A presentation on medical ethics and medical professionalism

1. PHYSICIAN, THE FINEST FLOWER
OF CIVILIZATION
Dr. F H D Shehan Silva MBBS MD
Senior Registrar in Medicine
University Medical Unit
Colombo North Teaching Hospital
Young Physicians’ Forum 2016
Ceylon College of Physicians

2.  There are men and classes of men that
stand above the common herd…
Physician, the finest flower of civilization
– R L Stevenson

3.  A flower as a sweet smelling rose

4.  or as the pungent Rafflesia

5. OUTLINE
 Medical Ethics
 Professionalism
 Codes
 Professionalism Development

6. DOCTOR
 In Latin - Docere ‘I teach’
“No greater opportunity, responsibility or obligation
can fall to the lot of a human being than to become a
physician…
Preamble Harrison’s Principles of Internal Medicine, 1950

7. … In the care of the suffering, the Physicians
needs technical skill, scientific knowledge and
human understanding… Tact, sympathy and
understanding are expected of the physician…
He who uses these with courage, humility and
wisdom will provide a unique service to his fellow
man and will build an enduring edifice of character
within himself.”
Preamble Harrison’s Principles of Internal Medicine, 1950

8. PATIENT
 In Latin - Patiens ‘I Suffer’
“The patient is no mere collection of symptoms,
signs, disordered functions, damaged organs and
disturbed emotions.
He is human, fearful and hopeful, seeking relief,
help and reassurance.”
Harrison’s Principles of Internal Medicine, 1950

9. THEY THAT ARE WHOLE HAVE NO NEED OF THE
PHYSICIAN, BUT THEY THAT ARE SICK (LUKE 5:31)
WHY? WHAT? WHO?
 High quality medical service (of choice)
 Privacy and Confidentiality
 Information and Health Education
 To decide/ Autonomous choice
 Dignity – treatment as a human being
RIGHTS OF PATIENTS
Adapted –
Declaration on Promotion of Patient’s Rights in Europe
World Medical Association Declaration of Lisbon on the Rights of the Patient

10. MORALITY AND ETHICS
 Not laws, but standards of conduct, defining
honourable behavior
 Morality – Belief of right and wrong
 Ethics – Choosing right action when doing
so may involve doing harm or wrong

11.  Patients… entitled to good standards of
practice and care from their doctors.
Essential elements of this are professional
competence, good relationships with
patients and colleagues and observance of
professional ethical obligations
Good Medical Practice – GMC UK

12. COMPONENTS
The Physician has a threefold interaction in
carrying out his duties
Physician— Patient
Physician— fellow Physician
Physician— Public (Society & Health System)

13.  “The practice of medicine is
an art, not a trade;
a calling, not a business:
a calling in which your heart will be
exercised equally with your head”
William Osler “Aequanimitas”

14. PRINCIPLES OF MEDICAL ETHICS
Building blocks
 Non maleficence
 Beneficence
 Autonomy
 Justice
 Confidentiality
 Veracity

15. NON-MALEFICENCE
Primum non nocere
– First do no harm
 Sanctity of life
 Limits chances of a doctor using enthusiasm/
opinion on Rx on harming the patient while
treating

16. BENEFICENCE
Salus aegroti suprema lex
 Benefiting or doing good…
Best interests of patient
Balancing benefits vs. risks
Protecting and defending rights of others/rescue
 Patients rely on physicians as they are laymen and
vulnerable
Hence physicians have a fiduciary duty for their best interest
 Constraints
Need to respect autonomy
Doctors’ opinion may differ in management
Ensure health is not bought at high expense
Consider rights of others

17. AUTONOMY
Voluntas aegroti suprema lex
 Patient has the right to choose or refuse treatment
personal interest vs. benefits of Rx
 Free and informed consent
 Respect and dignity maintenance
 Complements – non maleficence and beneficence
as they allow a paternalistic (physician based)
approach
 Constraints
Capacity
Mental incompetence

18. JUSTICE
Lustitia
 Impartial treatment without bias
Distributive justice
 Social Responsibility…
Defending and protecting rights of others
Rescue persons in danger
 Greater good of society
 May impinge other ethical principles but is
required on larger social interest

19. CONFIDENTIALITY
 Loyalty and trust
 Information regarding patients is private and
has limits on disclosure to third party
except when legally and ethically challenged

20. VERACITY
 Truth telling
 Obligation to full and honest disclosure
 Violation of this results in loss of credibility
and respect from other professional and
patients alike

21. ETHICAL DILEMMA - DOUBLE EFFECT
1) Medically ‘right’ vs. patient preference
Jehovah’s witnesses and blood transfusions
2) Patient preference vs. proxy decision maker
Rights of minor vs. legal guardians
3) Best for patient vs. Best for society/others
Legal commitments, notification

22. ETHICAL DILEMMA
4) Blockade
Necessity for expensive option in poverty
5) Priority setting
Critical care option for a previously healthy young patient
vs. elderly patient with comorbidities
6) Conflict resolution
Differing views of team members in care of patient
Conflicts between patient and carers regarding options

23. RED FLAGS ON WIGWAM
Checklist to avoid skating over ethical issues
 Wishes of the patient are unknown (e.g. living will)
 Issues of confidentiality/ disclosure (e.g. HIV + but
partner unaware)
 Goals of care: are these confused and contradictory?
 Wants to discharge himself against advise. Is he
informed and competent
 Arguments among relatives as how best to proceed:
listen to all sides
 Monetary problems: cost of care or earnings lost
 Oxford Handbook of Clinical Medicine

24. ONION PEEL EFFECT – IN A ETHICAL DILEMMA

25. ETHICAL ANALYSIS – ONION PEEL EFFECT
 Patient Preferences – Data gathered from patient and carers
Are their wishes considered?
What do the carers think?
 Medical goals – Data from literature/guidelines/expert opinions
What do my colleagues/ team members think?
 Legal and cultural issues – Local laws and socio cultural
values
What do patient representations think?
 Basic ethical principles – Building blocks
Is this principal universally applicable?
Am I happy with my decision? Is it only tactical?

26. PROFESSION
 Professio – I profess
 Epstein and Hundert’s Definition
1) Acquisition and application of body of knowledge and technical
skills
education, examination, apprenticeship
2) Members bound together in shared commitment
3) Self Regulation
Regulatory bodies…
Power to admit and discipline members
Some monopoly
Alan Bullock & Stephen Trobley, The New Fontana dictionary of Modern Thought, London: Harper-Collins, 1999, p.689.

27.  But!
Noblesse oblige
Privilege entails obligation

29. OUR PROFESSION
 To heal… To preserve lives as long as
possible
To cure diseases… To prevent suffering
 Right Healing – informed by scientific and clinical
evidence
 Good Action – consider patients values and
preferences

30. Professionalism
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Ethical and Legal Understanding
Communication Skills
Clinical Competence – Principles and Practice of Medicine
STERN’S MODEL OF MEDICAL PROFESSIONALISM

31. PROFESSIONAL VS. NON PROFESSIONAL
 We judge ourselves by our motives
whereas others judge us by our behaviour
Anonymous

34. SOCIETY –
YOU DID NOT CHOOSE ME BUT I CHOSE YOU!

35. SOCIAL CONTRACT
 Professionalism
The basis of medicine’s contract with society
 Professional Privileges
Professions are given prestige, autonomy,
the privilege of physician-led regulation,
and rewards on the understanding that they
will be altruistic, regulate well , be
trustworthy, and address the concerns of
society

36.  Professional Status is NOT an Inherent Right
It is GRANTED BY SOCIETY
 It Must Be Constantly Earned by Meeting the
Obligations Expected of a Professional
 If Medicine FAILS to meet its’ OBLIGATIONS
society will CHANGE its’ STATUS

37. WHY SHOULD PHYSICIANS TAKE DUTIES OF
CARE SERIOUSLY?
 Professional regulation
 Law – constitutional. civil and criminal law
 Rational self interest – own medical Rx
 Clinical importance of trust
 Doctor patient relationship

38. MEDICAL PROFESSIONALISM CHALLENGED?
“The profession of medicine is under siege.
Our resistance must be professionalism.”
Harris 2000

39. • Healer
• Professional
Served simultaneously
Analyzed separately
A Neologism - “PHYSICIANSHIP”
Centre for Medical Education – McGill University
PHYSICIANS HAVE TWO ROLES

40. Autonomy
Regulating Bodies
Responsibility
to society
Team work
Caring/ compassion
listening
Insight
Openness
Respect for the
healing
Respect patient
dignity/
autonomy
Presence
PHYSICIANSHIP
Prof Ian Hart – Ottawa Conference
ATTRIBUTES
Competence
Commitment
Confidentiality
Altruism
Trustworthy
Integrity/Honesty
code of ethics
Morality/Ethical
Behavior
Responsibility

41. HIPPOCRATIC TRADITION
 Sustained appreciation for limits of medicine
and the need to prevent unnecessary
iatrogenic harm
 Art is long, life is short; the crisis fleeting;
experience perilous and decision difficult.

43. SIR THOMAS PERCIVAL
 First modern code of medical ethics
 Coined the term ‘Medical Ethics’
Medical ethics; or a Code of Institutes an precepts, adapted to the professional interests of the
Physician and Surgeons. Manchester:S. Russell,1803

44. CODES OF MEDICAL ETHICS IN HISTORY
 Third Dynasty (Egypt) 2700 BC
 Code of Hammurabi (Babylon) 1750 BC
 Oath of the Hindu Physician (Vaidya’s Oath) 15thc. BC
 Hippocratic oath (c460-370 BC)
 Oath of Asaph and Yohanan (6thc. CE)
 Advice to a Physician (Persia) 10thc. CE
 Oath of Maimonides 12 thc. CE
 Ming Dynasty (China) 14 thc. CE
 Seventeen Rules of Enjun 16 thc. CE
 Percival's Code (England) 1803
 Beaumont's Code (United States) 1833
 American Medical Association (AMA) Code of Medical Ethics 1847
 Berlin Code, or Prussian Code (Germany) 1900
 Nuremberg Code (1947)
 Geneva Decleration (1948, 1968, 1984, 1994, 2005, 2006) World Medical Association
 Code of Medical Ethics AMA revision (1957)
 Declaration of Helsinki,(1964, rev. 1975, 1983, 1989, 1996, 2000
 Belmont Report (1979)
 AMA revision (2001)

45. CODES
 AMA Code of Ethics 1847
 ACP Ethics Manual 2005

46. DOCTORS IN SOCIETY MEDICAL
PROFESSIONALISM IN A CHANGING WORLD
Six vital themes emerged in RCP report:
 Team working
 Education
 Appraisal
 Career management
 Research
 Leadership
 signifies a set of values, behaviours, and
relationships that underpins the trust the public has in
doctors

47. MEDICAL PROFESSIONALISM IN THE NEW
MILLENNIUM – A PHYSICIAN CHARTER
 ABIM 2007
 The Physician Charter
has been endorsed by
more than 130
organizations, translated
in to 12 languages, and
100,000 copies have
been distributed

48. 3 PRINCIPLES
1. Primacy of patient welfare
2. Patient autonomy
3. Social Justice

49.  Commitment to professional competence.
Lifelong learning in maintaining medical knowledge, clinical and
team skills
 Commitment to honesty with patients
Empower to decide
Acknowledge report and analyze medical errors
 Commitment to patient confidentiality
Earn trust and confidence . Extension to proxy sos
 Commitment to maintaining appropriate relations with
patients.
Inherent vulnerability and dependency of patients
Avoidance of certain relationships

50. Commitment to improving quality of care
Collaboration to reduce error, increase safety, minimize
overuse, optimize outcomes and routine assessment
Commitment to improving access to care
Uniform and adequate standard of care,,, Reduce barriers for
equity
Promotion of public health and preventive medicine and public
advocacy
Commitment to a just distribution of finite resource
Wise and cost-effective management of limited resources
Scrupulous avoidance of superfluous tests and procedures

51. Commitment to scientific knowledge
Scientific standards, promote research, create knowledge and
integration
Commitment to maintaining trust by managing conflicts of
interest
Compromise responsibilities by private gain or personal
advantage
Recognize, disclose and deal conflicts of interest
Commitment to professional responsibilities
Collaboration, Respectfulness
Self regulation (remediation and discipline)

52. GOOD MEDICAL PRACTICE - GMC
4 Key Domains
I) Knowledge, skills and performance
II) Safety and quality
III) Maintaining trust
IV) Communication, partnership and teamwork

53. IN SRI LANKA
 Guidelines on ethical conduct
 At the time of registration each applicant is
given a copy of a declaration by the Registrar
and the applicant shall read, sign and abide by it

54. QUO VADIS, SRI LANKAN PHYSICIAN?
 We need to move ahead
Active and Passive Learning
Our Undergraduate and Postgraduate curricula
Personal and Professional development
as Continuous Medical Education
Associations of shared commitments
SLMA, CCP, CSSL etc.
Governing bodies – SLMC
Legislature – Medical Ordinance etc
In loyal lowly service let each from other learn. Rev. W S Senior

55. PROFESSIONALISM DEVELOPMENT

56. Propositional Knowledge
Knowing what needs to be done
Can be taught and learned
Process Knowledge
Knowing how to proceed
Gained by experience
Personal and Professional
Values
Doctor as a professional and
individual
Role of the doctor within the health
service and community
Performance
Of task
BMA Ethics Department. Medical
Ethics Today: The BMA handbook of
ethics and law 2004

57. Didactic Teaching?

58. Preach one... Practice another?

59. Example is better than
precept

60. REACHING IDEALS … A UTOPIA?

61. SIR ROBERT HUTCHISON’S PETITION…
A PRAYER FOR US PHYSICIANS
 From inability to let well alone
From too much zeal for the new and contempt for what is
old
From putting knowledge before wisdom,
science before art,
and cleverness before common sense;
From treating patients as cases;
And from making the cure of the disease more grievous
than the endurance of the same,
Good Lord, deliver us
Modern Treatment BMJ 1953; 1;671

62. CAN WE AS A PHYSICIAN BLOSSOM INTO A FINE
FLOWER OF THE CIVILIZATION?
 A Symbol of purity of body, mind and spirit
 Blossoms on above muddy water of attachment and desire
 A symbol of detachment as water drops easily slide on petals
LOTUS

63. ACKNOWLEDGEMENT
 My wife, parents and parents in law
 My alma mater
 Faculty of Medical Sciences, University of Sri
Jayewardenepura and all my teachers
 Consultants and the Professorial Medical Unit,
Colombo North Teaching Hospital
 The GREAT PHYSICIAN and my FAITH…
to help maintain balance in midst of insanities of
life and work

64. THANK YOU
 Arogya Shanthi Sukkam
Cure Relieve Comfort
If (for a Physician) by Prof. K Rajasuriya