Ethics in Medicine 1. Physician’s professionalism and ethics. 2. What ethics is not? The Central Person in Healthcare To be a physician is extremely complex profession. What does a physician’s professionalism means to you? Take a minute or two and write down your thoughts as a definition! What is Physician’s Professionalism? Physician’s professionalism comprise numerous qualities of physicians: It is a vocation or calling and implies service to others It has a scientific knowledge base which is kept up to date It has a special relationship with those whom it serves – patients. It has particular ethical principles and norms Scientific questions Scientific questions Ask testable questions about the world Can be explored through scientific inquiry Rely on empirical and measurable evidence Example: How does kidney transplant function in the organism of recipient? Cultural/Religious questions Cultural/Religious questions Ask us what would be in line with the common practices of a particular culture, or with religious belief or practice Example: What does my religion or culture say on whether it is acceptable to donate kidney transplant? Legal questions Ask us what the law requires or forbids us to do. Non-compliance with law leads to legal sanctions or punishment. Ethics informs the law, but sometimes laws are not ethical and other times the ethically right thing to do may be illegal. Example: Is it legal or not to sell kidney in your home country? Is it morally right? Ethical questions Ethical questions Ask us what the ‘right’ thing to do is – what we ‘should’ or ‘ought’ to do? Arise because of our social responsibility to others and because our behavior can influence the welfare of other people Are generated by conflicts among principles and values held by individuals or groups Ethical questions (cont.) Require moral reflection, i.e. consideration of person’s responsibilities, duties, values, and principles Example: Should individual who donate kidney transplant choose who should be the recipient of their organ? What answer is morally right? Case 1. Truth-telling and Trust Thao, 80-year-old Asian woman is hospitalized with pulmonary tuberculosis. Her family asks that she not be told about her diagnosis, because in her home country tuberculosis was considered fatal and to tell her would be like giving her "a death sentence.“ 1.Ask questions (scientific/ legal/ cultural/ ethical) proper for the case! 2.Should you respect the family's concerns? Case 2. Truth-telling and Trust Timothy, 65-year-old is diagnosed with metastatic cancer of the pancreas. Timothy has just retired from a busy professional career, and he and his wife are about to leave on a round-the-world cruise that they have been planning for years. 1. Ask questions (scientific/ legal/ / ethical) proper for the case! 2. Should you tell him his diagnosis? Right to Know the Truth Telling the truth in clinical context is an ethical obligation, but determining just what constitutes the truth remains a clinical judgment. Right to know the truth for individual patient: “Doctors must take appropriate steps to find out what patients want to know about their condition and treatment”. JMC / British Medical Association Relations between doctor and patient changed radically (cont.) Key Concepts Values Values are the inner standards by which we make decisions about right and wrong, should and shouldn't, good and bad. They also tell us which are more or less important when we have to posit one value over another. Morals Morals have a greater social element to values and tend to have a very broad acceptance. Morals are far more about good and bad than other values. We thus judge others more strongly on morals than values. We can describe a person as immoral, yet there is no word for them not following values. Key Concepts (continued) Ethics As opposed to ‘commonsense morality’, ethics involves a critical reflection on how best to live a moral life (Aristotle). 1) A theory or a system of moral values (e.g. ethic of nonviolence). 2) A branch of philosophy dealing with values relating to human conduct, with respect to the rightness and wrongness of certain actions and to the goodness and badness of the motives and ends of such actions. 3) The rules or standards governing the conduct of a person or the members of a profession (e.g. medical ethics). 2. What ethics is not? * What ethics is not? A. Codes of ethics “If we call them ethics we may to believe that they are all there is of ethics, and presently be worshipping the code rather than the ethics itself, so unreasoning a reverence is in our souls for statutes, fines, and punishments, so strong a tendency to make rules the end and aim of life rather than simply conveniences, changeable contrivances” Lavinia Dock (1900) Nevertheless, codes could serve as helpful instruments “to prop up the steps of those who are young in selfgovernment or feeble in self-control”. What ethics is not? B. Law Law is the body of official rules and regulations, generally found in constitutions, legislation, judicial opinions, and the like, that is used to govern a society and to control the behavior of its members. Legal decision Is made on the basis of what is required or prohibited by law. Is motivated by desire to avoid legal sanctions or punishment for non-compliance. ‘What is not forbidden, is permitted’ (‘Your Liberty To Swing Your Fist Ends Just Where My Nose Begins’). Law controls the scope of ‘outer’ freedom (liberty). Ethical decision Is guided by personal moral values and principles. Moral principles are chosen autonomously on the basis of critical reflection. They are backed by moral reason and/or by feelings of guilt, shame, moral remorse which operate as kinds of moral sanctions. Ethics controls the scope of ‘inner’ freedom. Clinical decision Is based on an established body of knowledge and ‘reasonable’ professional opinion on how this knowledge should or should not be applied in a clinical situation. Case 1. An advise to seek a ‘second opinion’. A middle-aged woman suffering moderately severe retrosternal chest pain and shortness of breath presented to the emergency department of a large city hospital. The ECG showed a number of cardiac arrhythmias, all of which where suggestive of an acute cardiac condition. A junior first-year medical resident examined the woman and decided she should be admitted immediately for further cardiac monitoring and tests. The registrar ‘on call’ declined to admit her, since there were no ‘cardiac beds’ available and he was not convinced that the ECG findings indicated a life-threatening cardiac condition. He discharged the woman, advising her to see her own general practitioner the following morning. What ethics is not? C. Hospital etiquette Ethics speaks to morally significant rights and wrongs, with behavior guided by reflective reasoning and application of moral values, and seeks to maximize moral interests of all people equally. Etiquette speaks more to professional style, with behavior guided by unreflective requirements of custom and convention, and serves the interests of particular institution or person in particular circumstances.