richard l. elliott, md, phd, fapa professor and director medical ethics and professionalism mercer...
TRANSCRIPT
RICHARD L. ELLIOTT, MD, PHD, FAPAPROFESSOR AND DIRECTOR
MEDICAL ETHICS AND PROFESSIONALISMMERCER UNIVERSITY SCHOOL OF MEDICINE
ADJUNCT PROFESSORMERCER UNIVERSITY SCHOOL OF LAW
Medical Ethics and Professionalism
Goals
What is medical ethics?Medical ethics and professionalism at MUSMExpectations for Community Medicine IWhat is an ethical dilemma?What are the principles of medical ethics?How to analyze an ethical problemIntroduction to informed consent and
confidentialityIntroduction to surrogate decisionmakingIntroduction to professionalism
What is Medical Ethics?
The application of moral principles and analysis to medical situations
Not bioethics
Overview of MUSM Medical Ethics and Professionalism
First Year Orientation White Coat ceremony Medical history, Delivering bad news, . . . Intro to Medical Ethics and
Professionalism Research opportunity as Summer Scholar Basics of Health Care Reform Ethics Interest Groups – Savannah and
Macon
Medical Ethics and Professionalism Overview
Second Year Clinical research Pharmaceutical companies Physician impairment Student abuse Malpractice and risk management BMP
Medical Ethics and Professionalism Overview
Third Year Professionalism as a third year student Internal medicine – end-of-life, futility of care,
physician assisted suicide Pediatrics - child abuse, neonatal care Obstetrics and gynecology – reproductive
technologies, genetic screening Surgery – case analyses Psychiatry – competence, involuntary treatment,
boundary violations, duties to third parties Family medicine – elder abuse, domestic violence,
medical errors
Medical Ethics and Professionalism Overview
Fourth Year Senior Case analysis Ethics in the Emergency Room Electives Capstone
Risk management Health care and resource allocation Special topics, e.g., social media, licensure
Medical Ethics and Professionalism – Year One
First week - two lectures Introduction to Medical Ethics and Professionalism
Principles of medical ethics Informed consent and surrogate decisionmaking Confidentiality Procedure for ethical case analysis
Principles and Codes of Medical Ethics and Professionalism Oath of Geneva
Second week Group discussion of two cases on medical ethics site
Advance directives Confidentiality
At the end of these two weeks, you should be able to:
Describe principles of ethics and professionalism
Identify an ethical dilemmaDescribe process of ethical case analysisState basis and principles of informed
consentState basis and exceptions to patient
confidentialityDescribe current challenges to the medical
profession
Resources and Examination
[email protected]. Greenberg
[email protected] Ethics site
Academics Degree Programs
Doctor of Medicine -> Medical Ethics -> First Year
Powerpoints posted on Ethics site Exam on Powerpoint material
10-15 questions MDE format Not a fluff exam – look at details!
What is an Ethical Dilemma?
A conflict between ethical principles, i.e., “what is the right thing to do?” What is “medically” right vs. patient preference
Jehovah’s Witnesses and transfusions What is preferred by patient vs. proxy decision
maker Rights of minor vs. legal guardians
What is best for patient vs. what is best for society Commitment laws, notification of sexual partners of
patients with HIV
What do Mercer Students Consider Ethical Dilemmas?
2008 2009 Confidentiality 17 6 Decisionmakers 17 15 Right to refuse 4 8 Right to treatment 4 3 Futility of care 4 15 Medical error 2 3 AIDS/HIV 7 4 Pregnancy 6 8 Jehovah’s Witness 3 4 DNR/ventilator 4 Professionalism 12
What Would You Do?
Case 1: 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 to know.
Case 2: A 25 year old woman victim of a single car MVA enters a persistent vegetative state. After four years, her parents petition to have her feeding tube removed. The hospital insists on a court order, and the victim’s closest friend and parents testify that she would not have wanted to have a feeding tube.
Two Medical Dilemmas
Case 1 – HIV and confidentiality The patient has a right to keep his records confidential The wife has a right to be protected
Case 2 - PVS and feeding tube removal Patient has right to have wishes respected State has right to have its laws respected Hospital has a right to determine what interventions it
supports Physicians have a right to decide what treatments
they provide
How to Analyze an Ethics Case,(or how do I figure out what’s the right thing
to do?)
What are the medical issues? Risks, benefits, alternatives, prognoses
Who are the stakeholders? Patient, family, medical staff, hospital, state Cultural and religious concerns
What are the relevant laws, regulations, ethical codes?
Why is an ethical dilemma being created? Conflicts between decision makers, law and
ethicsWho are possible consultants?
Medical, family, ethicists, ethics committee, lawyers
Possible courses of actionProposed resolution
What are the Medical Issues?
Rule #1 We are doctors (not moral philosophers or lawyers) Know your medicine! Most ethical problems have a clinical solution
Diagnosis, nature of treatment proposed, risks, benefits, prognosis with and without treatment, alternatives Evidence-based decisions
Remember this when you analyze cases next week!
Medical Issues
Case 1 – HIV and confidentiality What is course, prognosis, and treatment for HIV? What is likelihood wife is or will be infected? What is wife’s prognosis without treatment? What is likelihood wife will infect fetus, children?
Case 2 - PVS and feeding tube removal What is PVS? What are possible alternatives? What is prognosis with and without feeding tube?
Who are the stakeholders (potential decisionmakers)?
Patient Quality of life, autonomy, spiritual needs
Family Proxy decision makers, quality of life
Physician Risk management concerns
Medical profession Standards
Hospital Policies, accreditation, affiliations
State Resource allocation, legal regulation
Stakeholders
Case 1 – HIV and confidentiality Patient Wife Children Physician Medical profession State
Case 2 - PVS and feeding tube removal Patient Parents Medical profession State
What are the Relevant Laws?
Statutory vs. case lawOfficial Code of Georgia, Code of Federal
Regulations (Federal registry)Case law
Binding at appellate level in jurisdictionTwo famous (board material) ethics cases
Karen Ann Quinlan Nancy Cruzan
Legal Issues – HIV and Confidentiality
Case 1 – HIV and confidentiality HIPAA O.C.G.A and confidential nature of HIV information
§ 24-9-47. Disclosure of AIDS confidential information (b) Except as otherwise provided in this Code section: (1) No person or legal entity which receives AIDS confidential information pursuant to this Code section or which is responsible for recording, reporting, or maintaining AIDS confidential information shall: (A) Intentionally or knowingly disclose that information to another person or legal entity; or
Legal Issues – HIV and Confidentiality
But: (g) When the patient of a physician has been determined to
be infected with HIV and that patient's physician reasonably believes that the spouse or sexual partner or any child of the patient, spouse, or sexual partner is a person at risk of being infected with HIV by that patient, the physician may disclose to that spouse, sexual partner, or child that the patient has been determined to be infected with HIV, after first attempting to notify the patient that such disclosure is going to be made; And:
A physician having a patient who has been determined to be infected with HIV must disclose to the Division of Public Health (O.C.G.A. 31-12-2(b)) (A) The name and address of that patient; (B) That such patient has been determined to be infected with HIV; and (C) The name and address of any other person whom the disclosing physician or administrator reasonably believes to be a person at risk of being infected with HIV by that patient.
Legal Issues – Removal of Feeding Tube
Case 2 - PVS and feeding tube removal The patient did not have an advance directive
Power of attorney for health care Living Will
In the absence of an advance directive, the state may require by clear and convincing evidence a showing of what the patient would have chosen under the same or similar circumstances
Georgia Advance Directive for Health Care Combines Living Will and Durable Power of Attorney
for Health Care
Ethical dilemmas are conflicts between or among ethical principles
What are commonly accepted ethical principles in medicine?
Principles of Medical Ethics
Autonomy “Every human being of adult years and sound mind has a
right to determine what shall be done with his own body” Schloendorff, 1914
Right to PrivacyBeneficence
Act for the good of the patient Promote good Remove or prevent harm
Non-maleficence Primum non nocere First, do no harm
Social justice Access to heath care resources
What Are the Four Principles of Medical Ethics?
AutonomyBeneficenceNonmaleficenceSocial Justice
Why Does an Ethical Dilemma Exist?
Case 1 – HIV and confidentiality The patient has a right to keep his records confidential
Autonomy, Nonmaleficence HIPAA
The wife has a right to be protected Right to privacy (?)
Case 2 - PVS and feeding tube removal Patient has right to have wishes respected
Right to privacy, Autonomy State has right to have its laws respected Hospital has a right to determine what interventions it
supports Physicians have a right to decide what treatments
they provide
Possible Consultants
Case 1 – HIV and confidentiality Infectious disease
Clinical Policy on HIV and confidentiality
Division of Public Health Ethicist Health or malpractice insurance lawyer
Case 2 - PVS and feeding tube removal Medical
Establish prognosis, possible alternative interventions Others who knew patient’s wishes Ethics Committee Medical Director
Futility Policy? Mediator
Possible Courses of Action
Case 1 – HIV and confidentiality Do nothing Contact wife Contact Division of Public health Refer to another physician
Case 2 - PVS and feeding tube removal Do nothing Remove tube Contact hospital attorney to block family’s wishes
Proposed Resolution
Case 1 – HIV and confidentiality Attempt to meet with patient and wife to discuss test
results and implications, offer to test wife If patient refuses, contact DPH for partner notification
Case 2 - PVS and feeding tube removal Remove tube or refer to another physician/hospital
Two Ethically Problematic Situations
Informed consent Surrogate decisionmakers Right to die/wrongful life
Karen Ann Quinlan, Nancy Cruzan, Terry Schiavo Advance directives Rights of minors Treatment refusal
Jehovah’s Witnesses, dialysis, Dax
Confidentiality When to breach confidentiality Tarasoff
Ethical and Legal Bases of Informed Consent
What is the ethical basis for informed consent?
Autonomy underlies informed consentAssault and (intentional tort of) battery
Informed Consent
Three Elements of informed consent Voluntariness Information Competence (capacity)
Three Elements of Informed Consent
What three elements comprise informed consent?
Information How much?
Competence (capacity) How do we determine this?
Voluntariness What constitutes coercion?
Voluntariness
Freedom from undue influenceIncentives for research?Would decision of patient with HIV to disclose
information to wife be voluntary if alternative is partner notification through public health? Voluntary within constraints
Would decision of family to request withdrawal of feeding tube be voluntary if hospital threatened them with threat of massive health care costs?
Information – What must be disclosed??
No doctrine of informed consent in Georgia. Georgia requires disclosure “in general terms the treatment or course of treatment” but for surgical or diagnostic treatments standard is higher (O.C.G.A.31-9-6.1)
For surgical procedures, amniocentesis, contrast material “disclosure of the material risks generally recognized and accepted by reasonably prudent physicians which, if disclosed to a reasonably prudent person in the patient's position, could reasonably be expected to cause that person to decline the proposed treatment or procedure because of the risk of injury that could result”
Good practice to disclose diagnosis, nature of treatment, risks, benefits, alternatives, prognosis with and without treatment, and to invite questions
What should be disclosed?
Case 1 – HIV and confidentiality Meaning of test Risk of infecting wife Possible criminal consequences for failing to inform
her Woodrow Grady, Macon, sentenced to two years in 2009
HIV and fetus, children Treatment possibilities, alternatives, side effects,
prognosisCase 2 – PVS and removal of feeding tube
Prognosis with and without feeding tube Alternatives Costs – make it clear care does not depend on ability
to pay
Competence
§ 31-9-2.(c) For purposes of this Code section,
"inability of any adult to consent for himself" [shall mean the adult] "lacks sufficient understanding or capacity to make significant responsible decisions" regarding his medical treatment or the ability to communicate by any means such decisions.
Competence
Competence or capacity is specific to a particular decision Competence is a legal decision, but used synonymously
with capacityRange of competence:
Ability to communicate decision Not refusing Simple assent
Simple Understanding E.g., able to paraphrase
Appreciate complexities of decision Medical Interpersonal Spiritual
Level of competence needed related to risk/benefit
Competence
Case 1 – HIV and confidentiality Was patient competent to release or to deny release of
information? What if retarded? Depressed? Demented (HIV dementia)? Delirious?
Case 2 – PVS and PEG removal Were parents competent to request tube removal?
When the Patient is Incompetent
Karen Ann Quinlan1954-8521 yo, Valium and
ETOHPVS, ventilatorParents sued to
remove ventilator1976 New Jersey
Supreme Court decided on right to privacy
“Right to die”
When the Patient is Incompetent
Nancy Cruzan1983 MVAPVS, feeding tube1987 parents sued to
remove tubeCourt liberty interest
in being free from unwanted intrusions
Loosely “right to die”Patient Self-
Determination Act 1990
Patient Self-Determination Act
1990 after CruzanWritten notice upon admission to the health
care facility of decision-making rights The right to accept or refuse medical
treatment The right to make an advance health care
directive Facilities must ask whether the patient
has an advance health care directive Facilities must educate staff about
advance health care directives.
When the Patient is Incompetent
Guardian Probate court Guardian of person or estate or both
Advance directive Specifies what is to be done in the event patient is unable
to make a decision Durable Power of Attorney for Health Care
Who will make decision Living Will
Specifies particular decisions, e.g., ventilators Georgia Advance Directive for Health Care includes both
Power of Attorney and Living Will provisions (posted on ethics site, First Year)
Georgia Advance Directive for Health Care
GUIDANCE FOR HEALTH CARE AGENT When making health care decisions for me, my health care
agent should think about what action would be consistent with past conversations we have had, my treatment preferences as expressed in PART TWO (if I have filled out PART TWO), my religious and other beliefs and values, and how I have handled medical and other important issues in the past. If what I would decide is still unclear, then
My health care agent should make decisions for me that my health care agent believes are in my best interest, considering the benefits, burdens, and risks of my current circumstances and treatment options.
Substituted Judgment v Best Interests
Substituted judgment – for persons who have been competent to express a choice but who presently lack capacity Dementia Delirium Severe mental illness
Best interests standard – for persons never competent to have decided Children Mentally retarded/developmentally disabled
Georgia Advance Directive for Health Care
PART TWO will be effective if I am in any of the following conditions: A terminal condition, which means I have an incurable
or irreversible condition that will result in my death in a
relatively short period of time, and/or; A state of permanent unconsciousness, which means I
am in an incurable or irreversible condition in which I am
not aware of myself or my environment and I show no behavioral response to my environment.
To be determined by personal and second physician
Georgia Advance Directive for Health Care
Try to extend my life for as long as possible, using all medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive. If I am unable to take nutrition or fluids by mouth, then I want to receive nutrition or fluids by tube or other medical means, OR;
Allow my natural death to occur. I do not want any medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive but cannot cure me. I do not want to receive nutrition or fluids by tube or other medical means except as needed to provide pain medication, OR;
Georgia Advance Directive for Health Care
I do not want any medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive but cannot cure me, except as follows:
[Initial each statement that you want to apply to option (C).] If I am unable to take nutrition by mouth, I want to receive nutrition by tube or
other medical means. If I am unable to take fluids by mouth, I want to receive fluids by tube or other
medical means. If I need assistance to breathe, I want to have a ventilator used. If my heart or pulse has stopped, I want to have cardiopulmonary resuscitation (CPR) used.
Default Surrogate Decisionmakers I
§ 31-9-2. Persons authorized to consent to surgical or medical treatment
(a) any one of the following persons is empowered to consent: (1) Any [competent] adult, for himself or herself, whether by living
will, advance directive for health care, or otherwise; (1.1) Any person authorized to give such consent for the adult under
an advance directive for health care or durable power of attorney for
health care (2) In the absence or unavailability of a living spouse, any parent,
whether an adult or a minor, for his or her minor child; (3) Any married person, whether an adult or a minor, for himself or
herself and for his or her spouse;
Default Surrogate Decisionmakers II
(4) Any person temporarily standing in loco parentis, whether formally
serving or not, for the minor under his or her care; and any guardian, for his or
her ward; (5) Any female, regardless of age or marital status, for herself when
given in connection with pregnancy, or the prevention thereof, or childbirth;
or (6) Others (A) Any adult child for his or her parents; (B) Any parent for his or her adult child; (C) Any adult for his or her brother or sister; or (D) Any grandparent for his or her grandchild. (E) Grandchild (F) Niece, nephew, aunt, or uncle Treatment which the patient would have wanted had the patient
understood the circumstances under which such treatment or procedures are provided.
Medical Consent in Minors
Under the age of 18 may consent to: Treatment for drug abuse HIV testing Prevention of pregnancy Treatment during pregnancy and
childbirth Treatment for STD Abortion with parental notification
Informed Consent
Not just a piece of paperInformed consent is a means of engaging a
patient in important health care decisionsThere is therapeutic value to true informed
consent
Exceptions to Informed Consent
Emergency exceptions to informed consent Consent is implied in emergency when patient is lacks
capacity and surrogate unavailableTherapeutic privilegeWhat is Rule #1?Rule #1 - We are doctors, not lawyers
Follow-up to first lecture
Informed consent is a process, not a piece of paper
Optional review at end of lecture
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 myselfHippocrates
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.
Health Insurance Portability and Accountability Act (HIPAA)
1996
Intent to restrict release of information to only that necessary to achieve the purpose
Patients may be guaranteed access to their medical records and may amend
N.B., “psychotherapy” notes, therapeutic privilege
What about disclosing information to a family member in an emergency? Consent not required if disclosure necessary for
treatment Family notification may be necessary for treatment
Subpoena Duces Tecum
Immediate response: Reply, don’t comply
Check with patientAdvise patient to
contact attorneyGet legal advice if
neededRelease minimum
information necessary
Breaking Confidentiality
Reporting child abuse or neglectAbuse of seniorsAbuse of disabledResidents of long term care facilitiesReporting HIV to stateNotifying sexual partners of HIV“Tarasoff” warningsCalifornia decision that clinicians have an
obligation to protect some third parties “protective privilege ends where the public peril
begins”
Tarasoff
There is a duty to protect identifiable third parties when a clinician knows, or, pursuant to the standards of the profession ought to know, that the patient presents an imminent threat of danger to that third party.
Review from November 2014
Why talk about professionalism?
Only a recent topic – past 25 yearsWhat’s changed that we talk on professionalism
now?“The business of medicine”
Erosion of trust between society and medicine Affluent doctors becoming wealthy Does healthcare prioritize profits over patients?
Personal life over professional sacrificeConsumerism: Are we professionals or “providers?”The Internet and “professional” laypersonsRise of other “professions”
Professions and the Social Contract
Society grants authority, autonomy, and privileges to professionals based on an understanding that in so doing, something of value is expected in return
Expectations – value of service, trustworthiness, competence, altruism, personal morality, self-sacrifice, accountability, exposure to long hours and danger
Privileges – trust, respect, status, relative autonomy (right to regulate profession and limit competition), income
Abuse of privileges and other unprofessional conduct which undermines trust may result in loss of privileges
Professionalism and trust
At the core, professionalism is what promotes trust among members of society, and what we talk about as promoting professionalism are aspects of what is needed to promote trust.
Imagine a patient or patient’s family in here now, or in your tutorial rooms. Would you do anything differently?
Medical professionalism
A self-regulating profession needs to operationalize its meaning of professionalism
ABIM ACP Charter on ProfessionalismMedical Professionalism in the New
Millennium: A Physician Charter. Ann Int Med 2002;136:243-246
Three “Fundamental principles” Primacy of patient welfare Principle of patient autonomy Principle of social justice
ABIM ACP Charter on Professionalism 10 Physician responsibilities or commitments
CompetenceHonesty with patientsPatient confidentialityAppropriate relationships with patientsImproving quality of careImproving access to careJust distribution of resourcesScientific knowledgeManaging conflicts of interestProfessional responsibilities
ABIM ACP Charter on Professionalism
Commitment to professional responsibilities
As members of a profession, physicians are expected to work collaboratively to maximize patient care, be respectful of one another, and participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards. The profession should also define and organize the educational and standard-setting process for current and future members. Physicians have both individual and collective obligations to participate in these processes. These obligations include engaging in internal assessment and accepting external scrutiny of all aspects of their professional performance.
(Some) Problems with Professionalism
Too much formal curriculumToo much of the wrong hidden curriculumToo much of the wrong media portrayalsMyths
You can be professional part-time, do what you want in your private life
Doctor-doctor relationshipsTrivialization – stand up straight, dress
nicely!
Professionalism and trust
At the core, professionalism is what promotes trust among members of society, and what we talk about as promoting professionalism are aspects of what is needed to promote trust.
Conversely, unprofessional conduct are those things which adversely affect society’s trust in the profession
Some Characteristics of a “Professional”
Self-regulatingSpecialized education, training, knowledge
CompetenceBehaviors
Dress Timeliness Preparedness Courtesy Hard working
What does it mean to be professional?
As a preclinical student? Prepared On time Respectful
As a clinical student? Appearance Prepared On time Respectful
Nurses Extra duty
On Entering a Profession
An oath is taken pledging to uphold the standards of that profession
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”).
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 antianxiety (Xanax), pain, 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.”
Secrets
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.”
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.
Click icon to add pictureThreat to professionalism
Mangled care
Click icon to add pictureThreat to professionalism
Medical Industry
Unprofessional Conduct and Board Action
235 MDs disciplined by board 1990-2003469 MDs controlled for school and year of
graduationDisciplined 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 108Unprofessional conduct 82Conviction for a crime 46Negligence 42Prescribing/acquisition substances 39Violation of Board order/condition 32Sexual misconduct 29
Other – Failure to meet CME, fraud, billing, failure to maintain adequate records
Disciplined vs. Control Physicians
No gender differencesHighly significant differences (p< 0.05–
0.001) Medical school academic performance USMLE
Unprofessional conduct in school predicted subsequent disciplinary problems 39% of disciplined physicians displayed unprofessional
behaviors in school vs 19% of undisciplined physicians (disciplined physicians twice as likely to have records of unprofessional conduct during school)
P<0.001
Unprofessional Conduct in School
OR
Irresponsibility (>2) 8 Attendance, follow-up
Lack of self-improvement (>2) 3 Response to criticism
ImmaturityPoor initiative
Motivation, enthusiasmRelationships (students, nurses, faculty,
patients)
Lessons
Professionalism starts nowGood news – the two most significant
predictors are modifiable If you have problems with attendance,
preparedness – change! If you have a problem accepting criticism –
learn! Smiling inward is deadly
Groups
Prepare as a professional
Read the cases
Analyze using case analysis format
Discuss with colleagues as you like
Rule #! - Wear white coats to our groups
Optional (!) review
What are the steps to follow when analyzing the cases for next week?
Review
What is an ethical dilemma?Conflict between or among ethical
principles, decisionmakers, and/or laws
What are the four principles of medical ethics?
AutonomyBeneficenceNon-maleficenceSocial justice
The principle of autonomy in medical ethics concerns the patient’s
Right to determine what shall be done to her own body
A capacity determination isA judgment about the patient’s ability
to make a particular decision about her medical care
When obtaining informed consent from a patient for a surgical procedure, amniocentesis, or use of IV contrast material, the standard in Georgia for disclosure of risks includes material risks which are
“Accepted by reasonably prudent physicians that would cause a reasonably prudent patient in similar circumstances to refuse the procedure”
When a decision must be made about the medical care of an adult patient who has had, but who no longer has, decision-making capacity, should the surrogate decision-maker use the “substituted judgment” standard to reach a decision,( i.e., what the patient would have decided if competent) or the best interest standard?
Substituted judgment
Which three elements comprise valid, informed consent?
Capacity (Competence), relevant information, voluntary
Which of the following is recognized as the primary ethical foundation for informed consent?
Principle of autonomy
The case of Tatiana Tarasoff in California led to the enunciation of which legal principle?
There is a duty to protect identifiable third parties when a clinician knows, or, pursuant to the standards of the profession ought to know, that the patient presents an imminent threat of danger to that third party.
The Karen Ann Quinlan and Nancy Cruzan cases were both related to:
Right to die (right of surrogate decision-makers to refuse life-sustaining treatment)
Which law led to the requirement that hospitals ask about the presence of Advance Directives?
Patient Self-Determination ActFrom which case did this law evolve?Nancy CruzanWhat does the Oath of Hippocrates have to
say about confidentiality?A warning to keep secret knowledge
learned from professional contacts as well as knowledge learned “in the daily commerce with men”
Principles of Medical Ethics
Which of the following is NOT widely considered a principle of medical ethics? Autonomy Beneficence Respect Social justice Non-Malfeasance
HIPAA
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
Mandatory Disclosure
In which of the following cases is disclosure of information NOT required:
Suspected child abuse (REQUIRED)New HIV patient (REQUIRED)After receipt of a subpoena for medical
records to be used at a divorce proceeding (NOT REQUIRED)
Previously undisclosed criminal history (NOT REQUIRED)
Match case with the concept most closely identified with it
National attention on “right to die” and removal of life sustaining devices
Duty to protect third parties
Removal of feeding tube, Patient Self Determination Act
TarasoffNancy CruzanKaren Ann Quinlan
Autonomy
The principle of autonomy concerns the patient’s Right to be treated with compassion Right to determine what shall be done with one’s
body 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
Which is the more acceptable view?
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 Both
Best Interests or 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 Interests or 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 (capacity) Witnessed
Minors and Medical Decisions
To which medical decisions may a minor in Georgia give consent?
Drug abuse treatmentSTDTreatment of the minor’s childPregnancyPrevention of pregnancyAbortion with parental notification (except
emergency or with court approval)
Slides from this point on were not part of the presentation in 2015
So why talk about professionalism?
Only a recent topic – past 25 yearsWhat’s changed that we talk on professionalism
now?“The business of medicine”
Erosion of trust between society and medicine Affluent doctors becoming wealthy Does healthcare prioritizes profits over patients?
Personal life over professional sacrificeConsumerism: Are we professionals or “providers?”The Internet and “professional” laypersonsRise of other “professions”
What is a profession?
What would you conclude about “professions”?
Professions and the Social Contract
Society grants authority, autonomy, and privileges to professionals based on an understanding that in so doing, something of value is expected in return
Expectations – value of service, trustworthiness, competence, altruism, personal morality, self-sacrifice, accountability, exposure to long hours and danger
Privileges – trust, respect, status, relative autonomy (right to regulate profession and limit competition), income
Abuse of privileges and other unprofessional conduct which undermines trust may result in loss of privileges
Becoming a Profession: Isn’t everyone a professional?
An occupation becomes a full-time occupation Apprenticeships
Establishment of standards through formal training and education – trade schools
Establishment of a local and national associations/guilds/lobbyists
Codes of professional ethics and oaths To profess an oath
Exclusion through licensureSelf-regulation
Professionalism and trust
At the core, professionalism is what promotes trust among members of society, and what we talk about as promoting professionalism are aspects of what is needed to promote trust.
Imagine a patient or patient’s family in here now, in your tutorial rooms. Would you do anything differently?
Medical professionalism
A self-regulating profession needs to operationalize its meaning of professionalism
ACGMEABIM ACP Charter on Professionalism
Medical Professionalism in the New Millennium: A Physician Charter. Ann Int Med 2002;136:243-246
Three “Fundamental principles” 10 physician responsibilities
ABIM ACP Charter on Professionalism Principle of primacy of patient welfare
This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician–patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.
Emphasis on trust between physicians and patients – what about trust between physicians and society?
ABIM ACP Charter on Professionalism Principle of patient autonomy
Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.
But does emphasis on patient autonomy affect the trust placed in physician’s judgment and trust in physicians ability to protect broader interests?
ABIM ACP Charter on Professionalism Principle of social justice
The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.
How does fair allocation of resources relate to first two principles, primacy of patient welfare and patient autonomy?
ABIM ACP Charter on Professionalism 10 Physician responsibilities or commitments
CompetenceHonesty with patientsPatient confidentialityAppropriate relationships with patientsImproving quality of careImproving access to careJust distribution of resourcesScientific knowledgeManaging conflicts of interestProfessional responsibilities
ABIM ACP Charter on Professionalism
Commitment to professional responsibilities
As members of a profession, physicians are expected to work collaboratively to maximize patient care, be respectful of one another, and participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards. The profession should also define and organize the educational and standard-setting process for current and future members. Physicians have both individual and collective obligations to participate in these processes. These obligations include engaging in internal assessment and accepting external scrutiny of all aspects of their professional performance.
(Some) Problems with Professionalism
Too much formal curriculumToo much of the wrong hidden curriculumToo much of the wrong media portrayalsMyths
You can be professional part-time, do what you want in your private life
Doctor-doctor relationshipsTrivialization – stand up straight, dress
nicely!
Professionalism and trust
At the core, professionalism is what promotes trust among members of society, and what we talk about as promoting professionalism are aspects of what is needed to promote trust.
Conversely, unprofessional conduct are those things which adversely affect society’s trust in the profession
Professors, students, and the social contract
Is there is a social contract between society and medicine, there is a social contract between society, professors, and medical students
Society pays for much of medical education, including the salaries of professors and subsidies for student tuition
Society expects that professors and students will conduct themselves so as to promote trust that medical education will further medicine’s role
What is the relationship (contract) between professors and students?
Students expect professors to develop a curriculum that prepares them to become capable physicians, and to deliver it with respect for their commitments in time and money
Professors expect that students will commit themselves fully to learning
Trust and mutual respect underlie the relationship
Social contracts and oathsWe have oaths to profess our beliefs when we
become physiciansShould we have oaths to express our mutual
commitments to teaching and learning in medical school?
But we do have the MUSM Professionalism Statement, the AAMC Compact between Teachers and Learners, and the Honor Code.
Careers in Medicine
Compact Between Teachers and Learners of Medicine
Preparation for a career in medicine demands the acquisition of a large fund of knowledge and a host of special skills. It also demands strengthening of those virtues that undergird the patient/physician relationship and sustain the profession of medicine as a moral enterprise. This Compact serves as both a pledge and as a reminder to teachers and learners that their conduct in fulfilling their mutual obligations is the medium through which the profession inculcates its ethical values.
Careers in Medicine
Guiding Principles –Integrity The learning environments conducive to
conveying professional values must be suffused with integrity. Students learn enduring lessons of professionalism and caring by observing and emulating role models who epitomize authentic professional values and attitudes.
Careers in Medicine
Guiding Principles – DutyMedical educators have a duty, not only to convey …knowledge …but also to inculcate the values and attitudes required for preserving the medical profession’s social contract across generations.
Careers in Medicine
Guiding Principles –RespectFundamental to the ethic of medicine is
respect for every individual. Mutual respect between learners, as novice members of the medical profession, and teachers, as experienced and esteemed professionals, is essential for nurturing that ethic. Given the inherently hierarchical nature of the teacher/learner relationship, teachers have a special obligation to ensure that students and residents are treated respectfully.
Careers in Medicine
The Learning Environment at Mercer University School of Medicine
The educational policies and procedures at the School of Medicine are consistent with those of the Liaison Committee on Medical Education and Mercer University. They have been developed to foster and maintain an educational and clinical community that nurtures learning in an environment where students, faculty and staff work together in an atmosphere free of all forms of harassment or intimidation. Diversity is valued recognizing that exposure to students, faculty, staff, and patients from a wide range of backgrounds, enhances the educational experiences of all students
Does MUSM need a teacher – student compact?
HONOR CODE
IN STUDENT HANDBOOKALL DEFINITIONS OF PROFESSIONALISM INCLUDE THE THEMES OF HONESTY AND
INTEGRITY
Honor Code
I will respect the integrity of the patients with whom I deal and the confidential nature of their communications. I will not discuss cases except under appropriate professional or academic circumstances.
Honor Code
I will clearly identify my role as a medical student to each patient. I will not undertake any clinical procedure unless I have been judged competent or am supervised by a qualified instructor. I will not attempt to advise, prescribe, or prognosticate for the patient without appropriate consultation. I will accept the responsibility to question plans or directives for patient care when, after careful consideration, I believe such plans not to be in the best interest of the patient.
Honor Code
I recognize that I am an important member of the health care team and I will abide by the rules and regulations and Code of Honor in all settings in which I train or work. When given responsibility for some portion of the total care of a patient, I will assume this obligation and follow it through to the full extent of my abilities. If for some reason I am unable to fulfill my obligation, I will promptly notify the physician in charge of the patient and secure a colleague who can and will assume the care of the patient. I will be punctual, reliable, conscientious and truthful in fulfilling clinical responsibilities, never purposely falsifying information or misrepresenting a situation.
On behalf of our sponsor . . .
Preventing sexual violence - Clery ActHandoutResource for your patients, colleaguesBystander videoshttps://www.youtube.com/watch?v=1ycYPmzi
sfkhttps://www.youtube.com/watch?v=Sha-
he0XPIw
YOUR CAPACITY TO HEAL AND TO RELIEVE SUFFERING WILL DEPEND GREATLY ON
HOW YOU ARE PERCEIVED AS A PROFESSIONAL. PATIENTS WHO HAVE
HIGH REGARD FOR YOUR PROFESSIONALISM IN ALL ASPECTS WILL
TRUST YOUR REMEDIES AND WILL RESPOND MORE POSITIVELY.
Click icon to add pictureThreats to professionalism
“Alternative health care”
Social justice and lack of access
Mandatory Reporting to Georgia Department of Public Health (partial list)
anthraxacute arboviral (e.g., equine encephalitis)botulismbrucellosischoleradiphtheriaE coli O157hepatitis A,B,C
measlesMeningitispertussispoliorabiessyphilisTBBirth defectsDph.georgia.gov/