Ethics and Professionalism

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Ethics and Professionalism

Clinical Fundamentals
Author Credentials 

Susan McCammon, MD
Associate Professor and Vice Chair and Clinical Ethics Consultant
Department of Otolaryngology
University of Texas Medical Branch
Galveston, TX

Andrew G. Shuman, MD
Assistant Professor and Director of Clinical Ethics
Department of Otolaryngology-Head and Neck Surgery
University of Michigan Health System
Ann Arbor, MI

Module Summary

The role of ethics in a surgical subspecialty comprises clinical ethics, professional or organizational ethics, and bioethics. Clinical ethics is a pragmatic field of practice that informs medical decision making at the bedside. Professional ethics guides behavior among colleagues and with patients and society. Organizational ethics refers to the principles and values that guide the actions of organizations when they act as moral agents. Bioethics is an academic field of inquiry that uses the tools of philosophy, the humanities and the social sciences to analyze critically controversies arising in the health sciences.This includes theoretical research as well as research ethics.

In terms of organizational ethics, the AAO-HNS/F has a “Code of Ethics” which articulates our highest values. It serves as both an aspirational statement as well as a baseline expectation for member behavior. On a more detailed level, the AAO-HNS/F has endorsed a Code for Interactions with Companies which describes some of the ways in which we as an organization manage coincidence of interests and demonstrate the integrity of our research and educational products.

In terms of clinical and research ethics, the role of the society is primarily educational. Topics such as informed consent, surrogate decision making, allocation of resources and end of life care have been addressed in scientific sessions and panel discussions at the annual meeting as well as in durable educational materials available on AcademyU. This enables clinicians and researchers to share information and skills that improve our delivery of ethical care and performance of ethical research.

In terms of bioethics, some members of our society engage in research addressing philosophical principles such as autonomy, political issues such as the social determinants of health, and economic concerns with emerging technologies.

There are opportunities for development in each of these areas of ethics in the AAO-HNS/F and the Ethics Committee encourages member engagement.

Module Learning Objectives 
  1. Demonstrate proficiency in clinical, professional and research ethics.
Philosophical Basis for Medical Ethics

Learning Objectives

  1. Define autonomy, paternalism, shared decision making, directive counsel, abandonment, personhood.
  2. Describe and critique different ethical frameworks including: Principlism v. Casuistry, Virtue Ethics, Deontology (duty-based ethics, fiduciary responsibility), Consequentialism, narrative inquiry, justice theory.
     

References

  1. Lo B. Resolving Ethical Dilemmas: A Guide for Clinicians. 5th ed. Philadelphia, PA: LWW Publishers. 2013.
  2. Johnsen, AR, Siegler, M, Winslade, WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 6th ed. New York, NY: McGraw-Hill. 2006.
  3. Aulisio, MP, Arnold, RM, Youngner, SJ. Ethics Consultation: From Theory to Practice. Baltimore, MD: Johns Hopkins University Press. 2003.
  4. Beauchamp, TL, Childress, JF. 2001. Principles of Biomedical Ethics. 5th ed. New York, NY: Oxford University Press. 2001.
Clinical Ethics

Learning Objectives

  1. Contrast the terms competence and capacity, and list the elements required to determine medical decision-making capacity.
  2. Understand the importance of making wishes known and the possibility of loss of capacity.
  3. Recognize the ethical and legal guidelines governing privacy and confidentiality including HIPAA, the Hippocratic Oath, and institutional regulation thereof.
  4. Demonstrate the ability to introduce advance care planning in the outpatient setting, which includes differentiating various forms of advance directive documents, e.g. directive to physicians, medical power of attorney, DNAR (in-patient v. out-patient); describing how to implement an advance directive in clinical care; and knowing the legal ramifications of advance care documentation.
  5. Differentiate the levels of surrogate decision making including advance directive, legal guardian, medical (durable) power of attorney, health care agent, next of kin, surrogate of highest priority, best interest standard (as compared to patient preference and substituted judgment).
  6. Describe the approach to the unbefriended adult.
  7. Prepare for and effectively share the delivery of difficult information (breaking bad news), active listening, engagement.
  8. Interpret patient-centric, goal-oriented risks and benefits for individual patient decisions.
  9. Define the doctrine of double effect and explain how it is applied in the contexts of pain management and proportional palliative sedation. 
  10. Lead conversations that mitigate conflicting perspectives of potentially non-beneficial or futile interventions.
  11. Employ basic and advanced techniques of facilitating medical decision making including motivational interviewing; shared decision making; risk stratification; outcomes and discharge destination prognostication.
  12. Use evidence-based decision-making for airway management.
  13. Contrast palliative medicine and hospice care.
  14. Describe the evolving role of artificial nutrition and hydration by distinguishing eating/drinking, from artificial nutrition/hydration from a legal, philosophical, and ethical perspective.
  15. Appraise critically the arguments for and against physician aid in dying.
  16. Understand the rationale and role of clinical ethics consultants.
     

References

  1. Grady, C. Enduring and Emerging Challenges of Informed Consent. N Engl J Med. 2015;372(9):855-862.
  2. Appelbaum, PS. Clinical Practice. Assessment of Patients’ Competence to Consent to Treatment. N Engl J Med. 2007;357:1824-40.
  3. AMA Code of Ethics
  4. Fins JJ. A Palliative Ethic of Care: Clinical Wisdom at Life’s End.Burlington, MA. Jones and Bartlett Publishers. 2006.
  5. Sulmasy, DP, Snyder, L. Substituted Interests and Best Judgments: An Integrated Model of Surrogate Decision Making. JAMA. 2010;304(17):1946-1947.
  6. Diekema, DS. Revisiting the Best Interest Standard: Uses and Misuses. Journal of Clinical Ethics. 2011;22(2):128-33.
  7. Eves, MM, Esplin, BS. "She Just Doesn’t Know Him Like We Do”: Illuminating Complexities in Surrogate Decision-Making. J Clin Ethics. 2015 Winter;26(4):350-4.
  8. White DB, Curtis JR, Wolf LE, Prendergast TJ, Taichman DB, Kuniyoshi G, et al.  Life Support for Patients without a Surrogate Decision Maker: Who Decides? Ann Intern Med. 2007 Jul 3;147(1):34-40.
  9. Pope, TM. Making Medical Decisions for Patients without Surrogates. N Engl J Med. 2007 Sep 10;167(16):1711-5.
  10. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES: A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-11.
  11. Coulehan, JL, Platt, FW, Egener, B, Frankel, Lin, CT, Lown, B, Salazar, WH. “Let Me See If I Have This Right . . . ”: Words That Help Build Empathy. Ann Intern Med. 2001 Aug 7;135(3):221-7.
  12. Back, A.L., Arnold, R.M. Dealing with Conflict in Caring for the Seriously Ill, “It Was Just Out of the Question. JAMA. 2005 Mar 16;293(11):1374-81.
  13. Edelstein, LM, et al. Communication and Conflict Management Training for Clinical Bioethics Committees. HEC Forum. 2009 Dec;21(4):341-9.
  14. Springer, E. Communicating Moral Concern: An Ethics of Critical Responsiveness. Cambridge, MA: MIT Press. 2013.
  15. Kon et al. Defining Futile and Potentially Inappropriate Interventions: A Policy Statement From the Society of Critical Care Medicine Ethics Committee. Crit Care Med. 2016 Sep;44(9):1769-74.
  16. Bosslet, GT, Pope, TM, Rubenfeld, GD, Lo, B, Truog, RD, White, DB. et al. An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units. Am J Respir Crit Care Med. 2015 Jun 1;191(11):1318-30. 
  17. Brett, Allan S., and Paul Jersild. "Inappropriate" treatment near the end of life: Conflict between religious convictions and clinical judgment. Arch Intern Med. 2003 Jul 28;163(14):1645-9.
  18. Dubler, NN, Liebman, CB. Bioethics Mediation: A Guide to Shaping Shared Solutions. New York, NY: United Hospital Fund of New York.
  19. Venkat A. The threshold moment: ethical tensions surrounding decision making on tracheostomy for patients in the intensive care unit. J Clin Ethics. 2013;24(2):135-43.
  20. Cassell EJ. The nature of suffering and the goals of medicine. NEJM. 1982;306(11):639-45.
  21. Brody H, Hermer LD, Scott LD, Grumbles LL, Kutac JE, McCammon SD. Artificial nutrition and hydration: the evolution of ethics, evidence, and policy. J Gen Intern Med. 2011 Sep;26(9):1053-8.
  22. Snyder Sulmasy L et al. Ethics, Professionalism and Human Rights Committee of the American College of Physicians. Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper. Ann Intern Med. 2017;167(8):576-578.
  23. American Society of Bioethics and Humanities. Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants. 
  24. American Society of Bioethics and Humanities. Core Competencies for Healthcare Ethics Consultation. 2011. 2nd ed. Glenview, IL: Core Competencies Task Force.
Professional Ethics

Learning Objectives

  1. Explore the necessary traits and virtues of a physician, e.g. tolerance, moral courage, self-reflection, empathy, truth telling, integrity, humility, cultural competence, etc.
  2. Choose appropriate methods of error disclosure and understand the evidence and ethics thereof.
  3. Recommend resources for the impaired physician and reporting requirements.
  4. Manage billing and compliance and appreciate ethical components considering legal and regulatory precedent.
  5. Describe conflicts of interest and commitment.
  6. Discuss the role of industry in the development and control of biomedical advances.
  7. Recognize the challenges of scarce resource allocation and rationing.
  8. Recognize the signs of burnout and select coping strategies for self-care.
     

References

  1. Epner DE, Baile WF. Patient-centered care: the key to cultural competence. Ann Oncol. 2012 Apr;23 Suppl 3:33-42.
  2. Conley J. Ethics in otolaryngology. Acta Otolaryngol. 1981;91(5-6):369-74.
  3. Mello MM, Boothman RC, McDonald T, Driver J, Lembitz A, Bouwmeester D, Dunlap B, Gallagher T. Communication-and-resolution programs: the challenges and lessons learned from six early adopters. Health Aff (Millwood). 2014;33(1):20-9.
  4. AMA Code of Ethics
  5. Diehl, M, Hay, EL, Chui, H.  Personal Risk and Resilience Factors in the Context of Daily Stress. Annu Rev Gerontol Geriatr. 2012;32(1):251–274.

 

Research Ethics

Learning Objectives

  1. Demonstrate protection of human subjects as stipulated in the Belmont Report, and the Common rule.
  2. Understand fundamental ethical differences between clinical care versus research, duties to patient v. research participants (fiduciary v. protective).
  3. Understand the nuances involved in surgical innovation.
     

References

  1. Emanuel EJ, Wendler D, Grady C. What makes clinical research ethical? JAMA. 2000 May 24-31;283(20):2701-11.
  2. Joffe S, Miller F. Bench to bedside: mapping the moral terrain of clinical research. Hastings Cent Rep. 2008;38(2):30–42. 
  3. Biffl WL, Spain DA, Reitsma AM, Minter RM, Upperman J, Wilson M, Adams R, Goldman EB, Angelos P, Krummel T, Greenfield LJ; Society of University Surgeons Surgical Innovations Project Team. Responsible development and application of surgical innovations: a position statement of the Society of University Surgeons. J Am Coll Surg. 2008 Jun;206(6):1204-9.
Resources 

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  1. Annual Meeting Webcasts (AMW):