Professional EthicsBy Dr. Tom Vaughan '55 | Dean Emeritus
A commentator of considerable renown was expressing concern over our dissolving ethics in the United States during the postwar period and identifying the scapegoat as “the younger generation,” that segment of our population that questions the validity of our entire system of ethics to the consternation of their parents. The writer alluded to the conflicts in religion and philosophy and the explosion of scientific knowledge. He noted that the most popular philosophy teaches the young modern that the test of validity is “workability.” He further observed that those who have lived long enough have become reconciled or hopeless over the situation, but that the young who saw the poverty, the social injustice, and the emotional maladjustment between the individual and society did not accept that this was the way things had to be. The writer argued that it was the older generation who had sowed the wind and the younger who would reap the whirlwind, concluding on the ominous note that, “Never has the road been wilder nor the signposts fewer.” These remarks gained considerable currency in that they were published in the Atlantic Monthly by a no less quotable source than James Truslow Adams…in 1926!
In a recent address, Dr. James T. Laney, President of Emory University, expressed concern over what some have diagnosed as serious deficiencies in professional education and a corresponding decline in professionalism. He voiced dismay that traditional values were being displaced by career objectives associated with instant gratification of the good life—unbridled liberty and the pursuit of self-interest. To counter such drifts, it is as important for a faculty to provide worthy models of how to live as it is how to learn. In the inculcation of a professional ethos, schools should engender moral sensibility, restraint and commitment befitting a noble profession that is dedicated to serving the public trust beyond the selfish interests of the individual. Concern about our public image is not limited to the veterinary profession, but is symptomatic of a greater disaffection with all health professions. For a decade now, greater emphasis has been placed on accountability, grievance hearings, complaint investigations and due process. There has been rising public anxiety about the behavior of all professionals, the size of the health industry and moral dilemmas created by medical and technological breakthroughs. The health professions have been the object of increasing debate about everything from the high cost of health care to the depersonalizing of the patient. Legalistic remedy has become the court of first instance rather than last resort, and good medicine is defensive medicine regardless of the expense.
Why all this public attention to a normally quiescent branch of philosophy that has traditionally been an in-house concern dealt with in the process of policing our own ranks? Is not this the province of medicine that requires no instruction and brooks no trespass by the laity? Has not the professional degree long been accorded an unchallenged social cachet? The thinly veiled disdain for soft disciplines, together with a tradition of empiricism and positivism,1 has only served to heighten suspicion about any possible value of public discourse about biomedical ethics. However, there are always grounds for concern against what has been called the omnipotent paternity of physicians, which, when self-reliance reaches self-sufficiency, is easily construed as professional arrogance. This is especially true if viewed as a threat to the autonomy and dignity of the patient.
The Hippocratic Ethic
Since more than 400 years before Christ, the Hippocratic Oath, progenitor of the Veterinarian’s Oath,2 has served as a stern charge that places the patient’s welfare uppermost and admonishes the doctor of his solemn duty to heed the principles and conduct governing the practice of medicine. It places the moral burden squarely on the physician. No code has ever been more influential in strengthening the moral fiber of ordinary men.3 It is a mixture of high ideals, common sense and practical wisdom. In addition to its overriding concern for the patient, it emphasizes the obligations inherent in the acquisition of a professional education, and the perpetuation of that knowledge to subsequent generations. Closely related is the implied collegiality of the profession—mutual regard that transcends fraternity or polity. It recognizes the limits of one’s own competence and defers to the skills of the specialist in consideration of the welfare of the patient. It imposes absolute moral constraints that show respect for women, for the patient’s household, the dignity of the individual regardless of rank or station and for the confidentiality of the doctor-patient relationship. The primary motivation is altruism, and the reward— the opportunity to practice their profession with humanitarian concern and to earn the respect of their fellowman.3
Mindful of some of the breaches of ethics we see today, we may contemplate the more fitting appellation, “hypocritic oath” for a few of our fellows3 who take a cavalier attitude toward such matters.
Contemporary Biomedical Ethics
In contrast to the patient-centered ethic, the veterinarian is accustomed to having to translate his3 role in manifold ways to human health, environmental safety and animal agriculture, as well as to the welfare of the patient. Humanitarian concerns and economic realities have always been interwoven, though not always coherently so. There is an increasing interaction between ethics, law and regulation, which appears to favor individual rights at the expense of the public interest. This situation is at least partially obscured by confusion between law and morality, the distinction often being left up to the court, with no little posturing by the government. This overuse of the language of rights trades heavily on the natural leanings of American individualism, which in this latter day seems to flourish paradoxically in the context of pluralism typical of the makeup
of our modern society, where individual interests have come to supersede the public interest. The rugged and self-reliant individualism of yesteryear sought only opportunity to engage in free enterprise and required of the government but to guard the coast and tote the mail. Today, this has been supplanted by the self-interest groups that seek more and more federal assurances and entitlements, provoking George Will to refer to this as “the Age of Entitlement.”
Whether it be members of a family or of a profession, conflicts are precipitated by divergent personalities and circumstances. Practitioners complain about their colleagues’ unprofessional behavior in unscrupulous business practices and disparagement of professional reputations. Institutional clinics are criticized for failure to communicate promptly with the referring practitioner, for failure to request referrals from clients or for disregard of any referral policy at all. Particularly sensitive nerves are the perceived condescension or outright criticism of the practitioner in front of students as well as clientele, and the discourteous treatment of valued clientele who have been carefully and properly referred. On the other hand, practitioners are faulted for using institutional clinics as dumping grounds for hopeless cases and deadbeat clients, for making little effort to provide complete or accurate case histories and for failing to provide follow-up care and reporting when the patient is returned home. Some doctors appear too ready to collect a fee for providing expert testimony in court proceedings against a colleague, or for providing a second opinion in a contested insurance claim.
Specialty boards are counseled to allow alternative pathways for the admissions process so that they are less liable for litigation on the grounds of discrimination or restriction of free trade and health care competition. Denial of degree, of license, of certification or any evaluation that may be translated as working papers must be careful to show proper respect for due process and to make public knowledge that institution’s appeals procedure for filing grievance by anyone who construes such denial as a violation of his/her civil liberties.
Anyone who touches a dollar of the taxpayers’ money is doubly accountable and subject to external audit at any time. The prospect of withdrawal of federal funds threatens every administrator of public programs, who must comply with the regulations of every federal agency in the book. Every budget request, grant proposal or strategic plan must show evidence of economic impact and societal demand. New academic programs must include not only mission statements, goals and objectives, but also methods of performance evaluation and assessments of outcome. Continuation of institutional operations depends upon periodic accreditation and renewal of licensure. In the governance of pharmaceuticals and biologics alone, the practitioner is regulated by no fewer than eight federal and four state agencies.
Law and medicine, like farming, are irresistible to the amateur. When every man tries to be his own horse doctor and dabbler in legal remedies as well, when society cuts its teeth on warranties, guarantees and a growing list of fringe benefits, when livestock that used to sell for a nickel a pound goes for 50 cents and bloodstock is calculated in ten to the seventh power, you have all the ingredients for a litigious stew guaranteed to cause every professional in sight a royal case of indigestion. A kind of paranoia has medical groups borrowing money in six figures at above prime rate to pay annual premiums on their liability insurance. Voluntarily, they add their own exclusions, such as not operating on anyone from a particular town or a certain population known to have a bad history of malpractice suits. Underwriters have generated catechisms of caveats by which their clientele may better avoid what appears to be inevitable. Paraphrasing the AVMA dozen:
- Don’t guarantee success
- Point out risks beforehand
- Get owner’s consent
- Don’t apologize or call undue attention
- Autopsy only when permitted
- Use specialist labels with caution
- Maintain complete records
- Beware of seconds and thirds (putting out someone else’s fire)
- Don’t use clients as assistants
- Use lots of labels (P, FEUO, KOOROC)4
- Practice according to currently accepted practices
- Obey the law and do what you say you’re going to do
- Declare the value before the fact
- Notify insurer (owner, mortgager)
- Establish good doctor-client relationships
- Communicate promptly; bad news immediately… and as directly as possible — word-of-mouth, face-to-face, eye-to-eye, far superior to email, voicemail or third person
- Respect fellow professionals and fellow man
- Recognize self-limitations and refer without procrastination
- Show compassion and consideration for patient and client
- Maintain confidentiality
- Make a good trial lawyer your childrens’ godfather
The St. Paul Fire and Marine Insurance Company’s safeguards stressed the point that factors other than negligence can and do influence the initiation and outcome of malpractice claims. Never underestimate the importance of keeping accurate and comprehensive records, including telephone and answering service logs. Documentation is as crucial to legal defense as it is to scientific reporting.
Regarding communication, you may believe your client understood your instructions, but if they were not given in writing, you should reconfirm that understanding. Poor rapport is a breeding ground for litigation. Clients who would not ordinarily entertain the thought may be provoked into filing suit due to a doctor’s callousness or failure to communicate.
Office staff may either compensate for deficiencies in your own personality or aggravate matters and complicate relationships. Not infrequently are practitioners’ spouses criticized for officiousness in the professional quarters.
Telephone calls constitute a great deal of the communications and even consultations in practice. Be careful how far you go in diagnosis and treatment by phone. House calls or office visits should be recommended as part of every such conversation, and follow-ups are advisable, cautioning the client about adverse reactions, including no response, and suggesting alternative courses in such a case.
An overdue bill may indicate an unhappy client, sometimes with a legitimate complaint, who could be provoked into a countersuit if pressure tactics such as a collection agency are used automatically in all such instances. Potential problems may be averted simply by telephone inquiry to see if anything is wrong or if reasonable excuses exist before taking stringent action.
Bad news travels fast, or at least it should, and this applies whether you have the unpleasant duty to advise the client that something has gone awry or to notify the insurance agency of a claim against them or yourself. Initial contact should be made immediately by telephone. Verbal communication can be confirmed as soon as possible by a fax, telegram, night letter or overnight air courier service. A cover-up may be temporarily face-saving, but nothing provokes a suit quicker than deceit.
Disparagement of a colleague may plant seeds of distrust unnecessarily. Better to say nothing than to give a client reason to question another doctor’s competence except in the most reprehensible of instances.
In the case of contested judgment of malpractice proceedings, a generally useful threshold against being pulled too quickly into making depositions and giving testimony against another doctor is to require a subpoena before you appear in court. It causes the attorney no great inconvenience, and creates the desirable impression that you are not eager to testify against a fellow professional, agreeing to do so only under the threat of being held in contempt of court or perjuring yourself. The surer way to exclude yourself from such entanglements is to convince the attorney honestly and sincerely that you can provide no testimony that will aid or abet his or her case.
Finally, avoidance of malpractice assumes possession of a proper and current license and operation within the guidelines of the state practice act, as well as the policies and procedures followed by the clinic or institution where employed.
Of human failings, fatigue, haste and ignorance are more apt to be forgiven than arrogance, laziness and deceit.
Yr humbl and obdt svt,