DOC-20240806-WA0197..pdf

MEDICAL ETHICS Medical Professionalism DR. MILIMO BSc.HB, MBChB, MPH, MSc.EB*, MSc,DTM, AdvCert.Psy.  Medical professionalism is a belief system in which group members (“professionals”) declare (“profess”) to each other and the public the shared competency standar...

MEDICAL ETHICS Medical Professionalism DR. MILIMO BSc.HB, MBChB, MPH, MSc.EB*, MSc,DTM, AdvCert.Psy.  Medical professionalism is a belief system in which group members (“professionals”) declare (“profess”) to each other and the public the shared competency standards and ethical values they promise to uphold in their work and what the public and individual patients can and should expect from medical professionals. At the heart of these ongoing declarations is a three-part promise to acquire, maintain and advance: (1) An ethical value system grounded in the conviction that the medical profession exists to serve patients' and the public's interests, and not merely the self-interests of practitioners. (2) The knowledge and technical skills necessary for good medical practice. (3) The interpersonal skills necessary to work together with patients, eliciting goals and values to direct the proper use of the profession's specialized knowledge and skills, sometimes referred to as the “art” of medicine. Rights and privileges of a registered Medical practitioner 1. Right to practice medicine 2.Right to choose patient 3.Right to prescribe/dispense medicines 4.Right to possess, dispense or prescribe drugs listed in the Dangerous Drug Act 5.Right to add professional titles to his name 6.Right to perform surgical operations 7.Right to issue certificate 8.Rights for appointment to public (government) hospital 9.Right to give evidence as an expert witness in the Court of law 10.Right to claim payments of fees for professional services given.  Doctor’s responsibilities To treat all his/her patients equally and provide them with the same level of concern. Although a doctor has the right to choose his/her patients, such choices may never amount to unfair discrimination and emergency treatment may never be refused. Doctors have the duty not to harass patients, colleagues or others on the basis of sex, gender, sexual orientation, race or any (presumed) group characteristic. To protect life, within the confines of a patient’s right to physical autonomy and decision-making power. To protect the privacy and confidentiality of his/her patients and to only disclose health care, treatment, diagnostic and other health information with the patient’s informed and written consent or when authorised by law or a court to do so.  To respect the religion, beliefs and opinions of their patients, even if it differs from their own, and not to force any patient or colleague to prescribe to any religious practice, belief or opinion. Doctors have the responsibility to respect the clinical independence of their colleagues and not to succumb to pressures of dual loyalty. To ensure that any political affiliation and activities does not interfere with his/her duties to good patient care. To ensure that medical waste are disposed off appropriately and that appropriate protocols are followed in terms of infectious disease control. Doctors have the responsibility to inform their patients of the harmful effects of medicines and how to store and use it properly. To ensure that s/he is informed about the latest developments in their fields and take part in educational activities.  To ensure that medical reports are fair and accurate, and that only particulars that are authorised by law are disclosed to insurance and assistance agencies. To provide access to information requested by their patients and to ensure that health data is stored safely and not sold or passed on without the patient’s informed consent. To assist in legal proceedings when called upon as expert witnesses. Doctors have a particular responsibility in relation to crimes such as child abuse, domestic violence and abuse of the elderly.  Conduct of a doctor/expert witness in court Modest Well dressed and have appropriate personal appearance Honest Impartial in your evidence Maintain dignity and show respect for the court; High Court Judge is addressed as ‘My Lord’ Magistrate as ‘Your Honour’ He should be modest in stating his qualifications and experience Refresh your memory (previous notes on the case etc) Your speech should be clear, easily audible, confident and polite Use plain and simple language; avoid technical terms as far as possible He should state the facts observed by him Do not evade any question Keep cool Always remember to be honest and impartial  Breaches of Medical Professionalism 1. Abuse of power 2. Poor interactions with patients and colleagues 3. Discrimination, bias, harassment, and bullying 4. Breach of confidentiality 5. Arrogance 6. Greed 7. Misrepresentation 8. Impairment 9. Lack of conscientiousness 10.Conflicts of interest  Professional misconduct A health practitioner commits professional misconduct if the health practitioner: (a) Contravenes the provisions of the Health Professions Council’s Act. (b) Unlawfully discloses or uses to the health practitioner’s advantage any information acquired in the health practitioner’s practice. (c) Engages in conduct that is dishonest, fraudulent or deceitful. (d) Commits an offence under any other law; (e) Engages in any conduct that is prejudicial to the health profession or is likely to bring it into disrepute. (f) Breaches the Code of Ethics or encourages another health practitioner to breach or disregard the principles of the Code of Ethics of the Health Professions Council. Professional misconduct which may lead to disciplinary proceedings Neglect or disregard by the health practitioner of his/her professional responsibilities to patients and clients under his/her care and treatment. Abuse of professional privileges or skills. Personal behaviour or conduct of the health practitioner derogatory to the reputation of the health profession. Improper Advertising. Disparagement of professional colleagues. Ethical considerations on stigmatising conditions which disadvantage the patient or client. Participation in or conducting clinical or other health research not approved by the relevant Ethics Committee. Improper relationships between the health professionals and the Associated Industries. Continuing Professional Development and Supervision related issues Case scenario Charlene, a 28-year-old female patient presented to a doctor with complaints of throat and back pain. The physician prescribed clarithromycin for pharyngitis and oxycodone for the her back pain. Even though she was asked to sign a contract to receive the oxycodone, neither her nor the doctor honored the terms of the contract. Shortly after she was first seen in the office, the doctor entered into a romantic relationship with her. He continued to treat her for back pain, giving multiple prescriptions and sample medications. Not all the prescriptions were recorded in the patient’s medical record, and several were written in the name of the patient’s fiancé, who was not the physician’s patient. Case scenario The physician provided numerous narcotic pain medicine prescriptions over the course of eight months’ time. After eventually discovering that this patient was obtaining additional pain medication from other physicians and acknowledging to himself that she was manipulating him, the physician ended his personal relationship with the patient and discharged her from his practice. Shortly after the physician broke up with her, Charlene sued him, alleging improper prescribing of pain medications resulting in her addiction. Experts agreed that this physician’s care was below the standard, and the case was ultimately resolved short of trial. In addition, the physician had his license revoked by his state’s medical board. What is the main ethical issue in this scenario? Comment on this scenario BOUNDARIES WITHIN THE PATIENT- PHYSICIAN RELATION A boundary may be defined as the “edge” of appropriate professional behavior, transgression of which involves the therapist stepping out of the clinical role or breaching the clinical role. Boundaries define the expected and accepted psychological and social distance between practitioners and patients. Boundaries are derived from ethical treatise, cultural morality, and jurisprudence. Sometimes, it is difficult to clearly define the perimeter of these boundaries and the integrity of the relationship  Boundary Issues Boundary issues are disruptions of the expected and accepted social, physical, and psychological boundaries that separate physicians from patients. The therapeutic relationship between a doctor and the patient is established solely with the purpose of therapy and whenever this relationship deviates from its basic goal of treatment, it is called boundary violation and becomes non- therapeutic. As the therapeutic relationship is prolonged and more personal as many confidential matters are discussed, there is likelihood of developing strong emotional bonds. This may lead to non-therapeutic activity.  Two types of boundary issues: Boundary crossings Boundary violations This may result or manifest as nonsexual or sexual boundary crossings and boundary violations. A boundary crossing is a deviation from classical therapeutic activity that is harmless, non-exploitative, and possibly supportive of the therapy itself. In contrast, a boundary violation is harmful or potentially harmful, to the patient and the therapy. It constitutes exploitation of the patient. Similarly, boundary crossings and violation may arise from the therapist or from the patient.  Ethical principles in boundary issues Respect for the dignity of the patient is the fundamental ethical principle in boundary problems. The patient’s authentic goals or choices must be respected. The concept of autonomy that is fostering the patient’s independence and separateness as a self-directing person, along with promoting the self-determination attitude of the patient form the central core in the perseveration of the boundary concepts. The fiduciary relationship, namely the concept of trust or good faith, must be maintained. A fiduciary in healthcare is one whose actions are worthy of trust. A fiduciary partnership has been described as being characterized by “sincerity without reserve” and “loving care”.  Fiduciary rubric components like altruism, beneficence, nonmaleficence, and compassion have to be observed in the treatment setting. The therapist has to observe and see that his personal gain does result in exploitative situation and damage the principles of neutrality and abstinence. Clear professional boundaries create safety for both patients and physicians as well as for society. Boundaries establish clear roles for physicians and define the therapeutic territory; they do not undermine the physician-patient relationship. If boundaries are ignored, physicians can find themselves acting in their own best interest instead of the patient’s best interest.  Slippery slope concept The doctor is responsible for preserving the boundary and he should ensure that boundary violations do not occur. If even a minor violation occurs, it is better to transfer the patient to a colleague. The boundary violation typically starts small and become incrementally problematic and the dyad starts sliding down the slope. This is known as Slippery Slope Concept.  Non-sexual boundary issues The role played by a physician is to be “synonymous with the Hippocratic obligation to act always in the interest of the patients and avoid harming them.” It is essential that the physician not reverse his or her professional role with that of the patient. Role boundaries may be crisp, flexible, or fuzzy, depending on the role under consideration and on the cultural climate. The boundary examines the quality and quantity of time spent with the patient.  When physicians spend great lengths of time with attractive patients but less with unattractive ones, there is a potential boundary difficulty. Likewise, scheduling patients outside regular hours, giving “special” late appointments, or offering more frequent follow-up than is medically necessary suggests that physicians’ needs are being met before patients needs. Patients should be treated similarly when deciding where treatment is to occur either in the consultation room, bedside, or if needed at home and must be seen in similar contexts. The place of consultation should be clinic and the time should also be during the consultation hours. If the physician charges fees, he should keep charges that are reasonable for that area.  It would be difficult to claim that gifts from a physician to a patient are beneficial. The most obvious form of gifts are consumer goods, but there are more subtle “gifts,” such as generous prescriptions or excessively large amounts of drug samples to selected individuals. These medication favors are particularly dangerous with addictive medications, because they place the patient in a dependent position.  Likewise, the physicians must relent to accept gift or favors from the patient. Very often, influential people like politicians and government officials may offer special privileges for the doctor or his department, but all such concessions or allurements are also unethical. Whenever the physician and the patient start becoming friendly, then the therapeutic relationship is compromised. The objectivity is compromised and factors outside the therapeutic relationship may become destructive to the therapeutic process. Business relationship with a current patient is unethical except when one is living in a small community where such relationship cannot be avoided.  Physicians should avoid seductive or revealing dress when treating patients. Clinical apparel can help maintain the appropriate professional distance between physician and patient. The way the physician addresses his client is most important. Doctor should be dressed formally. Dresses that are flashy or reveal body part in a provocative manner should be avoided. The language used should be formal and abusive or double meaning words should be avoided. Physicians sometimes reveal increasingly personal details to patients and end up violating appropriate boundaries. Unlike regular social conversation, our main task is to listen, not to talk. Any clinical decision should be based on what is best for the patient; the physician’s ideology should play as little apart as possible in such decisions.  Touch is an extremely powerful bonding tool, but like most tools, it cannot be used indiscriminately. Though touch is a necessary component of diagnosis and healing in medicine, it can be misunderstood. Physicians must be clear about why touch is necessary. Boundary issues involve circumstances in which health professionals encounter actual or potential conflicts between their professional duties and their social, sexual, religious, or business relationships.  Health professionals should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. A professional enters into a dual relationship whenever he or she assumes a second role with a client, becoming health professional and friend, employer, teacher, business associate, family member, or sex partner.  Conflicts of interest occur when professionals find themselves in “a situation in which regard for one duty leads to disregard of another or might reasonably be expected to do so.” Health professionals should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Boundary issues may thus result or originate from the way in which the physician schedules his working with the client by the time and place of consultations, contacts on phone, in social meetings, etc., or by accepting or giving of gifts, money, or by the types of clothes the doctor wears and the language he uses. Boundary issues involve the physician’s role and his relationship with the patient and his family.  Sexual misconduct Four elements appear in all boundary violations, and these are particularly notable in sexual abuse of patients by physicians. Role reversal. Secrecy. Double bind. Indulgence of professional privilege. First, sexual misconduct usually begins with relatively minor boundary violations, which often show a crescendo pattern of increasing intrusion into the patient’s space that culminates in sexual contact. A direct shift from talking to intercourse is quite rare; the “slippery slope” is the characteristic scenario.  A common sequence involves a transition from last- name to first name basis; then, personal conversation intruding on the clinical work; then, some body contact (e.g., pats on the shoulder, massages, progressing to hugs); then, trips outside the office; then, sessions during lunch, sometimes with alcoholic beverages; then dinner; then movies or other social events; and finally, sexual intercourse. Second, not all boundary crossings or even boundary violations lead to or represent evidence of sexual misconduct.  “An absolutist position concerning treatment boundary guidelines cannot be taken. Otherwise, it would be appropriate to refer to boundary guidelines as boundary standards. Effective treatment boundaries do not create walls that separate the therapist from the patient. Instead, they define a fluctuating, reasonably neutral, safe space that enables the dynamic, psychological interaction between therapist and patient to unfold.” -T. L. Beauchamp Boundaries within the Patient- Physician relation: scenario Charlene, a 28-year-old female patient presented to a doctor with complaints of throat and back pain. The physician prescribed clarithromycin for pharyngitis and oxycodone for the her back pain. Even though she was asked to sign a contract to receive the oxycodone, neither her nor the doctor honored the terms of the contract. Shortly after she was first seen in the office, the doctor entered into a romantic relationship with her. He continued to treat her for back pain, giving multiple prescriptions and sample medications. Not all the prescriptions were recorded in the patient’s medical record, and several were written in the name of the patient’s fiancé, who was not the physician’s patient. Boundaries within the Patient- Physician relation: scenario The physician provided numerous narcotic pain medicine prescriptions over the course of eight months’ time. After eventually discovering that this patient was obtaining additional pain medication from other physicians and acknowledging to himself that she was manipulating him, the physician ended his personal relationship with the patient and discharged her from his practice. Shortly after the physician broke up with her, Charlene sued him, alleging improper prescribing of pain medications resulting in her addiction. Experts agreed that this physician’s care was below the standard, and the case was ultimately resolved short of trial. In addition, the physician had his license revoked by his state’s medical board. What is the main ethical issue in this scenario? Comment on the scenario  Risk Management Recommendations — Interactions in which Boundaries Could Be Compromised Strive to provide objective examinations for all patients. Recognize that as a physician, your professional responsibility includes a duty to care for patients and to maintain appropriate boundaries. Do not allow friendship with or manipulation by a patient to influence your adherence to the standard of care. Avoid flirtatious behavior and keep patient communication focused on the evaluation of medical symptoms and the discussion of treatment options. Do not enter into romantic or sexual relationships with patients. The primary reason “for this hard and fast rule is that the physician’s position of authority and the patient’s position of vulnerability raise the risk of exploitation.”  Speak frankly with the patient and document concerns if he or she is exhibiting drug-seeking behavior such as requesting refills too frequently or making visits to the emergency department and complaining of pain. Do not prescribe a controlled substance unless there is a legitimate medical purpose. Take a medical history from a patient who has presented with a complaint of pain, and establish a logical connection between the complaint, the medical history, the physical examination and the drug you are prescribing. Consider using a pain medication agreement with patients who are taking opioid medications. Pain medication contracts generally call for a patient to agree to obtain pain medication only from you and to take the medication as prescribed.  The contracts help you and patients define and agree on appropriate behavior, and they hinder patients from obtaining large quantities of drugs. Keep thorough records. Obtain and document a thorough patient history, including possible or potential illegal drug use or abuse. Document all medications prescribed. Document the rationale for medications prescribed as well as treatment plans and goals. Re-evaluate and document the patient’s level of pain and response to treatment at each visit.  Sexual encounters: Ethical guidelines-American Psychological Association Sexual Harassment: Sexual harassment is unwanted/offensive sexual solicitation, physical advances, or conduct that is sexual in nature, which may be deemed abusive to another party. Physicians avoid sexually harassing those with whom they work. Avoid harm: Physicians take reasonable steps to avoid/minimize harming their clients, students, supervisees, research participants, and others. Multiple Relationships: A multiple relationship occurs when a physician is in both a professional and additional role with another person, with a person associated with the person with whom the physician has a professional relationship, or when he/she promises to enter into another relationship in the future with any of these persons. If such a dual relationship impairs objectivity and/ or competence, or could potentially risk exploitation or harm to those who are served, the actions are deemed unethical.  Exploitative Relationships: Physicians do not exploit persons over whom they have power/ authority. Informed Consent to Therapy: This is pertinent to the nature of therapy, so that clients have realistic expectations; the therapeutic relationship is a professional one, which should be made explicit to clients at the outset. Sexual Intimacies with Current Therapy Clients/Patients: Physicians must not engage in sexual intimacies with current therapy clients.  Sexual Intimacies with Relatives or Significant Others of Current Therapy Clients/Patients: Physicians must not engage in sexual intimacies with relatives or significant others of current therapy clients. Therapy with Former Sexual Partners: Physicians must not conduct therapy with former sexual partners. Accepting former sexual partners as therapy clients is considered unethical.  Sexual Intimacies with Former Therapy Clients/Patients: Physicians must not engage in sexual intimacies with former therapy clients for at least two years after cessation or termination of therapy. After this interval, physicians can potentially, albeit infrequently, become exempted from this principle if they demonstrate that no client exploitation occurred in the following areas: The amount of time that has passed since therapy terminated. The nature, duration, and intensity of the therapy. The circumstances of termination. The client’s/patient’s personal history. The client’s/patient’s current mental status. The likelihood of adverse impact on the client/patient. Any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a post- termination sexual or romantic relationship with the client/patient Case scenario Maria, a 5-year-old girl with Atrial Septal Defect (ASD), has been working with Nathan, a therapist, for about 6 months. Jennifer, Maria’s mother, grills Nathan on a variety of personal matters. At first, he focused more on building a cordial working relationship with the family than he did on the questions. But recently, Jennifer started probing Nathan about his love life. She has also boosted her exercise routine and frequently wears tight workout attire around him. She has started to inquire about Nathan’s assessment of her appearance, and he typically responds courteously and makes brief but pertinent remarks about the value of exercise. As a result of Jennifer’s conduct getting worse, Nathan has now been sexually approached by her. She has also implied that if he does not reciprocate her overtures, she will complain to his boss about his performance on the job. What are the potential ethical issues/concerns? What ethical dilemma is Nathan facing? What is the ideal potential course of action that Nathan should take? Case scenario Potential ethical concerns: Nathan has unknowingly entered into a dual relationship with Jennifer. Nathan is facing an ethical dilemma. He can either engage in a sexual relationship with Jennifer, which would be highly unethical, or potentially have a false accusation made that can jeopardize his career and overall future. Potential course of action: Nathan should immediately report Jennifer’s statement to the designated human resources (HR) representative or other appropriate staff member where he works and request to be removed from the case. He should not compromise his career and future by considering her offer or failing to report her behavior.