Ethics 3

NO LONGER ACCREDITED. DO NOT COMPLETE FOR CPD PURPOSES

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Professionalism

Medicine, encompassing the allied health occupations may be considered a profession. By its very definition the term ‘profession’ sets a high standard. The words ‘profession’ and ‘professional’ are derived from the Latin word professio, meaning ‘a public declaration with the force of a promise’.

The marks of a profession are:

1) Competence in a specialized body of knowledge and skill
2) An acknowledgment of specific duties and responsibilities toward the individuals it serves and toward society
3) The right to train, admit, discipline and dismiss its members for failure to sustain competence or responsibilities.

Professionals thus have the responsibility to act or behave in certain manner and have the knowledge that failure to do so may result in disciplinary action from fellow members or society in general. All professions have a code of ethics stating the standards by which its members must behave. Other professions include law, education and the clergy.

In South Africa’s large scale private health care industry, the line between a business and a profession is often blurred as it is a multi-billion rand industry. However, one crucial difference distinguishes professionalism from business: professionals have a duty toward those they serve. This means that professionals must ensure that their decisions and actions serve the welfare of their patients or clients, before their personal gain. Professions have codes of ethics which specify the obligations arising from this duty and ethical issues often occur when this boundary is crossed

The following principles define the basis of health professionalism:

Altruism: an obligation to attend to the best interest of patients, rather than self-interest.
Accountability: to patients, to society and to the profession.
Excellence: commitment to life-long learning and continuing professional development
Honor and integrity: a commitment to being fair and truthful in interactions with patients and the profession.
Respect: for patients and their families and other health professionals

The Health practitioner- patient relationship.

Fiduciary derives from the Latin word for “confidence” or “trust”. This trust between the patient and the health professional is vital to the diagnostic and therapeutic process and indeed forms the basis of the relationship. In most cases accurate diagnoses and management require unimpeded communication regarding illness or injury.

This relationship has dramatically evolved over the years. Previous, the health practitioner-patient relationship involved patient dependence on the physician’s professional authority. Beliefs that the patient would benefit from the professionals actions and superior knowledge meant that their preferences were usually not taken into account.

Over the last few decades, this relationship has moved towards a partnership of shared decision making. This newer model respects the patient as an autonomous entity with a right to hold views and to make informed choices and decisions based on personal knowledge and beliefs. Patients have been increasingly able to consider the benefits and risks of alternative treatments, or of no treatment, whatsoever. They have been shown to respond well to a clinician who adds a personal touch to the encounter as this likely humanizes them and makes it easier to connect. It is however, essential to maintain professional integrity and make sure that the patient and their concerns, are the focus of every visit.

This ‘softening’ of the boundaries of the patient clinician relationship has created new difficulties. One of the toughest tests of this already tenuous relationship is when a health professional faces requests for services, which may raise a personal or religious conflict for the physician. Abortion is one that comes immediately to mind. Clinicians have the right to not provide medical services in opposition to their personal beliefs but professionalism dictates that while they may decline to personally provide the requested service, the patient’s decision must respected. Alternatives may be discussed in a thoroughly non-judgmental or self-serving manner, but should the patient so desire, and if legal, they should be provided with resources about how to obtain the desired service.

‘There are patients, and there are patients. The difficult ones can be “demanding,” “noncompliant,” “whiny,” “entitled,” or “manipulative.” They can be too different from or too similar to the clinician, too seductive, too unclean, too smart, too fat, too thin, or too anxiety-provoking …’ Roberts and dyer 2003

Negative or overly positive reactions evoked by the patient provide a serious ethical pitfall. Difficult patients are at risk of receiving care that deviates from usual ethics standards. Clinical neglect of patients is more likely when they are unlikable, frustrating, noncompliant, extraordinarily tragic, or otherwise atypical. On the opposite end of the spectrum, when patients closely resemble their caregivers in terms of having similar backgrounds, professions, or interests, professional boundaries may also be crossed. The clinician and patient may begin relating to one another in a manner more congruent with a friendship than a professional relationship.

Barriers to effective clinician-patient communication are very common from a patient’s perspective. They may feel that they are wasting the clinician’s time; omit details of their history which they deem unimportant or embarrassing and not elaborate as they believe the medical professional is disinterested.

Generally maintaining a professional facade and paying attention to personal feelings helps to avoid a number of these issues. The following list provides some guidelines in this regard. Think closely if these steps apply to your personal interactions.

Sit down
Make sure the patient is comfortable
Establish eye contact
Listen without interrupting
Show attention with nonverbal cues, such as nodding
Allow silences while patients search for words
Be positive during examinations
Explain thoroughly using props (books, models etc.)

In essence the patient / clinician relationship is the basis of medicine and supersedes diagnostics and intervention. It thus makes little sense that it is often neglected. Like becoming a skilled diagnostician or practitioner it requires much practice and attention to detail.

Informed consent

As mentioned above, there has been a marked shift in the health practitioner patient relationship. Informed consent has had a significant role to play in this change. It is in essence the process by which a fully informed patient can participate in choices about his or her health care. It originates from the legal right the patient has to decide what happens to their body and from the ethical duty of the clinician to fully involve the patient in their health care.

Mainly due to increasing medico-legal pressure, most invasive procedures requiring some form of anesthetic in South Africa, require signed informed consent. As mentioned above the patient has a full ethical and legal right to the information that will provide them an adequate understanding of the procedure and the risks and benefits thereof. Good explanation will, also likely improve communication and compliance. Lack of knowledge is thus disadvantageous on all fronts.

With Full informed consent it is necessary to consider and fully explain following elements:

1) The process and nature of the proposed intervention and risk and benefits thereof
2) Potential alternatives and associated pros and cons
3) Analysis of patients understanding of the procedure
4) Voluntary and competent acceptance of the intervention by the patient

Basic consent for less rigorous procedures (i.e. tetanus injection) entails informing the patient what you would like to do and them verbalizing consent.

Contrary to what many clinicians have thought in the past, a number of studies have shown that patients want to be told the truth about diagnosis and prognosis. In a recent study 90% of patients surveyed said they would want to be told of a diagnosis of cancer or Alzheimer’s disease. This change in thought process follows through to health practitioners. For example, whereas in 1961 only 10% of physicians surveyed believed it was correct to tell a patient of a fatal cancer diagnosis, this had by 1979 increased to 97%.

In emergency incidences when a person is unconscious or incapacitated, informed consent may be presumed and the clinician is expected to select the best course of action available to assist the patient. Other cases may not be as cut and dry. In cases where the patient displays obvious decision making difficulty or inconsistency that is deemed to be disadvantageous to health outcomes, a family member may be consulted to help with the informed consent process. This is obvious a legally and ethically difficult situation and clinicians must proceed with due caution.

Confidentiality

Confidentiality is one of the ethical cornerstones of modern medical practice. Despite this, it is a daily challenge.

The nature of health professions dictates that patients share extremely personal information with clinicians. It is the moral, ethical and professional duty of the health professional to respect the patient’s trust and keep this information confidential. Failure to do so may open a medico legal ‘hornets’ nest’ and if discovered will at the very least destroy the professional relationship.

The conflict lies in the fact that often, it is critical to patient care to discuss their case with other professional. This is obviously an integral part of the learning experience in a teaching hospital. Precautions must however be taken. Discussions must occur in a professional setting and must be limited only to those integral to the discussion. Where possible exclude the patients name from the discussion and care must be taken, to limit the ability of others to hear or see confidential information.

In certain settings, such as trauma, flippantly discussing cases in the cafeteria or the lift, almost seems to be a means of coming to terms with a highly stressful environment. This does not however make it ethically correct!

There are cases when confidentiality may be legally breached. In such cases it makes legal sense to discuss the case with a superior. In essence one needs to clinically reason if maintaining confidentiality will bring about greater harm than disclosing confidential information. Two instances when this might occur are:

1) Individuals or groups are placed in danger by a patient (homicidal tendencies)
2) Concern for public welfare due to infectious disease

While often the health professional feels compelled or justified to share confidential information regarding the patient with family members, without explicit permission from the patient, it is generally not ethically justifiable to do so. This is once again at the discretion of clinician and notable exceptions would include severe trauma cases

Medical mistakes


All health professionals will, at some stage, make mistakes. The majority of mistakes will not be considered negligence. Numerous factors may force mistakes and in the medical setting, lack of sleep and patient numbers often play a significant role

As discussed in detail above, medical professionals have an ethical and legal responsibility to be truthful with their patients. This includes situations in which a patient suffers consequences, serious or otherwise, because of an error. Medical professionals should not take decisions to withhold information lightly and before making these decisions should at the very least discuss them with another professional. The clinician must be prepared and able to publicly defend a decision to withhold information about a mistake from the patient.

In South Africa, litigation has not yet reached the levels it has in the USA and the UK, but public awareness surrounding legal rights and the ability to sue is definitely on the increase. In the USA where litigation is a common occurrence, it has been shown that patients are less likely to consider litigation when a physician has been honest with them about mistakes. Lawsuits are often initiated because a patient feel the truth has been withheld. Furthermore, clinicians who have been dishonest are not likely to do well in the legal situation.

One of the main reasons for withholding information regarding mistakes is the fear of looking foolish in front of the patient and perceived loss of trust in the medical professional by the patient. This is a well-founded fear. Hhowever, Loss of trust and legal consequences will be more serious if a patient discovers that errors have been hidden from them.

One of the most difficult situations occurs when a health professional bears witness to a mistake by a colleague, as this places the professional in an awkward and difficult position. Professionals often feel the necessity to protect their own and to maintain their social position within the professional setting. Nevertheless, it is the ethical, legal and moral obligation of the health professional to tell the truth regarding the error. This is obviously an extremely delicate situation and before taking it forward, the clinician must be absolutely certain an error was made. Generally the best course of action is to initially discuss the situation and encourage the professional to disclose their mistake to the patient. Should they refuse; the professional will need to decide whether the error was of enough consequence to justify taking the case to a supervisor. At this stage it is probably a good idea to inform the offending party of your decision to do so. Directly informing the patient is unlikely to be a good path to follow as it carries a sense of ‘telling on’ the offending clinician and will not appear professional to the patient.

Accreditation: Accreditation: PPB004-MD271-0023-2-2013

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