Professionalism and ethics

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Professionalism and ethics

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Outline

• Recent expressions of concern re the professional
  status of medical practitioners (NB Such concerns
  are not new!)
• The possible origins of these concerns
• The responses on behalf of the profession
• What this might all mean for regulators

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Themes

• Professionalism and ethics, and the connection
  between them
• The influences that may be at work
• The responses from sections of the profession
• What might be learned

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Definitions

• What is a profession?
• What do we mean by ethics?
• What do we mean by professional ethics?
• And what is medical professionalism?

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What is a profession?

• Historical notions of a life time commitment to
  service
• In modern times there is no agreed definition
• For the medical profession, I suggest that the
  defining quality is putting the patients
  interests ahead of personal interests

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What is ethics?

• How we choose to live our lives after
  considering all the issues
• Ethics searches for reasons for acting or
  refraining from acting, for approving or not
  approving conduct, for believing or denying
  something about virtuous or vicious conduct or
  good or evil rules
• NB. Simple definitions encourage community input
  to ethical debate.

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What do we mean by professional ethics?

• Are professional ethical codes designed to
  entrench professional status and privilege?
• Or are they designed to foster conduct which will
  best serve the community?
• And how does a profession answer these questions?
• Or how does a profession engage with the
  community they purport to serve?

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What is medical professionalism?

• Professionalism is the basis of medicines
  contract with society. It demands placing the
  interests of patients above those of the
  physician, setting and maintaining standards of
  competence and integrity and providing expert
  advice to society on matters of health (1)
• Medical professionalism is a set of values,
  behaviours and relationships that underpin the
  trust the public has in doctors. (2)
• 1. A physicians charter. Lancet 2002
  359 520-522.
• 2. Medical professionalism in a
  changing world. Royal College of Physicians,
  December 2005

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What really lies behind the recent papers?

• Today, at the dawn of a new century, genuine
  medical professionalism is in peril.
  Increasingly, physicians encounter perverse
  financial incentives, fierce market competition,
  and the erosion of patients trust, yet most
  physicians are ill-equipped to deal with these
  threats.(1)
• Physicians today are experiencing frustration as
  changes in the health care delivery systems in
  virtually all industrialised countries threaten
  the very nature and values of medical
  professionalism. (2)
• (1) Wynia et al NEJM 1999341 1612-1616.
• (2) A Physicians Charter

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What really lies behind the recent papers? (cont)

• the exercise of medical professionalism is
  hampered by the political and cultural
  environment of health, which many doctors
  consider disabling and (at the end of its
  summary) our collective and abiding wish is to
  put medical professionalism back onto the
  political map of health in the UK.
• Royal College of Physicians. Medical
  professionalism in a changing world.

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Why is the sky falling in?

• A cottage industry no longer
• Rising health care costs
• The need for government to use health budgets
  wisely
• Changing community expectations
• Fragmentation of the profession
• Diminished community respect ?

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The weaknesses of the responses so far (to a
profession seeing itself under siege?)

• A one sided contract
• No or very little attempt to negotiate with, or
  consult with, the community
• Our collective and abiding wish is to put
  medical professionalism back onto the political
  map of health in the UK.
• Royal College of Physicians

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The real issues to debate

• What purpose does a code of ethics serve?
• Should a code of ethics be aspirational or should
  it be a set of standards below which failure
  would lead to disciplinary action?
• If is it agreed that a code be aspirational, who
  should prepare the code and what should be the
  core aspirational values/principles/ ethical
  qualities in it?
• Should the regulator set the ethical standards?
  If so, how would community expectations be
  included?
• Should codes of ethics be enforced? Should they
  have penalties attached?
• If so by whom should they be enforced and by what
  mechanisms?

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Can professionalism be taught?

• Changes to undergraduate and post graduate
  curricula in a number of countries suggest we
  believe this to be the case.
• Character formation cannot be avoided by medical
  educators. Students enter medical school with
  their characters partly formed. Yet they are
  still malleable as they assume roles and models
  on the way to their formation as physicians
  (Pellegrino 2002)

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The changing balance of application of ethical
principles

• The central ethical principle which seemed to be
  lived out by my mentors was beneficence.
• In one generation this has been overshadowed by
  the principle of patient autonomy and respect.
• We are now moving into an era where justice will
  become the dominant influence, because of the
  evident need to use finite resources wisely.

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Some ideas you might wish to debate

• 1. What is the role of a code of
  ethics?
• 2. Should a code of ethics be aspirational
  vs lowest common denominator?
• 3. Should a code of ethics be prepared by
  the profession at large (with community and
  regulator input) or by the regulator?
• 4. Should the regulator have informal or
  formal mechanisms for community consultation and
  involvement?
• 5. Do you agree that justice is becoming a
  more important ethical principle and if so who
  should take responsibility to show leadership in
  this issue?

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WMA Declaration of Geneva 2006

• At the time of being admitted as a member of
  the medical profession
• I solemnly pledge to consecrate my life to the
  service of humanity
• I will give to my teachers the respect and
  gratitude that is their due
• I will practise my profession with conscience and
  dignity
• The health of my patient will be my first
  consideration
• I will respect the secrets confided in me, even
  after the patient has died
• I will maintain, by all means in my power, the
  honour and noble traditions of the medical
  profession
• My colleagues will be my sisters and brothers
• I will not permit considerations of age, disease
  or disability, creed, ethnic origin, gender,
  nationality, political affiliation, race, sexual
  orientation, social standing or any other factor
  to intervene between my duty and my patient
• I will maintain the utmost respect for human
  life
• I will not use my medical knowledge to violate
  human rights and civil liberties, even under
  threat
• I make these promises solemnly, freely and upon
  my honour.

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WMA Declaration of Geneva 2006 (cont)

• What a pity the authors failed to add
• Despite my patient being my first
  consideration, I will also seek to use resources
  wisely and to play a constructive part in the
  health care system my country chooses to
  establish!

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Thank you for your attention