Clinical and professional ethics guidelines for the practice of thyroidology.

Avariety of medical professional societies have developed ethics practice guidelines or position statements regarding specific ethics issues (1–6). The Endocrine Society published its Code of Ethics for practice in 2001 (1); however, none of the practice guidelines are specific to thyroidology. In the field of thyroidology, specific clinical ethics issues arise in different clinical contexts. For example, autoimmune thyroid disease raises different clinical ethics issues compared with thyroid oncology. Within thyroid oncology, each type of thyroid cancer raises unique and distinct clinical ethics issues and dilemmas. For example, the clinical ethics dilemmas that present in hereditary medullary thyroid cancer surrounding genetic screening are not the same as in thyroid cancers that are not familial or do not yet have defined germline genetic markers. The dilemmas associated with poorly differentiated and aggressive thyroid cancers (such as anaplastic thyroid cancer) and raising end-of-life issues such as code status, existential suffering, and palliative care are not the same that present in well-differentiated thyroid cancers that respond well to treatment. In many cases, there is clinical disagreement over what constitutes beneficent care for patients. Additionally, new clinical ethics dilemmas are resulting from drug shortages (e.g., recombinant human thyrotropin), medical isotope shortages (e.g., I), as well as nuclear disasters where priority-setting guidelines for distributing potassium iodide are not in place or not identified. Despite the prevalence of clinical ethics dilemmas in thyroid disease, clinical ethics guidelines specific to the thyroid disease context have been notably absent. Clinical ethics expertise can provide morally sound frameworks for (i) the nuances and complexities of diagnosis and treatment, and (ii) allocation of resources in situations where the demand is greater than the supply. The field of thyroidology comprises both clinical ethics and research ethics issues; in both arenas, complex professional ethics and research integrity dilemmas may arise as funding for basic research shrinks, investigators move from clinical to corporate cultures, and competition for funding increases. Conflicts of interest are often poorly understood, which can range from financial to interprofessional conflicts of interest. The clinical and professional ethics guidelines presented here are intended to provide clear guidance about specific, yet common, ethics dilemmas and questions that arise in this unique subspecialty. These guidelines mainly address two groups of ethics dilemmas that are typically encountered by thyroidologists: clinical ethics dilemmas—those that arise in the patient care setting; and professional ethics dilemmas— those that revolve around disclosure of conflicts of interest and professional integrity. These guidelines also provide clear guidance on research ethics issues, such as when innovative therapy becomes ‘‘research,’’ the role of an institutional review board, as well as publication and data-sharing integrity issues. Finally, as enormous changes begin to take effect consequent to The Affordable Care Act (www.healthcare.gov/law/ index.html), thyroid practitioners find themselves in a new clinical landscape involving numerous resource allocation decisions. As aggressive, non-iodine-avid thyroid cancer continues to rise in incidence, more questions about end-oflife care, palliative care, or clinical trial candidacy have arisen. We offer these guidelines in recognition of this unique subspecialty that confronts wide clinical and research diversity.