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International
Association of Medical Colleges
Ethics Committee
The IAOMC established an Ethics
Committee to reflect the centrality of medical ethics to the practice of
medicine. It is a Standing Committee that reports to the Board.
Physicians are confronted by ethical issues every day of their working lives so
medical education and training must ensure they are equipped with the knowledge,
skills and confidence needed to deal with clinical challenges in a trustworthy
way.
The importance of a set of values that underpin the moral standards of
physicians goes back to the beginning of medicine and has been reflected
consistently in the many codes of medical ethics. Learning of medicine requires
assimilating core values and acquiring the skills to implement those values in
clinical practice. To cope with the increasing complexities posed by scientific
advances the teaching of medical ethics has become more systematised and is now
recognized to be an essential core component of the medical curriculum.
The Ethics Committee is composed of both practicing physicians and prominent
scientifically trained academic teachers of medical ethics.
Committee Members
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Julia Frank MD Assoc Prof Dept of Psychiatry,
George Washington University
-
Haavi Morreim, PhD Professor,
University of Tennessee School of Medicine
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Barbara Schuster,
MD Chair Dept of Internal Medicine Wright State University
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Henry Haddad,
MD Assoc. Professor of Medicine Sherbrooke University, Canada
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Roberta Sonnino MD, FACS, FAAP Assoc.
Dean Creighton University
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James Appleyard MD FRCP,
Past President World Medical Association
All members of the Advisory
Council and other ‘Standing’ Committees of the IAOMC are ‘corresponding’
members.
The members are tasked to review and advise on the development of standards for
medical ethics teaching within the medical curriculum
The Committee meets twice a year at the main meetings of the IAOMC and works
though electronic correspondence and governed by the Associations e-mail voting
by laws.
Comments from interested physicians and other associations of Physicians and
Medical Ethicists are always welcome
To set the scene, a background paper on Medical Professionalism – Being a
Physician has been presented to the IAOMC Council after widespread consultation
and follows. The Committee aims to provide a common basis for more detailed
discussion on the development of the standards expected in medical schools.
The Committee will also generate a platform for a dialogue on the core
curriculum for medical ethics in undergraduate medical education including
opportunities for ‘distance learning’.
The World Medical Association stresses the importance of medical ethics
As an essential part of medical Education
The World Federation for Medical Education has set a Basic Standard for
Undergraduate Medical Education that ‘The Medical School must identify and
incorporate in the curriculum the contributions of the behavioural sciences,
social sciences, medical ethics and medical jurisprudence that ensure effective
communication, clinical decision making and ethical practices’.
Of all the 44 standards required for a medical school to be accredited in the
US, the Deans of US medical schools rank ethical behaviour the highest. The
accrediting standard 21 of the LCME is; “Students must be encouraged to
develop and employ scrupulous ethical principles in caring for patients''
The U.K. General Medical Council’s 1993 ‘Tomorrows Doctors’ stated two
objectives for the medical curriculum
-
to ensure that students
acquire a knowledge and understanding of ethical and legal issues relevant
to the practice of medicine
-
to ensure that the students
develop an ability to understand and analyse ethical problems so as to
enable patients, their families, society and doctors have proper regard to
such problems in reaching decisions
In 1998 the Journal of Medical
Ethics (Ashcroft et al JME 1998 24 188-192) published a ‘consensus’ statement by
teachers of medical ethics in the UK stressing that medical ethics and Law
should be introduced systematically through out the entire clinical curriculum
and each clinical discipline should address the ethical and legal issues of
particular relevance to it. They did not suggest ‘rigid’ guidelines about how
medical ethics should be taught.
Members of the Ethics Committee will bring their own and invite other
experienced teachers experience to share in the discussion about differing
methods of instruction and assessment to achieve our agreed objectives.
James Appleyard MD FRCP.
Chair
Haavi Morreim, PhD.
Secretary
The essence of
Medical Professionalism
Professionalism has been at the
heart of the practice of medicine for over two millennia
Medical practice is by definition a “vocation whose core element is work based
upon the mastery of a complex body of knowledge and skills and whose members
‘profess’ a commitment to competence, integrity, morality, altruism and the
promotion of the public good within their domain.
These commitments form the basis of a social contract or covenant between a
profession and society, which in turn grants the professions the right to
autonomy in practice and the privilege of self regulation.
Professions and their members are accountable to themselves, those they serve
and to society” (Oxford English Dictionary)
Society benefits by having those who control the knowledge and skills for
providing essential services primarily for the good of others rather than
personal gain or political advantage.
Thus, In exchange for the privilege and authority to be responsible for key
aspects of their professional work including the setting of professional
standards, education ,credentialing with a significant influence on the medical
market and their working conditions society demands that professionals maintain
and develop high standards of competence and moral responsibility.
By virtue of their autonomy and authority, physicians may at times be obliged to
direct others in the care of their patients, to advocate for patients' interests
against those of other social constituencies. In modern times, physicians must
respect the wishes of competent patients, but in many instances they may exert
considerable pressure on patients to take actions or accept interventions they
would prefer to forego. The basis for physicians' persuasive power is their
competence, skill and assurance of ethical conduct.
Public awareness of the professions’ ethical standards serves to maintain the
professions’ devotion to medical science and to advocate for health care values
in the context of competing social imperatives.
Historically noteworthy physicians of ancient Hindu, Confucian or Hippocratic
Schools practiced ‘virtue based ethics. From this practice certain ‘codes’ have
explicitly delineated the covenant between society, physicians and their
patients. The code of Hammurabi provided gave detailed advice to practitioners
of medicine, literally carved into stone. The Hippocratic Oath outlines key
principles for medical practice, most importantly the exhortation to place
concern for patient welfare above every competing demand.
After World War 2, World Medical Association’s Declaration of Geneva (1948)
re-affirmed this ‘covenant’ between the world's physicians and all peoples
specifying principles later incorporated into the WMA Document of the Duties and
Responsibilities of Physicians Worldwide.
The Eight Characteristics of a Profession
There are eight characteristics of a Profession. While some may pertain to other
endeavors, a true profession must adhere to all eight. The eight core elements
are :
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Morality and Integrity
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Code of Ethics
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Service
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Altruism
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Complexity of Knowledge
-
Autonomy
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Accountability
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Professional Associations
Present day circumstances
challenge the expression of these values.
For instance with the vast increase in information available on the web, some no
longer acknowledge the value of professional competence, believing that anyone
can find information and follow a protocol – the ultimate in cook book medicine
Others, especially Heath Service Managers feel it is possible to reduce medicine
to its component parts, apply those parts in isolation and save money by
deskilling the process.
The profession continues to exist because people, especially when ill, want
personalized information from a trustworthy source. As Dr Mike Magee has shown,
people still consult doctors for information. They are justifiably uncertain
about the validity of the information on the web and are confused by its
complexity and contradictions.
Patients need their physicians to help them interpret and apply that knowledge
to their own individual circumstances. Providing coherent, well-informed care is
the art of our profession.
Morality and Integrity
A fundamental characteristic of any profession is the expectation that its
individual members and the associations and institutions representing them are
‘moral’ and carry out their activities with integrity
Code of Ethics
Code of ethics from the time of Hippocrates represent the applied morality of
the Profession governing the behaviour of members.
The Hippocratic Oath was written in the language of 2,500 years ago but the
principles underlying it are as valid today as them.
It has been updated by the WMA’s Declaration of Geneva and embraces many core
principles of professional ethics. Even Hippocrates' invocation to Gods in which
we no longer believe, has its modern analog in attention to the spiritual
aspects of medicine, a dimension of professional care that commitment to
rationality has not extinguished.
Service
Professional knowledge must be used in the service of others, individual
patients and society in general
Altruism
The trust placed in the profession and medicine's privileged status are only
justified if we consistently place the interests of individual patients and
society above our own
Knowledge
Professions are given stewardship over their body of knowledge They are
responsible for the integrity of the knowledge base. In medicine, this requires
dedication to scientific evidence and clinical experience. The proper
professional application of knowledge includes responsibility for its expansion
–( promoting research and development) - and for its transmission to future
practitioners –( medical education ). The profession must also apply its
knowledge to the public good in order to improve public health and the health of
nations.
Autonomy
Professions are granted autonomy in order that they may respect the autonomy of
the individual patient, and act in the best interest of both their patients and
society, in the face of competing social priorities.
The Profession's autonomy should be recognised under the broad heading of
‘self-regulation’
General respect for the personal autonomy of both physician and patient creates
trust, ennobles and professionalizes the relationship. Essentially autonomy
demands that individual patients have the right to choose both their physicians
and their treatment.
Authoritarian governments continually undermine this right because of their
concern about the influence the medical profession may exert by independently
advocating for the health needs of individuals and society. In more democratic
societies, medical autonomy is threatened by capitalist values that place
efficiency and the generation and concentration of wealth over sometimes costly,
seemingly irrational or apparently inefficient individual preferences and
practices.
Accountability
Autonomy does not absolve the physician of accountability. Physicians are
accountable personally to their patients and to their profession for adhering to
medicine’s time honoured ethical principles
politically to the public as whole (political) and economically to third party
payers.
Professional Associations
Professional collegiality establishes common goals and encourages all members of
a profession to comply with them.
Independent associations and State sanctioned licensing bodies exist to set and
maintain professional standards, discipline unethical behaviour, and establish.
educational standards. At their best, they are custodians of the medical
professions' conscience
The values of professionalism are expressed in the doctor patient relationship
by seven principles, recognized around the world as essential to ethical
practice. These are
Patient Autonomy
Patients' decisions about their care must be respected. They prevails long as
they are in keeping with ethical practice and appropriate care. Physicians
should empower patients to make informed decisions about their treatment.
Beneficence – Physicians must always aim to do good, look after patients'
best interests and recognize circumstances where conflict of interest may
compromise professional judgment.
Non Malfeasance – Physicians must endeavour to do no harm – ‘primum non
nocere”-- avoiding unnecessary risks with treatments and refusing to take
advantage of the intimacy of the patient physician relationship
Fidelity – Physicians' ‘duty of care’ is the free acceptance of a
commitment to service. This commitment entails being available and responsive
when needed, accepting inconvenience to meet the needs of patients, advocating
the best possible care within the available resources regardless of ability to
pay, seeking active roles in teaching and professional organizations, and
volunteering skills and expertise for the welfare of the community. Medical
professionals, therefore, should be encouraged to participate in professional
organizations, community programs and institutional committees.
This duty also includes a commitment to competence and life long learning. Where
appropriate, a physicians duty may require referring the patient on to those
that have greater competence in a particular area to meet a patients needs.
Truthfulness – Physicians must ensure that patients are completely and
honestly informed before consenting to treatment and after treatment has
started. They must not mislead patients when medical errors have occurred. It
implies keeping one’s word and meeting commitments. It also requires the
recognition of possible conflicts of interest and avoidance of relationships
that allow personal gain to supersede the best interest of the profession.
Confidentiality – Confidentiality is one of the foundations on which the
trust between patient and physician is based. It may only be breached where
there is a real and imminent threat to the patient or to others if this
confidentiality were maintained
Justice – Physicians must treat all people equally according to their
need. Physicians should work actively to eliminate discrimination based on race,
gender socio-economic status, religion or ethnicity and promote justice in a
health system based on individual and community clinical need. This effort
demands a commitment to reduce barriers to access to medical care based on
education, geography, finances and legal structures.
These ‘principles’ need to be ‘internalized’ and become a physician's
professional conscience, a compass guiding the journey through the complex
scientific and medico social scenes.
‘ The physician's individual conscience provides the foundation of the ‘trust’
given by the patient to the physician. The profession's collective conscience
shapes the essential wider ‘contract’ between the medical profession and society
in general.
The ‘Art’ of Medicine is the application of our knowledge and skills within this
framework of our collective conscience to make judgments in the best interests
of individuals seeking our help.
At times it is enormously difficult to balance these principles as they may
internally conflict within the individual circumstances in which the physician
finds him or herself. It is very rewarding to get the judgment ‘right’ for the
individual patient but equally devastating for the physician if the judgment
proves to be wrong . Physicians need to be called to account by their patients
and their peers to justify their actions within a delegated professional
regulatory framework which respects the difficulty and contradictions of
professionalism. Imposition of a political, bureaucratic or business ethic would
distort this accountability and work against the best interests of the patient.
Industries as well as professions acknowledge the importance of appropriately
structured internal regulation. Any external regulation should re-enforce good
practice rather than impose inappropriate unprofessional standards.
Overregulation leads to poor professional morale when it conflicts with
physicians' duties to their patients and diminishes research and innovation. An
alienated profession spends much time attempting to circumvent regulations that
interfere with, rather than promote, best practices.
Except in the case of research, reliance on strict imposed protocols outside may
compromise independent professional judgment . Protocols are not necessarily
designed to put the individual patient's interests first. Clinical guidelines
may be helpful but they usually are ‘consensus’ documents which may not provide
sufficient evidence to meet the needs an individual patient.
On the other hand, physicians always need to justify what action they take with
their patients to the patients themselves and be able to do so to their peers
through audit and peer reviews.
In his comparative study of relationship based Health Care in the US, United
Kingdom, Canada, Germany South Africa and Japan Dr Mike Magee concluded that the
patient physician relationship is a critical underpinning of stable societies
second only in importance to family relationships in all the countries studied.
The emancipation, empowerment and active engagement of patients as ‘health
consumers has reinforced the high expectation in the humanistic, access to heath
care and advocacy dimensions measured in the study. Physicians ability to align
with and aspire to meet these expectations in support of patients continued
evolution (as their advocates) will define the physicians future effectiveness
as a health care leader. The design of different health care systems, including
methods of financing, demonstrated significant difference in the positioning of
patients and physicians as partners or adversaries’ within each system. This
trend has already bean recognized based on many reports related to the
experience and perceptions of physicians (12) It reinforces the need to instill
the concept of professionalism at the start of medical training.
Instilling Ethics in Medical Education
All medical decisions need to be made on a case by case basis within the overall
medical ethical framework.
The World Medical Association has exhorted all medicals schools in the world to
ensure the teaching of medical ethics within their curricula . Of all the 44
standards required by the American Boards for a medical school to be accredited
in the US, the Deans of US medical schools rank ethical behaviour the highest.
Undergraduate Medical Curricula have been developed to ensure that ethical
issues are always reviewed in medical decision making.
The Arnold Gold Foundation of Columbia University in New York recognized the
difficulties of fostering the medical conscience and initiated in August, 1993,
the White Coat Ceremony in which medical students publicly committed themselves
to the professions ethics. . The ceremony also reinforces the professional
culture amongst the teaching faculty and administration of the School. Now 90%
of US medical schools have introduced the ceremony, and it is spreading into
Europe.
The Arnold P. Gold Foundation’s White Coat Ceremony welcomes entering medical
students and helps establish a psychological contract for the practice of
medicine. The event emphasizes the importance of compassionate care for the
patient as well as scientific proficiency and includes several elements:
-
Recitation or discussion of
an oath (such as the Hippocratic Oath) which represents public
acknowledgment by students of the responsibilities of the profession and
their willingness to assume such obligations in the presence of family,
friends, and faculty
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Cloaking of students in
their first white coats
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An address by a eminent
physician role model
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Celebration at a reception
with students' invited guests
At the ceremony, students are
welcomed by their deans, the president of the hospital, or other respected
leaders who represent the values of the school and the profession the students
are about to enter. The cloaking with the white coat—one of the mantles of the
medical profession—is a hands-on experience that underscores the bonding
process. It is personally placed on each student's shoulders by individuals who
believe in the students' ability to carry on the noble tradition of doctoring.
It is a personally delivered gift of faith, confidence and compassion.
An example of such an Oath of Commitment during a ‘White Coat Ceremony’ is taken
at the University of Kansas School of Medicine:-
As I begin my training as a physician at the University of Kansas School of
Medicine I pledge the following:
-
I promise to earn the trust
and respect of my teachers and to return them in kind, for only through
mutual trust and respect can we learn the skills required of a physician.
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I will accept
responsibility for those medical duties that I feel prepared for;
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I will hold back when I am
not prepared; and I will seek the experience that I need to prepare myself.
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I will strive to preserve
the dignity, the humanity and the privacy of all my patients, and through my
openness and kindness I will seek to earn their trust in turn.
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I will treat my patients
and my colleagues as my fellow beings and never discriminate against them
for their differences; and I will ask that they do the same for me.
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I will value the knowledge,
and the wisdom of the physicians who have preceded me;
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I will add to this legacy
what I am able, and I will pass it on to those who come after me. As my
skills and my knowledge grow so too will my awareness of my limitations and
my errors;
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I will strive to recognize
and understand my weaknesses; And I promise never to put an end to my
studying and learning that I might improve myself every day of my practice,
in all the years to come.
The Association of American
Medical Colleges have published a ‘Compact between Teachers and Learners of
Medicine based on three guiding principles
The Duty of medical educators to inculcate the values and attitudes required for
preserving the medical professions ‘social contract across generations
The need for integrity and role models who epitomize authentic professional
values and attitudes
Respect as a fundamental part of the ethic of medicine for every individual
Some medical schools have found it helpful to link these concepts with the
students ‘code of conduct’ and the disciplinary procedures required to
re-enforce them
This is important because the social milieu or ‘informal’ curriculum of a
medical school has a great influence on the values and professional identities
acquired by its students
The University of Chicago, USA emphasizes six principles (Their six Cs) in
teaching clinical ethics namely
Clinically based – for relevance
Cases (real) – narratives for fidelity and effectiveness
Continuous – the reinforcement of learning outcome
Coordinated – an integrated approach to all issues pertaining to the ‘case’
Clean (i.e. simple case) for clearer take home messages and better impact and
Clinicians as Instructors – for source credibility and all round case discussion
The Guy’s, Kings an St Thomas Hospital’s problem based undergraduate medical
curriculum ensures that ethical aspects were always considered during discussion
of each clinical problem which reinforces to the student the ethical structure
within which medicine should be practiced
During their preclinical courses, students are introduced to medical decision
making. As they progress, some clinical tasks delegated to them, within the
ethical framework described above. They come to understand through their
teachers , mentors and role models that the unifying umbrella of medical ethics
does not mean uniformity. It is the very diversity of the clinical problems
faced by their patients and the issues surrounding them that make medicine not
only such a fascinating and interesting career. but a vocation where their
individual conscience as a physician is key to the application of their
knowledge and skills in the best interests of their patients
At Graduation publicly professing of the same ethical principles helps to
reinforce the importance of maintaining and developing the ethical standards
expected of members of the medical profession.
These principles are embedded in the WMA’s Declaration of Geneva and some
Medical Schools use these words as an updated version of the Hippocratic Oath.
Declaration of Geneva
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At the time of being
admitted as a member of the medical profession:-
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I solemnly pledge myself to
consecrate my life to the service of humanity
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I will give to my teachers
the respect and gratitude which is their due
-
I will practice my
profession with conscience and dignity
-
The Health of my patient
will be my first consideration
-
I will respect the secrets
which are confided in me, even after the patient has died
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I will maintain by all the
means in my power, the honour and the noble traditions of the medical
profession
-
My colleagues will be my
sisters and brothers
Medical Graduates surveyed in
the British Medical Association’s 1995 Cohort study placed Competence, Caring
and Compassion as the most important three core professional values with
integrity 5th. In 2004 with nine years experience as a physician the leading
three values became Competence, Integrity and caring.
In our process of Accrediting Medical Schools we will need to assess the
cultural environment within which medicine is being studied and re-enforce and
develop the current standards expected by the WFME and LCME
(Further comment and advice on this will be welcomed)
References.
-
The Short Oxford English
Dictionary 3rd Edition 1979.
-
‘Medical Professionalism in
the New Millennium: a physicians charter’ Medical Professionalism Project,
Lancet 359 520-522, 2002
-
‘Core Values of the Medical
Profession in the 21st Century’
British Medical Association Conference 1994
-
‘Professionalism in
Medicine’ Canadian Medical Association 2001
-
‘International Code of
Medical Ethics’, World Medical Association
Pilanesberg, South Africa 2006
-
On the importance and
validity of Medical Accreditation Standards
Kassebaum DG Cutler ER Engle RH Academic Medicine 74 553- 563 1998
-
Ethical Practice of
Medicine – Education and training
‘Medical Ethics Today’ BMA/BMJ 2004
-
Compact between Teachers
and Learners of Medicine
Association of American Medical Colleges 2006
-
Medical Professionalism in
the New Millennium – A Physical Charter
ABIM and ACP Foundations and The European Federation of Internal Medicine
-
‘Medical Graduates’ BMA
Cohort Study , Health Policy and Economic Research Unit , BMA London WC1H
9JP 2005
-
Silver HK Medical Students
and Medical School JAMA, 247(3) 309-310 1982
-
The “Dean’s Advisory Group
on Professionalism” The University of Kansas School of Medicine, Roberta E
Sonnino MD (Chair) July 2000
-
“ Relationship Based Health
Care – a Comparative Study of patient and Physicians perceptions worldwide”
.Mike Magee MD, World Medical Association Helsinki 2003
-
‘Professionalism in
Medicine’ K.R Sethuraman MD Regional Health Forum 10 1 2006
-
‘Doctors in Society –
Medical Professionalism in a changing world’
Report of a Working Party Royal College of Physicians 2005
-
The meaning of
Professionalism in Medicine’ SR Benitar SAMJ 87 427- 31 1997
Declaration of Geneva
-
At the time of being
admitted as a member of the medical profession:-
-
I solemnly pledge myself to
consecrate my life to the service of humanity
-
I will give to my teachers
the respect and gratitude which is their due
-
I will practice my
profession with conscience and dignity
Declaration of Geneva
-
The Health of my patient
will be my first consideration
-
I will respect the secrets
which are confided in me, even after the patient has died
-
I will maintain by all the
means in my power, the honour and the noble traditions of the medical
profession
-
My colleagues will be my
sisters and brothers
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I will not permit
considerations of age, disease or disability, creed, ethnic origin, gender,
nationality, political affiliation, race, sexual orientation, or social
standing to intervene between my duty and my patient
-
I will maintain the utmost
respect for human life from its beginning even under threat and I will not
use my knowledge contrary to the laws of humanity
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I make these promises
solemnly, freely and upon my honour
Declaration of Helsinki 1964
In Biomedical Research introduced concepts of:-
-
Potential benefits must
outweigh hazards
-
The need for informed
consent
-
The need for research
protocols to be scrutinized by ‘Ethics Committees
-
A distinction between
Scientific and Clinical Research
Declaration of Tokyo 1975
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The doctor shall not
countenance, condone or participate in the practice of torture or other
forms of cruel, inhuman or degrading procedures, whatever the offense of
which the victim of such procedures is suspected, accused or guilty, and
whatever the victims beliefs or motives, and in all situations, including
armed conflict and civil strife
Declaration Of Ottawa
The Right to privacy - entitles
people to exercise control over the use and disclosure of information about them
as individuals
The privacy of the patients personal health information is secures by the
physician’s duty of confidentiality
Confidentiality is at the heart
of medical practice and is essential for maintaining trust and the integrity of
the patient-physicians relationship
Knowing that their privacy will be respected gives patients the freedom to share
sensitive personal information with their physician
Principles
Access to information by patients
De-identified data
Confidentiality
Data integrity
Patients’ consent
Documentation
Authorization and use of data
Management procedures
Access
Patients have the right to know what information physicians hold about them,
including information held on data bases.
Patients should have the right to decide that information about their health in
a data base be deleted
Confidentiality
All physicians are individually responsible and accountable for the
confidentiality of the personal health information they hold. Physicians must
also be satisfied that there are appropriate arrangements for the security of
personal health information when it is stored, sent, or received, including
electronically.
Confidentiality
Medically qualified person (s) should be appointed to act as a guardian of a
health data base, to have the responsibility for monitoring and ensuring
compliance with the principles of confidentiality and security
Patients consent
Patients should be informed if their health information is to be stored on a
database and of the purposes for which their information may be used.
Patients consent is needed if the inclusion of their information on a data base
involves disclosure to a third party or would permit access by people other than
those involved in the patients care, unless there are exceptional circumstances
as described in paragraph 11
Authorization and use of data
Authorization from the guardian of the health data base is needed before
information held on data bases may be accessed by third parties. Procedures for
granting authorization must comply with recognized codes of confidentiality.
Approval from a specially appointed ethical review committee must be obtained
for all research using patient data, including new research not envisaged at the
time the data was collected.
Data accessed must be used only for the purposes for which authorization has
been given
“We hold these truths to be self evident, that all men were created equal; that
they are endowed by their Creator with certain unalienable rights; that among
these are life, liberty and the pursuit of happiness.” Thomas Jefferson
“Care more for the individual patient than for the special feature of the
disease.” Sir William Osler
“Wherever the Art of Medicine is loved, there is also the love of Humanity.
Hippocrates 400 BC
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