MUSM Professionalism and Ethics

1. MUSM Professionalism and Ethics Richard L Elliott MD, PhD Professor and Director Professionalism & Ethics Adjunct Professor Mercer Law School

2. Ethics and Professionalism at MUSMFaculty • Richard L. Elliott, MD, PhD (Macon) • Room 62, East Hall, MUSM • Elliott_rl@mercer.edu • Martin H. Greenberg, MD (Savannah) • R. Stephen Williams, MD, MHSA (Macon) Resources at: medicine.mercer.edu/ethics

3. MUSM Professionalism and EthicsFirst Year - Introduction • Principles of medical ethics • Autonomy, beneficence, non-maleficence, social justice • How to analyze ethical issue • Informed consent • Ethical basis • Voluntariness, information, capacity • Exceptions • Rule #1 • Be a doctor • Rule #2 • The attending is (almost always) right

4. MUSM Professionalism and EthicsFirst year – End-of-Life • Karen Quinlan • Nancy Cruzan • End-of-life decisions • Advance directives • Surrogate decisionmaking

5. MUSM Professionalism and EthicsFirst Year – Confidentiality and Privilege • Exceptions • Response to a subpoena • Tarasoff warnings

7. MUSM Professionalism and EthicsFirst Year • Professionalism • Challenges to the Oath of Geneva • Cooperative vs. competitive medicine • Mercer Student Handbook • Oath of Geneva

8. MUSM Professionalism and Ethics • Ethics of healthcare reform

9. 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?

10. I WILL GIVE to my teachers the respect and gratitude which is their due 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.

11. I WILL PRACTICE my profession with conscience and dignity 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?

12. 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.

13. 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 antianxiety (Xanax), pain, and stimulant medications.

14. I WILL RESPECT the secrets which are confided in me, even after a patient has died 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.”

15. 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.

16. MUSM Professionalism and Ethics • Third year ethics covered later this week • Senior thesis required

17. MUSM Professionalism and EthicsSecond Year • Research and ethics • Tuskegee Study of Untreated Syphilis • Working with medical industry • Impairment and abuse in medicine • Medical malpractice • Four Ds • Three pillars of risk management • Communication, consultation, documentation

18. Questions?

20. Ethics and Professionalism • 34 year-old single woman, on public assistance, comes to you for IVF • Previous IVF resulted in six children, all living with her • What would you do? • Why?

21. Ethics and Professionalism at MUSMOffice of Professional Practice • Medical ethics • Professionalism • Legal regulation • Malpractice, EMTALA, HIPAA, . . . • Health administration • Payment systems, accreditation, reform • Interest group

22. Ethics and Professionalism at MUSMCurriculum • Orientation • Community Medicine I • Informed consent, confidentiality, professionalism • Community Medicine II • Research ethics, abuse of trainees, pharmaceutical industry malpractice • Clerkships • Internal medicine, pediatrics, ob-gyn, family medicine, surgery, EC • Senior papers and electives • Capstone

23. What to do? A child in an MVA is losing blood rapidly, mom refuses permission for transfusion based religious beliefs

24. What to do? An HIV-positive man admits he is sexually active, states he cannot tell his fiancee his HIV status

25. What to do? A patient comes repeatedly to the EC demanding opiates for headaches

27. Medical EthicsCurrent Controversies • Use of embryonic stem cells – is it OK to “sacrifice” embryos to save lives of adults? • Transplantation – how do we establish priorities for recipient lists • Futility of care – when can MDs “pull the plug” over the wishes of patient and family? • When can we override wishes of parents and treat children (e.g., JW)? • How do we handle performance enhancers?

30. Between your first and second years of medical school, you do laboratory research at a hospital near your home. After a couple of months of hard work, you collate your data and write a draft paper for the faculty advisor to revise before submitting it for publication. After reviewing your draft and making many comments, you see that they have included the name of one of the second-year students, although he didn’t have anything to do with your work. Afraid of angering him, you don’t say anything. However, a few weeks later, you discover that your name has been added to a paper the other student has written with you were not involved with.

31. Financial Aid • A third year student receives the FAFSA packet in February of her second year, signing a form acknowledging that she received it. The Office of Financial Aid sends several reminder emails to the student that she needs to fill out the application. In the first week of her third year, her financial aid check is not at the bursar’s office. The student calls the Director of Financial Aid and yells at her saying that no one gave her the packet, she didn’t get any emails reminding her, and demands a check

32. I’m lonely • You are interested in a competitive specialty and you have heard that the best way to get in is to have a lot of research publications. A male faculty member has a reputation of having many students in his lab and many of them get published. One evening, he calls a female student and tells her that his wife is out of town, he is lonely, and he wants her to come over to keep him company.

33. A helpful resource? A faculty member provides a list of the answers to an upcoming test and tells you to let everyone know on your campus, but not to let the other campus know about the list.

34. Is it cheating? A first year student asks a second year student for advice regarding his upcoming MDE exam. She gives him a list of old exam questions and review sheets that will help you greatly. She states that you should “keep it quiet” when around faculty, because some have been disgruntled with old questions floating around, but that each class has done so in the past. She encourages you to pass the materials on to your friends.

35. Can’t we be friends? • You are a woman third year student who studied in the company of a group of friends the first two years. During your first clerkship one of the group begins to make unwanted advances and, despite your insistence this can go no further, he persists and becomes aggressive.

36. It’s tough to make predictions.

37. Especially about the future.

38. Who will be disciplined by medical boards? • Greatest risk if disciplined during medical school • Drugs and alcohol • Who is your AIMS representative? • Reliability • Preparation, on time • Volunteering • Respect for colleagues

41. Ethics and Professionalism Richard L. Elliott, MD, PhD, FAPA Professor and Director, Medical Ethics Mercer University School of Medicine Adjunct Professor Mercer University School of Law