) and 2011 (17), respectively. These guidelines offered specific recommendations to providers, such as separating personal and professional social media accounts and regularly reviewing their online presence. The most frequent and comprehensive professional guidelines regarding communication concerned expert witness testimony (Table 2). Although concerns regarding the accuracy of these communications and protection of patient confidentiality were most central, the guidance also offered specific language regarding objectivity and navigating advocacy and expert roles. Most of the expert witness guidelines explicitly encouraged involvement in judicial and other policy domains. Finally, we examined documents for their mention of general language about public communication. Many of the 15 societies that included such language described a general clinician responsibility to participate in activities that improve the health and well-being of the community. Others described a narrower responsibility to make specific information available to the public or advocate through strategic communications to improve public health. Among the cancer-related societies, both the Oncology Nursing Society and the American College of Radiology emphasized the accuracy of information as an important principle, with the Oncology Nursing Society highlighting the importance of timely communication. Although these claims indicated positive responsibilities for clinicians to engage in public communication, they rarely offered specific guidance on how to do so other than to be accurate, truthful, and avoid deception. The AMA guidance offered the most comprehensive language on communication, describing the importance of working to improve Americans’ comprehension of health and science matters as well as physicians’ social responsibility to make their perspectives heard. The AMA was the only society to describe a reactive role, indicating that clinicians should “make timely responses to misleading and inaccurate media releases . . . [to] giv[e] the general public a more accurate and balanced perspective of the medical profession and medical issues.” (18). Discussion We found that clinical societies often provide general language to their members about the ethical importance of public communication as a clinician responsibility, norm, or duty, but few offer specific guidance on how to interact with traditional or social media outlets to exert those responsibilities. Our findings are consistent with a 2001 review of professional ethics codes that identified little content about public communication (19), as well as a recent article observing a lack of scholarship around the ethics of scientists’ public relations activities (20). Cancer-related societies offered even less public communication-related guidance than other societies. This gap is concerning given that cancer issues tend to be viewed as confusing by the public, with cancer communications characterized by mixed messages, hyperbole, and controversy (21–24). Previous research confirms that cancer specialists indeed view communicating to the public as an important responsibility but are not often clear about how to do it or with what objective (25). Our analysis revealed several consistent communication-relevant ethical principles that clinical societies value, including accuracy, avoidance of deception, timeliness, protection of privacy, and objectivity. These principles generally address individual-level patient or provider–patient relationship issues, rather than population- or policy-level considerations. These principles may also compete. For instance, fidelity to truthfulness, accuracy, and use of scientific evidence could conflict with the moral tenet of improving public health. In particular, communication research on framing indicates that communication that engages audience values is particularly effective (26,27). This suggests that clinicians seeking to influence the public to improve public health may want to be strategic in framing controversial cancer-related issues in terms of social values, instead of, or in addition to, communicating accurate scientific evidence. Limited scholarly work has examined the ethics of framing in communication by clinicians or scientists (28). Another source of tension concerns whether the principle of truth-telling extends to a moral responsibility for clinicians to correct others’ misstatements. New research indicates that correcting misunderstandings may make the original misperceptions more entrenched (29), suggesting that clinicians may face a dilemma over whether or not to publically correct misperceptions. More work is needed to analyze the ethics of clinician communication in light of new research on framing, a changing communication landscape with novel opportunities to reach the public, and an increasingly politicized discourse surrounding science. Limitations and Future Directions Our research has some limitations. First, we may not have captured all relevant documents because societies may have other sources of confidential member guidance to which we did not have access; in addition, clinicians may be guided by the policies and procedures of other organizations, such as state medical societies, health-care institutions, or other professional societies (30). Second, we examined documents available at one point in time (October 2012), but heightened attention to social media (3,5) suggests societies may develop new guidance in the future. For example, in April 2013, the American College of Physicians and the Federation of State Medical Boards jointly published new guidelines about online medical professionalism (31). Third, we only examined guidance for clinicians; other types of experts communicate to the public about cancer, including public health professionals, advisory panelists, nonclinician cancer scientists, and health advocates. Finally, our study was not intended to analyze the ethics of one-on-one clinician–patient communication or ethical issues in other forms of health communication, such as strategic campaigns (32). Overall, we found a paucity of existing resources guiding clinicians in their public communications. 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Journal

JNCI Monographs – Oxford University Press

Published: Dec 26, 2013

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