Transcript Professionalism in Health Care

Professionalism in Health
Care
Jillian Gardner
Steve Biko Centre for Bioethics
Tel: 011 7172719
[email protected]
Outline
The concept of professionalism
History
Definition
The moral grounds of professional
ethics
Clashes between personal and
professional values
Professional guidelines
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The concept of professionalism
History
Religious derivation of the concept: to profess
publicly to serve the public good.
Prioritize public over private (sectarian)
interests.
Professional autonomy. – Accountant vs. taxi
driver.
Exercise own professional judgment and
discretion.
Guiding principles of professional activities
have significant moral content
Impartiality.
License to be ruthless.
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The concept of professionalism
Profession - (n) type of job that needs
special training or skill, especially one that
needs a high level of education;
medical/legal/teaching.
‘The Profession’ – all the people who work
in a particular type of profession.
Professionalism – the high standard one
expects from someone who is well-trained
in a particular job.
Oxford Advanced Learner’s Dictionary (6th
Ed). 2001. Oxford University Press.
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The concept of professionalism
“The core of every profession contains two elements:
possession of a specialized body of knowledge and
a commitment to service… self regulation is granted
to those who have specialised knowledge because
that knowledge is not readily available to the rest of
society, and the professional is best able to
determine for society how the knowledge, should or
should not be used. Autonomy is given on the
understanding that professionals will devote
themselves to serving the best interests of society
and will self-regulate to maintain high quality
service.” [1]
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The concept of professionalism
“Effacement of self-interest is the
distinguishing feature of a true
profession that sets it apart from other
occupations. It is the heart of the
professing of medicine, that is, the
public declaration and promise that
physicians can be trusted to use their
skills for something other than their
own benefit.”[2]
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The concept of professionalism
Set of values, attitudes, behaviours &
relationships that underpin the trust
the public has in HCPs; it sets the
standard for what PTs should expect
from HCPs; provides framework of
values that shapes the HCP-PT
relationship & it lies at the heart of
being a good HCP. [3]
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Characteristics of professions
Specialized body of knowledge & skills over
which members have control.
Duration of training & education.
Provision of & monopoly of usually crucial
goods or services to public; socially
sanctioned
Commitment to well being of others; serve
best interests of society.
Professional autonomy & self regulation.
Have agreed-upon values & a code of ethics.
Held to higher standards of behaviour.
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Moral grounds for professionalism
“The core of every profession contains two elements:
possession of a specialized body of knowledge and
a commitment to service… self regulation is granted
to those who have specialised knowledge because
that knowledge is not readily available to the rest of
society, and the professional is best able to
determine for society how the knowledge, should or
should not be used. Autonomy is given on the
understanding that professionals will devote
themselves to serving the best interests of society
and will self-regulate to maintain high quality
service.” [1]
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Moral grounds for professionalism
Moral contract with society.
Voluntary commitment to serve society; act in
certain ways.
Promised held out by profession.
Rights & privileges given by society.
Legal power over life & death.
Monopoly on provision of health care .
Individual & collective autonomy.
Societal investment in training & sustaining the
work of HCPs.
Can be held to higher standards of public
accountability.
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Moral grounds for professionalism
The professions’ monopoly in the
provision of services means they can
be accused of failure when they fail to
use their power, influence & expertise
for the proper purpose, or even fail to
do so with sufficient energy &
perseverance. A monopoly enlarges
the significance of sins of omission.
[4]
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General and special obligations
We all have general obligations in virtue of our
being human. At a minimum, these obligations
require of us to respect the liberty (freedom;
people’s efforts to choose, act & live in accordance
with their own values, goals, ideals or principles,
provided that their actions in turn respect the
comparable liberty of others & the dignity (inherent
moral worth) of others.
As human beings our general obligations thus
entail obligations to not coerce, cheat or defraud
others & to respect the inherent moral of others.
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Professional obligations
Is it sufficient for HCPs to merely
refrain from wrongdoing, i.e. merely
refraining from interfering in a moral
agent’s freedom to decide what is
best for him or her?
Libertarians
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Professional obligations
Health care is not simply a commodity to
be sold and bought on the basis of
people’s desires to buy it.
Health has objective value. It is important
to people’s well-being.
In principle then, a health care
professional’s recommendations for
services are not identical to for example a
shoe-salesperson’s recommendation on
how a pair of shoes look on one’s feet.
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WMA Declaration of Geneva
(2006, France)
Pledge to consecrate my life to the service of
humanity
Practice my profession with conscience & dignity
The health of my patient will be my first
consideration
Respect the secrets that are confided in me, even
after the PT has died
By all means in my power maintain the honour &
noble traditions of the medical profession
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WMA Declaration of Geneva (2006)
Not allow considerations of age, disease or
disability, creed, ethnic origin, gender,
nationality, political affiliation, race, sexual
orientation, social standing or any other
factor to intervene b/w my duty & my PT
Not use medical knowledge to violate
human rights & civil liberties, even under
threat
I make these promises solemnly, freely &
upon my honour
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New forces
Participatory democracy
Public education
Democracy in information access
Managed care
Fiduciary vs Market-type relationship
Introduction of layers of management
(bureaucracy)
State involvement in service delivery
Disagreement among HCPs
Revelations of unethical behaviour
Responsibility to PT vs Obligations to self, family &
others
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Patient vs Consumer
Rejection of traditional the
paternalistic model of HCP-PT
relationship
Changes in society - human rights
framework, consumer rights, patient
rights, patients as consumers
Pt rights vs HCPs values
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Special obligations
Expected to provide vital and socially
sanctioned services.
There should be powerful
justifications for exemptions from
providing socially valued and legally
sanctioned services.
Exemption should not be so easy as
to trivialise moral decision-making. [5]
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Clashes between personal &
professional values
Is it permissible for HCPs to refuse to
treat certain PTs?
May they object on moral grounds to
be involved in treatment?
Can they respect PT autonomy while
adequately giving recognition to their
own personal values?
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Conscientious objection
Conflict b/w personal morals & PT needs – which
should prevail?
Idea arose out of wartime tension b/w religious
freedom & national obligation.
Objector had to show the extent of his
commitment to the religion, duration & depth of the
commitment & the consistency in these beliefs
from which the objection stemmed.
Should the same burden of proof rest with HCPs?
How would one evaluate a subjective,
immeasurable moral conviction?
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Conscientious objection
A doctor can conscientiously excuse
themselves from treating as long as
there are other doctors prepared to
carry out the procedure. The patient’s
right to autonomy should not be
purchased at the price of the
physician’s parallel right to
professional autonomy. [6]
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Conscientious objection
In the context of military, the objector had
to show the extent of his commitment to
the religion, duration & depth of the
commitment & the consistency in these
beliefs from which the objection stemmed.
Should the same burden of proof rest with
HCPs?
How would one evaluate a subjective,
immeasurable moral conviction?
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Extent of conscientious objection
Limits? Actual treatment only?
What about aftercare? Catholic Church allows
legitimate co-operation ‘the good that is sought can
be found only through co-operation with what we find
morally unacceptable’
What about referrals? Seen as a solution but
assumes that sufficient doctors, facilities to refer to.
Assumes that doctors will refer!
Should conscientious objection be limited in
resource-poor countries? Lack of infrastructure,
stigma, lack of education contribute to ineffective
delivery of health care. Exacerbated by
conscientious objection.
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Extent of conscientious objection
Which employees may object?
Janaway case (USA): Medical secretary
refused to type referral letter for abortion.
Objection to formal cooperation because it
intends the ‘evil’ purpose.
How far does it extend-referral,
counselling, etc
Secretarial work seen as remote; can’t
claim conscientious objection; not
participating.
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Conscientious objection &
employment
Can you ask a job applicant if
he/she is a conscientious objector
– and then not employ them?
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Conscientious objection &
employment
In a small dept or in a rural area, this
could cripple the service.
In a larger dept, where a critical mass
of objectors, could cripple the service.
Conflict between the duty of the
hospital to provide a legally mandated
service and the moral conscience of
the employees.
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Conscientious objection &
employment
Labour Relations Act prohibits unfair
discrimination, treating applicants or
employees differently for arbitrary
reasons.
Fair discrimination relates to the
inherent requirements of the job
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Conscientious objections by
pharmacists
Refusal to honour valid prescriptions for
emergency contraceptives even for rape
survivors, or to direct them elsewhere.
Should there be an absolute right to object,
no right to object, limited right to object?
First 2 untenable-pharmacists have
professional autonomy but also
professional obligation to PT; greatly
affects health of PT. But can’t abandon
morals completely. Is there a middle way?
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A middle way [7]
Non-objecting pharmacist on duty
Prominently displayed sign that states
contraception not provided & Tel no.
to call, details of another pharmacy
Toll-free hotline
www.not-2-late.com in USA
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Some process recommendations
Board, right of appeal
Sincere, scruple-based objection to
the procedure
Consistent with other beliefs
Key component of petitioner’s moral,
religious framework
Alternative form of public-benefiting
service?
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Prudential refusals to treat certain
patients
Should there be a limit to the risks a
HCP must accept, for herself & her
family?
Haemorrhagic fevers, SARS, AIDS,
XDR-TB, avian flu…
Does one’s duty to PTs entail a moral
requirement to treat all PTs regardless
of risks they pose?
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May health care professionals
refuse to treat certain patients?
YES
Libertarian: specific
contract with individual
patients, business
transaction
No special obligations
owed to PTs
Violates HCP
autonomy
Costs to society in
forcing HCPs
NO
Moral contract with
society & covenant
with individual
patients
Consent to risk;
voluntary
commitment
Costs to
society/profession
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Refusals to treat certain patients
Are HCPs required to take all risks?
“ At some point some risks are too great
to demand of any occupation…even
soldiers are not required to face
certain death. Suicide missions are
voluntary.” [8]
When is risk of infection high enough
to defeat a duty to treat?
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What level of risk is reasonable?
Risk of occupational HIV infection
varies depending on the nature of the
interaction b/w HCP & PT.
HCPs performing non-invasive
procedures on PTs will have zero risk.
However, HCPs who are exposed to
the blood of infected PTs will be at
greater risk than zero.
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How great is the risk?
Dependent on several factors:
Prevalence of HIV infection
Frequency of exposures to HIV
infected blood
Efficiency of transmission from each
exposure
Probability of exposure to blood can
be reduced by implementing protective
measures (universal precautions)
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HIV-infected health care
professionals & duty to treat
Can be argued that HIV-infected HCPs are
not morally obligated to care for PT
infected with HIV & can choose whether or
not to go beyond the requirement of duty.
Distinction b/w normal & immunosuppressed HCPs is important, as well as
the inference that the level of risk to the
individual determines whether treatment is
within or above the call of duty.
May be reasonable for infected HCP to
refrain from ‘high risk’ procedures
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Guidelines, codes, declarations
www.wma.net
Manual on Medical Ethics
Declaration on Professional Autonomy & Self
Regulation (2005)
Declaration on Duties of Physicians (2006)
www.hpcsa.co.za
Professional guidelines & ethical codes
www.sapharmcouncil.co.za
www.sanc.co.za
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