Excerpt From Medical Ethics: Real-World Application By Afshin Nasser

Code of Ethics and Professionalism

Ethics have been one of the building blocks of medicine since the time of Hippocrates, where the medical profession was first conceptualized, and the first public promise was made for physicians to place the interests of the patients above their own.


Study of Medical Ethics

Medical ethics are learned by observing experienced physicians’ practices and actions. Ethics are learned at home and through the family, and not at medical institutions. The importance of ethics in medical education cannot be understated, yet sadly, the subject of ethics does not play a major role in the medical school curriculum.

Ethics have been one of the building blocks of medicine since the time of Hippocrates, where the medical profession was first conceptualized, and the first public promise was made for physicians to place the interests of the patients above their own.

The subject of Medical Ethics has evolved and been influenced by multiculturalism, the development of human rights, and governmental and administrative contributions. Medical ethics are also closely analyzed in parallel to the law, and medical licensing authorities

sanction physicians for ethics violations. Ethics mandate higher standards than the law, and where the law falls short, ethics is considered the prevailing factor in medical licensure adjudication.

The ethical physician is exemplified by virtues such as compassion, where the physician recognizes vulnerability and suffering, and attempts to understand each patient in order to alleviate the patient’s condition.

The Honest physician is forthright and makes every attempt to communicate the truth – despite sensitivities – to the patient in a respectful manner.

Humility serves as a barrier for the physician to not overstep the limits of his/her knowledge and skills, or the limits of medicine, and encourages the physician to collaborate and seek support from colleagues when needed.

The physician with integrity consistently demonstrates his/her intentions through thought processes and actions by acting in a truthful manner in accordance with professional expectations, despite potential adversity.

The prudent physician uses his/her best clinical capabilities and moral reasoning to make thoughtful decisions in good conscience regarding medical care.

Being Honest

A physician must be forthright, respectful of the truth, and must both demand and communicate truth both sensitively and respectfully.

Code of Ethics

Do the right thing.

This sounds rather trivial and simple, but it is not. Opinions vary about every medical issue raised in private, public, and governmental forums. But which opinion is right?

Medical ethics set guidelines and principles to help us make decisions as physicians, however, these guidelines may come into conflict with each other. In such cases, options

must be weighed via logic and ethical theories. Medical ethics explore subjective areas of decision-making, as decisions are usually not binary.

Consider the following cases:

1-Dr. You, is again faced with a patient with multiple comorbidities who makes a follow up appointment and as soon as her medications are called in to the pharmacy, she no-shows, or cancels the appointment and is nowhere to be found, no working phone, and mail returned.

2-Dr. Me becomes increasingly frustrated with patients or their family members who call after hours, particularly on Friday evenings and requesting pain killers for their older family members in pain, despite previous warnings.

3-Dr. Z is becoming increasingly frustrated with patients who come to him after consulting another health practitioner for the same illness. She considers this to be a waste of health resources and counter-productive for the health of the patients. She decides to tell these patients that she will no longer treat them if they continue to see other practitioners for the same condition.

4-Dr. X discovers that his patient of 15 years, is in violation of her pain management agreement and confronts her. The patient apologizes and pleads not to be discharged from the practice. Two weeks later she drops off a letter at the front desk addressed to Dr. X, pleading not to dismiss her and how she appreciates his services for the past 15 years. Dr. X declined to engage in correspondence as violating the pain management contract has obvious consequences. After 4 weeks, the said patient complained to the Board of Medicine that she was kissed by Dr. X.

5-Dr. N is seeing a known patient for a routine visit. He claims that he was ill ten days ago and had to call out from work for a week. Dr. N asked if he was seen by a Doctor during his illness. “No, I did not, but please give me a medical note or I will lose my job, I have been a good patient to you…”

6-Dr. C, a third-year surgical resident is annoyed by the behavior of the senior surgeon in the operating room. The surgeon uses techniques that prolong operative time and cause greater post-operative pain, and longer post-op recovery times. Additionally, he constantly makes inappropriate jokes and intimidates the surgical assistants.

7-Dr. K examines a female patient with severe facial eczema. Patient had already been seen at a local walk-in clinic where she was given a Medrol Pak 3 days prior by a nurse practitioner, without any improvement and now advancing to periorbital area. Given the patient’s level of discomfort, patient agreed to an intramuscular steroid injection. In two

days, patient’s eczema had completely resolved. She complained to Board of Medicine about a small dimple at the site of her injection.

Each of these cases mandate ethical reflection. They raise questions about physician behavior and decision-making. It is not about how to treat pheochromocytomas, hypertension or diabetes, it is about reflection, responsibilities, values, morality and rights. Physicians face these kinds of questions every day and truly one cannot generalize scenarios. Such profound decisions must be entertained in minutes. There are no in-house attorneys, ethics committees and no board rooms, it’s the physicians, the patients and the oath they took.

Ethical questions in medicine are not all equally challenging. Some are relatively easy to answer, mainly because there is a well-developed consensus on the right way to act in particular situations, for example, the physician should always ask for a patient’s consent before a procedure.

Ethics is the study of morality, reflection and analysis of moral decisions and driven behavior.

Medical Ethics

The American Medical Association has written a “Code of Medical Ethics” for healthcare providers facing ethical questions in their careers, which consists of guidelines and opinions written by ethics scholars and physicians. The American College of Physicians has also published a similar, yet concise, handbook of ethical guidelines.

Medical ethics consists of four pillar-like principles as an elementary guide to the practice of medicine. Each individual case can be analyzed, and the decision-making process can be facilitated, using these principles.

The four principles of medical ethics:

Autonomy: This relates to a patient’s independence or freedom. A competent adult has the right to make decisions about what happens to his/her body. This person must be capable of rational thought process and not be coerced into a decision. An adult can refuse medical care or treatment or accept treatment when his provider suggests it. That patient then lives with the consequences of his/her decision.

A physician cannot examine you, do blood work, perform a colonoscopy, or treat your ear infection without your consent.

The rights to autonomy and confidentiality is limited where there is potential harm to an innocent third party.

Patient autonomy gives you the right to make the wrong choice about your healthcare regime. Even if you are unable to make your health-care choices, the physician cannot simply make decisions on your behalf. This stands even if your choices would be harmful to you.

This is one of the most difficult things for a physician to understand and abide by. Doctors are trained to act in the best interest of their patients, but a patient’s right to act against his/her own best interest comes first.

Beneficence: A physician must act in the best interests of the patient. Providers are required to be engaged in their patient’s health and well-being. Beneficence means providers must be committed to helping their patients.

Nonmaleficence: Physicians must not harm a patient through carelessness, malice, hatred, vengeance. This principle is balanced with beneficence, in that any risks of a treatment or procedure for a patient must be outweighed by the benefits. Procedures or treatments always carry a risk of harm, but when the treatment is very risky, the benefit must be greater than the risk of not performing the procedure.

“Double effect” is a derivative of nonmaleficence. This doctrine states that if doing something morally good has a bad outcome, it’s ethical to do it providing the effect was unintentional. This is true even if with the foresight that the outcome was probable.

Justice: The principle of justice states that there should be an element of fairness in all medical decisions that both burden and benefit patients, as well as equal distribution of scarce resources and new treatments. Additionally, it is necessary for medical practitioners to uphold applicable laws and legislation when making choices.

Conflict of Interest

A Physician must resolve all conflicts of interest in the best interest of the patient.
A Physician must make full, transparent, and timely disclosure of any conflict of interest. Physicians must NOT:

1. Seek or accept any benefit for a referral, service or product provided by another Physician to a patient, other than for services provided by a partner, associate, employee or locum of the primary Physician.

  1. Offer an inducement to another Medical professional conditional on providing a referral, service or product to a patient, whether medically appropriate or not.
  2. Encourage another person to offer or accept an inducement conditional on providing a referral, service or product to a patient, whether such referral, service or product is medically appropriate.
  3. Refer a patient to any facility or healthcare business in which the Physician has a direct or indirect financial interest. There should be no terms or conditions that require the Physician to make referrals to a facility or generate business for a facility

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State Medical Boards

The medical board’s duty is to protect the public, not the physician. State medical boards today focus on licensed physicians who violate professional ethics, and their mandate has significantly evolved to focus on disciplining physicians.

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National Practitioner Data Bank

Since 1990, the state medical and dental boards have been required to report certain disciplinary actions taken against the professionals they license to the National Practitioner Data Bank.

Read More »

Boundary Violation

Boundaries create a therapeutic distance between physician and patient and clarify their respective roles and expectations. Boundaries define limits of the therapeutic relationship.

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Medical Ethics: Real-World Application By Afshin Nasser

You may have acquired this book as a result of conflicts with peers, administrators, patients, or State Medical Boards, where the outcomes of those interactions have left you wondering, “…what if I had done things differently?”

In that case, I hope that this book answers some of your questions and guides you with regards to any future quandaries you may encounter.

If you are a healthcare worker seeking to understand the subject of medical ethics, then I hope this book helps you acquire the clarity you seek.
If you are an individual simply curious about medical ethics, then I raise my hat to you for your pursuit of knowledge.