Ethics and Professionalism

CHAPTER 32
Ethics and Professionalism

Robert D. Barraco and Stephen E. Lammers

Test Taking Tip

Know the order of who consents and makes decisions for a patient when he or she is not able to.

ETHICS

PRINCIPLES

What is respect for autonomy?

When the patient has the capacity to act intentionally, with understanding, and without controlling influences that would mitigate against a free and voluntary act, surgeons ought to respect patient decisions, even when those decisions are different from the surgeon’s recommendations.

What is beneficence?

The duty of health care providers is to benefit the patient and to bring about good for the patient.

What is nonmaleficence?

Health care providers may not intentionally create a needless harm or injury to the patient, through acts of commission or omission. In addition, health care providers ought to take positive steps to remove harm from the patient.

What is justice?

In our context, it is defined as a form of fairness. This implies the fair distribution of goods and services in society, which are in short supply; thus, some fair means of allocating scarce resources must be determined.

DECISION MAKING—SFNO APPROACH

What is the SFNO approach?

So Far No Objections = Stakeholders, Facts, Norms, Options

What are the 3 major sources of uncertainty in medical ethics decisions?

1. Different people are involved who have competing interests.

2. Uncertainty or disagreement exists about relevant facts.

3. Uncertainty, conflict, or disagreement exists regarding ethical norms.

Who are the stakeholders?

Those who will be affected by the decision made. It helps to state why people are stakeholders or how they are affected.

What are the facts?

They are factual issues that might generate disagreement or are relevant to a solution. It may be helpful to refer to the experts or the literature.

What are the norms?

They are ethical principles (see above), norms, or values that are at stake. Some may be relevant and others only appear to be. For assistance, reference can be made to professional ethical codes or regulations. Advice of colleagues should be sought when it is not clear what ethical principle or principles apply.

What defines the options?

They are actions or policies as well as compromises that deserve consideration for potential solutions. They may be best arrived at by group brainstorming with others.

JUSTIFYING ETHICAL DECISIONS

How do I justify an ethical decision?

It depends on the source of the disagreement.

If the source of the disagreement involves the competing interests of stakeholders, 2 questions must be asked:

1. Do ethically justified reasons exist for giving priority to the interests of one party over another?

2. Who is invested with decision-making authority?

If the source of the disagreement involves the facts in the widest sense of the word (benefit and harms of procedures or research, worldview beliefs), the resolutions differ. It is easiest if concerning facts where irrefutable data exist. When the facts concern probabilities, experts in given areas as well as existing literature may help. Other considerations here include quality of life, autonomous wishes, etc.

If the source of the disagreement involves ethical norms and values, goals must be clarified first.

How many types of norms are there to consider?

2: moral absolutes and prima facie norms. An example of a moral absolute is “it is wrong to kill a human for personal gain.” Professional codes and laws often contain such norms. If a worthy goal conflicts with a moral absolute, the absolute trumps the goal. Prima facie norms express commitment to a value that deserves respect and should always be taken into account. Examples include confidentiality, or informed consent. Although these values should always be considered, there are circumstances where a breach of the norm is appropriate. An example includes the Tarasoff case, where a viable threat to another human being warrants the potential victim being informed.

PROFESSIONALISM

What is a profession?

An occupational group with internal ethical standards related to the primary goals of the profession.

What is professionalism?

It is “something that resides in the interface between the possession of specialized knowledge and a commitment to use that knowledge for the betterment of others.” (Goode, 1969)

It is “aspiring toward altruism, accountability, excellence, duty, service, honor, integrity, and respect for others.” (American Board of Internal Medicine, 1995)