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This article is adapted from a lecture Dr. Lucas presented on March 2, 2007, at Methodist Hospital in Memphis, Tenn.The AAOS Code of Ethics and Professionalism for Orthopaedic Surgeons can be found at: www.aaos.org/ethicsThe AAOS Standards of Professionalism can be found at www.aaos.org/profcomp

AAOS Now

Published 7/1/2007
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George L. Lucas, MD

Ethics for 21st century medicine

Medical professionalism can be defined as the ability to meet the relationship-centered expectations required to practice medicine competently. Over the years, various programs have been instituted to teach ethics and professionalism, but at the end of the day, an informal curriculum is central to their development.

Albert Schweitzer summed this up by saying, “Example is not the main thing in influencing others, it is the only thing.”

Professionalism is based on the principles of primacy of patient welfare, patient autonomy, and social justice, and involves commitment to the following professional responsibilities: competence, honesty, confidentiality, appropriate relationships with patients, improving quality of care, improving access to care, just distribution of finite resources, commitment to scientific knowledge, and maintaining trust by managing conflicts of interest.

Modern developments such as managed care and HMOs often seem to place doctors in a no-win situation, and we must be careful not to retreat into our own small technical world. If we become too dependent on test results, we are abandoning the real responsibilities that we have to patients as fellow human beings.

Simply stated, ethics means “doing the right thing,” but ethical applications and analyses are obviously more complex than that. Philosophers have discussed questions of ethics and morality since antiquity, but in American medicine, physicians tend to be most influenced by the AMA Code of Medical Ethics. First articulated in 1847, the code is regularly revised, and currently lists some 60 social policy issues—from abortion to information gained from unethical experiments.

The dignity of the individual
The dignity of the individual must be a paramount concern. The individual person is not an abstraction but a living entity whose life involves shared experiences in a particular community. Partly because of the interdependence of the individual and society, the concept of human dignity is not static. Only in the 19th century, for example, did American society recognize the full evils of slavery and child labor. In our own generation we have seen progress in the areas of sexism, racism, ageism, and other –isms that we now consider to be affronts to human dignity. Unfortunately, society can forget the consequences of such ideas and, as resources become scarcer, may be tempted to downgrade the dignity of the sick, the elderly, the poor, and the powerless.

As we value the dignity of the individual, we must also consider his or her rights, both moral and legal. Legal rights appear, change, develop, or even disappear altogether according to developments in society’s code of law. Moral rights exist as a part of a moral perspective. In professional ethics, general moral rules yield more refined rules that are subject to interpretation. As an example, 75 years ago, blood transfusions were almost universally fatal and thus considered unethical. After World War II, the risks became very small and transfusions generally posed no ethical problems. With the spread of AIDS and hepatitis, we must again consider the ethical problems with the transfusion of blood.

For much of its history, American medicine followed the Hippocratic tradition, which paternalistically saw the physician in charge of everything. It was not until 1980 that the AMA’s Principles of Medical Ethics first mentioned patients’ rights and obligations.

Informed consent, or something else?
We all think we know what is meant by informed consent, but it is really a very complex issue. Some have even questioned whether there is really any such thing. Former U.S. Supreme Court Justice Benjamin N. Cardozo stated in 1914, “Every human being, being of adult years and sound mind, has the right to determine what shall be done with his own body; a surgeon who performs an operation without his patient’s consent commits an assault...” Avoiding the obvious gender bias in that statement, I wonder what Justice Cardozo would say about those who are not of an adult age or of sound mind. Surely, these groups are entitled to some form of informed consent, although legally, the ultimate decision must be made by a parent or bona fide care giver.

For a patient to give informed consent, the physician must present alternative rational treatment choices in an understandable way while respecting the patient’s autonomy.

Three other basic principles of medical ethics should be mentioned here—beneficence, nonmaleficence, and justice. Beneficence fundamentally means the promotion of what is best for the patient; nonmaleficence means avoiding harm. Justice means that all patients in similar situations should have fair access to our limited healthcare resources.

This concept of justice necessitates examining the question of physician reimbursement. Can a healthcare provider ethically reject a patient who is unable to pay? The answer is both yes and no. The physician who never does charity work is certainly not practicing the profession of healing as much as operating a business, and such a person is not worthy of the name of doctor. At the same time a physician must have some discretion in how many nonpayers to accept. Although the doctor’s role calls for charitable work, it does not require becoming a charitable institution.

The relationship between surgeons and medical device representatives can be understandably close, with sales reps playing an important role as a source of product information and professional support. On another level, surgeons collaborate with industry to develop or improve next generation technology that will improve health and mobility. Although these relationships result in better products and better clinical outcomes for the patient, whenever money, goods, or services are exchanged between industry and the doctor, the potential exists for conflicts of interest and increased government scrutiny.

For further reading, I recommend The Healer’s Power by Howard Brody, MD, PhD. Dr. Brody points out that medical ethics is about power and its responsible use. Clearly, we must recognize the power we have, channel such power appropriately, and recognize opportunities for power sharing.

Ethics is not simply something for ivory tower philosophers to debate, but is a powerful force in the practice of medicine. It is imperative that we continually act with ethics and professionalism.

George L. Lucas, MD

Two views of morality
Among philosophers, there are two major concepts of morality—one espoused by Emanuel Kant (1724-1804) and the other by John Stuart Mill (1806-1873). Kant stated that an act is moral only if it springs from what he calls a “good will,” that is, a will governed by a natural moral principle. Kant’s ideas gave rise to a new term—deontological, which means that which is binding or a duty. Simply stated, Kant’s philosophy echoes the command to “do unto others as you would have them do unto you.” One strength of the deontological position is its emphasis on the moral significance of the individual. In fact, the individual is so exalted that community becomes a nonexistent category. Unfortunately, we cannot deny the role of social experience.

Mill, on the other hand, promoted the idea of utilitarianism, or “the greatest happiness principle.” Utilitarianism holds that actions are right in proportion to their tendency to promote happiness, and wrong as they tend to the reverse. There are many areas of healthcare ethics in which society might rightfully judge that the utilitarian approach is the most reasonable approach. For example, a December 2006 perspective in the New England Journal of Medicine discusses the ethics and politics of compulsory human papillomavirus vaccination. Similar discussions could be held about a variety of other vaccines and, indeed, bioethicists who generally hold the values of patient autonomy and informed consent to be preeminent tend to be skeptical of compulsory vaccination laws.

These two formulations are not entirely mutually exclusive, but there have been strong arguments in favor of one or the other. One possible compromise is the concept of “virtue ethics,” which can be defined as the integration of virtues such as truthfulness, compassion, and unselfishness with practical wisdom or right reason.