Individual Conscience, Institutional Mission, Professional Code: Which Allegiance is Primary?

1. Individual Conscience, Institutional Mission, Professional Code:Which Allegiance is Primary? Glenn C. Graber Department of Philosophy Center for Applied and Professional Ethics University of Tennessee, Knoxville

2. Short Answer • “It Depends” • “depends on . . . .”

3. Levels of ResponsibilityEngineering Ethics • Irresponsibility • Fulfilling one’s job description • Professional standard • Personal standard

4. EXAMPLE: auto safety • Job Description: Your employer is satisfied with the current federal regulations that specify a collision test at x mph. Indeed, they are lobbying against proposed changes in federal regulations to strengthen that requirement. • Professional Standard: There is a strong consensus within your profession that the current standards are too weak and that the only adequate test of safety would be at x + y mph. Your professional organization is pushing for strengthening the federal regulation. • Personal Standard: If you were choosing a car for your mother, you would not be satisfied with even this level of safety. You would want to see the results of tests at x + y + z mph.

5. EXAMPLE: auto safety • Job Description: Your employer is satisfied with the current federal regulations that specify a collision test at $ mph. Indeed, they are lobbying against proposed changes in federal regulations to strengthen that requirement. • Professional Standard: There is a strong consensus within your profession that the current standards are too weak and that the only adequate test of safety would be at $ + $ mph. Your professional organization is pushing for strengthening the federal regulation. • Personal Standard: If you were choosing a car for your mother, you would not be satisfied with even this level of safety. You would want to see the results of tests at $ + $ + $ mph.

6. EXAMPLE: auto safety - PINTO • Job Description: Your employer is satisfied with the current federal regulations that specify a collision test at 10 mph, fixed. Indeed, they are lobbying against proposed changes in federal regulations to strengthen that requirement. • Professional Standard: There is a strong consensus within your profession that the current standards are too weak and that the only adequate test of safety would be at 20 mph, fixed. Your professional organization is pushing for strengthening the federal regulation. • Personal Standard: If you were choosing a car for your mother, you would not be satisfied with even this level of safety. You would want to see the results of tests at 20 mph, moving.

7. Pharmacy • Job Description: You read in the paper that your employer has signed a contract with the state Department of Corrections to have the chief pharmacist (you) prepare the vials of drugs to be used for execution by lethal injection. • Professional Standard:American Correctional Health Services Association: “The correctional health professional should not be involved in any aspect of execution of the death penalty.” • Personal Standard: -??- What does your conscience dictate with regard to personal involvement with capital punishment?

8. Pharmacy #2 • Professional Standard: American Pharmaceutical Association: “opposes laws and regulations which mandate or prohibit the participation of pharmacists in the process of execution by lethal injection.” [Emphasis added]

9. The Cumulative Multiple Sources of Professional Responsibility

10. 1. Duty of Beneficence • To benefit others whenever we can • prima facie duty, not absolute • perhaps fairly easily overridden • but a duty nonetheless e.g., Walking past, I see a child fallen face-down in a puddle. There may be no legal duty to rescue, but I contend that there is a moral duty.

11. 2. Expertise Heightens Duty • As I am walking with a physician, we both see a person collapse clutching his chest. • I have a moral duty to go to his aid. <from 1 above> • The physician has a greater moral duty, since she has expertise that makes her help more effective.

12. 3. Social contract • Society subsidizes professional education – so professional expertise cannot be said to be a proprietary resource of the individual. (contra Sade) • Society grants deference to professionals in various ways. • Society vests the professional with this body of expertise – we don’t all bother to master it for ourselves. • In exchange, we expect professional service.

13. Social Role • “Professional” or “physician” or “<substitute name for another professional role>” is a social role • Rule-governed behavior • Expectations for behavior • Internal to the individual • Internal to the group • External to the group

15. You’re a dead duck, man! No way we can cure you!

16. I assure you, it’s a benign procedure!

17. <you supply the caption>

18. Professional Obligation • i.e., obligation of professional qua professional • Integral to social role / social contract

19. Professional Obligation / Core Professional Values As part of an appreciation of the ethical claims of professionalism, physicians must be prepared to set aside their personal values and morality, to set aside what the legal system and their employers want them to care about, and to take up instead the question of what the responsible physician ought to care about. The profession’s core values inform those purposes that each medical professional should have in common with colleagues. [Kipnis (2006), p. 11]

20. Professional Obligation / Core Professional Values As part of an appreciation of the ethical claims of professionalism, physicians must be prepared to set aside their personal values and morality, to set aside what the legal system and their employers want them to care about, and to take up instead the question of what the responsible physician ought to care about. The profession’s core values inform those purposes that each medical professional should have in common with colleagues. [Kipnis (2006), p. 11]

21. Professional Obligation / Core Professional Values • Professionalism can require that one set aside one’s personal morality or carefully limit one’s exposure to certain professional responsibilities. . . . For some, it may be a mistake to choose a career in medicine. [Kipnis(2006), p. 10]

22. Professional Obligation / Core Professional Values - CRITERIA • Consensus within the profession • Attention to these values forms part of professional education • They are “goods that the rest of us want our doctors to care about.” • An exclusive reliance upon the profession as the means by which certain matters are to receive due attention. [Kipnis (2006), p. 12]

23. Where do we find the core professional obligations and values? • Starting Point: Codes of Ethics • Further source: client expectations • Additional Clues: popular culture

24. Professional Obligation / Core Professional Values • A sound code of ethics consists of a set of standards that, if adhered to broadly by the profession’s membership, will result in the profession as a whole discharging its responsibilities. [Kipnis (2006), p. 12]

25. Primacy of Professional Duty • Ed Pellegrino (& others) argue for an overriding principle: “Doctors must not kill” • e.g., A.M.A. policy opposing physician participation in executions • physician-assisted suicide, euthanasia • Kipnis argues for an overriding principle: “Doctors must not tell” • An exceptionless principle of confidentiality

26. Personal Conscience / Commitments

27. Miss. Code Ann. § 41-107-3 (2007) (h) "Conscience" means the religious, moral or ethical principles held by a health care provider, the health care institution or health care payer. For purposes of this chapter, a health care institution or health care payer's conscienceshall be determined by reference to its existing or proposed religious, moral or ethical guidelines, mission statement, constitution, bylaws, articles of incorporation, regulations or other relevant documents.

28. Miss. Code Ann. § 41-107-5 (2007) § 41-107-5. Rights of Conscienceof Health Care Providers (1) Rights of Conscience.A health care provider has the right not to participate, and no health care provider shall be required to participate in a health care service that violates his or her conscience. However, this subsection does not allow a health care provider to refuse to participate in a health care service regarding a patient because of the patient's race, color, national origin, ethnicity, sex, religion, creed or sexual orientation.

29. James F. Childress • . . . a state is a better and more desirable one if it puts the presumption in favor of exemption for conscientious objectors (not merely to war). It is prima facie a moral evil to force a person to act against his conscience. (Childress, 1979, p. 330). Childress, J.F. (1979). “Appeals to conscience,” Ethics, 89, pp. 315-335. Quoted in John F. Peppin, “The Christian Physician in the Non-Christian Institution: Objections of Conscience and Physician Value Neutrality,” Christian Bioethics 1997, Vol. 3, No. 1, pp. 39-54

30. However, This cannot be taken as an absolute principle.

33. Childress • If my analysis of conscience is correct, a state is a better and more desirable one if it puts the presumption in favor of exemption for conscientious objectors (not merely to war). It is prima facie a moral evil to force a person to act against his conscience, although it may often be justified and even necessary. • P. 330

34. Duties to Employer

36. Ideal: congruence • Professional code = • Employer mission = • Personal conscience

37. When these do NOT coincide, • The first responsibility is to try to bring them into congruence through reconsideration, negotiation, and compromise. • Institution, individual have an interest in supporting professional code to extent possible. • Institution, profession have an interest in honoring personal conscience to extent possible. • Profession, individual have a commitment to institution.

38. For example, a pharmacy can tolerate a pharmacist who cannot in good conscience dispense “Plan B” if (s)he: • is not the only pharmacist in town • (or perhaps) is not the only pharmacist in the store • and is willing to refer requests to a pharmacist willing to fill them. I am not sure we can tolerate a total refusal to have anything to do with the drug.

39. First trained intensivist in town • Ordered much larger doses of morphine than this ICU had seen before • Nurses were uncomfortable administering those doses – expressed their concerns • Intensivist came over – administered them himself – kept this up for several days, until • Nurses came to understand that it was aggressive treatment but not lethal treatment

40. No unilateral action is justified • Institution • Profession • Individual Communication & negotiation essential on all sides.

41. Duty to treat • When a physician visited the 1995 Ebola virus outbreak in Kikwit (DRC), he found 30 dying patients in an abandoned hospital, left to care for themselves amid rotting corpses, sometimes in the same bed. Was the last doctor justified in leaving the patients, or should he or she have been obliged to single-handedly treat the highly and dangerously infectious Ebola patients? Daniel K. Sokol, “Virulent Epidemics and Scope of Healthcare Workers’ Duty of Care” Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 8, August 2006, p. 1240.

42. http://www.utoronto.ca/jcb/home/documents/pandemic.pdf

43. Individual liberty Protection of the public from harm Proportion-ality Privacy Duty to provide care Reciprocity Equity Trust Solidarity Stewardship B1. Ten substantive values to guide ethical decision-making for a pandemic influenza outbreak

44. Individual liberty Protection of the public from harm Proportion-ality Privacy Duty to provide care Reciprocity Equity Trust Solidarity Stewardship B1. Ten substantive values to guide ethical decision-making for a pandemic influenza outbreak

45. B1. Ten substantive values to guide ethical decision-making for a pandemic influenza outbreak • Duty to provide care Inherent to all codes of ethics for health care professionals is the duty to provide care and to respond to suffering. Health care providers will have to weigh demands of their professional roles against other competing obligations to their own health, and to family and friends. Moreover, health care workers will face significant challenges related to resource allocation, scope of practice, professional liability, and workplace conditions.

46. Four Key Ethical issues C1. Health workers’ duty to provide care during a communicable disease outbreak C2. Restricting liberty in the interest of public health by measures such as quarantine C3. Priority setting, including the allocation of scarce resources, such as vaccines and antiviral medicines C4. Global governance implications, such as travel advisories

47. Four Key Ethical issues C1. Health workers’ duty to provide care during a communicable disease outbreak C2. Restricting liberty in the interest of public health by measures such as quarantine C3. Priority setting, including the allocation of scarce resources, such as vaccines and antiviral medicines C4. Global governance implications, such as travel advisories

48. Four Key Ethical issues • C1. Health workers’ duty to provide care during a communicable disease outbreak • Recommendations 3. Governments and the health care sector should develop human resource strategies for communicable disease outbreaks that cover the diverse occupational roles, that are transparent in how individuals are assigned to roles in the management of an outbreak, and that are equitable with respect to the distribution of risk among individuals and occupational categories.

49. ANA Position Statement: “Risk and Responsibility in Providing Nursing Care” • “the most precious possession of this profession is the ideal of service, extending even to the sacrifice of life itself . . . .” [Committee on Ethical Standards, 1926] http://www.nursingworld.org/readroom/position/ethics/RiskandResponsibility07.pdf

50. ANA Position Statement: “Risk & Responsibility in Providing Nursing Care” “A moral obligation exists for the nurse if all four of the following criteria are present: • The patient is at significant risk of harm, loss, or damage if the nurse does not assist. • The nurse’s intervention or care is directly relevant to preventing harm. • The nurse’s care will probably prevent harm, loss, or damage to the patient. • The benefit the patient will gain outweighs any harm the nurse might incur and does not present more than an acceptable risk to the nurse.”