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					Medical Ethics and Professionalism II:
  Introduction to Professionalism

  RICHARD L. ELLIOTT, MD, PHD, FAPA
      PROFESSOR AND DIRECTOR,
           MEDICAL ETHICS
MERCER UNIVERSITY SCHOOL OF MEDICINE
     What does it mean to be professional?

 As a preclinical student?
   Prepared

   On time

   Respectful

 As a clinical student?
   Prepared

   On time

   Respectful
        Nurses
    Extra duty
    Humble
     Some Characteristics of a “Professional”

 Specialized education, training, knowledge
 A role model by virtue of behavior, attitude,
  relationships
 Behaviors
    Dress
    Timeliness
    Preparedness
    Courtesy
    Hard working
The Oath of Geneva
AT THE TIME OF BEING ADMITTED AS A MEMBER OF THE MEDICAL
PROFESSION:
I SOLEMNLY PLEDGE myself to consecrate my life to the service of
humanity;
I WILL GIVE to my teachers the respect and gratitude which is their due;
I WILL PRACTICE my profession with conscience and dignity;
THE HEALTH OF MY PATIENT will be my first consideration;
I WILL RESPECT the secrets which are confided in me, even after a patient
has died;
I WILL REMAIN by all means in my power, the honor and the noble
traditions of the medical profession;
MY COLLEAGUES will be my brothers and sisters;
I WILL NOT PERMIT considerations of religion, nationality, race, party
politics or social understanding to intervene between my duty and my
patient;
I WILL MAINTAIN the utmost respect for human life from its beginning,
even under threat, and I will not use my medical knowledge contrary to the
laws of humanity;
I MAKE THESE PROMISES solemnly, freely and upon my honor.
       “Consecrate My Life”

 I SOLEMNLY
PLEDGE
myself to
consecrate my
life to the
service of
humanity
      “Respect and Gratitude”

I WILL GIVE
to my
teachers the
respect and
gratitude
which is their
due
       “Conscience and Dignity”

 I WILL
 PRACTICE my
 profession with
 conscience and
 dignity
       “My First Consideration”

THE
HEALTH OF
MY PATIENT
will be my
first
consideration
           “Confided in Me”

 I WILL
 RESPECT the
 secrets which
 are confided in
 me, even after a
 patient has
 died
             “Traditions”

 I WILL
 REMAIN by all
 means in my
 power, the
 honor and the
 noble traditions
 of the medical
 profession
       “Brothers and Sisters”

 MY
 COLLEAGUES
 will be my
 brothers and
 sisters
            No Other Considerations

 I WILL NOT PERMIT
 considerations of
 religion, nationality,
 race, party politics or
 social understanding
 to intervene between
 my duty and my
 patient
         “Respect for Human Life”

 I WILL MAINTAIN
 the utmost respect
 for human life from
 its beginning, even
 under threat, and I
 will not use my
 medical knowledge
 contrary to the laws
 of humanity
               “Promises”

 I MAKE THESE
 PROMISES
 solemnly, freely
 and upon my
 honor.
               The Oath of Geneva

 Challenges to professionalism – But what about . . .?
                   Consecrate My Life

 I SOLEMNLY PLEDGE myself to consecrate my
 life to the service of humanity
    What does it mean to “consecrate?”
    Are you ready when you come to class/rounds?
    Do you do just the minimum work required (e.g., number of
     patients)?
    Resident work hours – what to do when you’ve reached the
     limit and patient continuity of care or a learning might be
     compromised?
    Will you take responsibility for your continuing education,
     attending meetings, reading journals, obtaining consultations?
                     Respect Teachers

 I WILL GIVE to my teachers the respect and
 gratitude which is their due
    An attending asks you to suture a deep facial wound. You have
     little experience with this and express your concern. The
     attending tells you “Well, this is how you learn” and leaves.
    An attending asks you to obtain informed consent regarding a
     complex procedure with which you are unfamiliar and brushes
     aside your reservations about your ability to describe the
     procedure, its risks and benefits, prognosis, and alternatives.
    An attending deliberately exposes parents of a newborn to a
     surgical procedure on their baby to demonstrate the futility of
     further intervention. They are devastated.
                          Conscience

 I WILL PRACTICE my profession with conscience
 and dignity
    A recent graduate opens a primary care clinic advertising itself
     as catering to gay and lesbian patients. It is one of very few
     clinics in this rural area. Residents who are not gay or lesbian
     are reluctant to visit the clinic.
    A fertility specialist is approached by a woman who seeks to
     have six stored fertilized embryos implanted. She has six
     children at home.
    A woman approaches you for advice about an elective
     abortion, to which you are opposed for religious reasons.
     Should you refer her to a colleague who performs abortions?
                  Health of My Patient

 THE HEALTH OF MY PATIENT will be my first
 consideration
    Your patient comes to you for an exam prior to traveling to
     Greece for his wedding. You discover him to have TB and
     express your concern over his trip.
    A woman is brought by her husband to the EC with a history of
     severe depression, auditory hallucinations, and has been
     suicidal in the past. She gave birth six weeks ago to a health
     baby. She tells you “Whatever you do, don’t take my baby or
     make me come in the hospital. I couldn’t take it.” You are
     considering involuntary hospitalization (“commitment”).
                               Secrets

 I WILL RESPECT the secrets which are confided in
 me, even after a patient has died
    36 year old man presents in respiratory distress, in the course of
     which he is found to be infected with HIV. He is firm that he does
     not want his wife or friends to know. What do you do?
    Your patient is going through a painful divorce and, during his
     annual physical examination, tells you “Sometimes I think the only
     way to protect the kids from her is just to get her out of picture
     entirely, if you know what I mean.”
                   Confidentiality

 What I may see or hear in the course of the
 treatment or even outside of the treatment in regard
 to the life of men, which on no account one must
 spread abroad, I will keep to myself
    Hippocrates
                   Confidentiality

 Confidentiality is the obligation on the physician not
  to reveal what has been learned during the course of
  treatment
 Privilege is the right of a patient, established only by
  statute, whereby a patient may prevent his physician
  from testifying. Privilege is a legal right belonging
  only to the patient and not to the physician.
               Breaking Confidentiality

 Reporting child abuse or neglect
 Reporting HIV to state
 Notifying sexual partners of HIV
 “Tarasoff” warnings
   “protective privilege ends where the public peril begins”
       Psychiatrist Jailed for Contempt

 “The defendant’s side of the courtroom was filled
  with his patients.”
 The Jones County News February 7 2010
                                  HIPAA

 Health Insurance Portability and Accountability Act
     Title I Health Access, Portability, and Renewability
         Limits restrictions on exclusions for preexisting conditions
                               HIPAA

   Title II: Preventing Health Care Fraud and Abuse; Administrative
    Simplification; Medical Liability Reform
     Privacy Rule of 2003 regarding Protected Health Information
     Intent to restrict release of information to only that necessary to
      achieve the purpose
     Patients are guaranteed access to their medical records and may
      amend
        Not “psychotherapy” notes

     What about disclosing information to a family member in an
      emergency?
        Consent not required if disclosure necessary for treatment

        Notification of family may be necessary for treatment

        HIPAA disclosure document
              Subpoena Duces Tecum

 Immediate response
  :Reply, don’t comply
 Check with patient
 Advise to get legal advice
  if needed
 Release minimum
  information necessary
                  Brothers and Sisters

 MY COLLEAGUES will be my brothers and sisters
   Another student has been coming to groups late, lives by
    himself, and there is concern among other students over his
    drinking and use of anxiety (Xanax) and stimulant
    medications.
   During your EC and Internal medicine rotations you become
    aware of a community physician who seems to have a large
    number of patients coming to the hospital toxic on pain
    medications for which the indications are unclear, e.g.,
    “fibromyalgia.”
                       Respect for Life

 I WILL MAINTAIN the utmost respect for human
 life from its beginning, even under threat, and I will
 not use my medical knowledge contrary to the laws
 of humanity
    Patient Rights groups strongly support the “Death with Dignity
     Act” in Oregon and seek to pass a similar law in Georgia. Your
     local legislator asks for your opinion.
    Your hospital is considering a futility of care policy applicable
     to newborns and adults with severe medical conditions for
     which medical care is unlikely to provide anything but
     maintenance of vegetative functions. The policy would permit,
     after due process, termination of life supports over the
     objections of family.
Threat to
professionalism
Mangled care
Threat to
professionalism
Medical
Industry
Threats to
professionalism
“Alternative
health care”
Social justice
and lack of
access
 Unprofessional Conduct and Board Action

 235 MDs disciplined by board 1990-2003
 469 MDs controlled for school and year of graduation
 Disciplined for:
  Unprofessional conduct (74%)
  Incompetence
  Other




 Papadakis et al. Disciplinary Action by Medical Boards and
 Prior Behavior in Medical School. NEJM 2005;353:2673-82
   740 Board Violations by 235 Physicians

 Use of drugs or alcohol                  108
 Unprofessional conduct                    82
 Conviction for a crime                    46
 Negligence                                42
 Prescribing/acquisition substances        39
 Violation of Board order/condition        32
 Sexual misconduct                         29

 Other – Failure to meet CME, fraud, billing, failure
 to maintain adequate records
        Disciplined vs. Control Physicians

 No gender differences
 Highly significant differences (p< 0.05– 0.001)
   Medical school academic performance

   USMLE

 Unprofessional conduct predicted subsequent
 disciplinary problems
    39% vs 19%
    P<0.001
       Unprofessional Conduct in School

                                             OR

 Irresponsibility (>2)                       8
   Attendance, follow-up

 Lack of self-improvement (>2)              3
   Response to criticism

 Immaturity
 Poor initiative
   Motivation, enthusiasm

 Relationships (students, nurses, faculty, patients)
          Examples of Unprofessional Behaviors

 Attending demands parents witness surgery on dying infant
 Attending frequently prescribes addictive substances
 Attending prescribes addictive substances for self
 Attending asks student to obtain informed consent on
    surgical procedure – forbidden by law in that state
   Attending insults students in front of patients
   Student “reports” exam finding without doing exam
   Resident demands student do rectal over patient’s protest
   Attending mocks patient during surgery
                               Lessons

 Professionalism starts now
 Good news – the two most significant predictors are
 modifiable
    If you have a problem with attendance, follow-up – change!
    If you have a problem accepting criticism – learn!
        Smiling inward is deadly
            Case Analyses Next Week

 Prepare as a professional
 Read the cases
 Analyze using case analysis format
 Discuss with colleagues as you like
 Wear white coats to our groups
 Which of the following is NOT widely considered a
 principle of medical ethics?
    Autonomy
    Beneficence
    Respect
    Social justice
    Malfeasance
 HIPAA is an important piece of federal legislation
 covering:
    Privacy of health care information
    Treatment in emergency rooms
    The right to privacy in medical decisionmaking
 In which of the following cases is disclosure of
 information NOT required:
    Suspected child abuse
    New HIV patient
    Receipt of a subpoena for medical records to be used at a
     divorce proceeding
    Previously undisclosed criminal history
 Match case with the concept most closely identified with it

 National attention on          Tarasoff
  “right to die” and             Nancy Cruzan
  removal of ventilator          Karen Ann Quinlan
 Duty to protect third
  parties
 Removal of feeding tube,
  Patient Self
  Determination Act
                    Autonomy

 The principle of autonomy concerns the patient’s
   Right to be treated with compassion

   Right to determine the course of her own life

   Right to basic medical care

   Right to drive an automobile
               Capacity (competence)

 A capacity determination is
   A judgment about the patient’s ability to be a good
    patient
   A judgment about the patient’s ability to make good
    decisions in general
   A judgment about the patient’s ability to make good
    medical decisions
   A judgment about the patient’s ability to make a
    particular decision about her medical care
               Most ethical choice?

 Providing the degree of information necessary for
 genuine informed consent is understood to require
  Disclosing what a reasonable physician would disclose in
   the circumstances
  Disclosing information that a reasonable person in those
   circumstances would judge relevant
     Best Interest vs Substituted Judgment

 When a decision must be made about the medical
 care of an adult patient who has had, but who no
 longer has, decisionmaking capacity, the surrogate
 decisionmaker should
  Use the “best interest” standard to reach a decision, i.e.,
   what, in the opinion of the surrogate decisionmaker is in
   the best interests of the patient
  Use the “substituted judgment” standard to reach a
   decision, i.e., what the patient would have decided if
   competent
     Best Interest vs Substituted Judgment

 When a decision must be made about the medical
 care of a patient who never had decisionmaking
 capacity, the surrogate decisionmaker should
  Use the “best interest” standard to reach a decision, i.e.,
   what, in the opinion of the surrogate decisionmaker is in
   the best interests of the patient
  Use the “substituted judgment” standard to reach a
   decision, i.e., what the patient would have decided if
   competent
  Neither a nor b
                 Informed Consent

 Which of the following is NOT one of the three
 elements of a valid informed consent?
  Information
  Confidentiality

  Voluntariness

  Competence
 To which medical decisions may a minor in Georgia
 give consent?
    Drug abuse
    STD
    Treatment of the minor’s child
    Pregnancy
    Prevention of pregnancy
    Abortion with parental notification (except emergency or with
     court approval)
Questions?
Groups
Read cases on site

medicine.mercer.edu

Academics-Degree
Programs-Doctor of
Medicine

Analyze using case
analysis form
 All slides from this point on are strictly optional!!!
 Not test material!!!!
             Challenges to Professionalism

 Outside influences
   Pharmaceutical companies
   Manufacturers of medical devices

   Financial conditions in teaching institutions

     Teaching hospitals and indigent care
     Medical schools and state funding
     Student debt level
   Third party payors

 Conflicts within profession
   Primary care vs subspecialties

 Duty to patients vs public
 Challenges from other providers
   Prescription privileges

   Alternative health care
             ACGME and Professionalism

 Residents must demonstrate a commitment to carrying out
  professional responsibilities, adherence to ethical principles, and
  sensitivity to a diverse patient population. Residents are expected to:
 • Demonstrate respect, compassion, and integrity; a responsiveness to
  the needs of patients and society that supersedes self-interest;
  accountability to patients, society, and the profession; and a
  commitment to excellence and on-going professional development
 • Demonstrate a commitment to ethical principles pertaining to
  provision or withholding of clinical care, confidentiality of patient
  information, informed consent, and business practices
 • Demonstrate sensitivity and responsiveness to patients' culture, age,
  gender, and disabilities
 Medical Ethics and Professionalism Program Goals

 Adhere to highest ethical and professionalism standards
 Recognize and respond to ethically problematic situations
  using relevant principles, codes, and laws
                       Goals

 History of Ethics and Professionalism
 AMA Code of Medical Ethics
 ACP-ABIM Charter of Professionalism
      What is a Profession or a Professional?

 Clergy, law, medicine
 To profess:
   Knowledge in specialized area
         Universities
     Willingness to put skills to use in service of others
     Adherence to code of conduct
       AMA Code of Ethics: Background

 Fifth century B.C.     Oath of Hippocrates
 1803 Thomas Percival   Code of Medical Ethics
 1847 AMA               Code of Medical Ethics
 1949 WMA - Geneva      Declaration Oath
Hippocrates
460-370 B.C.




               Hippocrates refusing the gifts of Artaxerxes
               Anne-Louis Girodet , 1792
                  Dr. Thomas Percival

 The Medical Professions
   Physicians, surgeons, apothecaries

 1803 Medical Ethics
 Not widely accepted
   Gentlemen already know how to behave
                             AMA

 Medicine in America was in disarray
   No standardized training

   Licensure not common

   Frontier/domestic medicine ruled

   Few effective treatments

 1847
   Code of Ethics

   First widely accepted standards for medical conduct

   Birth of medical professionalism
Every duty or obligation implies, both in equity
and for its successful discharge, a corresponding
right. As it is the duty of a physician to advise, so
has he a right to be attentively and respectfully
listened to. Being required to expose his health
and life for the benefit of the community, he has a
just claim, in return, on all its members,
collectively and individually, for aid to carry out
his measures, and for all possible tenderness
and regard to prevent needlessly harassing calls
on his services and unnecessary exhaustion of
his benevolent sympathies.
    AMA Code of Medical Ethics Timeline

 1847 AMA founded, first Code of Medical Ethics
 1858 Advocated for women physicians
 1903 Principles of Medical Ethics
 1934 Outlawed physicians serving organizations that
  would make a profit from their services
 1957 Principles changed from specific regulation of
  activities to broad principles, allowing Council on
  Judicial Affairs latitude in interpretation
 1974 Addressed protection of humans subjects
 1989 Cruzan brief
      AMA Principles of Medical Ethics

 What is the essence of an ethical dilemma?
          Principles of Medical Ethics

• Preamble
• The medical profession has long subscribed to a body
 of ethical statements developed for the benefit of the
 patient. As a member of this profession, a physician
 must recognize responsibility to patients first and
 foremost, as well as to society, to other health
 professionals, and to self. The following Principles
 adopted by the AMA are not laws, but standards of
 conduct which define the essentials of honorable
 conduct for the physician.
               A physician shall . . .

 I. be dedicated to providing competent medical care,
  with compassion and respect for human dignity and
  rights.
 II. uphold the standards of professionalism, be
  honest in all professional interactions, and strive to
  report physicians deficient in character or
  competence, or engaging in fraud or deception, to
  appropriate entities.
               A physician shall . . .

 III. respect the law and also recognize a
  responsibility to seek changes in those requirements
  which are contrary to the best interests of the
  patient.
 IV. respect the rights of patients, colleagues, and
  other health professionals, and shall safeguard
  patient confidences and privacy within the
  constraints of the law.
               A physician shall . . .

• V. continue to study, apply, and advance scientific
  knowledge, maintain a commitment to medical
  education, make relevant information available to
  patients, colleagues, and the public, obtain
  consultation, and use the talents of other health
  professionals when indicated.
• VI. in the provision of appropriate patient care,
  except in emergencies, be free to choose whom to
  serve, with whom to associate, and the environment
  in which to provide medical care.
                A physician shall . . .

 VII. recognize a responsibility to participate in
  activities contributing to the improvement of the
  community and the betterment of public health.
 VIII. while caring for a patient, regard responsibility
  to the patient as paramount.
 IX. support access to medical care for all people.
                Compare and Contrast

 Principles of medical ethics
   Principles upon which decisions are based
     Autonomy
     Beneficence
     Non-maleficence
     Social justice

 AMA Principles of medical ethics
   “Shall” statements governing conduct
                  Professionalism

 How does it differ from ethics?
              What is Professionalism?

 Two key documents
   American Council for Graduate Medical education (ACGME)

   American College of Physicians – American Board of Internal
    Medicine
            ACGME and Professionalism

 Residents must demonstrate a commitment to carrying out
  professional responsibilities, adherence to ethical principles, and
  sensitivity to a diverse patient population. Residents are expected to:
   demonstrate respect, compassion, and integrity; a responsiveness to
    the needs of patients and society that supersedes self-interest;
    accountability to patients, society, and the profession; and a
    commitment to excellence and on-going professional development.
   demonstrate a commitment to ethical principles pertaining to
    provision or withholding of clinical care, confidentiality of patient
    information, informed consent, and business practices
   demonstrate sensitivity and responsiveness to patients’ culture, age,
    gender, and disabilities
                        ACP - ABIM

 Three Principles:
   Primacy of patient welfare

   Patient autonomy

   Social justice.
   ACP- ABIM Professional Responsibilities

 Commitment to professional competence
 Commitment to honesty with patients
 Commitment to patient confidentiality
 Commitment to maintaining appropriate relations
 with patients
 Commitment to improving quality of care
 Commitment to improving access to care
 Commitment to a just distribution of finite resources
 Commitment to scientific knowledge
 Commitment to maintaining trust by managing conflicts
 of interest
 Commitment to professional responsibilities
Threats to Professionalism
                        Oath of Geneva
I solemnly pledge to consecrate my life to the service of
humanity;
I will give to my teachers the respect and gratitude that is their
due;
I will practice my profession with conscience and dignity;
The health of my patient will be my first consideration;
I will respect the secrets that are confided in me, even after the
patient has died;
I will maintain by all the means in my power, the honour and the
noble traditions of the medical profession;
My colleagues will be my sisters and brothers;
I will not permit considerations of age, disease or disability,
creed, ethnic origin, gender, nationality, political affiliation, race,
sexual orientation, social standing or any other factor to
intervene between my duty and my patient;
I will maintain the utmost respect for human life;
I will not use my medical knowledge to violate human rights and
civil liberties, even under threat;
I make these promises solemnly, freely and upon my honour.
                      Next Week

 Go to Medical Ethics site via Academics – Degree
    Programs – Doctor of Medicine – Medical Ethics
   First Year
   Read Lessons 1 and 2
   Analyze associated cases using what we’ve covered
    and case analysis form on site
   Wear White Coats to group sessions and bring
    analyses for discussions
                          Mini-quiz

 What are the four principles of medical ethics?
 Difference between best interest and substituted
  judgment?
 When is each appropriate?
    Child (or never competent adult) vs previously competent
     adult
 What are the three elements of informed consent?
 When are breaches of confidentiality permissible?

				
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