SCCD HM 546: Introduction to Ethics and Professionalism

1
SCCD HM 546 Introduction to Ethics and
Professionalism
8/05

• Howard Brody, MD, PhD
• Center for Ethics Humanities and
• Department of Family Practice

2
Main Goals

• Define ethics and professionalism
• Discuss relationship
• How should each be taught?
• What about the CHM virtues?
• Propose and evaluate a 3 legged stool model of
  professional integrity

3
Medical Ethics and Events in Iraqi Prisons

• Lifton RJ. Doctors and torture. N Engl J Med
  351415, 2004
• Miles SH. Abu Ghraib its legacy for military
  medicine. Lancet 364725, 2004
• How complicit are doctors in abuses of detainees?
  Lancet 364637, 2004
• Bloche MG, Marks JH. When doctors go to war. N
  Engl J Med 3524, 2005

4
Case

• AR 15-6 Investigation of the Abu Ghraib Detention
  Facility and 205th Military Intelligence Brigade,
  MG George R. Fay
• http//news.findlaw.com/nytimes/docs/dod/fay82504r
  pt.pdf

5
Case (2)

• Incident 19 (approx 4-13 Dec 2003) SGT Adams
  found DETAINEE-06 without clothes or blanket, his
  wounds were bleeding and he had a catheter on
  without a bag. The MPs told her they had no
  clothes for the detainee. SGT Adams ordered the
  MPs to get the detainee some clothes and went to
  the medical site to get the doctor on duty. The
  doctor (Colonel) asked what SGT Adams wanted and
  was asked if he was aware the detainee still had
  a catheter on.

6
Case (3)

• The Colonel said he was, the Combat Army Surgical
  Hospital (CASH) had made a mistake, and he
  couldnt remove it because the CASH was
  responsible for it. SGT Adams told him this was
  unacceptable, he again refused to remove it and
  stated the detainee was due to go back to the
  CASH the following day. SGT Adams asked if he had
  ever heard of the Geneva Conventions, and the
  Colonel responded fine Sergeant, you do what you
  have to do, I am going back to bed.

7
Analysis

• Was the physician in this case acting
  professionally?
• Was the sergeant in this case acting
  professionally?
• What does professionalism require of the military
  physician?

8
Basic Obligations of Military Physicians Toward
Detainees

• Provide medical care (ideally as good as would be
  received by US soldiers)
• Monitor sanitation and public health
• Refuse to participate in torture
• Report torture
• Train subordinates appropriately
• Geneva Convention Army regs WHO Code of Ethics

9
One Physicians Comment

• All military physicians are officers
• Therefore have a dual responsibility to
  report/prevent torture or abuse
• As physicians
• As officers

10
An Irony

• Several Republican senators have offered
  amendment to Pentagon funding bill
• White House has threatened veto
• Amendment requires that standards of
  interrogation of detainees be consistent with
  Army manual
• What does this say about professionalism in
  military?

11
Suggested Distinction

• Duties owed to all other human beings
• Duties owed to others because one occupies a
  specific social role
• Duties owed to others arising from the core
  nature of that social role
• All are ethics
• Last is professionalism

12
Medical Examples

• Duty not to have sex with patients
• Duty to respect confidentiality
• Duty to respect patients autonomy
  (self-determination)

13
Hippocratic Duties

• Long historical tradition
• Suggests that despite radical changes in other
  social practices, physicians have discerned that
  commitment to their profession requires such a
  duty
• Therefore part of professionalism

14
Respect for Autonomy

• Different from other duties?
• Historically physicians felt no such duty
• In other cultures physicians may feel no such
  duty
• Therefore not required by core notion of
  profession?
• Ethics but not professionalism
• Yet profession is evolving

15
Promise-Keeping

• Professionalism has a component of
  promise-keeping that need not be shared by ethics
  more generally
• When one professes to the status of physician,
  one promises the community that one will behave
  according to expected core duties

16
The CHM Virtue List

• Competence
• Honesty
• Compassion
• Respect for Others
• Professional Responsibility
• Social Responsibility

17
Ethics and Virtue

• The CHM list of professional behaviors describes
  a set of virtues of the good (student) physician
• How does virtue fit in with ethics?

18
Two Ethical Questions

• What ought to be done in this situation, all
  things considered?
• Snapshot ethics
• Main focus of HM 546 ethics module
• How ought I live a life of moral excellence in my
  chosen profession?
• Video ethics
• Main focus of professionalism curriculum

19
What Are Virtues?

• Excellences in human behavior
• Represent core moral values
• One tries to live a life so that ones daily
  behavior exemplifies those core values
• Obituary test (inherently biographical view)

20
Example Compassion

• Core personal and professional value (defines
  ideal physician)
• What would the ideally compassionate physician do
  in this situation?
• How would the ideally compassionate physician go
  about living a life with medicine as a chosen
  career?

21
A Famous Musician

• If I dont practice for one day, I know it. If I
  dont practice for two days, the critics know it.
  If I dont practice for three days, the audience
  knows it.
• Fine discernment and virtue

22
Fine Discernment

• Virtue ideally involves doing the right thing, in
  the right way, for the right reasons, with the
  right attitude
• Like becoming a music virtuoso, achieving optimal
  virtue is a life long project
• Irony The more virtuous one is, the better one
  can detect even slight lapses

23
Compassion

• Response to the fellow human who is suffering
• Beginner Oh, dont worry, it cant be that bad
• Responds to my discomfort at others suffering
• Challenge To appropriately be present with the
  suffering person, appropriately vulnerable to
  their suffering, while remaining whole oneself
• Requires extensive experience and practice

24
Compassion, cont.

• Conscious and unconscious elements
• Conscious wish to reflect carefully on what
  compassion is and why it is important (e.g., why
  not sympathy?)
• Unconscious I wish in the future to respond
  automatically to a new situations as a
  compassionate person would
• Goal To be compassionate even when Im having a
  bad day

25
Important Concepts

• Ethics
• Virtue
• Integrity ( wholeness)

26
Three-Legged Stool

• Proposed model to describe typical moral tensions
  that arise in trying to live a life of integrity
  in medicine

27
A Traditional Argument

• The physicians professional and social
  responsibility is solely and completely
  determined by one ethical role serving as a
  single-minded advocate for each individual patient

28
physicians are required to do everything that
they believe may benefit each patient without
regard to costs or other societal considerations.
--N. Levinsky, NEJM 3111573, 1984
29
The Virtuous Physician
Individual patient advocacy
30
Medicines Future

• Resources will be limited and some system of
  rationing will be needed
• Physicians will increasingly be held accountable
  for how they spend other peoples money

31
Newer Argument

• Physicians cannot be completely ethical merely by
  being advocates for individual patients they
  must advocate for all patients collectively by
  concerning themselves with the prudent allocation
  of limited resources

32
The Tension The Physician as--
Prudent allocator of limited resources
Loyal patient advocate
33
The Virtuous Physician
Individual patient advocacy
Advocate for population of patients
34
Example Time Spent with Each Patient

• Complaint Managed care forces the physician to
  rush patients through too quickly
• Does the managed care contract require
  limitations of time per visit?
• Or must the physician see more patients faster if
  he/she wishes to maintain a certain level of
  income?

35
If the providers can somehow insist upon
driving Cadillacs, then a given health care
budget set aside by societywill make available
to patients fewer real health services than would
be available if providers could be induced
somehow to make do with Chevrolets.
--U. Reinhardt, Milbank Q 1987
36
The Virtuous Physician
Advocate for popu- lation of pa- tients
Individual patient advocacy
Reasonable self-interest
37
Three-Legged Stool

• Argues that to live a whole life, one has to
  consider ones own personal interests as being in
  some sort of reasonable balance with competing
  interests
• Ignoring these tensions seems to portray medical
  ethics in an unrealistic light (Sunday sermon)

38
The Virtuous Physician
39
The Virtuous Physician?
Reasonable self-interest
Advocate for popu- lation of pa- tients
Individual patient advocacy
40
The Virtuous Physician?
Reasonable self-interest
Advocate for popu- lation of pa- tients
Individual patient advocacy
41
Tension Virtuous and Non-virtuous Behavior
Deficiency Golden Mean Excess
Nontrustworthi-ness Individual advocacy Wastefulness
Wastefulness Population advocacy Pure statistician
Self-abnegation Reasonable self-interest Greed
42
Three-Legged Stool

• The ideally virtuous physician strives throughout
  a professional life to balance these tensions
• Among the three competing values (legs)
• Against the pulls on each leg to move away from
  the golden mean