Organisational culture

and individual ethics

Associate Professor Justin Oakley,

Monash Bioethics Centre, Monash University

2

Outline

1. Elder abuse in residential aged care as an assault on residents’ dignity

2. The role of aged care practitioners

3. Practical wisdom, and hitting the targets of medical virtues.

4. Creating institutional environments conducive to phronesis and role virtues in

medicine.

5. Creating regulatory environments conducive to medical virtue.

3

What is elder abuse?

Elder abuse has been defined as “‘a single, or repeated act, or lack of

appropriate action, occurring within any relationship where there is an

expectation of trust which causes harm or distress to an older person’. It can be

of various forms: physical, psychological/ emotional, sexual, financial or simply

reflect intentional or unintentional neglect.” World Health Organization, Toronto

Declaration on the Global Prevention of Elder Abuse (2002), p. 2.

Elder abuse is an assault on the dignity of the older person.

4

The concept of dignity

Objective dimensions of dignity

All rational agents have dignity considered as a rational agent, as all rational

agents are ‘beyond price’ (cannot be exchanged for other things)(Kant)

Subjective dimensions of dignity

Respecting the person in light of their particular ends (Kant).

See: ‘Dignity of risk’ in residential aged care: the freedom to engage in activities

that the resident particularly values but which may involve risks to them.

(Compare the ‘crippling indignity’ of a safety-first approach in aged care.)

5

Factors in elder abuse

Those who engage in elder abuse are not usually thoroughly bad people, with

malevolent motives or intentions.

Poor organisational culture can be a contributing factor: eg. where ethical

practitioner behaviour is not supported or appropriately recognised, and bias-

awareness is not encouraged.

Practitioners are sometimes ignorant of how their good motives/intentions

may impact on residents. Practitioners can be influenced by various cognitive

biases, such as stereotyping of others, and blind spots about their own

behaviour.

6

Virtues and practical intelligence

Professional guidelines are important, and help to ameliorate unethical

behaviour by RACS practitioners, but guidelines are not enough.

Attention to the professional character-traits of RACS practitioners is

also important

However, an emphasis on individual practitioner’s character-traits is

often interpreted as suggesting that the responsibility for acting

virtuously is all down to you as an individual.

Organisational/institutional factors also have a role to play in promoting

virtuous behaviour by RACS practitioners.

The RACS regulatory environment is also an important background

factor.

7

Practical wisdom, and hitting the targets of medical virtues

American Medical Association, first Code of

Medical Ethics (1847):

“the physician should be the minister of hope

and comfort to the sick; that, by such cordials

to the drooping spirit, he may smooth the bed

of death, revive expiring life, and counteract

the depressing influence of those maladies

which often disturb the tranquility of the most

resigned in their last moments”.

8

Phronesis

Phronesis can be understood

as an overarching normative

disposition which regulates the

more specific dispositions

involved in particular virtues.

Avoiding:

- Moral ineptitude

- Unmeticulousness

Dan Russell: phronesis, or practical

intelligence, is involved in all virtues.

9

Moral ineptitude

Moral ineptitude is shown by someone

who may be well-intentioned, but who

is lacking in sufficient practical know-

how and perhaps also emotional

intelligence to succeed in bringing

about the good that they intend to

bring about.

10

Unmeticulousness

Unmeticulous agents possess the practical

know-how and what emotional intelligence

may be necessary for their good intentions to

have a reasonable chance of succeeding, but

their efforts may nevertheless fail because

they are ill-prepared with strategies to

circumvent common decision-making biases

and similar countervailing factors that can

deflect their interventions at the penultimate

stage.

11

Individual vs. policymaker/regulator responsibilities

for creating virtue-conducive environments

Individual responsibilities: Learning how to avoid moral

ineptitude and failures of meticulousness are crucial ways in

which practical wisdom can assist medical role virtues to hit

their respective targets.

Policymaker and regulator responsibilities: Institutional and

regulatory interventions to help remove environments hostile to

phronesis and to professional role virtues; and to help create

institutional and regulatory environments conducive to the

development and exercise of practical wisdom and

professional role virtues.

12

Two ways policymakers and regulators can help

create virtue-conducive environments

1. Creating institutional environments that help practitioners identify common

biases in clinical practice, and to prevent such biases diverting medical role

virtues from their targets.

2. Consider whether a policy or law puts doctors in a position whereby acting

from the relevant role virtues becomes exceedingly difficult, and so threatens

to undermine therapeutic doctor-patient relationships themselves.

13

Cognitive biases prevalent in medical practice

Availability bias: eg. A doctor gives undue weight to similarities that the

patient’s symptoms have with conditions which that doctor sees commonly (such

as misdiagnosing as viral pneumonia the less frequently seen condition of

aspirin toxicity).

Confirmation bias: eg. A doctor ‘cherry-picks’ symptoms to confirm a diagnosis

that they have already decided on.

(See Groopman 2007; Blumenthal-Barby & Krieger 2015; Saposnik 2016, Scott

2017)

14

Cognitive biases in doctors’ antibiotic prescribing behaviour

Cognitive biases can lead a doctor to give insufficient weight to their own contributions to

antimicrobial resistance. A recent survey of 889 US physicians indicated that they often lacked

insight into the broader harms of their own antibiotic prescribing decisions.

Most of the respondents expressed concern about the problem of antimicrobial resistance.

However, the researchers found that: “While 62% of respondents agreed that other doctors

overprescribe antibiotics, only 13% agreed that they themselves overprescribe antibiotics”.

The researchers concluded that “While most respondents agreed that other doctors

overprescribe antibiotics, a much smaller proportion…felt that they themselves overprescribe”

(Abbo et al., 2011, pp. 715-716).

This significant underestimation by physicians of the contribution that their own antibiotic

prescribing decisions are likely having on the broader problems of antimicrobial resistance can

be characterised as an example of confirmation bias, where an agent interprets information in a

way that confirms a view that they already hold, regardless of whether this information actually

supports or undermines that view.

15

Creating institutionalenvironments conducive to phronesis and role virtues in medicine

1

6

17

Addressing cognitive biases in clinical practice

The UK Behavioural Insights Team successfully reduced the over-prescription of

antibiotics by sending GPs with relatively high rates of antibiotic prescription a

letter stating that “80% of practices in your local area prescribe fewer antibiotics

per head than yours” (Hallsworth 2016; Halpern 2015).

The establishment of a national register of serious events (injuries and

preventable deaths)(Ibrahim, Bugeja, et al 2017) could be used to provide

practitioners with a broader context for comparing any such events at their own

aged care facility.

18

Swiss Cheese Model (James Reason)

19

The ‘hidden curriculum’ in medicine

Poor role models are a strong

countervailing influence on medical

graduates acting on the ethical

principles and dispositions they

learn in medical school.

20

Creating regulatory environments for medical virtues

Policymakers should consider

whether a policy or law puts makes

acting from the relevant role virtues

exceedingly difficult, and so threatens

to undermine therapeutic doctor-

patient relationships themselves.

Motives: What a doctor acts out of in

deciding/acting.

Governing conditions: Preconditions

or provisos a doctor applies to

commencing or terminating a doctor-

patient relationship with a particular

patient.

21

Incentives to provide futile interventions to dying patients

“Generous fee-for-service payments give

physicians incentives to – even in the final

weeks of life – provide high-intensity, high-

cost services, consult multiple subspecialties,

order tests and procedures, and hospitalize

patients. And because referring patients to

hospice reduces the income of some other

providers, the fee-for-service system

discourages timely referrals to hospice”.

23

References

Lilian Abbo et al., ‘Faculty and Resident Physicians’ Attitudes, Perceptions, and Knowledge about Antimicrobial Use and Resistance’, Infection Control and

Hospital Epidemiology 32, no. 7, July 2011, pp. 714-718, p. 715.

JS Blumenthal-Barby and H Krieger, ‘Cognitive Biases and Heuristics in Medical Decision-Making: A Critical Review’, Medical Decision Making 35, no. 4, 2015,

pp. 539-557.

Atul Gawande, The Checklist Manifesto, London: Profile Books, 2010.

Michael Hallsworth, et al., ‘Provision of Social Norm Feedback to High Prescribers of Antibiotics in General Practice: A Pragmatic National Randomised Controlled

Trial’, The Lancet 387, no. 10029, 23 April 2016, pp. 1743-1752.

David Halpern, Inside the Nudge Unit, London: WH Allen, 2015.

Joseph E Ibrahim, Lyndal Bugeja, Melissa Willoughby, Marde Bevan, Chebiwot Kipsaina, Carmel Young, Tony Pham, and David L Ranson, ‘Premature deaths of

nursing home residents: an epidemiological analysis’, Medical Journal of Australia 206, no. 10, 2017, pp. 442-447.

Immanuel Kant, Foundations of the Metaphysics of Morals (trans. L.W. Beck), Indianapolis, Bobbs-Merrill, 1959.

Justin Oakley, ‘Creating regulatory environments for practical wisdom and role virtues in medical practice’ in David Carr (ed.), Cultivating Moral Character and

Virtue in Professional Practice, London, Routledge, 2018, pp. 83-95.

Justin Oakley, ‘Toward an empirically informed approach to medical virtues’, in Nancy E. Snow (ed.), The Oxford Handbook of Virtue, Oxford, Oxford University

Press, 2018, pp. 571-590.

Justin Oakley, ‘Practitioner courage and ethical health care environments’, Hastings Center Report 45, no. 3, May-June 2015, pp. 40-42.

Justin Oakley and Dean Cocking, Virtue Ethics and Professional Roles, Cambridge: Cambridge University Press, 2001.

Daniel C. Russell, ‘What Virtue Ethics can Learn from Utilitarianism’, in Ben Eggleston and Dale E. Miller (eds.) The Cambridge Companion to Utilitarianism,

Cambridge: Cambridge University Press, 2015.

Daniel C. Russell, Practical Intelligence and the Virtues, New York, Oxford University Press, 2009.

G Saposnik, D. Redelmeier, CC Ruff, and PN Tobler, ‘Cognitive biases associated with medical decisions: A systematic review’, BMC Medical Informatics and

Decision Making 16, 138, 2016, pp. 1-14.

IA Scott, J Soon, AG Elshaug, and R Lindner, ‘Countering cognitive biases in minimizing low-value care’, Medical Journal of Australia 206, no. 9, 15 May 2017, pp.

407-411.

Nancy E. Snow, Virtue as Social Intelligence: An Empirically Grounded Theory, New York: Routledge, 2010.

Christine Swanton, Virtue Ethics: A Pluralistic View. Oxford: Oxford University Press, 2003.