Ethics and Professionalism in Surgery

1. Ethics and Professionalism in Surgery Dr ibtisam albader Mubarak al kabeer hospital 26March 2013

2. Islam and the Promotion of Science • Stressing the importance and respect of learning. For example, the first word revealed to Prophet Mohammad (peace and blessings be upon him) was “read.” • In that time, a captured enemy was freed if he paid a ransom or taught ten Muslims reading and writing.

3. The general philosophy in Islamic medicine is that the healer is Allah Most High and the doctor is the instrument that Allah uses to heal the people. • The doctor-patient relationship is stronger in Islam than it is in modern medicine as he has responsibilities, which Allah on the Day of Judgment will ask about

4. Certification! Practicing physicians: Only qualified physicians were allowed by law to practice medicine. In CE 931, the Caliph Al-Mugtadir from the Abbasid dynasty, ordered the Chief Court-Physician SinanIbn-Thabit to screen the 860 physicians of Baghdad, and only those qualified were granted license to practice.

5. Early teachings I Al-Tabari, the chief physician in 970 CE, described the Islamic code of ethics in his book Fardous Al Hikma

6. Remember this! • The physician should be modest, virtuous and merciful. He should wear clean clothes, be dignified, and have well groomed hair and beard. He should select his company to be persons of good reputation. He should be careful of what he says and should not hesitate to ask forgiveness if he has made an error. He should be forgiving and never seek revenge. He should be friendly and a peacemaker. He should avoid predicting whether a patient will live or die, only Allah knows. He should not lose his temper when his patients keep asking questions, but should answer gently and compassionately. He should treat alike the rich and the poor, the master and the servant. God will reward him if he helps the needy. He should be punctual and reliable.He should not wrangle about his fees. If the patient is very ill or in an emergency, he should be thankful, no matter how much he is paid. He should not give drugs to a pregnant woman for an abortion unless necessary for the mother's health. He should be decent towards women and should not divulge the secrets of his patients. He should speak no evil of reputable men of the community or be critical of any other’s religious belief. He should speak well of his colleagues. He should not honor himself by shaming others."

7. Ishaq bin ali al-rahawi (854-931) • This is an excerpt from Transactions of the American Philosophical Society, Vol. 57, Part 3, 1967. "Medical Ethics of Medieval Islam with Special Reference to Al-Ruhawi'sPractical Ethics of the Physician", translated by Martin Levey. Permission for printing of excerpts from TAPA has been obtained

8. Ishaq bin ali al-rahawi (854-931) 1.The loyalty and the faith of the Physician, and Ethics He Must Follow to improve His Soul and Morals. 2. Care of the Physician's Body 3. What the Physician Must Avoid and Beware of 4. Directions of the Physician to the Patient and Servant 5. Manners of the Visitors 6. Care of Remedies by the Physician 7. What the Physician Asks the Patient and the Nurse 8. What the Patient May Conceal from the Physician 9. How the Healthy and ill Must Take Orders of the Physician 10. Training of Servants by the Patient before Illness 11. Patient and Visitors 12. Dignity of the Medical Profession 13. Respect for the Physician 14. Physicians and Peculiar Incidents to Aid Treatment 15. Medical Art for Moral People 16. Examination of Physicians 17. Removal of Corruption of Physicians 18. Warning against Quacks 19. Harmful Habits 20. Care of the Physician Himself

9. Ishaq bin ali al-rahawi (854-931) First medical peer review • Visiting physician must make duplicate notes of a patient condition on every visit • When a patient was cured or died , the notes were examined by a local medical council of other physicians, who would review the practicing physician notes to decide whether his/her performance have met the required standards of medical care. • If the reviews were negative the practicing physician could face a law suit from a maltreated patient.

10. Principles of Medical EthicsRevised and adopted by the AMA House of Delegates (June 17, 2001) • I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights. • II. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities. • III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. • IV. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.

11. Principles of Medical EthicsRevised and adopted by the AMA House of Delegates (June 17, 2001) • V. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated. • VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care. • VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. • VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount. • IX. A physician shall support access to medical care for all people.

12. Principles of Health care Ethics • Bioethicists often refer to the four basic principles of health care ethics when evaluating the merits and difficulties of medical procedures.  Ideally, for a medical practice to be considered "ethical", it must respect all four of these principles: autonomy, justice, beneficence, and non-maleficence. 

13. Autonomy           Requires that the patient have autonomy of thought, intention, and action when making decisions regarding health care procedures/ decision making.  Therefore, the decision-making process must be free of coercion or coaxing.  In order for a patient to make a fully informed decision, she/he must understand all risks and benefits of the procedure and the likelihood of success. 

14. Justice = EquityThe idea that the burdens and benefits of treatment / access must be distributed equally among all.

15. Beneficence Requires that the procedure be provided with the intent of doing good for the patient involved.  Demands that health care providers develop and maintain skills and knowledge, continually update training, consider individual circumstances of all patients, and strive for net benefit.

16. Non-maleficence • Primum non nocere = first do no harm Requires that a procedure does not harm the patient involved or others in society.  • Weigh benefit vs. harm !

17. Respect for persons The patient (and the person treating the patient) have the right to be treated with dignity.

18. Last but not least • Truthfulness and honesty - the concept of informed consent

19. AMA • Informed consent is more than simply getting a patient to sign a written consent form. It is a process of communication between a patient and physician that results in the patient's authorization or agreement to undergo a specific medical intervention. • In the communications process, you, as the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with your patient:

20. AMA • The patient's diagnosis, if known • The nature and purpose of a proposed treatment or procedure • The risks and benefits of a proposed treatment or procedure • Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance) • The risks and benefits of the alternative treatment or procedure • The risks and benefits of not receiving or undergoing a treatment or procedure. • In turn, your patient should have an opportunity to ask questions to elicit a better understanding of the treatment or procedure, so that he or she can make an informed decision to proceed or to refuse a particular course of medical intervention

21. AMA • communications process itself be documented. • Good documentation can serve as evidence in a court of the law that the process indeed took place. • A timely and thorough documentation in the patient's chart by the physician providing the treatment and/or performing the procedure can be a strong piece of evidence that the physician engaged the patient in an appropriate discussion.

22. AMA • A well-designed, signed informed consent form may also be useful, but an overly broad or highly detailed form actually can work against you.

23. AMA • Forms that serve mainly to satisfy all legal requirements (stating for example that "all material risks have been explained to me") may not preclude a patient from asserting that the actual disclosure did not include risks that the patient unfortunately discovered after treatment DO NOT STAND IN A COURT OF LAW

24. Example , imaging • Dallas medical liability defense attorney Linda M. Stimmel recently represented a group of physicians who were sued after a patient experienced a poor outcome following coronary artery bypass grafting. During discovery, the plaintiff attorney called into question whether the doctors had reviewed patient films and lab reports during a consultation. • “I'm sure the physicians reviewed them, but they didn't note that in their charting,” said Stimmel, who was featured in a January report on charting errors by AHC Media, a publisher and provider of continuing medical education. “It was alleged in the lawsuit that the physician didn't take the time to look at the computer and go over the labs. By the time [the doctors] are deposed, it's three years later and they say, 'I'm sure I looked at that,' but there's no charting to back it up.” • The case eventually settled. • Legal experts say they are noticing more liability cases that involve faulty medical charting, whether or not the documentation relates to the claim itself. Plaintiff attorneys use such discrepancies to show carelessness, sloppiness or dishonesty

25. Example, EHR • Dr. Davenport recalled a recent case where a woman who underwent a mastectomy visited her physician for an exam of the remaining breast. The doctor found nothing wrong. After the visit, the electronic template mistakenly entered that both of the woman's breasts were “normal” in the chart, Dr. Davenport said. Months later, a lesion was discovered in the patient's remaining breast, and she sued the doctor. • “Obviously it's something that a physician can try to explain, but it makes a physician look sloppy and, at worst, untruthful,” he said. The case settled “because the defense did not want to take the case to trial because of the carelessness of the charting. It was an otherwise defensible case.”

26. Example, EHR • Copying and pasting information from one chart to another also can prove to be detrimental in medical liability cases, Cohen said. This is especially true if a chart looks exactly the same after visits to several doctors because each has re-pasted the same note. • In one such case, Cohen said a common word was misspelled five times throughout the record of a neurologically impaired infant. • “There were other medical issues involved, but those coupled with the poor documentation during a critical time period did not help with the defense,” he said

28. Kuwait 1981 • The first International Conference on Islamic Medicine held in Kuwait in January 1981 published the oath of Muslim doctor, which says • I swear by God, the Great, to regard God in carrying out my profession. To protect human life in all stages and under all circumstances, doing my utmost to rescue it from death, malady, pain and anxiety. To keep peoples’ dignity, cover their privacies, and lock up their secrets. To be, all the way, an instrument of God’s mercy, extending my medical care to near and far, virtuous and sinner, friend and enemy. To strive in the pursuit of knowledge and harness it for the benefit, but not the harm, of Mankind. To revere my teacher, teach my junior, and be brother to members of the medical profession. To join in piety and charity. To live my faith in private and in public, avoiding whatever blemishes me in the eyes of God, His apostle and my fellow faithful. And may God be witness to this oath.”