Medical Ethics - City University of New York

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Professional Ethics, Health Care and Ethics

|Five Major Moral Principles in Health Care |

|NON MALFEASANCE |

|BENEFICENCE |

|UTILITY |

|DISTRIBUTIVE JUSTICE |

|AUTONOMY |

|The Principles |

|The Health Care System |

|Professional Ethics and Medical Practice |

In Health Care settings and in the institution itself there are a number of basic principles of morality which evidence themselves. Even if one did not approach cases or situations holding the principles of any of the standard ethical traditions there would arise these basic considerations and concepts.

I. Non- Malfeasance- Do NO Harm!! Cause no needless harm or injury according to reasonable standards of performance. Observe “DUE CARE” . This does not mean that there must be no risk of njury but only that there be no more than acceptable risks.

II. Benificence – Promote the welfare of others. This is inherent in the relationship of a health care provider (HCP) and the recipient of care.

E.g. the Doctor-Patient relationship.

However, what exactly is the duty of the HCP?

This comes into particular focus as problematical when the health care providers are also researchers. There must exist standards so that the benefits to the subjects and others are real and with a real possibility to be realized.

III. Utility- Attempt to bring about the greatest amount of benefit to as many people involved as is possible and consistent with the observance of other basic moral principles. Greatest Benefit and Least harm

IV. Distributive Justice- All involved should have equal entitlements, equal access to benefits and burdens. Similar cases should be treated in a similar fashion. People should be treated alike regardless of need, contributions or effort.

The formal principle of Justice as Fairness (Rawls’ Theory) similar cases are to receive the same treatment. However, in what ways are the cases similar? In what relevant ways?

V. Autonomy- People are rational, self determining beings who are capable of making judgments and decisions and should be respected as such and permitted to do so and supported with truthful and accurate information and no coercion. They should have their actions: free of duress, options explained that are genuine possibilities and given the information for decision making. RESTRICTIONS on AUTONOMY:

1. HARM- stop an individual from causing harm

2. PATERNALISM- weak – stop a person from self harm

Strong – to benefit a person

3. LEGAL MORALISM- legislated morality

4. WELFARE PRINCIPLE- for the benefit of all

Health Care System

COMPONENTS:

• Providers: primary and secondary(medical schools, professional associations, drug suppliers,etc..)

• Consumers

• Mechanisms for financing/supporting the institution

VALUES

A. HUMANITARIAN

Freedom, Dignity, Privacy, Autonomy

B. FREE ENTERPRISE

Market System

Technology

C. INSTITUTIONAL

a. Efficiency

b. Economy

|Clash of Values |

|Free Enterprise |Individual Welfare |

|Self Interest |Benefit of Others |

|Technology |Dignity and Comfort |

|Institutional |Human |

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Social Function of Health Care:

a. Health Care

b. Employment

c. Knowledge

Bureaucratic Model versus the Human

Hierarchy of Control and Authority

Division of Labor with identifiable goals

Values of: Industry, efficiency, predictability and speed>>>Impersonal

Operational Problems:

i. Non-routine tasks

ii. Internal dynamics

iii. Conflicting values

iv. Separation of patients from social context into institutional context (persons become patients)

v. Information Control- elitism, paternalism

vi. Communications Breakdown

vii. Dilution of Authority

viii. Displacement of Authority

ix. Development of sub groups

Professional Model

Based on :

Education- professional organizations

Code- licensing, association, peer control

VALUES: Autonomy, Collegiality, Service to Others, Skill

Professional Model clashes with the Bureaucratic Model Tensions develop

• Medical versus Administrative Line of Authority

• Service versus Economic Good

• Specialized labor versus Flexibility

• Authority based on expertise versus Authority based upon Position

Role Conflicts

Incompatible Role Expectations

RN < > MD Relationship

a. educational status

b. career patterns

c. semantic differences

d. class differences

e. authority differences

f. sex differences

g. different orientations: care versus cure

h. different amounts of time with recipients of care

Three Cases

1. Whistle Blowing

2. Truth Telling

3. Letting Die

Ethics in the Context of Professional Activities

Definition of a Profession

Definition of Ethics

Medical Practice and Models

2 sets of Basic Relations

A) Physician >Patient

B) Physician > Physician

1. Paternalistic (Authoritarian)

2. Employer (less Authoritarian)

3. Collegial (non-authoritarian)

4. Contractual (non-authoritarian)

5. Possible return to COVENENTIAL

Models based upon Governing Ideals, Conceptual Frameworks, Perspectives

I. Code

1 Contract

II. Covenant

CODE

1. Unwritten, traditional guides, rules: technical proficiency

2. Written, official pronouncements: etiquette, philanthropy

3. Special language, initiation rites, secrecy, DUTIES, professional Guild

a. Anti-competition monopoly –price fixing, sliding scale

b. Group solidarity

Aesthetic code- life style, image, decorum- beautiful life

Concern for colleagues is greater than that for those served

Five (5) factors militate against self-criticism and self regulation

1. Sense of community

2. Power of the priestly caste

3. Power of the modern physician unstable- based on power over death

4. Suspicion of officiousness, injustice, hypocrisy

5. Basic conflict- 2 sets of obligations: to guild and to patient

Obligations to colleagues

Responsive, obligation and a debt

Obligations to patients are: self-incurred and duties

Physician > guild, colleagues, teachers, progeny

Hippocratic Oath

1. codal duties to patients

2. Conventional obligations to colleagues

3. context of oath –gods

a. no reference to gift

b. no promises

Initiatory Oath- Code- Covenant as chosen, profession and a transformation

CONTRACT

Pro :

1. Symmetry

2. Legal enforcement

3. Self-interest and not philanthropy, e.g., informed consent

Against:

1. Minimalism

2. Unpredictability

3. Maximalism- Defense Mechanism

4. Inequality

5. No freedom of choice

6. Denies transcendent rights and duties

COVENANT

Key elements are promise and fidelity to the promise

1. Responsive

2. Debt

3. Obligation

4. Canon of Loyalty, Fidelity (truth, promises, care) not proficiency

5. Change in Being- ontological nature, e.g., temporal aspect of being

Problems with this model:

Needs a transcendent reference for the proper context:

Transcendent norm for rights and duties of physicians and patients

Transcendent source of limits for expectations and duties

Pro: 1. Not so personal- applies to the whole profession, a covenant with society broadens accountability

2. Permits setting Professional responsibility for one human good (health) within social limits

Physicians’ indebtedness established by five (50 factors:

1. Education

2. Privileges

3. Social Largess- payments for services

4. Experimental Subjects

5. Continual Support of profession and individuals

Covenant includes and extends beyond code and contract

a. Includes code: fidelity to duty, responsibilities to patients and colleagues

b. Includes contract- terms of contract- fidelity

Covenant requires more- a surplus of obligations to society are is final advantage

Obligations (debts) to society are greater than debts to colleagues

Permits possibility of self-discipline

Patient Role relates to the Physician’s image

|Physician- as parent, priest |patient as dependant |

|Technician |Passive host of disease |

|Contractual partner |Equal participant |

|Covenantor |Active participant |

| |Mutual reciprocal rights and duties, gifts and debts, promises and |

| |obligations |

Application of the models and images to the three cases

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