eISSN: 2378-315X BBIJ

Biometrics & Biostatistics International Journal
Review Article
Special Issue

Ethics necessary in health care a review

Eldo E Frezza, Gianmarco Frezza, Edoardo G Frezza
Director medical quality, Eastern New Mexico University, New Mexico
Received: July 12, 2017 | Published: July 31, 2018

Correspondence: Eldo E Frezza, Eastern New Mexico University, Roswell New Mexico, University of Delaware, Cure Your Practice, Mexico, Email

Citation: Frezza EE, Frezza G, Frezza EG. Ethics necessary in health care a review. Biom Biostat Int J. 2018;7(4):317‒320. DOI: 10.15406/bbij.2018.07.00224

Abstract

Medical ethic is the duty of the physician towards the patient a necessity to practice medicine. The ethics theory is based on virtues and consequentialism, benefit for all. This should be the rule that will accompany the medical students, the residents, the physician, and the health care providers during their career. We realize that it extremely difficult to implement ethics principle in health care and that is why we need to start from the medical students and from training facilities. We might identify crack in the system, but is then that a good ethical frame will be helpful. The professional growth is directly correlated with the moral conduct. Ethics framework should be applying to all level in health care system. The constraints, the conflicts, which are imposed by the daily practice, by corporate structure, by hospital, by authority, limit the practice of medicine. A good health organization should represent the location where we can find the answer and not the constriction. Investing in medical students and residents is extremely important because those are insured our future. Ethical teaching should be active part of the medical students and administrators training. Ethics should be taught in four divisions; basic ethics, clinical ethics, legal principles relating to ethics and the ethics of research and affiliation. They need to understand who has the right to healthcare, the justice of clinical practice, what autonomy means for a patient giving consent, who is going to make any surrogate decision and so on. It also should be mandatory for administrator to become familiar with the same concepts.

Keywords: ethics, deontology, morality, navigate ethics issues, teaching ethics, medical school’s curriculum in ethics, ethics frameworks, ethical compromise, resolving ethics issues

Introduction

Medical ethics define the duty of the physician toward the patient. The Hippocratic Oath is its foundation. But before Hippocrates, even in earliest history, we find evidence of ethics in treating patients with disease by either the priests that were taking care of the patients or by the lay people who were selected as physicians. There is a history of ethics in medicine that goes back before Christian, Islamic and Jewish Scholarship and theology. But it wasn’t until the 19th century that medical ethics even had a name.

The term “medical ethics” was coined in the writings of Dr. Thomas Percival. In 1803 he authored “Medical Ethics, Or a Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons.” The book was created from his passion for jurisprudence. In 1847, at the American Medical Association’s first meeting they adopted the first American code of medical ethics. It was based on Dr. Percival’s work. The code remained largely unchanged until 1957 when a distinction between medical etiquette and medical ethics was deemed necessary.

Joseph Fletcher, founder of the theory of situational ethics, wrote “Morals and Medicine” in 1954 establishing himself as the father of bioethics. His premise of reasoned choice empowered greater technological advancement in medicine and greater patient education as well. It is not about the bylaws of the healthcare. It is about the boundaries within which the health care can safely grow. We hear the phrase “safety first” frequently. But how often do we think of it in an ethical framework? Only by working toward the good of all will we achieve success. Only through consistent ethical practices, as per Immanuel Kant, can a business and a practice grow and prosper.

The philosophers

Ethics is a major part of life for everybody. From the individual working person to the successful business, ethics plays a daily role. Ethics are the principles of morality and are consistent in belief and practice. They show in every day behaviors and are the perfect character indicator when choosing what is right or wrong, good or bad. The initial source of ethics comes from family, religion, life, experiences, historical perspective, personal training and education. The line of conduct was initially illustrated by Freud combining self-effacement, self-sacrifice, compassion, and intensity of action.

Deontology is the way people judge the morality and the actions of other based on rules. Initially people learn the rules within the family structure. Philosophers have helped to generate a greater understanding of ethics and the making of rules. Broad CD1 described the “five types of ethical theory” in his book of the same title. In it we found the concept that it is a duty and obligation to obey codes of conduct, and every action has consequences. This is where the word “consequentialism” was derived. So if morals and duty exist, a consequential judgment of those actions is always behind them.

Immanuel Kant2 expressed the concept of morality as the individual’s duty to do the right thing. A bad outcome being a product of a bad moral choice is based on the motive of the person and not on result. Therefore, he was suggesting the highest good for everybody, keeping in mind that which is good for everybody is good for the society. When it is good only in and of itself, it does not have morality. Intelligence, pleasure and perseverance aren’t simply moral by themselves, if they aren’t good for everybody. Pleasure is good for the person that enjoyed it, however it has no moral qualification by making it good for everybody. This means that the only good for all (moral action) is the goodwill that we can have for everybody.

Kant was suggesting that even if the things we do go wrong, but the motivation was for the goodwill of all they are still moral. We can practice good or bad will inside or outside the law. Therefore, what should be pushing us towards an action is the motive, the good will and not duty to authority. This is an interesting concept particularly if we apply this in the business world. We will discuss it more shortly. Summarizing Kant’s vision, we must:

  1. Act towards a universal good.
  2. Treat others like family, with a simple and positive mean.
  3. Act as you feel would be best for humanity.

There is no absolute right or absolute wrong. There is intention and action which brings consequences. Even a lie could be good if the motive is the good of all.

Deontology did not come from religion, nor does it follow God’s commandments. It was only after deontology became a study that religion had any influence on it. Kamm FM3 in 2006 published the book Intricate Ethics, in which she described new theories. She started with the premise that it is seen as bad to harm a person. She went on to illustrate how harming one person in the name of saving many people be good. Her point was to illustrate the relative nature of morality. Iain King,4 “How to make good decisions and be right all the time” modifies some of the deontological principles which are compatible with ethical virtues and consequences. He judges the morality of the action based on the consequences of the action which is different from what Kant and Kamm were doing.5–9

Why teaching in medical school?

With an eye toward bringing the principles of ethics to all, medical schools have introduced ethics into their curricula. But we need to include health care system, hospitals and health care corporations. They need all to work together if we want to achieve the ethics principle described by the philosopher. The basic principles are reported in Table 1. This, now mandatory subject is generally offered between the first and third year of medical school. This empowers students, tomorrow’s professionals, to make better decisions about their role in medicine. A greater understanding of medical ethics can help them decide if they wish to be a practicing physician, or if they would do better in an administrative role.

Mandatory curricula in medical school

Consisytent code of ethics

Foundational culture of safety

Health care justice

Clinical ethics

Legal principles

Health professional curricula

Hospital CEO curricula

System curricula

Health care corporation curricula

Health resources

Ethics framework for hospital

Patient need first

Table 1 Ethics in health care

Each student comes to their practice with the ethics and morals they learned at home. If they were lucky they would end up working with senior partners who showed a healthy ethical focus as well. But this was uncertain at best. Medicine must have a culture of safety instilled in the students before they enter the work world. Only through a consistent ethical code, a strict deontology taught alongside anatomy as foundational, can we create this culture of safety.

We must provide students with a conceptual tool to navigate through the ethical issues that they will encounter in clinical practice. Basic steps need to be taken during their training to focus on discussion, example, and basic principles. Ethics should be taught in four divisions, basic ethics, clinical ethics, legal principles relating to ethics and the ethics of research and affiliation. They need to understand who has the right to healthcare, the justice of clinical practice, what autonomy means for a patient giving consent, who is going to make any surrogate decision and so on. Case based examples are one of the greatest tools to help them in this study.

The culture of safety will not be strong if ethics studies stop after the first or second year of medical school. Ethics studies should continue into third and fourth year rotation, and into daily practice. This can be applied to hospitals, health professionals and healthcare systems as they follow through with their physicians to ensure that those principles are applied. We then not only welcome more teaching of ethics in medical schools within a more standardized framework, but we also welcome the physicians that will grow within this culture. These are the professionals who will develop a consistent code of ethical principles. These will be the administrators of hospitals, applying these same standards.

This solution benefits everyone. By teaching the students ethics from the start, they become physicians with ethical ontological principles. They can become administrators of hospitals and health systems. The new culture of safety they will create and maintain will benefit doctors, health care workers at every level, and most of all patients. We can divide the teaching of ethics in a medical school into different sections. Among those are value, autonomy, beneficence, non-maleficence, respect of human rights, euthanasia, informed consent and confidentiality, importance of communication, control, and resolution. Ethics committees generally set guidelines for each of these.

A foundational tenet of ethics in medical practice, as in many professions, is conflict of interest. Transparency is of utmost importance where physicians’ relationships are concerned. Futility of medical care and futility of information are also major concerns in bioethics. These values are based in respect for autonomy. A patient has a right to refuse treatment. They must be able to trust the beneficence of the physician, that the doctor is working in their best interest. Justice is another factor. Health resources must be available in a way that any patient who needs them can access them. This last has the United States on the horns of a dilemma, as all medical care, especially that centered on infectious disease, is not equally available.

Ethics at all levels in health care

The tradition of deontology and ethics theory is based on virtues as defined in consequentialism, with the goal of doing no harm and supporting the good for all. This should be the foundational value of every medical career. This is the ideal rule for a physician because they are one of the professionals that always need to consider the benefit of all as surely as they are careful not to harm the patient. When difficulties arise, the physician should look back at their values and ethics to formulate the solution. We suggest therefore that any doctor or medical students should have an “ethical framework” in which they base their practice and on which they base their line of conduct. This same framework is equally applicable to the Chief Executive Officer, Chief Medical Officer, Chief Financial Officer, and directors of the hospital. It is vital that the whole hospital and the healthcare system subscribe to the same code.

There are two important parts that accompany this ethical framework, the subjective and objective. The subjective is about dealing with the patient. To be effective here, you need to understand their background and culture to have better apply your clinical judgment and offer solutions. The objective must be agreed to by each participant and an understanding reached about how ethics will apply to your practice. It is important for a hospital and healthcare system to frame their business in a way that the whole organization can follow certain principles. The patient is the physician’s customer and the physician is the system’s customer. Therefore, a consistent ethical code needs to be applied by the health system towards the physician and by the physician towards the patient. This helps ensure a consistent discernment for greater mutual understanding and organization.

Curriculum

In medical schools, it is important to have role model physicians. In health care systems, it is necessary to have role model administrators. Both must focus on discussions which involve professional development, responsibilities, legal and ethical principles, research, and deontology. Therefore, both should go for training and have a curriculum in ethics. We suggested an ethics and Bioethical curriculum as in Table 2 and an extracurricular based on clinical experiences and problem oriented as in Table 3.

Ethics

Professionalism and responsibilities

Codes of Ethics

Confidentiality (where and with whom to talk)

Informed Consent: commitment to honesty

Autonomy and limitations

Conflict of interest

Non-Compliant patients

Sexual Harassment

Medical Records

Telemedicine

Bio-Ethics

Justice in Clinical Practice and legal regulatory environments

The Right to Health Care

Transplant Organs

Autonomy

Decision Making

Refusal of Treatment and Justified Paternalism

Advance Directives and Proxies

Ethical Dangers of Human Subject Research

The Importance of Research and The Development of New Therapies

The Common Rule: Requirements for The Ethical Conduct of Research

Table 2 Ethical and bioethical curriculum

Small group discussion

Case based ethics issues

Participating in ethics committees

End of life service rotation

Clinical skill practice

Deontology and ethics reasoning

Burn Out

Health Insurance

Abusive patients

Table 3 Extra curriculum during working schedule while on the job (residency or starting in hospitals)

Conclusion

We realize that it is extremely difficult to implement consistent ethical principles in health care and that is why we need to start with medical students and future hospital administrators. To a great degree health care has become a business and patients have had much of their autonomy stolen in this business culture. But the customers, the patients, eventually will understand who is conducting themselves with consistent ethics and will remain loyal. Only by setting up new physicians and new health systems that are ethical, will health care have a stable, solid foundation upon which to grow. Fraud, mistreating employees, and mismanaging finances will quickly bring any business down like a house of cards. Investing in students, resident and new hiring is also extremely important. It ensures our future. This is a solution where everyone benefits: You build goodwill in the community as you market your products and services. People will notice, and the time invested in Health Care ethical principles will pay overall. It also should be mandatory for administrator to become familiar with the same concepts.

Acknowledgements

None.

Conflict of interest

Author declares that there is no conflict of interest.

References

  1. Broad CD. Five Types of Ethical Theory. USA: Harcourt, Brace and Co, New York; 1930.
  2. Kant Immanuel. Groundwork of the Metaphysic of Morals. USA: Harper Collins; 1964. p. 1–148.
  3. Kamm FM. Intricate Ethics Rights, Responsibilities, and Permissible Harm Rights, Responsibilities, and Permissible Harm. 1sted, UK: Oxford University Press; 2006. p. 1–520.
  4. Iain King. How to make good decisions and be right all the time. UK: Bloomsbury Publishing, England. 2008. p. 1–256.
  5. Flew Antony. Consequentialism. In A Dictionary of Philosophy. 2nd ed, USA: Macmillan, St Martin’s, New York; 1979.
  6. Olson Robert G, Paul Edwards. Deontological Ethics. The Encyclopedia of Philosophy London: Collier Macmillan; 1967.
  7. Ross WD. The Right and the Good. USA: Clarendon Press, Oxford. 1930.
  8. Salzman Todd A. Deontology and Teleology: An Investigation of the Normative Debate in Roman Catholic Moral Theology. University Press; 1995.
  9. Waller Bruce N. Consider Ethics: Theory, Readings, and Contemporary Issues. USA: Pearson Longman, New York; 2005. p. 1–320.
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