Professional Ethics, Health Care and Ethics
Five Major Moral Principles in Health Care
1. NON MALFEASANCE
2. BENEFICENCE
3. UTILITY
4. DISTRIBUTIVE JUSTICE
5. AUTONOMY
The Principles
The Health Care System
Professional Ethics and Medical Practice
In Health Care settings and in the institution itself there are a number of basic principles of morality
which evidence themselves. Even if one did not approach cases or situations holding the principles
of any of the standard ethical traditions there would arise these basic considerations and concepts.
I.
Non- Malfeasance- Do NO Harm!! Cause no needless harm or injury according to
reasonable standards of performance. Observe “DUE CARE” . This does not mean that
there must be no risk of njury but only that there be no more than acceptable risks.
II.
Benificence – Promote the welfare of others. This is inherent in the relationship of a
health care provider (HCP) and the recipient of care.
E.g. the Doctor-Patient relationship.
However, what exactly is the duty of the HCP?
This comes into particular focus as problematical when the health care providers are also
researchers. There must exist standards so that the benefits to the subjects and others are
real and with a real possibility to be realized.
III.
Utility- Attempt to bring about the greatest amount of benefit to as many people involved
as is possible and consistent with the observance of other basic moral principles.
Greatest Benefit and Least harm
IV.
Distributive Justice- All involved should have equal entitlements, equal access to
benefits and burdens. Similar cases should be treated in a similar fashion. People should
be treated alike regardless of need, contributions or effort.
The formal principle of Justice as Fairness (Rawls’ Theory) similar cases are to receive the
same treatment. However, in what ways are the cases similar? In what relevant ways?
V.
Autonomy- People are rational, self determining beings who are capable of making
judgments and decisions and should be respected as such and permitted to do so and
supported with truthful and accurate information and no coercion. They should have
their actions: free of duress, options explained that are genuine possibilities and given the
information for decision making. RESTRICTIONS on AUTONOMY:
1. HARM- stop an individual from causing harm
2. PATERNALISM- weak – stop a person from self harm
Strong – to benefit a person
3. LEGAL MORALISM- legislated morality
4. WELFARE PRINCIPLE- for the benefit of all
Health Care System
COMPONENTS:
 Providers: primary and secondary(medical schools, professional associations, drug
suppliers,etc..)
 Consumers
 Mechanisms for financing/supporting the institution
VALUES
A. HUMANITARIAN
Freedom, Dignity, Privacy, Autonomy
B. FREE ENTERPRISE
Market System
Technology
C. INSTITUTIONAL
a. Efficiency
b. Economy
Free Enterprise
Self Interest
Technology
Institutional
Clash of Values
Individual Welfare
Benefit of Others
Dignity and Comfort
Human
Social Function of Health Care:
a. Health Care
b. Employment
c. Knowledge
Bureaucratic Model versus the Human
Hierarchy of Control and Authority
Division of Labor with identifiable goals
Values of: Industry, efficiency, predictability and speed>>>Impersonal
Operational Problems:
i.
Non-routine tasks
ii.
Internal dynamics
iii.
Conflicting values
iv.
Separation of patients from social context into institutional context (persons become
patients)
v.
Information Control- elitism, paternalism
vi.
Communications Breakdown
vii.
Dilution of Authority
viii. Displacement of Authority
ix.
Development of sub groups
Professional Model
Based on :
Education- professional organizations
Code- licensing, association, peer control
VALUES: Autonomy, Collegiality, Service to Others, Skill
Professional Model clashes with the Bureaucratic Model
Tensions develop
 Medical versus Administrative Line of Authority
 Service versus Economic Good
 Specialized labor versus Flexibility
 Authority based on expertise versus Authority based upon Position
Role Conflicts
Incompatible Role Expectations
RN <
a.
b.
c.
d.
e.
> MD Relationship
educational status
career patterns
semantic differences
class differences
authority differences
f. sex differences
g. different orientations: care versus cure
h. different amounts of time with recipients of care
Three Cases
1. Whistle Blowing
2. Truth Telling
3. Letting Die
Ethics in the Context of Professional Activities
Definition of a Profession
Definition of Ethics
Medical Practice and Models
2 sets of Basic Relations
(A) Physician >Patient
(B) Physician > Physician
1.
2.
3.
4.
5.
Paternalistic (Authoritarian)
Employer (less Authoritarian)
Collegial (non-authoritarian)
Contractual (non-authoritarian)
Possible return to COVENENTIAL
Models based upon Governing Ideals, Conceptual Frameworks, Perspectives
I.
Code
II. Contract
III. Covenant
CODE
1. Unwritten, traditional guides, rules: technical proficiency
2. Written, official pronouncements: etiquette, philanthropy
3. Special language, initiation rites, secrecy, DUTIES, professional Guild
a. Anti-competition monopoly –price fixing, sliding scale
b. Group solidarity
Aesthetic code- life style, image, decorum- beautiful life
Concern for colleagues is greater than that for those served
Five (5) factors militate against self-criticism and self regulation
1. Sense of community
2.
3.
4.
5.
Power of the priestly caste
Power of the modern physician unstable- based on power over death
Suspicion of officiousness, injustice, hypocrisy
Basic conflict- 2 sets of obligations: to guild and to patient
Obligations to colleagues
Responsive, obligation and a debt
Obligations to patients are: self-incurred and duties
Physician > guild, colleagues, teachers, progeny
Hippocratic Oath
1. codal duties to patients
2. Conventional obligations to colleagues
3. context of oath –gods
a. no reference to gift
b. no promises
Initiatory Oath- Code- Covenant as chosen, profession and a transformation
CONTRACT
Pro :
1. Symmetry
2. Legal enforcement
3. Self-interest and not philanthropy, e.g., informed consent
Against:
1. Minimalism
2. Unpredictability
3. Maximalism- Defense Mechanism
4. Inequality
5. No freedom of choice
6. Denies transcendent rights and duties
COVENANT
Key elements are promise and fidelity to the promise
1.
2.
3.
4.
5.
Responsive
Debt
Obligation
Canon of Loyalty, Fidelity (truth, promises, care) not proficiency
Change in Being- ontological nature, e.g., temporal aspect of being
Problems with this model:
Needs a transcendent reference for the proper context:
Transcendent norm for rights and duties of physicians and patients
Transcendent source of limits for expectations and duties
Pro: 1. Not so personal- applies to the whole profession, a covenant with society broadens
accountability
2. Permits setting Professional responsibility for one human good (health) within social limits
Physicians’ indebtedness established by five (50 factors:
1.
2.
3.
4.
5.
Education
Privileges
Social Largess- payments for services
Experimental Subjects
Continual Support of profession and individuals
Covenant includes and extends beyond code and contract
a. Includes code: fidelity to duty, responsibilities to patients and colleagues
b. Includes contract- terms of contract- fidelity
Covenant requires more- a surplus of obligations to society are is final advantage
Obligations (debts) to society are greater than debts to colleagues
Permits possibility of self-discipline
Patient Role relates to the Physician’s image
Physician- as parent, priest
Technician
Contractual partner
Covenantor
patient as dependant
Passive host of disease
Equal participant
Active participant
Mutual reciprocal rights and duties, gifts and
debts, promises and obligations
Application of the models and images to the three cases