WISE WORDS ON ETHICAL PRACTICE
By:
AUTHOR:
Pankaj D. DESAI MD (O&G)
• Consultant Obgyn Specialist
Janani Maternity Hospital, Vadodara, India
• Dean (Students), A. Professor and Unit Chief (VR)
Department of Obgyn, Medical College and S.S.G. Hospital
Vadodara, India
·
Past President: FOGSI
Ethics are
very important in clinical practice as in all spheres of
life. The behavior of doctors was always scrutinized by
society well before the Consumer Protection Act became
applicable to the medical profession in India. In more
recent times, I remember returning to my seat on the dais,
after giving the inaugural address at a medico-legal
conference as president FOGSI, I had then spoken on “Ethics
in Medical Practice”. The Late jurist Shri Ram Jethmalani,
who was the guest of honour for that conference whispered in
my ears, “Doctor, this is most relevant. More relevant than
all what we are going to deliberate on legal angles at this
conference”.
The
Challenge of Medical Ethics
Ethics are
defined as rightful behaviour. The precincts of ethics are
much larger than the law of which law are just one part.
Medical ethics involves examining a specific problem,
usually a clinical case, and using values, facts, and logic
to decide what the best course of action should be. Many
times it is a tight rope walking. Some ethical problems are
straightforward, as and when one has to decide a right from
wrong. But others can be more perplexing, such as deciding
between two ethics that conflict with each other. Both seem
to be right. To give an example – Patient’s right to choose
the route of delivery.
A 2016
Medscape survey, identified some common problems where at
least some physicians held different opinions 1:
•
Withholding treatment to meet an organization's budget, or
because of insurance policies;
• Accepting money from pharmaceutical or device
manufacturers;
• Up-coding to get treatment covered;
• Getting romantically involved with a patient or family
member;
• Covering up a mistake;
• Reporting an impaired colleague;
• Cherry-picking patients;
• Prescribing a placebo;
• Practicing defensive medicine to avoid malpractice
lawsuits;
• Dropping insurers; and
• Breaching patient confidentiality owing to a health risk.
The
so-called high professional standards are a way to provide
some guidance on ethical problems, but they cannot address
every issue, and they may not address troubling nuances,
such as reconciling two conflicting values.
Critical
Standards for Determining Ethical Issues
Many professional ethicists recommend
using four basic values, or principles, to decide ethical
issues 2.
• Autonomy: Patients basically have the right to determine
their own healthcare.
• Justice: Distributing the benefits and burdens of care
across society.
• Beneficence: Doing well for the patient.
• Non-malfeasance: Making sure you are not harming the
patient.
There are other important values also to consider, such as
telling the truth, transparency, showing deference to the
patient and her family, and showing reverence for the
patient’s values.
Besides, medical
ethics is not just a thought process. It also involves the
competence to handle people. This is in such a way so as to
gather the facts required for decision-making and the ob-gyn
specialist must be able to present these in such a way to
gain the confidence of all involved.
Listening skills including patience are an indispensable
part of medical ethics. Often, ethical disagreements occur
from not knowing all the facts, or not providing all the
facts to patients. A well-prepared ethical choice could be
overlooked if one could not win the confidence of the
patient. Sometimes ethics are often
perceived as a blinkered activity—telling us what we cannot
do. But if one sees with a broad-view, ethics can be very
liberating. Ethics can reassure you that you are doing the
right thing. If one goes through a proper ethical process,
the ob-gyn specialist has greater confidence that he/she is
on the right path. Once freed of irritating doubts, he/she
will be able to proceed more unswervingly and more
energetically with the chosen health-care plan.
As the health system evolves, ethical decisions could become
more challenging. For example, the cost factor in private
medical care facilities can make the patients avoid or
altogether not take the care they need, and this disturbs
the clinician's drawn health care plan.
Difference between Ethics and Ethos:
Ethics are constant. They don’t change. Ethos can change.
Ethics are the same all through generations but some
behaviour may be ethical in one generation and unethical in
the other. These are ethos. Primum non-nocere – (Do no harm)
was a core ethical behaviour in the time of Hippocrates and
is a core ethical behaviour in medical practice even now. On
the other hand, euthanasia was once a big NO, is being
accepted as ethical and legal by many societies and
countries now. Practical Consequences
of Medical Ethics Some doctors think
of medical ethics as a very mysterious field, delinked from
the practical considerations of clinical practice. But this
is not true. A practice where decisions are taken that are
not congruent with ethics is never justifiable. In reality,
a society where these type of practices become a routine,
the common patient loses faith in its doctors very quickly.
Here are some reasons to take medical ethics seriously
2: • To help resolve disputes
between family, patients, physicians, or other parties.
Often, the parties involved are operating strictly on
emotion, which makes it difficult to come to a logical and
fair decision. Ethics adds another dimension to help make
decisions. • To maintain a clear
conscience. All doctors want to be sure they have done the
right thing. Being an ethical physician is more important
than making money or seeing as many patients as possible.
• To not make yourself look uninformed. Physicians sometimes
stumble onto poor decisions because they did not understand
their role, had not bothered to identify an ethical
challenge, or hadn't thought the situation through to its
logical conclusion. • To maintain the
respect of your patients. Ethical missteps can destroy the
bond between doctor and patient. Patients often implicitly
trust their doctors, but once that trust has been breached,
it is difficult to repair. • To maintain
respectful relationships with other clinicians. Your
colleagues often have very definite opinions about what is
ethical, often enshrined in various codes of ethics of the
profession or learned from mentors. Those codes and ethics
role-modeling are created by people who practice some form
of ethical decision-making. • To
maintain some efficiency. Although ethical decision-making
often requires extra time, it also can save time by
anticipating disagreements that can slow down the care
process. If you aren't ethical, patients or other caregivers
who are upset with your decisions can seriously impede your
work. • To reduce burnout. One cause of
burnout is incongruence between physicians' personal values
and those of their organization. Physicians who can describe
their ethical concerns and use negotiating skills may be
able to change the organizational policies that produce
burnout. After working through this
dilemma, you may still decide to close off your practice,
but you will have thought the issue through. You will be
aware that the people you are turning away still need a
doctor, and some physicians might decide to find a way in
which they can help such people without burning themselves
out, such as volunteering in a free clinic occasionally.
Ethics, Morality, and Religion
Medical ethics differs from morality. Ethics are based on
values and reasoning and needs coaxing to get its message
through. On the other hand, morality is relatively easy. It
involves obeying to a detailed belief system or some code of
conduct. Morality relies at times on scriptures like The
Vedas or The Bhagwat Gita or the Bible, to defend its
message. Morality does not just involve religion. It can be
political or personal. In contrast, medical ethics has a
flexible set of solutions. It is based on facts and logic,
and not religious doctrine. You can still have political
opinions and religious faith, but you will need to set them
aside when forming and offering an ethical opinion to those
who do not follow your morality. A good
scientist, who is observing medical phenomena, would have a
pragmatic attitude about life, sickness, and death. Medicine
gets its human face from ethics. Ethical decisions should
respect the values and attitudes of patients. In a
predominantly vegetarian society like where I practice,
animal sources of Omega-3-fatty acids have to be very
carefully handled before prescribing. Pharma companies were
forced to come out with vegetarian sources of these fatty
acids as the value systems of the patients did not permit
its consumption if it was from an animal source.
Respecting the patient's wishes has a practical consequence:
Doctors who simply overrule the patient often end up seeing
their treatments fail. This is because patients will never
be convinced to follow their treatment advice. Patients who
are overruled do not tell the truth. It is therefore
advisable to be in dialogue and negotiations with the
patients. Sometimes it may mean coming to a reasonable
compromise - even if the doctor doesn't completely approve
of it. When Patients or Families
Disagree With the Doctor Sometimes
when patients or their families disagree with the doctor,
the obvious ethical decision isn't the right one. Here's an
example that occurred. A primigravida mother was found to
have severe fetal distress. She passed thick meconium-stained
liquor and the heartbeats of the fetus became irregular. She
and her family disagreed with the attending obstetrician for
a cesarean section. They stated that no one had ever needed
a cesarean section in their family. In spite of intense
counseling and persuasion, they refused to consent for the
operative delivery. In due course of time, she delivered
vaginally. The new-born was grossly asphyxiated. It was
revived after a very energetic and active resuscitation. But
alas the child developed cerebral palsy and had all its
challenges in life. Although we
obstetricians need to respect patients' values, it is
imperative that our own values should not control the
decisions. Conscience and the religious faith of the
physician should not automatically overrule the patient's
need to get the best treatment possible. For example, an
obstetrician cannot refuse medical contraception services to
her clients because his/her religious beliefs do not approve
of the same. Who Decides?
First and foremost, the doctor’s own integrity is the
biggest deciding factor on ethics. His/her own conscience
becomes their personal light-house guiding in most day to
day decision making situations. As regards the
organizations, in India Medical Council of India reviews,
arbitrates and decides ethics in different situations in all
aspects of medical practice including research.
Doctors also look to their hospitals'
ethics committees for answers, but these committees aren't
intended to be the final authorities on medical ethics. Most
hospitals, however, do not have ethical committees. These
committees are educators and work in an advisory capacity.
Their role is to develop specific hospital policies, educate
staff about clinical ethics, and oversee ethical consultants
on staff. So who is the ultimate arbiter
of clinical medical ethics? It is the individual doctor,
working in concurrence with the patient. A doctor’s ethical
decisions should go hand-in-hand with their clinical and
technical decisions.
The Grey Area:
Because there is no predetermined answer to most ethical
predicaments, disagreements on ethical solutions to problems
are not uncommon. Although they tend to hold the same basic
values ethical decisions can change over time. The morals
that guide certain ethical decisions can change. For
example, prescription of certain medicines in early
pregnancy for pregnancy “support” was very critically
evaluated and most of the times despised by ethicists. Over
a period of time, with new data coming in, prescribing some
of these agents are not considered irrational or unethical.
Performing frequent sonography in pregnancy was looked at
very critically by ethicists. However, over some time some
relaxations have been granted in this by the ethicists
responding to the prevailing societal norms and demands.
Cesarean section in breech was limited to very specific
breech presentations like breech with hyperextended head.
Now, liberal use of cesarean section for all breech
presentations is not considered unethical.
It must be reassuring to find that
whenever doctors make a clinical decision, they are almost
always making an ethical decision, consciously or not.
Interestingly, rather than not discerning about the ethical
dimension of health care, it makes more sense to be
conscious of it and make sure that our decision is sound.
Is It Ethical to Refrain From Judging Colleagues'
Behavior? Doctors who don't have a
managerial role over their colleagues have an unspoken
responsibility. They are expected to uphold the well-being
of patients in general, not just their own patients. They
have a duty to report a doctor who is indulging in drug
abuse or are outraging the modesty of their patients, for
example. Indeed, the AMA Code of Medical Ethics states that
physicians should report colleagues' behavior "in the first
instance so that the possible impact on patient welfare can
be assessed and remedial action taken”3. However,
criticizing a colleague’s clinical treatment decision or
skill is unethical and undesirable.
Medical Ethics and the Law Medical
ethics may have different standards from the law. Medical
ethics are the universal set of which law is a subset. As
the law is created by judges or legislators and may not
share the values and reasoning of ethical physicians, there
will be a difference. While terminating a pregnancy is legal
but terminating it without properly ascertaining that it
satisfies the tenets of law, is unethical.
Not getting a patient's informed consent for a procedure,
another ethical problem, also has an important legal
element. Doctors who do not get informed consent can be
liable for malpractice, even if the procedure meets all the
standards of clinical care4.
Additional Reading:
For those readers who are interested in this area of medical
practice, the article published in Medscape titled “What Is
Medical Ethics, and Why Is It Important?” can be a valuable
resource 2. This article also gratefully draws much from it.
REFERENCES
1. Reese S. Medscape Ethics Report 2016: money, romance, and
patients. Medscape News & Perspective. December 1, 2016.
Source Accessed April 21, 2018. 2.
Course: Medical Ethics: What Is Medical Ethics, and Why Is
It Important?
https://www.medscape.com/courses/section/898060
3. American Medical Association. Reporting incompetent or
unethical behaviours by colleagues. Code of Medical Ethics.
Opinion 9.4.2. Source Accessed April 13, 2018.
4. Medical malpractice cases: lack of informed consent. The
Law Office of Alan H. Crede. Source Accessed April 13, 2018 |