Shaping Professionalism: Medical Oaths and Codes of Ethics

Shaping Professionalism: Medical Oaths and Codes of Ethics [Insert Name of Presenter]

Ethical Scenario • Should physicians use surgical “placebo” controls (subjects undergo surgical procedures that have the appearance of therapeutic intervention but during which the essential therapeutic maneuver is omitted) when assessing the efficacy of a surgical intervention?

Surgical “Placebo” Controls • The use of placebo control is not justified when testing a surgical technique that represents a minor improvement of an existing surgical procedure.

Surgical “Placebo” Controls (cont’d) • When a new surgical procedure is developed with the prospect of treating a condition for which no known surgical therapy exists, using surgical "placebo" controls may be justified but must be evaluated in light of whether the current standard of care includes a non-surgical treatment and the benefits, risks, and side effects of that treatment.

Surgical “Placebo” Controls (cont’d) • During the informed consent process, careful explanation of the risks of the operation must be disclosed. Additional safeguards may include using a neutral third party to provide information and obtain consent.

Ethical Scenario • What are a physician’s reporting responsibilities if a patient’s medical problems impair his or her ability to drive safely?

Impaired Drivers and Their Physicians • Physicians should use their best judgment when determining when to report impairments that could limit a patient’s ability to drive. • In situations where there is a strong threat to patient and public safety, and where the physician’s advice to discontinue driving is ignored, it is desirable and ethical to notify the state’s Department of Motor Vehicles.

Ethical Scenario • Results of an experiment that does not meet contemporary standards of human subjects protection is submitted for publication in a medical journal. What should the editors do?

Information from Unethical Experiments • If data from unethical experiments can be replaced by other sources of sound data, then the results should not be published. • If data from unethical experiments are scientifically valid and are the only data available and necessary in order to save lives, then publication of such information may be appropriate.

Information from Unethical Experiments (cont’d) If the results are published, the editors should include a disclaimer that: • clearly describes the unethical nature of the experiment; • clearly states that the publication of the data is needed to save lives; • pays respect to the victims;

Information from Unethical Experiments (cont’d) If the results are published, the editors should include a disclaimer that: • avoids trivializing trauma suffered by the participants; • acknowledges the unacceptable nature of the experiments; and • endorses adoption of higher ethical standards for human subjects’ protection.

Ethical Scenario • A student is uncomfortable about medical students performing procedures on each other for educational purposes. How should the physician-educator respond to the student’s concerns?

Medical Students Performing Procedures on Fellow Students • Instructors should explain to students how the procedures will be performed, making certain that students are not placed in situations that violate their privacy or sense of propriety. • Students should be given the choice of whether to participate prior to entering the classroom.

Medical Students Performing Procedures on Fellow Students(cont’d) • There should be no requirement that the students provide a reason for their unwillingness to participate. • Students should not be penalized for refusal to participate.

Ethical Scenario • When residents or medical students are part of a health care team, what considerations must be taken into account by the attending physician when billing for services?

Billing for Housestaff and Student Services • When a physician assumes responsibility for the services rendered to a patient by a resident or student, the physician can bill for services which were performed under the supervisory physician’s direct personal observation, direction, and supervision.

Ethical Scenario • Should consent be obtained before filming patients for commercial programs that will be publicly broadcast?

Filming Patients in Health Care Settings • Filming patients without consent for commercial purposes is a violation of the patient’s privacy. • Consent is therefore ethically required for both initial filming and subsequent broadcast.

Ethical Scenario • A contract research organization is recruiting physicians to participate in clinical trials that involve patients to whom they provide care. What ethical issues do physicians have to consider?

Managing Conflicts of Interest in the Conduct of Clinical Trials • Physicians should only participate in trials that are scientifically sound and that have been approved by an appropriate IRB. • The informed consent process must differentiate the physician’s roles as clinician and investigator, and this is best achieved when someone other than the treating physician obtains consent.

Ethical Scenario • Is it ethically permissible to accept gifts from pharmaceutical representatives?

Gifts to Physicians from Industry • Any gift accepted by a physician should primarily entail a benefit to patients and should not be of substantial value. • Individual gifts of minimal value are permissible as long as they relate to the physician’s work.

Ethical Scenario • Is it ethically permissible for physicians to sell non–health-related goods from their offices?

Sale of Non–Health-Related Goods from Physicians’ Offices Physicians may sell non–health-related goods from their offices for the benefit of community organizations if: • the goods are low cost; • the physician earns no profit; • such sales are not a regular part of the physician’s business;

Sale of Non–Health-Related Goods from Physicians’ Offices (cont’d) Physicians may sell non–health-related goods from their offices for the benefit of community organizations if: • such sales are conducted in a dignified manner; and • patients are not pressured into making purchases.

Ethical Scenario • Is it appropriate to use terms such as “student doctor” to identify medical students who are caring for patients?

Medical Student Involvement in Patient Care • Patients should be informed of the training status of individuals involved in their care. • Terms that may be confusing when describing the training status of students should not be used. • Physicians should relate the benefits of student participation to patients and should ensure that they are willing to permit such participation.

Ethical Scenario • A medical error has occurred in the course of caring for a patient. Should the treating physician disclose this information to the patient?

Patient Information • When a patient suffers significant medical complications that may have resulted from a physician’s error, the physician is ethically required to inform the patient of all the facts necessary to ensure understanding of what has occurred.

Ethical Scenario • In the context of managed care, should physicians disclose financial incentives that raise potential conflicts of interest to their patients?

Referral of Patients: Disclosure of Limitations • Physicians must assure disclosure of any financial inducements that may tend to limit the diagnostic and therapeutic alternatives that are offered to patients. • Physicians may satisfy this obligation by assuring that the managed care plan makes adequate disclosure to patients enrolled in the plan.

Ethical Scenario • Should medical trainees perform procedures such as endotracheal intubation on the newly deceased patient?

Performing Procedures on the Newly Deceased Patient • In the absence of previously expressed preferences, physicians should request permission from the family before performing procedures. • Without such permission, physicians should not perform procedures for training purposes on the newly deceased patient.

Ethical Scenario • Should physicians treat themselves or members of their own families?

Self-Treatment or Treatment of Immediate Family Members • Professional objectivity may be compromised when an immediate family member of the physician is the patient. • In emergency or isolated settings, physicians can treat themselves or family members until another physician becomes available.

Ethical Scenario • Should physicians use strikes as a tactic in collective bargaining?

Collective Action and Patient Advocacy • Collective action should not be conducted in a manner that jeopardizes the health and interests of patients. • Physicians should refrain from the use of the strike as a bargaining tactic. • Alternative tactics available include informational campaigns and non-disruptive public demonstrations.

Ethical Scenario • A resident has concerns that an attending physician’s order is reflective of poor clinical judgment. How should this situation be handled?

Disputes Between Medical Supervisors and Trainees • Trainees should refuse to participate in patient care ordered by their supervisors in those rare cases in which they believe the orders reflect serious errors in clinical or ethical judgment, or physician impairment, that could result in a threat of imminent harm to the patient or to others.

Disputes Between Medical Supervisors and Trainees (cont’d) • Trainees may withdraw from the care ordered by the supervisor, provided withdrawal does not itself threaten the patient’s immediate welfare. The trainee should communicate his or her concerns to the physician issuing the orders and, if necessary, to the appropriate persons for mediating such disputes.

Disputes Between Medical Supervisors and Trainees (cont’d) • Third-party mediators of such disputes may include the chief of staff of the involved service, the chief resident, a designated member of the institutional grievance committee, or, in large institutions, an institutional ombudsperson largely outside of the hospital staff hierarchy.

Disputes Between Medical Supervisors and Trainees (cont’d) • Retaliatory or punitive actions against trainees who raise complaints are unethical and are a legitimate cause for filing a grievance with the appropriate institutional committee.

Strengthening Professionalism • Reaffirm core values and principles in medicine through oath taking • Increase awareness and understanding of medical codes • Promote mechanisms to encourage compliance with ethical guidelines • Foster lifelong mentoring and the importance of role models

Future of Professionalism For the benefit of patients and the public, the future vitality of professionalism depends on physicians: • Upholding and promoting the integrity of professional self-regulation and autonomy • Supporting the deliberative process by which professional associations establish and promote standards for medicine

Declaration ofProfessional Responsibility • Humanity is faced with unprecedented threats to its health and well-being • While these threats are new, physicians’ response is guided by their historical commitment to care for the sick and the suffering • A recommitment to professionalism underscores it as the foundation for the public’s trust in medicine

Instructions for Presenter To modify this presentation, copy to your desktop and keep this master copy for reference. Each slide contains talking points and notes for the presenter that can be viewed and printed out for easy reference. To view notes, go to “View” on the tool bar and click on “Notes Page.” The presentation includes a set of Ethical Scenarios (slides 15-55) from which you can retain those that are of the most interest to your audience.

Presentation Outline • History of medical oaths and codes • Awareness and understanding of the AMA’s Code of Medical Ethics • Relevancy of selected Code Opinions • Strengthening professionalism’s future

Hippocratic Oath “I swear by Apollo the Physician…to keep according to my ability and judgment the following oath” “I will prescribe regimen for the good of my patients according to my ability and my judgment and never do harm to anyone” The Oath of Hippocrates of Kos, 5th Century BC

Medical Oaths • Personal ethic of oaths • Medicine’s moral mandate, the duty to care for the sick, is reflected in the conduct of physicians with good character • Notion of binding covenant: “If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.”

Medical Codes • Professional ethics of codes • Developed through a process of collaboration, consensus, and finally codification • Notion of professional self-regulation

Shaping Professionalism: Medical Oaths and Codes of Ethics