This presentation was given for the staff of King Fahad Medical City in Riyadh, 11-14 May, 2016 Its content included: Professionalism: Approaches and Dimensions of professionalism Doctor’s Professional Relationships and Duties Saudi Code of Ethics for Medical Practitioners Conflict of Interests (COI) DISCLAIMER: This presentation is based on the Professionalism and Ethics Handbook for Residents Citation: Hussein GM, Kasule OH, Al-Kaabba AF. Professionalism and Ethics Handbook for Residents. Ware J, Kattan T, editors. Riyadh, Saudi Arabia 2015

1. PROFESSIONALISM IN
MEDICAL PRACTICE
(KFMC, MAY 9, 2016)
Ghaiath Hussein,
MBBS, MHSc. (Bioethics)

2. Outline of the session
■ Professionalism:
– Approaches and Dimensions of professionalism
– Doctor’s Professional Relationships and Duties
■ Saudi Code of Ethics for Medical Practitioners
■ Conflict of Interests (COI)
■ DISCLAIMER:
This presentation is based on the Professionalism and Ethics
Handbook for Residents
Citation: Hussein GM, Kasule OH, Al-Kaabba AF. Professionalism and Ethics
Handbook for Residents. Ware J, Kattan T, editors. Riyadh, Saudi Arabia 2015

3. PROFESSIONALISM
Doctor’s Professional Duties & Relationships

4. Clinicians Beyond Hospitals!
COUNTRY/REGION
Policy maker
Planner
Manager
COMMUNITY
Advocate
Researcher
Educator
CLINIC/HOSPITAL
Provider Manager Educator Researcher

5. Levels of Behavioural ‘Control’
Morality
Ethics
Laws & Regulations
Institutional Policies
Professional standards
Personal beliefs &
preferences
•General unchallenged community value; voluntarily followed
•Inherited as is; not argued
•Not written; changes slowly with time
•Argued; logically established (moral philosophy)
•Voluntarily; not universal
•Inspires codes, policies, & laws
•Binding to everyone
•Legal actions may follow, if not followed
•Binding to those in the institution
•Should be followed; disciplinary action might follow if not
followed
•Binding to those in profession
•Mostly voluntary; disciplinary action might follow if not
followed
•Written as Codes
•Varies individually
•Commits only you (and dependents)

6. So your expected roles are…
CanMEDS
(http://www.royalcollege.ca/)
SaudiMEDS
Saudi Meds: A competence specification for Saudi medical graduates
Rania G. Zaini , Khalid A. Bin Abdulrahman , Abdulaziz A. Al-Khotani , Abdol
Monem A. Al-Hayani , Ibrahim A. Al-Alwan , Saddig D. Jastaniah
Medical Teacher , Vol. 33, Iss. 7, 2011

7. SAUDI CODE OF
ETHICS FOR
HEALTHCARE
PRACTITIONERS
http://www.scfhs.org.sa/Reglations/CR/Documents/%D8%A3%D8%AE%D9%84%D8%A7%D9%82%D9%8A%D8%A7%D8%AA
%20%D8%A7%D9%84%D9%85%D9%85%D8%A7%D8%B1%D8%B3%20%D8%A7%D9%84%D8%B5%D8%AD%D9%8A.pdf

8. Overview on the Saudi Code of Ethics (1)
■ Introduction ..
(A) Medical Profession Ethics and
Regulations
(B) Honour of the Healthcare Professions
(C) Sources of Healthcare Professional
Ethics
(D) Healthcare Profession Honour .
(E) Role of Role-Models
■ Healthcare Practitioner Ethics
(A) Devotion and Feeling the Worship of
Allah (SWT)
(B) Demonstration of the Best of
Manners
(C) Self-accountability
(D) Avoidance of Trivialities and Pettiness
■ Healthcare Practitioner’s Duties Towards
Patients
(A) Good Treatment of Patient .
(B) Achieving Patient’s Interest and Guarding
His/Her Right
(C) Patient’s Consent
(D) Reassurance of Patient
(E) Maintaining Patient’s Secrets - Confidentiality
(F) Photographing Patients and Recording Their
Voices
(G) Dealing with Patients Who Refuse a Medical
Procedure
(H) Conscientious Objection to Refrain from
Treating a Patient
■ Healthcare Practitioner’s Duties Towards
Community .
■ Healthcare Practitioner’s Duties Towards
Professional Colleagues
■ Healthcare Practitioner’s Duties Towards
Him/Herself

9. Overview on the Saudi Code of Ethics (2)
■ Healthcare Practitioners’ Duties
Towards His/Her Profession
■ Observance of Religious Rulings
(A) Ruling on Exposing Private Parts of
the Body (Awra)
(B) Rulings in Abortion
(C) Relation Between the Opposite
Sexes
(D) Healthcare Practitioner’s Relations
Outside the Limits of the Profession
(E) Religiously Forbidden Procedures
and Treatment Methods
■ Ethics of Teaching and Learning on
Patients
■ Ethics of Documentation and
Authentication ..
(A) Medical Record ....
(B) Certificates and Reports ....
(C) Medical Prescriptions .
■ Ethics of Financial Affairs in the
Healthcare Field .
(A) Healthcare Practitioner’s Fee ....
(B) Practicing in Private Sector .
(C) Advertisements and Publicity ...
(D) Participation in the Media
(E) Gifts and Benefits
(F) Relationships with Pharmaceutical
and Medical Equipment Companies
(G) Insurance

10. Overview on the Saudi Code of Ethics (3)
■ Ethics of Conducting Biomedical
Research
(A) Conducting Biomedical Research
on Humans
(B) Conducting Research and
Experiments on Animals
(C) Regulations for Accepting Scientific
Research Grants
(D) Regulations for Innovative
Interventional Procedures
■ Ethics of Dealing with
Communicable Diseases
■ Ethics of Dealing with the
Developments in Healthcare
Practices
■ Ethics of Dealing with Emergency
Situations
■ Ethics of Dealing with Life-
threatening and Incurable Diseases
(A) Does the Patient Have the Right to
Refuse Treatment in Incurable
Conditions? .
(B) Should Medical Treatment Be
Stopped?
(C) Cardiopulmonary Resuscitation
(D) Conditions of Prolonged or
Terminal Coma due to Cerebral
Cortical Damage

11. Professionalism
“constituting those attitudes and behaviors that serve to
maintain patient interest above physician self-interest.”
American Board of Internal Medicine
 Professional competence is the habitual and judicious use of
communication, knowledge, technical skills, clinical
reasoning, emotions, values, and reflection in daily practice
for the benefit of the individual and community being served.
Epstein and Hundert

12. What is professionalism about?
Undesirable conductDesirable Behaviors
Abuse of power
Bias
(Sexual) harassment
Breach of confidentiality
Arrogance
Greed
Misrepresentation
Impairment
Lack of conscientiousness
and
Conflicts of interest
Altruism
Accountability
Excellence
Duty
Honor
Integrity
Respect for others, and
A commitment to lifelong
learning
Source:http://www.med.uottawa.ca/students/md/professionalism/eng/what_is_professionalism.html

13. Muslim Doctors’ Duties Towards Patients
 Respect for Patient ‫المريض‬ ‫احترام‬
 Respect for Privacy ‫المريض‬ ‫خصوصية‬ ‫ضمان‬
 Comprehensive care ‫للمريض‬ ‫الشاملة‬ ‫الرعاية‬
 Respect for patient’s autonomy ‫المريض‬ ‫استقاللية‬ ‫احترام‬
 Inform the patient about his/her condition ‫مرضه‬ ‫بطبيعة‬ ‫المريض‬ ‫تبصير‬
 Protect patient's interests ‫المريض‬ ‫مصلحة‬ ‫حماية‬
 Keep the patients’ secrets (confidentiality) ‫المريض‬ ‫سر‬ ‫كتمان‬
Source: Islamic Code of Medical & Health Ethics

14. Physician's Duties Towards Colleagues
 To deal with, and act towards his colleagues in a good
manner and in the same way he would prefer to be
treated
 To avoid direct criticism to his colleague in front of
patients
 Not to indulge in defaming the honor of his colleagues
 To exert every possible effort to educate the colleagues
 Respect the differences with colleagues (sex, culture,
belief…).
 The physician should respect other non-physician
medical profession colleagues, and appreciate their
roles in healthcare of the patient
 She/he must report the incidence in which a colleague

15. Doctor’s Duties Towards his/her Profession
 Respect the honour of the profession;
 Develop him/herself to develop the profession
through CME, research, and publications;
 Adhere to the standards of practice (GCP, EBM,
guidelines, etc.)
 Abstain from any behaviour/action that would
question his/her credibility, or establish dishonest
affairs with patients or their families;
 Avoid the request of fame on the account of the
professional ethics and standards
 To provide role model for his colleagues and
patients Source: Islamic Code of Medical & Health Ethics

16. Doctor’s Duties Towards his/her Profession
Reflect sincere devotion and dedication to the
medical profession.
To avoid any action that could lead to contempt of
the medical profession and to maintain the
standards of medical profession
To contribute in the development of the profession
through research and continuous learning.
The physician should not take advantage of his
profession position for obtaining any material or
moral gains, which are not in conformity with or
violate the laws and tradition.

17. Doctor’s Duties Towards his/her Profession
To take the appropriate procedure when he comes
to know that one of the members of the health
team is sick, ignorant or negligent of his duties; in
furtherance of protecting the patient in the first
place and the medical profession next.
The physician should refrain, when dealing with the
patient, from any act or conduct that would infringe
his honesty and integrity.
To avoid seeking fame at the expense of the
profession ethics and principles.

18. Doctor’s Role Towards Community
 Positive interaction with the community’s affairs
 Protect the community by reporting
reportable/epidemic diseases
 Improve health in the community through advocacy
and health education, and involvement in
community health activities
 Rational use of the healthcare institutions’
resources
 Effective contribution to the development of policies
and health systems that respond to the community
needs and facilitates easier access to health care.
Source: Islamic Code of Medical & Health Ethics

19. Doctor’s Role Towards Community
 To be as a role model in his/her attitude and religion
 Promotion of health equity among the society
members
 Maintenance of health resources and the ideal
utilization of such resources.
 Use his skills, knowledge and expertise to improve
the standards and quality of health services rendered
to the society.

20. Lack of Professionalism
Signs of lack of professionalism (ABIM, 2001)
1. Abuse of power:
– Abuse while interacting with patients and colleagues;
– Bias and sexual harassment; and
– Breach of confidentiality
2. Arrogance (offensive display of superiority and self-importance);
3. Greed (when money becomes the driving force);
4. Misrepresentation (lying, which is consciously failing to tell the truth; and
fraud, which is conscious misrepresentation of material fact with the
intent to mislead);
5. Impairment (any disability that may prevent the physician from
discharging his/her duties);
6. Lack of conscientiousness (failure to fulfill responsibilities);
7. Conflicts in interests (self-promotion/ advertising or unethical
collaboration with industry; acceptance of gifts; and misuse of services
– overcharging, inappropriate treatment or prolonging contact with
patients).

21. CONFLICT OF
INTERESTS
COI in research and clinical practice

22. What is an interest?
• An interest may be defined as a commitment,
goal, or value held by an individual or an
institution.
• Examples include a research project to be
completed, gaining status through promotion or
recognition, and protecting the environment.
Interests are pursued in the setting of social
interactions.

23. Conflict of Interests (COIs)
■ In research:
“situations in which
financial or other personal
considerations may
compromise, or have the
appearance of
compromising, an
investigator’s judgment in
conducting or reporting
research.” AAMC, 1990
■ In clinical care:
“a set of conditions in which
professional judgment
concerning a primary interest
tends to be unduly influenced by
a secondary interest” (Thompson,
1993).

24. Potential causes of COI
 In research:
• Stock ownership in pharmaceutical or
equipment companies
• Paid board membership
• Patent applications (pending or actual)
• Research grants (from whatever
source)
• Travel grants and honoraria
• Gifts Membership of lobbying
organizations
• Relationship with the Research Review
Committees, or with possible
reviewers of the paper
• Relationship with organizations and
funding bodies
■ In clinical practice (Sade, 2007):
■ Financial relationships with
pharmaceutical or medical
equipment’s companies
■ provision of a free lunch and drug
samples
■ reimbursement for costs associated
with professional meetings
■ receiving payments for consulting,
giving lectures, or enrolling patients in
trials.
■ Dual practice (working in Private &
Public facilities)

25. Are such relationships problematic?
Why?
■ Advantages
– Research needs financial and
technical support
– Free samples can help some
patients who cannot afford the
drug
■ Disadvantages:
– Researchers might feel
committed to provide
‘something’ in return
– Reordering of priorities towards
applied research
– Pharma rep.s emphasize
selective positive effects of
drugs citing selective literature
– Clinicians'’ decisions are not/ill-
informed
– Exploitation of trainees
– Loss of public trust

26. Discussion of Cases
■ Case of Dr Butcher, the well-known surgeon (Module 3)
■ Cases of COI (Module 10)