SOHL Advancement to Fellow Study Sessions:

Professionalism & Ethics

Overview

1. Professional codes of ethical behavior

2. Patients’ rights and responsibilities

3. Ethics committee’s roles, structure & functions

4. Cultural and spiritual diversity

5. Conflict of interest situations

Overview

6. Professional norms and behaviors

7. Consequences of unethical actions

8. Ethical implications of human-subject research

Professional Codes of Ethical Behavior

• Trade groups, from big to small publish principles & guidelines – Can serve as leverage to change local practice– Disclosure of physician consulting, ownership and

financial relationships with vendors– Limitations on drug company freebies

• AMA’s Principles of Medical Ethics• ANA’s Code for Nurses• Even Enron had core values• “All ethics is local”

ACHE Code of Ethics: Six Domains1. Responsibilities to the Profession of Healthcare Management

– Avoid the improper exploitation of professional relationships for personal gain

– Disclose financial and other conflicts of interest

2. Responsibilities to your Organization– When resources limited, ensure the resource allocation process

considers ethical ramifications– Conduct both competitive and cooperative activities in ways that

improve community healthcare services

ACHE Code of Ethics: Six Domains

3. Responsibilities to Patients Served – Institute safeguards to prevent discriminatory

organizational practices– Work to ensure that there is a process in place to

facilitate the resolution of conflicts that may arise when values of patients and their families differ from those of employees and physicians

– Demonstrate zero tolerance for any abuse of power that compromises patients or others served

ACHE Code of Ethics: Six Domains4. Responsibilities to Employees

– A work environment that discourages harassment or discrimination on the basis of race, ethnicity, creed, gender, sexual orientation, age, or disability

– Establish grievance & appeals mechanisms

5. Responsibilities to the Community & Society– Work to support access for all people– Participate in public dialogue on policy issues

6. Responsibilities to Report Violations of the Code

Hallmarks of Organizational Ethics

• “The tone at the top”– standards promoted & broadcast

• Staff level education• Monitoring program• Voluntary reporting & protection of

whistleblowers (non-retaliation provisions)• Prompt & equitable enforcement

Cornerstone of Patient Rights: Autonomy• TJC Standard: The hospital respects the

patient's right to participate in decisions about his or her care, treatment, and services

• Includes the right to know about medical errors• “This right is not to be construed as a

mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate”

Autonomy Begets Informed Consent & Informed Refusal Rights• The right to receive information in a manner the

patient understands• Patient's right to give or withhold informed

consent• Decisions about care, treatment, and services

received at the end of life• Organ donation• Prisoners & criminals rights

Limits on Patient’s Right of Autonomy

• Emergencies & minors• Emergencies & lack of decisional capacity• Danger to self or others• Overdoses

Advanced Directives & The Right to Die• The existence or lack of an advance directive

does not determine the patient’s right to access care, treatment, and services

• Palliative Care• Diversity/Inclusion Issues

Ethics Committees

• Roles: education, policy review & case consultation

• Structure: interdisciplinary Committee of Medical Staff, core group of on-call consultants

• Case Review– May involve ethical ambiguity & perplexity– Disagreement between care providers or between

providers and patients/families– withholding or withdrawal of life-sustaining treatment

not adequately addressed in policies

Ethics Committee Training

• Active bedside consultants need learned skills

• Legal & Ethical background

• Ability to find actionable solutions

Conflict of Interest

• Disclosure of private economic interests (investment, payment stream, consulting)

• Disqualification from participating in organizational decisions in which they have a personal financial interest

• Prohibition of certain “payment for referral” arrangements

• Conflict of interest codes often are very specific & tier limits by the categories of position titles

Professional Norms & Behaviors

• “Culture eats strategy for lunch”• What is culture? What they do when you’re not

there• Annals of Internal Medicine 2007, Campbell,

Institute for Health Policy– Physicians agreed with standards of professional

behavior promulgated by professional societies. Reported behavior, however, did not always conform to those norms.

Consequences

• “All men are created equal, but some are more equal than others”

• Question: Does the organization hold the big admitters to the same standard as your nurses?

• The challenge of equal justice in healthcare:– Privacy violations– Disruptive behavior

Ethical Implications of Human-Subject Research• The role of the IRB

– Prospective review of study design– Informed Consent– Confidentiality– Review of adverse events

• Office for Human Research Protections (OHRP)

Thank you

Questions?