Code of Ethics

North American Neuro-Ophthalmology Society

Code of Ethics

A. PREFACE

The Ethics Committee of the North American Neuro-Ophthalmology Society (NANOS) developed the North American Neuro-Ophthalmology Society Code of Ethics (the Code) to formalize the standards of professional behavior for all members of NANOS, regardless of the class of membership. The primary goal of the Code is to promote the highest quality of neuro-ophthalmologic research and patient care. The Code outlines the professional standards that NANOS requires its membership to observe in the advancement of their clinical and scientific activities. All references in the Code to neuro-ophthalmology and neuro-ophthalmologist refer and apply with equal force and affect to all members of NANOS irrespective of their individual field, training or licensure status.

The Code embodies traditional medical ethical standards dating from the time of Hippocrates as well as more contemporary standards. It includes general principles of medical ethics and provides for their application to the specific demands of neuro-ophthalmologic practice. The basic ethical principles and objectives outlined in the Code are intended to be interpreted in such a manner as to be consistent with the ethics codes of the American Medical Association Code of Medical Ethics, the American Medical Association Current Opinions of the Council on Ethical and Judicial Affairs, and the ethics committees of the American Academy of Neurology and the American Academy of Ophthalmology.  Any inconsistencies which currently exist or which may hereafter develop between these third party codes of ethics and this Code shall be submitted to the Ethics Committee for review and interpretation, as provided for in Section C of this Code.

While ethical principles are generally considered constant, developments in science, technology, and clinical practice may require the application of these ethical principles to be modified. Therefore, the Code is designed to be a dynamic instrument that can grow and adapt to future developments in the practice and science of neuro-ophthalmology.

The Code outlines the standards of professional conduct required of all NANOS members and applies to all categories of membership. Violations of the Code may serve as the basis for disciplinary action as provided for in the Code and the NANOS Bylaws.

B. RULES

1.0 The Neuro-ophthalmologist-Patient Relationship

1.1 The Practice of Neuro-ophthalmology

The profession of neuro-ophthalmology exists primarily to study, diagnose and treat disorders of the nervous system and the eye. The neuro-ophthalmologist should be dedicated to the ideals and obligations of the profession and must be educated and trained to provide neuro-ophthalmologic medical treatment and care.  The neuro-ophthalmologist should only perform those procedures in which the neuro-ophthalmologist is competent by virtue of specific training or experience or ensure that he/she is properly assisted by a physician who is competent.  The neuro-ophthalmologist-patient relationship forms the foundation for neuro-ophthalmologic care and should be carefully safeguarded.

1.2 Fiduciary and Contractual Obligations

The neuro-ophthalmologist owes the patient both fiduciary duties and contractual obligations. The neuro-ophthalmologist has a duty to consider the interests of the patient, to practice competently and to respect the patient’s autonomy, confidentiality, and welfare.

1.3 Beginning and Ending the Relationship

The neuro-ophthalmologist is free to determine to undertake the medical treatment or care of any person. However, the neuro-ophthalmologist must not decline a patient on the basis of race, religion, nationality, or gender.  Nor should a neuro-ophthalmologist refuse treatment to any patient solely because of any real or perceived health risks which the patient or his/her condition may pose to the physician. The neuro-ophthalmologist should take appropriate precautions to minimize any associated health risks to the physician and the physician’s staff which may arise from the treatment of any such patient.  Once the relationship has begun, the neuro-ophthalmologist must continue to provide adequate care to the patient until such time as the treatment is complete, the patient ends the relationship, or the neuro-ophthalmologist appropriately ends the relationship. If the neuro-ophthalmologist desires to end the relationship prior to the completion of treatment, he/she should provide the patient with adequate advanced notice and must assist in arranging for the patient to receive continued care from another qualified physician.

1.4 Communication

The neuro-ophthalmologist has a duty to communicate openly and effectively with the patient. The neuro-ophthalmologist should convey relevant information using language and terms which the patient can understand and allow adequate opportunity for the patient to raise questions and discuss matters related to the treatment. Patient confidentiality must be safeguarded by the physician in compliance with all state and federal laws, rules, and regulations.

1.5 Informed Consent

 The neuro-ophthalmologist whenever feasible must obtain the patient's informed consent prior to initiating neuro-ophthalmologic treatment. The neuro-ophthalmologist should provide the patient with information related to the treatment in such a way that an average adult would be able to understand the explanation and be able to formulate an informed decision. If the patient lacks medical decision-making capacity, the neuro-ophthalmologist whenever feasible must obtain informed consent from the patient’s legal guardian or the duly appointed power of attorney prior to beginning treatment when informed consent is required.

1.6 Emergency Care

While obtaining prior informed consent is desirable before beginning treatment, the neuro-ophthalmologist should not delay urgently needed treatment because of concerns about informed consent. When a neuro-ophthalmologist is presented, in his/her professional opinion, with an emergency situation, the neuro-ophthalmologist should render the necessary emergent neuro-ophthalmologic care to the patient to the best of his/her ability.

1.7 Medical Decision-Making

Treatment shall be recommended for a patient only after a careful consideration of the patient’s physical, social, emotional and occupational needs. The neuro-ophthalmologist must evaluate the patient and assure that the evaluation accurately supports the physician’s treatment plan. Recommendation of unnecessary treatment or withholding of necessary treatment is unethical.  The physician must communicate the treatment plan to the patient. The patient has the ultimate right to accept or reject the neuro-ophthalmologist's recommendation for medical treatment. The neuro-ophthalmologist should respect decisions made by the patient or when appropriate by the patient’s legal guardian or duly appointed power of attorney. If the neuro-ophthalmologist determines that he/she cannot honor the patient's or, where appropriate, the guardian’s decision, the neuro-ophthalmologist should notify the patient and seek to arrange for the transfer of the patient's treatment to another qualified physician.

2.0 General Principles of Neuro-ophthalmology

2.1 Professional Competence

The neuro-ophthalmologist must practice only within the scope of his/her training, experience, and competence. The neuro-ophthalmologist should provide care that represents the prevailing standards of neuro-ophthalmologic practice. To maintain this level of competency, neuro-ophthalmologists should participate in a regular program of continuing education. The neuro-ophthalmologist must not misrepresent credentials, training, experience, ability or results.

2.2 Medical Consultation

The neuro-ophthalmologist should obtain consultations when appropriate with other physicians or health care practitioners. The neuro-ophthalmologist should ensure that adequate medical information is conveyed to the consulting physician to enable him/her to make an informed recommendation. Any differences of opinion between the neuro-ophthalmologist and any medical consultant or between the neuro-ophthalmologist and the referring physician should be resolved in the best interest of the patient.

2.3 Patient Confidentiality

The neuro-ophthalmologist must maintain the patient’s privacy and confidentiality and must comply with all applicable state and federal confidentiality rules and regulations. 

2.4 Patient Records

The neuro-ophthalmologist should prepare and maintain thorough and accurate patient records which should include a statement of all relevant history, neuro-ophthalmic findings, assessments, and the proposed plan of evaluation and treatment. Upon request, patients should be provided with copies of their medical records, pursuant to prevailing regulations.

2.5 Professional Fees

The neuro-ophthalmologist is entitled to reasonable compensation for medical services to or on behalf of patients. The neuro-ophthalmologist should receive compensation only for services actually rendered or supervised. The neuro-ophthalmologist must not receive a fee for making a referral ("fee-splitting") or receive a commission from anyone for an item or service he/she has ordered for a patient ("kickback") or from other fee arrangements which are barred by the then current local, State or Federal laws, rules or regulations.   A reasonably agreed upon division of practice income among members of an organized medical group which complies with all relevant laws, rules and regulations is acceptable.

2.6 Appropriate Services

The neuro-ophthalmologist should order only those tests and perform only those services which are medically necessary for the patient.

2.7 Special Categories of Neuro-ophthalmologic Care - The Dying Patient

The neuro-ophthalmologist should strive to relieve the suffering of patients. The neuro-ophthalmologist should respect the expressed wishes of dying patients regarding life-prolonging therapy, including all lawful advance directives.

3.0 Professional and Personal Conduct

3.1 Respect for the Patient

The neuro-ophthalmologist should provide care to the patient with compassion, respect for human dignity, honesty and integrity. The physician should treat every patient with respect, honesty and meticulous care. No physician should ever engage in activities which result in physical, psychological, emotional, or financial abuse or exploitation of a patient.

3.2 Lack of Capacity

When the neuro-ophthalmologist’s patient lacks the capacity to make informed decisions, the neuro-ophthalmologist should take reasonable steps to safeguard the interests and rights of that patient.  

3.3 Official Agencies

The neuro-ophthalmologist must observe all applicable government rules, regulations and laws. Because many government and quasi-government agencies decisions impact the patient’s welfare, the neuro-ophthalmologist should cooperate and comply with reasonable requests from any such agency while safeguarding the patient’s rights to privacy and confidentiality.

3.4 Assisting, Soliciting, or Inducing Violations

A neuro-ophthalmologist shall not knowingly violate, attempt to violate, assist in, solicit, or induce any violation of this Code or of any State, Federal or local laws, rules or regulations.  Nor shall the neuro-ophthalmologist engage in conduct involving dishonesty, fraud, deceit or misrepresentation. 

3.5 Maintenance of the Neuro-ophthalmologist's Personal Health

The neuro-ophthalmologist should strive to maintain his/her own physical and emotional health. The neuro-ophthalmologist should refrain from practices that may impair his/her capacity to provide adequate patient care. A physically, mentally or emotionally impaired neuro-ophthalmologist should withdraw from those aspects of his/her practice which are affected by the impairment. If an impaired neuro-ophthalmologist fails to withdraw from those aspects of the practice which are affected by any impairment, it is the duty of other neuro-ophthalmologists who are aware of the impairment to take action to correct the situation including, but not limited to, the duty to report the impairment to the Ethics Committee and, when required by any law governing such physician’s practice the duty to report the impairment to the appropriate regulating authority.   

4.0 Conflicts of Interest

4.1 The Patient's Interest is Paramount

A conflict of interest exists when professional judgment concerning the well-being of the patient has a reasonable chance of being influenced by other interests of the physician providing treatment. When a conflict of interest occurs or when one becomes apparent the treating physician has a duty to disclose such conflict to the patient.  The neuro-ophthalmologist must attempt to resolve any conflict of interest which arises to ensure that the patient’s treatment plan continues to service the best interest of the patient. If the conflict cannot be eliminated, the neuro-ophthalmologist must notify the patient of the specific conflict and, if the patient requires, terminate the physician/patient relationship.

4.2 Conflicting Ethical Duties   

A neuro-ophthalmologist ordinarily must maintain the patient's confidentiality; however, if the neuro-ophthalmologist becomes aware that the patient intends to injure an identifiable third party, then the neuro-ophthalmologist must take reasonable steps to warn the third party or notify the appropriate authorities. Similarly, when the neuro-ophthalmologist becomes aware of the patient’s intent to injure members of the general public, the neuro-ophthalmologist must take reasonable steps to advise the appropriate public officials or agencies of the danger.  If the physician is uncertain of his/her duties he/she should immediately consult with the Ethics Committee.
 
5.0 Relationships with other Professionals

5.1 Cooperation with Health Care Professionals

The neuro-ophthalmologist should cooperate and appropriately communicate with other health care professionals, including other physicians, nurses, and therapists, in order to provide the best care possible to the patient.

5.2 Peer Review

The neuro-ophthalmologist should participate in peer review activities in order to promote the best care possible of patients.

5.3 Criticism of a Colleague

The neuro-ophthalmologist should avoid criticizing a colleague's judgment, training, knowledge, or skills. However, when a member of NANOS becomes aware of another  NANOS member’s incompetence or professional misconduct, then that NANOS member should report such concerns to the Ethics Committee.    

5.4 Expert Testimony

The neuro-ophthalmologist who elects to provide or who is otherwise called upon to provide expert medical testimony should provide such testimony in an objective manner using medical knowledge to form his/her expert medical opinions. He/She should testify only about those subjects for which he/she is qualified to provide as an expert by training and experience. Before giving testimony the neuro-ophthalmologist must carefully review the relevant records and facts of the case and the prevailing standards of practice.  Non-medical factors should not bias the testimony.  Compensation for testimony should be reasonable and commensurate with time and effort spent, and must not be contingent upon the outcome of the litigation.  Knowingly providing false testimony is a breach of this Code.

5.5 Health Care Organizations

The neuro-ophthalmologist may enter into contractual agreements with managed health care organizations, prepaid practice plans, and hospitals. The neuro-ophthalmologist must retain control of his/her ability to independently determine the medical treatment or other medical decisions for patients without undue interference from the organization, program, or hospital. 

6.0 Relationships with the Public and Community

6.1 Public Communication

The neuro-ophthalmologist must represent himself/herself to the public accurately. He/She must not convey false, untruthful, misleading, or deceptive statements.  The physician must not omit material information without which the communication could be deemed to be deceptive. Communications must not appeal to an individual’s anxiety in an excessive or unfair manner and they must not create unjustified expectations of results. The neuro-ophthalmologist’s credentials, training, experience or ability must be accurately represented.  In no event should a neuro-ophthalmologist publicly use or otherwise disclose any patient's medical condition or treatment without the patient's prior written consent.

6.2 Obligation to Community

Neuro-ophthalmologists should work toward improving the health of all members of their community and society. To achieve this goal, the neuro-ophthalmologist should strive to participate in continuing educational programs, research, public health activities, and to allocate a percentage of his/her practice to patients who would otherwise be economically unable to obtain such medical services. The neuro-ophthalmologist should be aware of the limitation of society's health care resources and should not squander those finite resources by ordering unnecessary tests and implementing known ineffective treatment plans.

6.3 Disclosure of Potential Conflicts

Neuro-ophthalmologists who make written or oral public statements in support of a product of a company from which they receive compensation or support, or in which they hold a significant equity position, have a duty to disclose their financial relationship with the company in that public statement.

6.4 Communications with Colleagues

Communications between colleagues must be accurate and truthful and must be conducted in a manner that, when pertaining to the treatment of a patient, advances that patient’s best interests. All communications between colleagues related in any way to the science or practice of medicine generally and more particularly of neuro-ophthalmology shall be conducted in a professional and collegial manner.

7.0 Research

7.1 Institutional Review

The neuro-ophthalmologist who elects to participate in any clinical research or study must first confirm that the research has been approved by an Institutional Review Board (IRB) or other comparable regulatory authority and must observe and comply with the requirements of the approved protocol.

7.2 Disclosure of Potential Conflicts

The neuro-ophthalmologist who is paid for treating patients in a clinical research project must inform the patient/subject of any additional compensation the neuro-ophthalmologist is entitled to receive as a result of the subject’s participation in the study. The compensation for research subject treatment should be reasonable in amount. The neuro-ophthalmologist should not bill the subject or their insurer for services which the physician has already received compensation for from the study sponsor.

7.3 Experimental Treatment

Any neuro-ophthalmologist who proposes to provide a patient with an experimental medical treatment program which has not received approval as a valid clinical study by an IRB or similar regulator agency should obtain prior written informed consent from the patient for all such experimental treatment.  Employment of experimental treatment must comply with all applicable institutional, local, State or Federal law.

7.4 Reporting Research Results

The neuro-ophthalmologist who publishes his/her research results must do so professionally, truthfully, completely, and without distortion. In reporting research results to the news media, the neuro-ophthalmologist should make statements that are clear, understandable, and supportable by the facts.  The neuro-ophthalmologist should not publicize results of any research project until after the data has been subjected to appropriate peer review and is determined to be accurate.

7.5 Scientific Misconduct

Members engaged in scientific research shall abide by the highest professional, ethical and scientific standards as determined by the National Academy of Sciences.  Scientific misconduct may include but is not limited to deception, plagiarism, fabrication, or falsification of data, and, is a breach of this Code. 

C. ADMINISTRATIVE PROCEDURES

The Administrative Procedures form the third part of this Code. They provide for the structure and operation of the Ethics Committee; they provide detailed procedures which must be followed by the Committee when handling Inquiries or Challenges raised under the Code. All members of NANOS are required to comply with these Procedures; failure to cooperate with the Ethics Committee in a proceeding on a Challenge may be considered by the Committee according to the same procedures and with the same sanctions as failure to observe the Code.

1. Ethics Committee.

1.1 The Committee. The President, with approval of the Board of Directors appoints at least five (5), but not more than nine (9), neuro-ophthalmologists who are active Voting Members of NANOS who are authorized pursuant to Article II, Section 11 of the Bylaws to hold office.  Article III, Section 7, Standing Rules, of the NANOS Bylaws and the Standing Rules of the North American Neuro-Ophthalmology Society, as they are from time to time amended, govern the formation, term, and termination of the Ethics Committee and its membership.  NANOS will provide the administrative resources, such as teleconferencing, necessary for Ethics Committee activities.  

The Ethics Committee is responsible for: (i) responding to each inquiry regarding ethics and, if appropriate, making a recommendation to the Board of Directors regarding action, such as the development of an advisory opinion interpreting the Rules of Ethics in this Code; (ii) investigating each challenge regarding ethics and recommending whether the Board of Directors should make a determination that a NANOS member, regardless of the class of membership, area of practice, type of practice or licensure, has failed to observe the Code, and recommending an appropriate sanction as outlined herein below and in the Bylaws; (iii) serving as a resource for NANOS, its members and its Board of Directors regarding professional ethics and ethical issues; and (iv) assessing the Principles of Ethics, Rules of Ethics and Administrative Procedures in this Code periodically and recommending any amendments to the Board of Directors.

1.2 The Chair of the Committee. The President of NANOS appoints one (1) member of the Ethics Committee as the Committee's Chair to serve, at the will of the President, as the principal administrative officer responsible for management of the promulgation, interpretation and enforcement of this Code. The Chair should be a distinguished neuro-ophthalmologist who possesses recognized integrity and broad experience.

The Chair of the Committee is responsible directly to the Board of Directors; and, upon the approval of the Board of Directors is provided, with staff, legal counsel and other resources necessary to fulfill the responsibilities of administering this Code. The Chair presides at, and participates in, all meetings and hearings of the Ethics Committee. The Chair is responsible for ensuring that these Administrative Procedures are followed. The Chair may maintain liaison with entities, both public and private, which are interested or involved in medical ethics, particularly as they relate to neuro-ophthalmology.

1.3 The Vice Chair of the Committee. The President of NANOS may appoint one (1) member of the Committee as the Committee's Vice Chair to serve, at the will of the President, in the place of the Chair when the Chair is unable to serve.

 

1.4 Meetings of the Committee. Meetings of the Ethics Committee are called upon issuing at least seven (7) days' advanced written notice to all Ethics Committee members which may include electronic mail notice, and which notice may include a copy of the agenda for the meeting. A quorum of members is required to conduct any meeting. A quorum consists of a majority of all the appointed Committee members. Voting is by a majority of those present at a meeting (or by a majority of those submitting votes in a mail or electronic mail vote). Mail including electronic mail voting without a meeting is permitted where all Committee members submit mail and/or electronic votes or abstentions. Voting by proxy is not permitted. Meeting by teleconference is permitted. 

 

A member of the Committee must decline to participate in the consideration of, or the decision in, any matter before the Committee in which the member has a personal interest.  In the event that there is a dispute between the Committee members as to whether or not such a conflict exists, the Chair of the Committee shall resolve such conflict. In the event that the Chair of the Committee is the member with a potential conflict, then the President shall resolve any such conflict issue.

1.5 Indemnification. All Ethics Committee members, staff, and other individuals engaged in investigations at the written request of the Chair, are indemnified and defended by NANOS against liability arising from Committee-related activities to the extent provided by Article IV Section 3 of NANOS’ Bylaws.

2. Inquiries and Challenges.

2.1 Inquiry and Challenge Defined

An Inquiry is a request for information on an ethical or educational issue related to NANOS.

A Challenge is a formal complaint alleging that a member of NANOS has violated this Code.  The Ethics Committee will only review those Challenges which are related to members of NANOS or to NANOS itself.

2.2 Submission

Any member, physician, patient or member of the general public may submit a Challenge to the Ethics Committee.  Inquiries may only be submitted by NANOS members to the Ethics Committee. All Challenges must be in writing, signed by the submitter and mailed by certified mail, return receipt requested, to the current NANOS President at the address listed on the NANOS website with a copy sent on the same date, by mail, to the NANOS Executive Director who will immediately provide a copy to the Chair of the Ethics Committee. Further, the submitter(s) must agree to have their name(s) disclosed to the party who is the subject of the Challenge.  Anonymous Challenges or Inquiries will not be considered.

2.3 Preliminary Review

The Chair preliminarily reviews each submission involving this Code of Ethics to consider whether it may be an Inquiry (e.g., a request for issuance by the Board of Directors of an advisory opinion interpreting the Rules of Ethics in this Code) or a Challenge (i.e., a request for a finding by the Board of Directors that a member of NANOS has failed to observe the Rules of Ethics in this Code). A submission involving this Code, whether or not it is designated or phrased as an Inquiry or Challenge, may be construed by the Chair or the Committee as either an Inquiry or a Challenge. Inquiries may be considered without regard to their means or form of submission.

The Chair, at his/her sole discretion, may impose such temporary interim actions as the Chair deems necessary under the circumstances. Temporary interim actions implemented pursuant to this section shall be ratified by the Ethics Committee within 10 days from the date of issuance. In no event shall the duration of any temporary interim action exceed 60 days from the date the member is notified of such measure. 

2.4 Investigation

The Chair shall review each submission to determine if it warrants investigation.  When the Chair determines that further review by the Ethics Committee is required, then the Ethics Committee shall conduct an investigation into the specific facts or circumstances of such submission to whatever extent the Committee deems is necessary in order to clarify, expand or corroborate the information provided by the submitter. The Chair may supervise each investigation or may conduct the investigation personally. The Chair may be assisted in the conducting of an investigation by other Ethics Committee members or by the NANOS Executive Office, or the Ethics Committee staff. With the prior written approval of the Committee and the Board of Directors, the Chair may also be assisted by any other individual: (i) whose location, professional position or expertise might facilitate the investigation; and (ii) whose assistance is requested in writing by the Committee Chair; and (iii) who agrees in writing to follow the Administrative Procedures of this Code; (iv) but, only when such individual meets all of these conditions.

A member of NANOS who is the subject of a valid and actionable Challenge is informed in writing, by certified mail sent to the last known address provided by such member to NANOS, at the beginning of the Committee's investigation as to: (i) the nature of the challenge; (ii) the member’s obligation to cooperate fully in the Committee's investigation of the Challenge; and (iii) the opportunity to request a hearing on the Challenge before the Ethics Committee. Investigations involving Challenges are conducted in confidence, with all written communications sealed and marked "Personal and Confidential." The investigation must be conducted objectively and without prejudgment.

An investigation may be directed toward any aspect of an Inquiry or Challenge which is relevant or potentially relevant. The investigation may include one (1) or more site visits and informal interviews with the member who is the subject of the Challenge.

3. Proceedings on Inquiries

3.1 Hearing

In the course of an investigation involving an inquiry, the Committee may conduct an administrative hearing to receive the views of those who are interested in, or may be affected by, any action taken by the Board of Directors related to this Code. Thirty (30) days' advanced written notice of the hearing must be provided to the member(s) subject to the investigation. 

The notice may, at the Committee’s discretion, include a tentative proposed advisory opinion. The hearing is conducted by three (3) or more members of the Committee. The Chair of the Committee serves as the Hearing Officer to preside at the hearing and assure that these Administrative Procedures are followed. The Hearing Officer may issue an appropriate procedural or evidentiary ruling in the course of the hearing and may be assisted by legal counsel. The Hearing Officer presents at the hearing the issues raised by the Inquiry, the results of the investigation up to the time of the hearing, and any tentative proposed Committee recommendation to the Board of Directors for an advisory opinion. Information is offered through witnesses who may be assisted by legal counsel and are subject to questioning by the Committee. Any information may be considered which is relevant or potentially relevant. A written transcript or audio recording of the hearing will be created providing an official record of the hearing.

3.2 Recommendation

Upon completion of an investigation involving an Inquiry, the Ethics Committee must develop an advisory opinion which must be submitted to the Board of Directors for approval.

3.3 Advisory Opinion

The Board of Directors will issue an advisory opinion interpreting the Rules of Ethics in this Code: (i) upon receipt of a recommendation of the Ethics Committee arising from an Inquiry and following an investigation, or (ii) upon the recommendation of the Committee arising from its own initiative. Once issued by the Board of Directors, the advisory opinion may be promulgated by publication to the members of NANOS. Advisory opinions will also be maintained by the Ethics Committee and will be made available to any NANOS member upon request.

4. Proceedings on Challenges.

4.1 Hearing

In the course of an investigation involving a Challenge, the Committee may conduct a private adjudicative hearing, if one is requested by the NANOS member who is the subject of the Challenge, or the Committee may conduct a hearing on its own initiative.

The member who is the subject of the Challenge shall be given at least thirty (30) days advanced written notice of the Challenge and of his/her right to request a hearing on the Challenge. In the event that the party does elect to exercise his/her right to a hearing on the Challenge, then he/she shall be provided with an additional thirty (30) days advanced written notice of the hearing. The notice shall include the date, time and location of the hearing. The hearing shall be conducted by the Committee with at least three (3) Committee members participating. The hearing shall not be conducted by the original investigator or any Committee member who assisted substantially in the investigation of the Challenge. The Chair of the Ethics Committee may be one (1) of the three (3) or more Committee members conducting the hearing unless the individual is otherwise disqualified.

The Committee members participating in the hearing elect from their number a Hearing Officer to preside at the hearing and assure that these Administrative Procedures are followed. The Hearing Officer may issue any appropriate procedural or evidentiary rulings in the course of the hearing and may be assisted by legal counsel. The Hearing Officer, or a person or persons designated by the Hearing Officer, shall summarize for the Ethics Committee the results of the investigation up to the date of the hearing which are believed to support a finding that the member has failed to observe the Rules of Ethics, and may make such other introductory factual remarks as the Hearing Officer or the Hearing Officer's designate deems appropriate. A person designated by the Ethics Committee shall present the facts indicating that the member has failed to observe the Rules of Ethics, including documentary evidence and the testimony of witnesses. Those witnesses shall be available in person or by telephone for questioning by the members of the Ethics Committee and its legal counsel and by the member or the member's legal counsel.

The member subject to the Challenge may be assisted at the hearing, at their sole cost and expense, by legal counsel. The member or member’s legal counsel may present documentary evidence and the testimony of witnesses in the member's defense. Those witnesses shall be available in person or by telephone for questioning by the member or the member’s legal counsel and by the Ethics Committee and its legal counsel. Any information may be considered which is relevant or potentially relevant. The member may submit a written statement at the close of the hearing.  There shall be created a transcript or audio recording of the hearing. The hearing is closed to all except the Committee, the Chair, the member who is the subject of the Challenge, the respective witnesses (when testifying and at other times as determined by the Hearing Officer), legal counsel, and the official reporter. The official record of the hearing becomes a part of the record of the investigation of the Challenge.

4.2  Recommendation

Upon completion of an investigation involving a Challenge, the Ethics Committee recommends to the Board of Directors whether it should make a determination that the member who is the subject of the Challenge has failed to observe the Rules of Ethics in this Code. When the Committee recommends a determination by the Board of Directors of non-observance, the Committee also recommends imposition by the Board of Directors of an appropriate sanction. A copy of the Ethics Committee’s recommendation and when appropriate its statement of the basis for the recommendation shall be provided to the member. If the Committee recommends against a determination of non-observance, the Challenge is dismissed, with notice to the member who is the subject of the Challenge and to the submitter of the Challenge, and a summary report is made to the Board of Directors. In the sole discretion of the Ethics Committee and with the written consent of the member who was the subject of the Challenge, the Committee may recommend to the Board of Directors that the fact of the dismissal of the Challenge (and, in appropriate cases, the reasons for the dismissal) be publicized, and the Board of Directors may, in its sole discretion, determine the nature, extent and manner of such publicity.

4.3 Determination of Non-Observance

The Board of Directors makes the determination whether a member has failed to observe the Rules of Ethics in this Code and imposes an appropriate sanction upon the recommendation of the Ethics Committee arising from a Challenge. The Board of Directors shall review the recommendation of the Committee based upon the record of the investigation. The Board of Directors may accept, reject or modify the Committee's recommendation, either with respect to the determination of non-observance or with respect to the sanction. When the sanction involves termination of a member from NANOS the Board of Directors must approve the sanction by a 2/3 supermajority vote; failure to achieve the 2/3 supermajority vote for termination, will result in the imposition of a five (5) year suspension for the member unless the Board of Directors agrees by 2/3 supermajority vote to impose an alternative sanction.  If the Board of Directors makes a determination of non-observance, this determination and the imposition of a sanction are promulgated by written notice to the affected member. The individual or entity who submitted the Challenge may be provided with this notice at the Board of Directors’ discretion, but this notice will only be provided if the submitter has previously provided the Board of Directors with his/her written statement agreeing to maintain all confidential information contained in the notice. Additional publication occurs only to the extent provided in the sanctions themselves. If the Board of Directors does not make a determination of non-observance, the Challenge is dismissed with notice to the affected member and to the submitter of the Challenge.

4.4 Alternative Disposition

Before the Committee makes any recommendation to the Board of Directors as to a determination that a member has failed to observe the Rules of Ethics in this Code, the Committee may extend to the member an opportunity to submit a proposed alternative disposition of the matter in whole or in part upon terms and conditions suggested by the Ethics Committee. The terms and conditions may include sanctions and restrictions which are the same as, different from, or more or less restrictive than the sanctions contained in the paragraph 4.5 herein below or in the Bylaws, but shall in all cases include a written assurance by the member that the possible non-observance has been terminated and will not recur.

The decision of the Ethics Committee on whether to extend such an opportunity is entirely within the Committee's own discretion, based upon its investigation of the Challenge.  The Committee will also assess the nature and severity of the possible non-observance when viewed from the point of view of what is in the best interests of patients of the member who is the subject of the Challenge, when applicable. If an opportunity to submit a proposed alternative disposition is extended by the Ethics Committee, an alternative disposition will be considered only if the member submits in writing to the Chair of the Ethics Committee his/her proposed alternative disposition within thirty (30) days from the date of the Ethics Committee's notice to the member that it has extended this opportunity to the member. Such alternative disposition must substantially comply with the Ethics Committee’s proposed recommendations. If the member timely submits his/her proposed alternative disposition and it is approved by the Ethics Committee then the Ethics Committee shall present the alternative disposition to the Board of Directors for review and approval.   If it is accepted by a majority of the Board of Directors then the matter shall be resolved on the basis of the alternative disposition. 

If the member who submitted the Challenge has provided an advanced signed writing to the Ethics Committee wherein he/she has agreed to maintain all information related to the Challenge in confidence, then notice of the Board of Directors’ acceptance of an alternative disposition resolving the matter shall be given to the submitter.

4.5  Sanctions

Any of the following sanctions may be imposed by the Board of Directors upon a member who the Board of Directors has determined by a majority or in the event of a sanction involving permanent termination of membership by a supermajority 2/3 vote, has failed to observe the Rules of Ethics in this Code, although the sanction applied must reasonably relate to the nature and severity of the non-observance. The focus in assessing sanctions is on correcting the misconduct and deterrence of similar conduct in others:

(i) Censure or reprimand of the member, with publication of the violating activity which publication may or may not, at the discretion of the Board of Directors, include the violating individual’s name;
(ii) Suspension of the member from NANOS for a designated period of time, with publication of the determination and with or without publication, at the discretion of the Board of Directors, of the member's name; or
(iii) Expulsion or permanent termination of the member from NANOS, with or without publication of the determination and of the member's name.

In addition to and not in limitation of the foregoing, in any case in which the Board of Directors determines that a member has failed to observe the Rules of Ethics, the Board of Directors may impose the further sanction that the member shall not be entitled to sponsor, present, or participate in a lecture, poster, film, instruction course, panel, or exhibit booth at any meeting or program of, or sponsored by, NANOS: (A) for a period of up to five (5) calendar years from and after the effective date a sanction described in clause (i) or (ii) of this paragraph 4.5 is imposed for the first time upon the member; or (B) at any time from and after the effective date a sanction described in clause (i) or (ii) of this paragraph 4.5 is imposed for a second time upon the member; or (C) at any time from and after the effective date a sanction described in clause (iii) of this paragraph 4.5 is imposed upon the member.

Members who are suspended are deprived of all benefits and incidents of membership during the period of suspension.   In no case shall dues be refunded in the case of suspension or termination.  In the event that a suspended or terminated member is eligible for re-admittance to NANOS, such suspended or terminated member must pay all applicable dues and fees in full when re-applying for membership status in NANOS.

In the event that the member is suspended or if his or her membership in NANOS is permanently terminated, and the appeal, if any, sustains the determination on which the sanction is based, the Board of Directors may at its discretion authorize the Ethics Committee to communicate the determination and transfer a summary or the entire record of the proceeding on the Challenge to an appropriate entity engaged in the administration of law, a governmental program, or the regulation of the conduct of physicians.  The Chair of the Ethics Committee may appear, if requested by such agency or program, as a witness to that determination and record. Except in the instance of communication of the determination and transferal of the record, or in the instance of request of the record by the member who was the subject of the Challenge, the entire record, including the record of any appeal, is sealed by the Ethics Committee and the Board of Directors and no part of it is communicated by the members of the Board of Directors, the members of any appellate body, the members of the Ethics Committee, the staff or any others who assisted in the proceeding on the Challenge to any third parties. Members whose membership has been terminated as provided in this paragraph 4.5 may not reapply for membership in any class.

4.6 Appeal

Within thirty (30) days of receipt of notice of a determination by the Board of Directors that a Member has failed to observe the Rules of Ethics in this Code and of imposition of a sanction, the affected Member may submit to the Board of Directors in writing a request for an appeal. The Board of Directors shall establish an appellate body consisting of at least three (3), but not more than five (5), neuro-ophthalmologists who are members of NANOS and who did not participate in the Ethics Committee's investigation or in the Board of Directors determination. The appellate body conducts and completes the appeal within ninety (90) days after receipt of the request for an appeal. The purpose of the appeal is to provide an objective review of the original Challenge, the investigation and recommendation of the Ethics Committee, and the determination of the Ethics Committee, and the determination of the Board of Directors, but not of the sanction imposed. The appeal is limited to a review of the Ethics Committee’s and the Board of Directors’ application of the Rules of Ethics in this Code to the facts established in the investigation of the Challenge and to a review of the procedures followed to ascertain whether they were consistent with those detailed in these Administrative Procedures.

An appeal may not take into consideration any matters not included as part of the record of the Ethics Committee's investigation and the Board of Directors’ determination. The appeal consists of a review by the appellate body of the entire record of the proceeding on the Challenge and written appellate submission of the member who was the subject of the Challenge. Written appellate submissions and any reply submissions may be made by authorized representatives of the member and of the Board of Directors. Submissions are made according to the schedule established by the appellate body.  The decision of the appeal will be communicated to the Board of Directors for final disposition, requiring a supermajority vote as defined in section 4.5 above.   The decision of the appellate body either affirms or overrules the initial determination of the Board of Directors. The decision does not address the sanction imposed by the Board of Directors. The decision of the appellate body, including a statement of the reasons for the decision, is reported to the Board of Directors and is binding upon the Board of Directors, the member who is subject of the Challenge, and the Ethics Committee. 

4.7 Resignation

If a member who is the subject of a Challenge resigns from NANOS at any time during the pendency of the proceeding of the Challenge, the Challenge is dismissed without any further action by the Ethics Committee, the Board of Directors, or an appellate body established after an appeal; the entire record is sealed; and the member is barred from reapplying for membership in NANOS. The Board of Directors may authorize the Ethics Committee to communicate the fact and date of resignation, the name and address of the member who resigned and the fact that a Challenge pursuant to the Code of Ethics was pending at the time of the resignation to the NANOS membership. Such communications shall not reveal the nature of the Challenge. In addition, the Board of Directors may authorize the Ethics Committee to communicate the fact and date of resignation, and the fact and general nature of the Challenge on which a proceeding was pending at the time of the resignation, to an appropriate entity engaged in the administration of law or the regulation of the conduct of physicians, in a proceeding that relates to the subject matter of the Challenge.

4.8 Overriding Reporting Requirement

Notwithstanding anything expressly or apparently to the contrary contained in this Code, NANOS shall report such information, to such agency or agencies, and in such form and manner and frequency as may from time to time be prescribed by the Health Care Quality Improvement Act of 1986 and by regulations promulgated thereunder, all as from time to time may be amended, as a condition to the continued availability to NANOS of the protection from liability for damages afforded by such Act.

References

Portions of this Code were modified from the following codes of professional ethics and professional conduct:

1.American Academy of Orthopedic Surgeons: Guide to the Ethical Practice of Orthopedic Surgery, 1990.

2. American Association of Neurological Surgeons: American Association of Neurological Surgeons Code of Ethics.

3. American Academy of Ophthalmology: Code of Ethics of the American Academy of Ophthalmology, Inc., 1991.
4. American College of Physicians: American College of Physicians Ethics Manual. Part I: history; the patient; other physicians; Annals of Internal Medicine; 1989; 111:245-252.

5. American College of Physicians: American College of Physicians Ethics Manual. Part II: the physician and society; research; life-sustaining treatment; other issues. Annals of Internal Medicine; 1989; 111:327-335.

6. American College of Surgeons: American College of Surgeons Statements on Principles, 1989.

7. American Psychiatric Association: The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry, 1989.

8. American Medical Association: Code of Medical Ethics and Current Opinions of the American Medical Association Council on Ethical and Judicial Affairs, 1992. American Academy of Neurology Code of Professional Conduct.1993

Ethics Subcommittee

Approved by the Ethics Subcommittee: Roy J. Meckler, MD - Chair, T. Goodglick, MD, M. Seybold, MD, H. S. Thompson , MD, and E. Fitzgibbon, MD (Copyright 2007 North American Neuro-Ophthalmology Society).

Re-Approved by the Ethics Subcommittee 2013: B. Frishberg, MD - Chair, E. FitzGibbon, MD, K. Kubis, MD, and P. McNussen, MD.