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- 2. The Culture of Health Care Ethics and Professionalism Lecture a This material (Comp 2 Unit 8) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
- 3. Ethics and Professionalism Learning Objectives • Discuss foundational concepts in medical ethics and professionalism (Lecture a). • Examine the relationships among ethical ideals, professionalism, and legal duties (Lecture a, b). • Apply the general principles of ethics and professionalism to specific topics (Lecture c, d). • Examine ethical issues in health informatics (Lecture d). 3
- 4. What Is Meant by Ethics and Professionalism? • Ethics is the study of what people think is right and wrong • Professionalism means that a person acts in a way that meets the standards of his or her profession – Training and skills – Ethical principles 4
- 5. Four Basic Principles Plus concern for the scope of application of these principles 8.1 Figure: Four basic principles of healthcare (CC BY-NC-SA 3.0, 2012). 5
- 6. Respect for Autonomy • Autonomy = Self-governance • Respect for autonomy = Patients have the right to make their own decisions without undue influence – Health care decisions are voluntary • Foundation of “informed consent” 6
- 7. Beneficence • The idea that actions of health care providers should benefit people – Prevent problems that may occur – Treat problems that have occurred • Widely accepted as an appropriate goal of health care • Applied at individual level and population- wide level 7
- 8. Nonmaleficence • The obligation to not intentionally create unnecessary harm or injury to the patient • Applies to both commission and omission Commission Omission Act that causes harm Failure to act when one should act Example: performing needless surgery Example: intentionally withholding a helpful drug 8.2 Table: Nonmaleficence (CC BY-NC-SA 3.0, 2012). 8
- 9. Justice • Justice in the medical ethics setting means fairness • Includes the concepts that – All people have the right to be treated equally – If there is not enough to go around, what is available should be distributed fairly 9
- 10. “Concern for the Scope of Their Action” • Who are health care professionals responsible to? – Everyone in their community? – Everyone in the country? • How far does respect for autonomy go? – Do animals have rights? – Does the environment have rights? 10
- 11. The Principles in Action • Respect for autonomy – Informed consent – Medical confidentiality • Beneficence and nonmaleficence – Requires that treatments be designed to maximize benefits and minimize risks • Justice – The risks of medical research should not fall disproportionally on one group of people 11
- 12. Prima facie Duties • Prima facie = “At first view,” or self-evident • Each ethical principle is binding unless it conflicts with another principle • When the principles conflict, a person must decide which one to act on • The theory of the four principles does not give guidance about which one to choose or how to prioritize them 12
- 13. Ethical Dilemma Occurs when someone must choose between conflicting ethical principles 8.3 Figure: Ethical dilemma (CC BY-NC-SA 3.0, 2012). 13
- 14. Obligation and Aspiration • Obligation = Minimum standard necessary to meet professional obligation – Provide competent medical care to individual patients – Make sure patients understand the risks and benefits of treatment • Aspiration = Standard that one should strive to achieve but is not always attainable – Providing equal worldwide access to health care – Find cures for currently incurable conditions 14
- 15. Ethics Committee • Group of people who meet to discuss ethical dilemmas • All accredited hospitals must have a process for resolving ethical questions • Membership is usually diverse and may include – Doctors and nurses – Other health care professionals – Social workers and lawyers – Religious professionals – Members of the community 15
- 16. Codes of Ethics • Examples: – American Medical Association – American Nursing Association – International Council of Nurses – American Health Information Management Association – American Medical Informatics Association 16
- 17. Hippocratic Oath • Historical foundation of medical ethics • States a moral obligation to maximize benefits of treatment and minimize harms of treatment • Much of the original oath is not relevant today • Modernized versions of the oath are used at some, but not all, medical schools 17
- 18. Professionalism • Profession = An occupation that – Requires special knowledge and training – Has standards for behavior • Health care professional = A person who, by training and experience, has the knowledge to provide some aspect of health care delivery • Professionalism means – Acting in a way that meets standards – Knowing ethical obligations and trying to meet them 18
- 19. Core Medical Professional Responsibilities • Professional competence • Honesty with patients • Patient confidentiality • Appropriate relations with patients • Improving quality of care American Board of Internal Medicine, 2005; Cassel, 2009 19
- 20. Core Medical Professional Responsibilities Continued • Improving access to care • Fair distribution of limited resources • Scientific knowledge • Managing conflicts of interest • Maintaining professional responsibilities American Board of Internal Medicine, 2005; Cassel, 2009 20
- 21. Ethics and Professionalism Summary – Lecture a • People in the health care profession have duties based in the four core principles of medical ethics: – Respect for autonomy – Beneficence – Nonmaleficence – Justice • Health care professionals must consider how broadly their ethical duties extend (“scope of their action”) • Professionalism requires that people in the health care industry act in accord with certain standards 21
- 22. Ethics and Professionalism References – Lecture a References American Board of Internal Medicine. (2005). Physician charter. Retrieved from http://abimfoundation.org/what-we-do/medical-professionalism-and-the-physician- charter/physician-charter Antiel, R. M., Kinghorn, W. A., & Reed, D. A. (2013, July). Professionalism: Etiquette or habitus?. In Mayo Clinic Proceedings, 88 (7), 651. Mayo Foundation for Medical Education and Research. Aulisio, M. P, Arnold R. M. (2008). Helping to address value conflicts or uncertainties: Role of the ethics committee. Chest, 134, 417–424. Cassel, C. K. (2009). 21st century medical professionalism: Renewing the social contract. Retrieved from http://www.slideshare.net/ABIMFoundation/medical-professinalism-renewing-social-contract CMPA, (2012) Physician professionalism. Is it still relevant? Retrieved from https://www.cmpa- acpm.ca/-/physician-professionalism-is-it-still-relevant- Ethics & Compliance Initiative. (n.d.). Ethics and compliance glossary. Retrieved from https://www.ethics.org/resources/free-toolkit/toolkit-glossary. Gholami-Kordkheili, F., Wild, V., & Strech, D. (2013). The impact of social media on medical professionalism: A systematic qualitative review of challenges and opportunities. Journal of Medical Internet Research, 15(8), e184. Retrieved from http://www.jmir.org/2013/8/e184/%23ref44 Gillon R. (1994). Medical ethics: Four principles plus attention to scope. BMJ, 309(6948), 184–188. Gillon R. (2003). Ethics needs principles: Four can encompass the rest—and respect for autonomy should be “first among equals.” Journal of Medical Ethics, 29(5), 307–312. 22
- 23. Ethics and Professionalism References – Lecture a Continued Jennings, B., Baily, M. A., Bottrell, M., Lynn, J. (Eds.). (2007). Health care quality improvement: Ethical and regulatory issues. The Hastings Center. Retrieved from http://www.thehastingscenter.org/uploadedFiles/Publications/Special_Reports/Health%20Care%2 0Quality%20Improvement.pdf Kirk, L. M. (2007). Professionalism in medicine: definitions and considerations for teaching. Proceedings (Baylor University Medical Center), 20, 13–16. Kong, W. M. (2015). What is good medical ethics? A clinician's perspective. Journal of Medical Ethics, 41(1), 79–82. Retrieved from http://jme.bmj.com/content/41/1/79.full McCormick, T. R. (2013). Ethics in medicine: Principles of bioethics. Seattle: University of Washington School of Medicine. Retrieved from http://depts.washington.edu/bioethx/tools/princpl.html Meslin, E. M., Alpert, S. A., Carroll, A. E., Odell, J. D., Tierney, W. M., & Schwartz, P. H. (2013). Giving patients granular control of personal health information: Using an ethics “Points to Consider” to inform informatics system designers. International Journal of Medical Informatics, 82(12), 1136– 1143. Retrieved from http://www.sciencedirect.com/science/article/pii/S1386505613001895 National Library of Medicine, History of Medicine Division. (2002). Greek medicine: The Hippocratic oath. Retrieved from http://www.nlm.nih.gov/hmd/greek/greek_oath.html Pearlman, R. A. (2013). Ethics in medicine: Ethics committees and ethics consultation. University of Washington School of Medicine. Retrieved from http://depts.washington.edu/bioethx/topics/ethics.html 23
- 24. Ethics and Professionalism References – Lecture a Continued 2 Wynia, M. K., Papadakis, M. A., Sullivan, W. M., & Hafferty, F. W. (2014). More than a list of values and desired behaviors: A foundational understanding of medical professionalism. Academic Medicine, 89(5), 712–714. Tables, Charts, Figures 8.1 Figure: Four basic principles of healthcare (CC BY-NC-SA 3.0, 2012). 8.2 Table: Non-Maleficence (CC BY-NC-SA 3.0, 2012). 8.3 Figure: Ethical dilemma (CC BY-NC-SA 3.0, 2012). 24
- 25. The Culture of Health Care Ethics and Professionalism Lecture a This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. 25
Editor's Notes
- No audio. Recording preparation.
- Welcome to The Culture of Health Care: Ethics and Professionalism. This is Lecture a. The component, The Culture of Health Care, addresses job expectations in health care settings. It discusses how care is organized within a practice setting, privacy laws, and professional and ethical issues encountered in the workplace.
- The objectives for Ethics and Professionalism are to: Discuss foundational concepts in medical ethics and professionalism Examine the relationships among ethical ideals, professionalism, and legal duties Apply the general principles of ethics and professionalism to specific topics Examine ethical issues in health informatics
- This lecture discusses ethics and professionalism. These topics are very broad and can include many ideas that are not clear-cut. This unit approaches the subject of ethics and professionalism by starting with some basic ideas, then showing how these ideas apply to the complicated situations that can occur in health care settings. Generally speaking, ethics is the study of beliefs about what is right and wrong and how people go about making those kinds of decisions. Professionalism is a term that describes generally accepted ideas of appropriate conduct within a specific profession.
- Many people who study medical ethics say that the basics of health care ethics can be captured by four principles: respect for autonomy, beneficence [beh-neff-fuh-sense], nonmaleficence [non-muh-leff-fuh-sense], and justice. Some experts are critical of this approach because each of the broad principles is open to a variety of interpretations. However, these four basic principles are widely used and serve as the starting point for many discussions of health care ethics. The following slides define each of these principles and show how they are applied in health care settings.
- Generally, autonomy means people have the right to make their own decisions. This concept is often called “self-governance.” In the health care setting, respect for autonomy means that health care professionals must recognize that patients have the right to make their own treatment decisions based on their individual preferences and beliefs. Respect for autonomy also includes the idea that health care decisions are entirely voluntary. Health care providers must not put excessive pressure on patients to make a particular choice or submit to treatments. The principle of respect for autonomy is the ethical basis for the concept of informed consent. Informed consent means that the patient knows, understands, and accepts the risks and benefits of treatment. This concept is discussed in more detail in a later lecture.
- The principle of beneficence simply means that health care providers should do things that benefit the patient. This includes both actions meant to prevent problems and actions to address problems the patient is already experiencing. The idea of beneficence is commonly recognized as one of the main purposes of health care. The idea is applied at the level of individuals and the level of populations. For example, giving antibiotics to a patient with pneumonia applies the principle of beneficence at the individual level. Giving elderly patients the opportunity to be vaccinated against pneumonia applies the principle at a population level.
- Nonmaleficence is the expectation that health care professionals won’t intentionally injure a patient. Medical students learn the famous saying that doctors should “First, do no harm.” There are two types of maleficent acts: acts of commission and acts of omission. An example of an act of commission is giving a patient a drug for the sole purpose of harming the person. Acts of omission might be less obvious. An example is intentionally withholding a drug from a patient who is expected to benefit from the drug.
- In discussions of medical ethics, the term justice is often used as a synonym for fairness. The concept of justice includes the idea that all people have the right to be treated equally. Distributive justice is the idea that if resources are scarce, they will be allocated in a fair manner. How distributive justice should be implemented is controversial in our society, and it’s discussed in more detail in a later lecture.
- Health care professionals have an obligation to consider difficult questions about how far and wide their ethical duties extend. Obviously, it’s not reasonable to think that every individual health care professional is responsible to care for every individual in the world. But is each health care professional responsible to everyone in their community? How about everyone in the country? Furthermore, does the health care profession as a whole have a duty to society as a whole? Do health care professionals have to respect the rights of laboratory animals, or of the whole natural environment? These are difficult questions, and well-meaning people can have fundamentally different beliefs about the answers. The phrase “concern for the scope of their action” means that when health care professionals are confronted with these kinds of difficult questions, they are obligated to think about them.
- The general principles of respect for autonomy, beneficence, nonmaleficence, and justice have many specific applications in the health care setting. As previously mentioned, informed consent is a major duty that flows from respect for autonomy. Another duty based in respect for autonomy is confidentiality. In general, a person has no obligation to keep the secrets of another. However, in the health care setting, confidentiality is both a legal and an ethical duty. The principles of beneficence and nonmaleficence are closely related. One implication of these duties is that health care treatments must be designed to maximize benefits and minimize risks. The principle of justice obliges the health care profession to ensure that the risks of medical research do not fall disproportionally on one group of people. As previously mentioned, another implication is that health care will be distributed fairly among patients.
- Experts in medical ethics say that each of the four principles is a prima facie [pree-muh fay-shee] duty. Translated from the Latin, prima facie means “at first view.” In the context of ethics, this term means it’s self-evident that an ethical principle is binding unless it conflicts with another principle. As an example of a conflict in principles, imagine a situation in which there’s only enough medicine for one patient, but two patients need to be treated, and half the medicine would do no good for either patient. This situation represents an ethical conflict between the duties of beneficence, nonmaleficence, and justice. Unfortunately, the concept of the four principles does not give guidance about how to choose between the principles when they conflict.
- A conflict between ethical principles is called an ethical dilemma. People working in the health care field are often faced with ethical dilemmas, and although the four principles are a guide, they do not always provide an answer. For example, a doctor may be unsure whether to recommend withdrawing life-sustaining treatment from a very premature infant who is not expected to survive. Another example of an ethical dilemma is how to decide which patient should receive a kidney that has become available for transplant.
- Sometimes, ethical issues are divided into those that are professional obligations and those that are aspirational. An obligation is a standard that must be met, the minimum of care that must be provided. Some examples of ethical obligations are to provide competent health care to individual patients and to make sure patients understand the risks and benefits of treatment. In contrast, an aspirational goal is a standard that would be met in an ideal world but is not currently achievable in the real world. Some examples of aspirational goals are providing equal worldwide access to care and finding cures for diseases that are currently incurable.
- A common way for health care professionals to resolve ethical dilemmas is to consult with others. This can be accomplished by having an ethics committee that is consulted to make ethical decisions. In the United States, all accredited hospitals must have a process for resolving ethical questions, and this usually takes the form of an ethics committee. Many long-term-care facilities and home health care organizations also have ethics committees. The members of the ethics committee usually represent the many kinds of people who have a stake in resolving ethical questions. This can include doctors, nurses, other health care providers, social workers, lawyers, members of the clergy, and people from the community who are not health care professionals.
- Another way in which health care professionals may get guidance about a difficult ethical situation is to consult a code of ethics created by an organization related to their specific profession. For example, the American Health Information Management Association has a code of ethics for health information management professionals who are responsible for oversight of the patient’s record. The American Nursing Association has a code of ethics for nurses, and the American Nursing Informatics Association supports ethical behavior through its bylaws. When doctors in private practice have ethical questions, they might consult the American Medical Association Code of Ethics or the American Medical Informatics Association. Many health care professional associations have codes of ethics and directives on ethical behavior. In addition, doctors and other health care professionals may talk the situation over with their coworkers and peers. In some cases, they might even consult a medical ethicist [eh-thih-sist], a person who is specially trained to deal with ethical questions. Codes of ethics can be statements of current professional standards, or they can be aspirational, seeking to raise the standards of the profession. Some codes of ethics contain both obligatory and aspirational statements. A code that contains both kinds of provisions should identify the statements that are intended to be aspirational. A code of ethics may also be called an ethical statement, statement of professional conduct, or something similar. In this unit, the American Health Information Management Association, the American Medical Association, American Medical Informatics Association, and the International Medical Informatics Association are used to discuss the role of codes of ethics.
- The Hippocratic [hip-po-crat-ick] oath is one of the historical foundations of medical ethics. Generally interpreted, it states that doctors have a moral obligation to maximize the benefits and minimize the harms of treatment. Those core values are still held today, as discussed in this lecture. However, other provisions in the oath reflect the beliefs of ancient Greek culture and are no longer relevant. Some, but not all, medical schools have new doctors take a modernized version of the oath.
- There are many definitions of the word profession. In this unit, it means an occupation that requires special knowledge and training. In addition, a profession has standards that must be met. A health care professional is a person who, by training and experience, has the knowledge to provide some aspect of health care delivery. Professionalism means acting in a way that meets the standards of the profession. In addition, professionals are aware of their ethical obligations and strive to fulfill them.
- A charter created jointly by several medical societies, including the American Board of Internal Medicine Foundation, states ten core principles of medical professionalism for physicians. These principles might equally apply to all medical professionals. The first five principles are as follows: Commitment to professional competence. Individual doctors must do what it takes to keep up with new discoveries in their field and keep their skills at the level needed to deliver appropriate care. The medical profession must monitor its members and provide ways for doctors to meet this goal. Commitment to honesty with patients. This principle includes the duty of informed consent. In addition, this principle requires doctors to be honest when medical errors occur. Commitment to patient confidentiality. Doctors must take steps to protect patients’ private information. Commitment to maintaining appropriate relations with patients. Because patients are often vulnerable and dependent on their health care providers, [quote] “physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose.” [end quote] Commitment to improving quality of care.
- The remaining five principles are as follows: Commitment to improving access to care. Doctors should work to reduce barriers and achieve a fair health care system. Commitment to fair distribution of limited resources. This principle requires that doctors provide cost-effective health care and avoid unnecessary tests and procedures. Commitment to scientific knowledge. Doctors have a duty to [quote] “uphold scientific standards, to promote research, and to create new knowledge and ensure its appropriate use.” [end quote] Commitment to maintaining trust by managing conflicts of interest. Doctors should not [quote] “compromise their professional responsibilities by pursuing private gain or personal advantage.” [end quote] An example is that doctors should report any relationships they have with pharmaceutical companies when they are conducting research or reporting the results of their research in journal articles. Commitment to professional responsibilities. Medical professionals should work together to get the most out of patient care, treat each other respectfully, and take part in the regulation of the profession.
- This concludes Lecture a of Ethics and Professionalism. In summary, people in the health care profession have duties that are based in the core principles of medical ethics: respect for autonomy, beneficence, nonmaleficence, and justice, plus concern for the scope of their action. Professionalism requires that people in the health care industry act in accordance with the standards of their profession. The proper applications of ethical principles and standards of professionalism are not always clear. Individuals can find guidance in codes of ethics, statements of professional standards, and consultations with colleagues, ethics committees, and ethics experts.
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