Introduction to Professionalism & Medical Ethics

Introduction to
Professionalism &
Medical ethics
IHAB B ABDALRAHMAN, MBBS, MD, ABIM, SSBB.
CONSULTANT OF ACUTE CARE MEDICINE,
SOBA UNIVERSITY HOSPITAL.
ASSISTANT PROFESSOR OF MEDICINE, U OF K

Aims

 To highlight the concept of professionalism
 To introduce the concepts of Ethics &
Medical Ethics
 To discuss ethical principles
 Beneficience, do good
 Non Maleficience, do no harm
 Autonomy,
 Privacy & confidenciality
 Self determination
 Justice
Ihab B Abdalrahman (Tarawa) 12/31/2012 2

Compartmentalization of life

 One man cannot do right
in one department of
life, whilst he is occupied
in doing wrong in any
other department

You make me cry


Compartmentalization of life

 One man cannot do right
in one department of life,
whilst he is occupied in
doing wrong in any other
department

SYSTEMS GOVERNING
HUMAN SOCIAL BEHAVIOUR

CUSTOM ETIQUETTE ETHICS LAW MORALITY
Mores Professional Professional State, Statutes Spirituality
Etiquette Values Legislature

Tradition Courtesy Competence Enforcement Religious
Integrity Compulsion Good vs Evil
Fairness Judiciary Right vs Wrong
Goodwill Punishment
Truth Justice


What type of professional?

or a good doctor


Definition
Profession
 An occupation whose core element is work
“
based upon the mastery of a complex body
of knowledge and skills.
 In which knowledge and practice of an art is
used in the service of others.
 Its members are governed by codes of ethics
 they are committed to the promotion of the
public good within their domain.
 Professions and their members are
accountable to those served and to society.”
• Derived from the Oxford English
Dictionary
















Why is Professionalism
Important?
“ Neither economic incentives, nor technology,
nor administrative control has proved an
effective surrogate for the commitment to
integrity evoked in the ideal of
professionalism ”

Sullivan, 1995

The Physician Has Two
Roles

 Healer
 Professional

P h y s ic ia n

H e a le r P ro fe s s io n a l

Caring and compassion Autonomy
Competence
Insight
Commitment Self-regulation
Openness Confidentiality
Respect for the Responsibility
Altruism to society
healing function
Integrity and Team work
Respect patient
dignity and honesty
autonomy Morality and ethics
Presence Responsibility to
the
profession

The Social Contract
 The social contract in health care is
based on professionalism.

 It serves as the basis for the
expectations of medicine and
society.

The Social Contract
Society Profession

Patient expectations Physician
obligations

Professionalism

The Social Contract

This Contract Has Always
Been
 Implicit (largely unwritten)
 Evolving (being constantly
renegotiated)

The Social Contract
Society’s Expectations of Medicine’s Expectations of Society
Medicine  trust
 autonomy
 to fulfill the role of the healer  self-regulation
 guaranteed competence  Health Care System
 altruistic service  value-laden
 morality, integrity, honesty  adequately funded
 role in public policy
 accountability
 rewards – non-financial
 transparency • respect
 source of objective advice • status
 promotion of the public good – financial

Individual and Collective Responsibilities

The Contract
Depends On
 mutual trust
 reasonable demands on both
sides
 communication

Professionalism

Communication
Ethics

Behavior


 Components of Medical Professionalism identified to be suitable for trainees:

 Behavior:
 Collaboration.
 Professional health care [e.g. Risk
management, Management of conflicts,
Exerting maximum effort, Appropriate relations
within the health system].
 Self regulation [Self health care, Continuous
Professional Development, Compliance with
regulation of Health authorities such as the
Medical Council].
 Health advocacy.


 Ethics:
 Beneficence (do good).
 Nonmaleficence (do no harm) & malpractice [e.g.
serious professional misconducts highlighted in
the Capital As: Abortion, Association,
Advertisement, Alcohol, Adultery].
 Justice.
 Autonomy [with its three components: Self
determination, Privacy, Confidentiality].
 Probity [e.g. Integrity, Truth telling, Trust].
 Sensibility in dealing with sensitive issues e.g.
dying patient, futility & organ transplant.
 Appropriate doctor-patient relationship

 Components of Medical Professionalism identified to be suitable for trainees:

 Communication – including effective
and professional communication with:
 Patients [e.g. History Taking, Consultation,
Delivering Information, Discussing Results, etc ].
 Relatives and Family,
 Colleagues (e.g. Medicals, Para-medicals, Nurses,
Admin & Supporting Staff, etc..).
 Public – including communication with Health
Authorities, Police, Courts, etc..
 Other Methods, such as communicating In Writing
& Electronically (e.g. Record keeping, Prescribing
skills, Referrals and Transfer letters, etc.


Professionalism

E Communication
Ethics

Behavior


Medical Technician

Skills
&
Knowledge

Ethical
principles

Skills & knowledge

Moral Character


Ethics
Skills & knowledge

Moral Character


 What is Ethics?


 Ethics is the branch of study dealing with

What is the proper
course of action.


 It is the study of right and
wrong.


 It answers the question,

"What do I do?"


The last of human freedoms

 Every thing can be taken from a man, but one
thing:

To choose one’s attitude in a
given set of circumstances,
to choose one’s way
Viktor Frankl


 It is your choice
 Emotion based
 Principle based


Why Ethics is important?

 Ethics is a requirement for human life.

 It is our means of deciding a course of action.


Moment of thought

In many cases
it might help to put yourself
in your patient shoes.

Seek to understand,
before to be understood
What do you want if you are a patient?

 What is medical ethics?

It is just, Doing
the right thing.

But what is right?

 Beginning of life
 End of life
 Limited resources
 When patient demands unacceptable
measures
 What is acceptable?
 Futility of care
 How to define futility?


Medical ethics

 Refers to those guidelines and behaviors that
we expect
 a medical professional
 with moral integrity
 to exhibit.


Medical Ethics

 Beneficence
 Non-maleficence & malpractice
 Justice?”
Principles
 Respect of autonomy
 Privacy
 Confidentiality
 Right to self-determination
 Probity (honesty & integrity) Moral Values

 Sensitivity in dealing with the dying, futility &
organ donation Situation
 Appropriate doctor-patient relationship
12/31/2012

Ihab B Abdalrahman (Tarawa) 41

Ethical Principles
BENEFICENCE
&
NON-MALEFICENCE

objectives

 Definition of beneficence
 Definition of Non-maleficence
 Interaction of these principles


The practice of medicine &
ethics are inseparable

Practice
of
medicine
Practice
of ethics

Ihab B Abdalrahman (Tarawa) 12/31/2012

Every medical
decision

Involve an
ethical decision

What we
Medicine
can do
not be apparent
be apparent and
clear
be apparent and
messy/
conflicting
What we
should
Ethics
do


 Beneficence  Non-maleficence
 (Do Good)  (Do No Harm)
 


Good Vs Bad

 What is good
 What is bad


The context of Good

Good Bad
 Strong  Weak
 Fortune  Misfortune
 Beautiful  Sickly
 Advantageous  Unlucky
 Gender  Opposite Gender


Beneficence

 Beneficence is action that is done for the
benefit of others.


Beneficence

 Beneficent actions can be taken to;
 help
 prevent
 remove harms
 simply improve the situation of others.


Beneficence

 To do good.
 To act on the best interest of your patient.
 To promote patient health and well being.
 Simply helping your patient.


Non-maleficence:

 Definition: Non-maleficence means to “do no
harm.”
 Physicians must refrain from
 providing ineffective treatments
 acting with malice toward patients.


Non-maleficence:
the Capital As
 Alcohol
 Adultery.
 Abortion
 Association
 Advertisement


Do good

Do no harm
• Capital As


Do
good

Do no harm
• Carelessness
• Malice
• Vengeance
• Dislike


Why do good & do no harm

 The goal of medicine is to promote the
welfare of patients.

 Physicians possess skills and knowledge that
enable them to assist others.


Beneficence

 Examples of beneficent actions:
 Resuscitating a drowning victim,
 providing vaccinations for the general population,
 encouraging a patient to
 quit smoking
 start an exercise program,
 Treat HTN & DM.


Non-maleficence: Examples

 Stopping a medication that is shown to be
harmful,
 Refusing to provide ineffective treatment.


Sami & samir are brothers and engineers in petroleum company
They came for routine medical check

 Sami 44 year  Samir 48 year
 No medical problems  No medical problems
 Mother has DM & HTN  Mother has DM & HTN
 Father has HTN  Father has HTN
 BMI 28kg/m2  BMI 32 Kg/m2
 BP 154/96 in several  BP 134/84 in several
occasions occasions


We should weigh and balance
possible benefits against
possible risks.
 Do good  Do no harm

 We have an obligation  We are expected to
to help our patients refrain from causing
harm.


Challenges

 Many beneficial therapies also have serious
risks.
 The pertinent ethical issue is whether the
benefits outweigh the burdens.


Balancing Beneficence and Non-maleficence

 It plays a role in nearly every medical
decision:
 Whether to order a particular test
 Medication
 Procedure
 Operation
 Treatment


Types of risk

 Physical
 Financial
 Social
 Moral
 Religious


Benefit
Benefit Harm Harm



 Physicians give patients the information
necessary to understand the
 Scope
 Nature
 Potential risks and benefits.



 One of the most common ethical dilemmas
arises in the balancing of beneficence and
non-maleficence.

Bad Good


Case study
36 years male presented 36 years pregnant lady
presented

 Fever 39.2,  Fever 39.2,
 Cough,  Cough,
 Production of green sputum  Production of green sputum
 Rt sided Pleuritic chest pain  Rt sided Pleuritic chest pain
 Shortness of breath.  Shortness of breath.
 He has bronchial breathing  He has bronchial breathing
 TWCC 14.000  TWCC 14.000


Case study

 Dr. X did his internship in obstetrics 20 years
ago.
 He did 15 CS.
 After the 7 CS, the registrar felt, Dr X was
competent enough to supervise junior HS.
 Now he is an internist.
 No surgical training for the last 15 year.


 Last week he was called to manage 25 years
lady (G1P0) at 34 weeks, pneumonia and
DKA.
 The lady went into premature labor.
 She went into maternal distress.
 Is it justifiable for Dr to do a CS?
 What is the appropriate course?


 What about if the same situation happened in
a rural area

 What is the appropriate course?


In dilemmas, we see the
content within the context


Autonomy


Reflect

 Definition of autonomy
 Prerequisite to acknowledge autonomy –
conditions need to be satisfied
 Limitations of autonomy


 72 male
 DM for 30 years
 HTN 20 years
 Stage 4 CKD with
Creatinine 4.6


Case study

 36 years old male
 Work as an engineer in Gulf area
 Visiting Sudan for 2 weeks vacation
 Has no significant pass medical history.
 came to the ER with acute right lower
quadrant pain.


Case study

 General examination revealed an ill patient
who is alert awake and oriented.
 His interaction with the staff was appropriate.
 Abdominal exam suggested an appendicitis.
 Urinalysis was normal & TWCC 14,800


 The patient had some doubts regarding the
diagnosis.
 He requested a second opinion.

 What would be the most appropriate actions?


Case study

 Arrangement was made for a second opinion.
 Appendicitis was re confirmed.

 At this point he requested a CT


 CT scanning has high diagnostic accuracy of
95-98%.

 CT scanning is highly accurate, time-efficient,
cost-effective way to evaluate adult patients
with equivocal presentations
for appendicitis.


 Opinion varies as to whether these modalities
should be performed in all patients with
suggested appendicitis or if radiology should
be reserved for select patients with atypical
or confusing clinical presentations.


Case study

 CT scan confirmed the diagnosis.

 Urgent appendectomy was recommended.

 At this point the patient declined surgery and
requested to be treated with antibiotics.
 What was most appropriate action at thas
point?


Autonomy

 Autonomy is a key component in medical
professionalism.

 Professional medical care depends on
 a well trained and competent physician,
 who delivers his care with empathy,
 to a willing patient.


Autonomy

 Patient’s independence .
 A competent adult has the right to make
decisions.
 Patient must be capable of rational thought.
 Not manipulated.
 He can refuse intervention.


Autonomy
Capacity is a prerequisite

 A competent patient has the right to
determine for himself


 Treating patients with respect requires
doctors to accept the medical decisions of
persons who are informed and acting freely.

 Individuals place different values on health,
medical care, and risk.


It is grey & uncertain

 In most clinical settings:
 different goals and approaches are possible,
 outcomes are uncertain,
 an intervention may cause both benefits and
harms.


 Thus competent, informed patients may
refuse recommended interventions and
choose among reasonable alternatives


Could make sense or
not

Satisfy his values

Well informed
Not manipulated

Sound mind •Capable


 Autonomy should prime all the time

 It is important to recognize the boundaries of
sound decision.

 The decision could be sound to the patient
since it satisfies certain values. The same
decision might not make sense to the
physician.

 Dr P K Bansal is an orthopaedic surgeon,
who practices near New Delhi.
He too performs amputations on beggars.
Dr Bansal belongs to a network of doctors
who amputate beggars for money.

 CNN-IBN Posted Saturday , July 29, 2006 at 19:24 Updated
Saturday , July 29, 2006 at 20:57


 Beggars comes to your office
 Autonomously
 He is competent
 Demanding amputation of his leg
 He is paying cash


 Should we do it?
 Why


When patient ask
for unacceptable
intervention

 Autonomy should not be seen as
synonymous with freedom.

 Freedom to choose treatment is not absolute,
rather, it is subject to constraints and thus
only involves a 'substantial degree' of
freedom of choice.


 Mr Z recently diagnosed with HIV and PCP.
 He is confused
 His brother asked you not to tell the wife.


Public hazards


case study

 73 year female with metastatic adenocarcinoma
of the ovary

 She has deposits in the spine, brain and lung

 She received palliative radiotherapy.

 She was found to be coagulopathic,
thrombocytopenic and anemic.


case study

 Evaluation by a hematologist confirmed
malignancy induced chronic DIC.

 He stated that it will be extremely
difficult to cure the DIC without curing her
malignant disease first.


 She was tender all over her body.
 Respiratory distress was noted.
 She was debilitated, malnourished and
cachexic.
 Edematous legs and ascites were noted.
 Her renal function was worsening with a
creatinine of 4.3mg/dl, K 5.4mg/dl, Hb 8.2
gm/dl, platelets 23,000 and INR 3.2.


Is it futility?


 Futility is defined as a judgment that further
medical treatment of a patient would have no
useful result.


 Medical futility is not a new concept. It was
reflected in Hippocratic collections
 “Whenever the illness is too strong
for the available remedies, the
physician surely must not expect
that it can be overcome by
medicine” .


 It is fundamental to recognize that the power
of medicine is limited.

 It is well established that sometimes the
disease process exceeds our medical
capability .


Examining patient’s autonomy

 Autonomy entitles a patient to choose from
among medically acceptable treatment
options (or to reject all options).

 It does not entitle patients to receive
whatever treatments they ask for .


Limitations on Autonomy

 Patient with limited capacity
 Emergency care
 Futility of care
 When patient ask for unacceptable
intervention
 Public hazards


Privacy & Confidentiality


Confidentiality

Walking the fine line
 23 years old unmarried female admitted with
severe right lower abdominal pain. She
reported 2 fainting episodes.

 As patient’s symptoms were worsening, she
was taken for exploration surgery.


 She was found to have ruptured ectopic
pregnancy in the right ovarian tube.
 Right salpingo-opherectomy plus appendectomy
were done.


 Next day the patient was informed about the
finding. She admitted that she missed her
cycle for 50 days and she was worried that
she was pregnant. She asked you to keep her
information confidential.


The unspoken
 Her mom who did not know the outcome
“she thought it was just appendicitis”
“ felt that surgery was delayed and her
daughter life was risked”.

 She complained to the medical manager that
the on call team was negligent.



 They go hand in hand.

 The difference between privacy and
confidentiality can be confusing.



 Privacy is the right of individuals to keep
information about themselves from being
disclosed.

 Patients decide who, when, and where to
share their health information.



 On the other hand, confidentiality is how we,
as health-workers, treat private information
once it has been disclosed to us or others.



 Confidentiality can be breached in case of
public hazard


justice


 Being in a society this requires:
 Peace
 Harmony

Justice
 Others


"Justice is the first virtue of
social institutions,


Justice is a basic need

 "Fairness is activating the same part of the
brain that responds to food in rats...

 This is consistent with the notion that being
treated fairly satisfies a basic need".


Justice

 Means giving others what is due to them;
 it is fair distribution of
 benefits,
 risks,
 costs.


Injustice,
historical reflection

 Patient Vs Sick Poor


He also claimed

 The life of a sick person can be shortened not
only by the acts, but also by the words or
Injustice murders
manner of a physician.

the soul


Justice in Medical practice

 In a medical setting, justice involves the
allocation of health-care resources in a fair
way.
 Egalitarianism This may be an equal
distribution
 Utilitarianism maximization of the total or
average welfare across the whole society.


Aristotle definition, more than 2000 years ago

"equals
should be
treated

Aristotle definition, more than 2000 years ago

 "Individuals should be treated the same,
unless they differ in ways that are relevant to
the situation in which they are involved."


as justifying differential
treatment,
 need,
 desert,
 contribution,
 and effort


?

 We are spending 2/3 of our budget in dialysis.


Justice

 Fairness with respect to the distribution of
medical resources.
 Who should receive scarce medical resource.
 How should we distribute them
 What is the best outcome.


Thanks


Introduction to Professionalism & Medical Ethics

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