SCCD HM 546: Introduction to Ethics and Professionalism

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

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/fay82504rpt.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 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.”

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 Physician’s 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 one’s 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 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

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, 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

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 I’m 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 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

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 311:1573, 1984

29. The Virtuous Physician Individual patient advocacy

30. 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

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. [I]f the providers can somehow insist upon driving Cadillacs, then a given [health care] budget set aside by society…will 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 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”)

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

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”