Ethics and Professionalism

PRINCIPLES

What is respect for autonomy?

• When the patient has the capacity to act intentionally, with understanding, and without controlling influences that would mitigate against a free and voluntary act, surgeons ought to respect patient decisions, even when those decisions are different from the surgeon's recommendations.

What is beneficence?

• The duty of health care providers is to benefit the patient and to bring about good for the patient.

What is nonmaleficence?

• Health care providers may not intentionally create a needless harm or injury to the patient, through acts of commission or omission. In addition, health care providers ought to take positive steps to remove harm from the patient.

What is justice?

• In our context, it is defined as a form of fairness. This implies the fair distribution of goods and services in society, which are in short supply; thus, some fair means of allocating scarce resources must be determined.

DECISION MAKING—SFNO APPROACH

What is the SFNO approach?

• So Far No Objections = Stakeholders, Facts, Norms, Options

What are the 3 major sources of uncertainty in medical ethics decisions?

1. Different people are involved who have competing interests.

2. Uncertainty or disagreement exists about relevant facts.

3. Uncertainty, conflict, or disagreement exists regarding ethical norms.

Who are the stakeholders?

• Those who will be affected by the decision made. It helps to state why people are stakeholders or how they are affected.

What are the facts?

• They are factual issues that might generate disagreement or are relevant to a solution.

• It may be helpful to refer to the experts or the literature.

What are the norms?

• They are ethical principles (see above), norms, or values that are at stake. Some may be relevant and others only appear to be. For assistance, reference can be made to professional ethical codes or regulations. Advice of colleagues should be sought when it is not clear what ethical principle or principles apply.

What defines the options?

• They are actions or policies as well as compromises that deserve consideration for potential solutions. They may be best arrived at by group brainstorming with others.

JUSTIFYING ETHICAL DECISIONS

How do I justify an ethical decision?

• It depends on the source of the disagreement.

If the source of the disagreement involves the competing interests of stakeholders, 2 questions must be asked:

1. Do ethically justified reasons exist for giving priority to the interests of one party over another?

2. Who is invested with decision-making authority?

• If the source of the disagreement involves the facts in the widest sense of the word (benefit and harms of procedures or research, worldview beliefs), the resolutions differ. It is easiest if concerning facts where irrefutable data exist. When the facts concern probabilities, experts in given areas as well as existing literature may help. Other considerations here include quality of life, autonomous wishes, etc.

• If the source of the disagreement involves ethical norms and values, goals must be clarified first.

How many types of norms are there to consider?

• 2: moral absolutes and prima facie norms. An example of a moral absolute is "it is wrong to kill a human for personal gain." Professional codes and laws often contain such norms. If a worthy goal conflicts with a moral absolute, the absolute trumps the goal. Prima facie norms express commitment to a value that deserves respect and should always be taken into account. Examples include confidentiality, or informed consent. Although these values should always be considered, there are circumstances where a breach of the norm is appropriate. An example includes the Tarasoff case, where a viable threat to another human being warrants the potential victim being informed.

What is a profession?

• An occupational group with internal ethical standards related to the primary goals of the profession.

What is professionalism?

• It is "something that resides in the interface between the possession of specialized knowledge and a commitment to use that knowledge for the betterment of others." (Goode, 1969)

• It is "aspiring toward altruism, accountability, excellence, duty, service, honor, integrity, and respect for others." (American Board of Internal Medicine, 1995)

CONCEPTS

What are the ACGME Core Competencies of Professionalism?

Resident should demonstrate:

• Respect, compassion, integrity, and altruism in their relationships with patients, families, and colleagues

• The ability to serve as patient's advocate

• Willingness to provide needed care regardless of ability to pay

• Avoidance of conflicts of interest

• Avoidance of inappropriate gifts

Residents should demonstrate knowledge of:

• The proscription against sexual relationships with patients

• Issues of impairment, including substance abuse

• Health care resources available in the community

• Health care needs of the community

What defines a conflict of interest?

• A conflict of interest exists whenever a duty of a physician to a patient is in tension with some interest or interests of the physician. This might possibly adversely influence a physician's decisions or actions.

Name 3 types of conflicts of interests:

• Financial—These include investments, gifts, and interactions with third-party payers.

• Professional—These include multiple roles, that is, research and patient care, and dealing with impaired or inappropriate colleagues.

• Personal—These include family, social, and other personal issues.

Name types of communication issues:

• Delivering bad news

• Truth telling about complications and bad outcomes

• Obtaining informed consent

List issues of palliative care, death, and dying

• Do Not Resuscitate (DNR) in the operating room

• Advance directives

• Futility

• Withdrawing and withholding treatment

• Euthanasia and physician-assisted suicide

What is an advance directive?

• A health care power of attorney, living will, a written combination of these, or other written expression of a patient's wishes for treatment or the person(s) they want to make decisions for them.

What is futile treatment?

• Any clinical circumstance in which the doctor and his/her consultants, consistent with the available medical literature, conclude that further treatment (except comfort care) cannot, within reasonable possibility, cure, improve, or restore a quality of life that would be beneficial to the patient.

What is euthanasia?

• Decisions or acts that end the life of a patient suffering from an illness. Active euthanasia involves the use of lethal substances. Withholding of life-sustaining treatments is accepted in modern medical practice under the right circumstances.

What is physician-assisted suicide?

• When a physician helps another person voluntarily end their life

What is confidentiality?

• The duty of the physician to not disclose protected health information or information obtained in the delivery of health care

Are there cases where a breach of confidentiality is warranted?

• Yes. They can include threat to specific individuals, reporting of issues such as child abuse to the authorities and to individuals assisting the care of the patient.

• There may also be cases where patient behavior has the possibility of harming others, and different jurisdictions might authorize or mandate reporting these cases.

Name 3 situations of inappropriate breaches of confidentiality:

• Discussing confidential information in public

• Giving information to a colleague not caring for the patient for personal reasons

• Leaving a hospital computer without logging out

What is an impaired physician?

• This is defined by the American Medical Association as a physician unable to fulfill professional or personal responsibilities due to psychiatric illness, alcoholism, or drug dependency.

What is the Hidden Curriculum in medical training?

• Day-to-day experiences that challenge or diminish professionalism in trainees