The Culture of Health Care

2. The Culture of Health Care Ethics and Professionalism Lecture a This material (Comp 2 Unit 8) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

3. Ethics and ProfessionalismLearning Objectives • Discuss foundational concepts in medical ethics and professionalism (Lecture a). • Examine the relationships among ethical ideals, professionalism, and legal duties (Lecture a, b). • Apply the general principles of ethics and professionalism to specific topics (Lecture c, d). • Examine ethical issues in health informatics (Lecture d).

4. What Is Meant by Ethics and Professionalism? • Ethics is the study of what people think is right and wrong • Professionalism means that a person acts in a way that meets the standards of his or her profession • Training and skills • Ethical principles

5. Four Basic Principles Plus concern for the scope of application of these principles 8.1 Figure: Four basic principles of healthcare (CC BY-NC-SA 3.0, 2012).

6. Respect for Autonomy • Autonomy = Self-governance • Respect for autonomy = Patients have the right to make their own decisions without undue influence • Health care decisions are voluntary • Foundation of “informed consent”

7. Beneficence • The idea that actions of health care providers should benefit people • Prevent problems that may occur • Treat problems that have occurred • Widely accepted as an appropriate goal of health care • Applied at individual level and population-wide level

8. Nonmaleficence • The obligation to not intentionally create unnecessary harm or injury to the patient • Applies to both commission and omission 8.2 Table: Nonmaleficence (CC BY-NC-SA 3.0, 2012).

9. Justice • Justice in the medical ethics setting means fairness • Includes the concepts that • All people have the right to be treated equally • If there is not enough to go around, what is available should be distributed fairly

10. “Concern for theScope of Their Action” • Who are health care professionals responsible to? • Everyone in their community? • Everyone in the country? • How far does respect for autonomy go? • Do animals have rights? • Does the environment have rights?

11. The Principles in Action • Respect for autonomy • Informed consent • Medical confidentiality • Beneficence and nonmaleficence • Requires that treatments be designed to maximize benefits and minimize risks • Justice • The risks of medical research should not fall disproportionally on one group of people

12. Prima facie Duties • Prima facie = “At first view,” or self-evident • Each ethical principle is binding unless it conflicts with another principle • When the principles conflict, a person must decide which one to act on • The theory of the four principles does not give guidance about which one to choose or how to prioritize them

13. Ethical Dilemma Occurs when someone must choose between conflicting ethical principles 8.3 Figure: Ethical dilemma (CC BY-NC-SA 3.0, 2012).

14. Obligation and Aspiration • Obligation = Minimum standard necessary to meet professional obligation • Provide competent medical care to individual patients • Make sure patients understand the risks and benefits of treatment • Aspiration = Standard that one should strive to achieve but is not always attainable • Providing equal worldwide access to health care • Find cures for currently incurable conditions

15. Ethics Committee • Group of people who meet to discuss ethical dilemmas • All accredited hospitals must have a process for resolving ethical questions • Membership is usually diverse and may include • Doctors and nurses • Other health care professionals • Social workers and lawyers • Religious professionals • Members of the community

16. Codes of Ethics • Examples: • American Medical Association • American Nursing Association • International Council of Nurses • American Health Information Management Association • American Medical Informatics Association

17. Hippocratic Oath • Historical foundation of medical ethics • States a moral obligation to maximize benefits of treatment and minimize harms of treatment • Much of the original oath is not relevant today • Modernized versions of the oath are used at some, but not all, medical schools

18. Professionalism • Profession = An occupation that • Requires special knowledge and training • Has standards for behavior • Health care professional = A person who, by training and experience, has the knowledge to provide some aspect of health care delivery • Professionalism means • Acting in a way that meets standards • Knowing ethical obligations and trying to meet them

19. Core Medical Professional Responsibilities • Professional competence • Honesty with patients • Patient confidentiality • Appropriate relations with patients • Improving quality of care American Board of Internal Medicine, 2005; Cassel, 2009

20. Core Medical Professional Responsibilities Continued • Improving access to care • Fair distribution of limited resources • Scientific knowledge • Managing conflicts of interest • Maintaining professional responsibilities American Board of Internal Medicine, 2005; Cassel, 2009

21. Ethics and Professionalism Summary – Lecture a • People in the health care profession have duties based in the four core principles of medical ethics: • Respect for autonomy • Beneficence • Nonmaleficence • Justice • Health care professionals must consider how broadly their ethical duties extend (“scope of their action”) • Professionalism requires that people in the health care industry act in accord with certain standards

22. Ethics and Professionalism References – Lecture a References American Board of Internal Medicine. (2005). Physician charter. Retrieved from http://abimfoundation.org/what-we-do/medical-professionalism-and-the-physician-charter/physician-charter Antiel, R. M., Kinghorn, W. A., & Reed, D. A. (2013, July). Professionalism: Etiquette or habitus?. In Mayo Clinic Proceedings, 88 (7), 651. Mayo Foundation for Medical Education and Research. Aulisio, M. P, Arnold R. M. (2008). Helping to address value conflicts or uncertainties: Role of the ethics committee. Chest, 134, 417–424. Cassel, C. K. (2009). 21st century medical professionalism: Renewing the social contract. Retrieved from http://www.slideshare.net/ABIMFoundation/medical-professinalism-renewing-social-contract CMPA, (2012) Physician professionalism. Is it still relevant? Retrieved from https://www.cmpa-acpm.ca/-/physician-professionalism-is-it-still-relevant- Ethics & Compliance Initiative. (n.d.). Ethics and compliance glossary. Retrieved from https://www.ethics.org/resources/free-toolkit/toolkit-glossary. Gholami-Kordkheili, F., Wild, V., & Strech, D. (2013). The impact of social media on medical professionalism: A systematic qualitative review of challenges and opportunities. Journal of Medical Internet Research, 15(8), e184. Retrieved from http://www.jmir.org/2013/8/e184/%23ref44 Gillon R. (1994). Medical ethics: Four principles plus attention to scope. BMJ, 309(6948), 184–188. Gillon R. (2003). Ethics needs principles: Four can encompass the rest—and respect for autonomy should be “first among equals.” Journal of Medical Ethics, 29(5), 307–312.

23. Ethics and Professionalism References – Lecture a Continued Jennings, B., Baily, M. A., Bottrell, M., Lynn, J.(Eds.). (2007). Health care quality improvement: Ethical and regulatory issues. The Hastings Center. Retrieved fromhttp://www.thehastingscenter.org/uploadedFiles/Publications/Special_Reports/Health%20Care%20Quality%20Improvement.pdf Kirk, L. M. (2007). Professionalism in medicine: definitions and considerations for teaching. Proceedings (BaylorUniversityMedical Center), 20, 13–16. Kong, W. M. (2015). What is good medical ethics? A clinician's perspective. Journal of Medical Ethics, 41(1), 79–82. Retrieved from http://jme.bmj.com/content/41/1/79.full McCormick, T. R. (2013). Ethics in medicine: Principles of bioethics. Seattle: University of Washington School of Medicine. Retrieved from http://depts.washington.edu/bioethx/tools/princpl.html Meslin, E. M., Alpert, S. A., Carroll, A. E., Odell, J. D., Tierney, W. M., & Schwartz, P. H. (2013). Giving patients granular control of personal health information: Using an ethics “Points to Consider” to inform informatics system designers. International Journal of Medical Informatics, 82(12), 1136–1143. Retrieved from http://www.sciencedirect.com/science/article/pii/S1386505613001895 National Library of Medicine, History of Medicine Division. (2002). Greek medicine: The Hippocratic oath.Retrieved fromhttp://www.nlm.nih.gov/hmd/greek/greek_oath.html Pearlman, R. A. (2013). Ethics in medicine: Ethics committees and ethics consultation. University of Washington School of Medicine. Retrieved from http://depts.washington.edu/bioethx/topics/ethics.html

24. Ethics and ProfessionalismReferences – Lecture a Continued 2 Wynia, M. K., Papadakis, M. A., Sullivan, W. M., & Hafferty, F. W. (2014). More than a list of values and desired behaviors: A foundational understanding of medical professionalism. Academic Medicine, 89(5), 712–714. Tables, Charts, Figures 8.1 Figure: Four basic principles of healthcare (CC BY-NC-SA 3.0, 2012). 8.2 Table: Non-Maleficence (CC BY-NC-SA 3.0, 2012). 8.3 Figure: Ethical dilemma (CC BY-NC-SA 3.0, 2012).

25. The Culture of Health CareEthics and ProfessionalismLecture a This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002.