SCCD HM 546: Introduction to Ethics and Professionalism
Howard Brody, MD, PhD
Center for Ethics & Humanities and
Department of Family Practice
8/05
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
Medical Ethics and Events in Iraqi Prisons
Lifton RJ. Doctors and torture. N Engl J Med 351:415, 2004
Miles SH. Abu Ghraib: its legacy for military medicine. Lancet 364:725, 2004
How complicit are doctors in abuses of detainees? Lancet 364:637, 2004
Bloche MG, Marks JH. When doctors go to war. N Engl J Med 352:4, 2005
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/fay82504rpt.pdf
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.
Case (3)
The Colonel said he was, the Combat Army Surgical Hospital (CASH) had made a mistake, and he couldn’t 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.”
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?
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
One Physician’s Comment
All military physicians are officers Therefore have a dual responsibility to
report/prevent torture or abuse As physicians As officers
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?
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”
Medical Examples
Duty not to have sex with patientsDuty to respect confidentialityDuty to respect patients’ autonomy
(self-determination)
“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
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
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
The CHM Virtue List
Competence Honesty Compassion Respect for Others Professional Responsibility Social Responsibility
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?
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
What Are Virtues?
Excellences in human behavior Represent core moral values One tries to live a life so that one’s daily
behavior exemplifies those core values “Obituary test” (inherently biographical
view)
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?
A Famous Musician
“If I don’t practice for one day, I know it. If I don’t practice for two days, the critics know it. If I don’t practice for three days, the audience knows it.”
“Fine discernment” and virtue
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
Compassion
Response to the fellow human who is suffering Beginner: “Oh, don’t worry, it can’t be that
bad” Responds to my discomfort at other’s suffering Challenge: To appropriately be present with the
suffering person, appropriately vulnerable to their suffering, while remaining whole oneself Requires extensive experience and practice
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 I’m having a
bad day
“Three-Legged Stool”
Proposed model to describe typical moral tensions that arise in trying to live a life of integrity in medicine
A Traditional Argument
The physician’s professional and social responsibility is solely and completely determined by one ethical role– serving as a single-minded advocate for each individual patient
“…physicians are required to do everything that they believe may
benefit each patient without regard to costs or other societal
considerations.”
--N. Levinsky, NEJM 311:1573, 1984
Medicine’s Future
Resources will be limited and some system of rationing will be needed
Physicians will increasingly be held accountable for how they spend other people’s money
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
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?
[I]f the providers can somehow insistupon driving Cadillacs, then a given[health care] budget set aside bysociety…will make available topatients fewer real health servicesthan would be available if providerscould be induced somehow to makedo with Chevrolets.
--U. Reinhardt, Milbank Q 1987
The Virtuous Physician
Advocatefor popu-lationof pa-tients
Individual patient advocacy
Reasonableself-interest
“Three-Legged Stool”
Argues that to live a whole life, one has to consider one’s 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”)
The Virtuous Physician?
Advocatefor popu-lationof pa-tients
Individual patient advocacy
Reasonableself-interest
The Virtuous Physician?
Advocatefor popu-lationof pa-tients
Individual patient advocacy
Reasonableself-interest
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