Ethical Standards Help to Define the Medical Toxicologist.

Abstract

The American College of Medical Toxicology (ACMT) recently published an updated Code of Ethics for Medical Toxicologists [1]. The guidelines laid out in this document are said to supplement the Code of Medical Ethics of the American Medical Association, rather than to replace them [2]. This begs the question, BWhy do medical toxicologists need their own code of ethics?^ Perhaps one reason is because ethical standards are a crucial element that can distinguish medical toxicologists from some other practitioners who offer services related to poisoning. Medical toxicologists continue to suffer an identity crisis. For example, the distinction between medical toxicologists, forensic toxicologists, environmental toxicologists, and laboratory toxicologists is often unclear to the public. While it may be easy to explain that a medical toxicologist treats patients while a laboratory toxicologist analyzes specimens, it becomes a bit more complicated to explain the difference between a medical toxicologist and another health practitioner who identifies as a ‘toxicologist’ and claims expertise in poisoning treatment. While the most obvious factors that differentiate medical toxicologists are specialized training in an ACGMEaccredited fellowship and confirmation of expert-level knowledge through subspecialty board certification by the Medical Toxicology Sub-board of the American Board of Emergency Medicine, a less recognized but incredibly important distinction is the high ethical standard expected of a medical toxicologist. The ACMT Code of Ethics addresses topics that are relevant to physicians across many specialties, such as the physician-patient relationship, expert testimony, and involvement in research and medical education. Situations that may be disproportionately encountered by medical toxicologists, such as treating a suicidal patient or establishing a nontreating relationship during an independent medical examination, can present challenges that the ACMT Code of Ethics may help guide. While all of these topics are important to the ethical practice of medical toxicology, it is the unassuming, short section toward the end of the document on BUse of NonAccepted Therapies^ that especially speaks to the differences between the fellowship-trained, board-certified medical toxicologist and a practitioner who promotes poisoning diagnoses and provides services that are not medically justifiable. Regarding the BUse of Non-Accepted Therapies,^ the code of ethics states that the medical toxicologist must never use personal gain as a motivating factor in choosing a therapy. Most obviously, personal gain may be financial. In fact, there is great financial opportunity in diagnosing and treating poisoning, regardless of whether poisoning is present. When scientific evidence does not support a test, diagnosis, or treatment, the medical toxicologist must discuss this with the patient honestly and respectfully. This honest discussion can be much more difficult than supporting a belief or previous diagnosis of toxicity and agreeing to initiate or continue an unproven therapy. And it leaves the medical toxicologist without the security of future patient visits and payments. ACMT’s participation in the ABIM Foundation’s BChoosing Wisely^ campaign reflects this position with many of its choices of BThings Providers and Patients Should Question^ [3]. ACMT asks providers not to recommend use of dietary supplements, which currently constitute a multi-billion dollar industry in the US. Other ACMT BChoosing Wisely^ action items recommend against the use of provoked urine tests to diagnosemetal poisoning, the use of unproven detoxification therapies such * Anne-Michelle Ruha michelle.ruha@bannerhealth.com