Transcript Individual Conscience, Institutional Mission, Professional

Individual Conscience,
Institutional Mission,
Professional Code:
Which Allegiance is Primary?
Glenn C. Graber
Department of Philosophy
Center for Applied and Professional Ethics
University of Tennessee, Knoxville
Short Answer
 “It
Depends”
 “depends on . . . .”
Levels of Responsibility
Engineering Ethics
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Irresponsibility
Fulfilling one’s job description
Professional standard
Personal standard
EXAMPLE: auto safety
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Job Description: Your employer is satisfied with the current
federal regulations that specify a collision test at x mph.
Indeed, they are lobbying against proposed changes in federal
regulations to strengthen that requirement.
Professional Standard: There is a strong consensus within
your profession that the current standards are too weak and
that the only adequate test of safety would be at x + y mph.
Your professional organization is pushing for strengthening
the federal regulation.
Personal Standard: If you were choosing a car for your
mother, you would not be satisfied with even this level of
safety. You would want to see the results of tests at x + y + z
mph.
EXAMPLE: auto safety
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Job Description: Your employer is satisfied with the current
federal regulations that specify a collision test at $ mph.
Indeed, they are lobbying against proposed changes in federal
regulations to strengthen that requirement.
Professional Standard: There is a strong consensus within
your profession that the current standards are too weak and
that the only adequate test of safety would be at $ + $ mph.
Your professional organization is pushing for strengthening
the federal regulation.
Personal Standard: If you were choosing a car for your
mother, you would not be satisfied with even this level of
safety. You would want to see the results of tests at $ + $ + $
mph.
EXAMPLE: auto safety - PINTO
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Job Description: Your employer is satisfied with the current
federal regulations that specify a collision test at 10 mph,
fixed. Indeed, they are lobbying against proposed changes in
federal regulations to strengthen that requirement.
Professional Standard: There is a strong consensus within
your profession that the current standards are too weak and
that the only adequate test of safety would be at 20 mph,
fixed. Your professional organization is pushing for
strengthening the federal regulation.
Personal Standard: If you were choosing a car for your
mother, you would not be satisfied with even this level of
safety. You would want to see the results of tests at 20 mph,
moving.
Pharmacy
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Job Description: You read in the paper that your
employer has signed a contract with the state Department
of Corrections to have the chief pharmacist (you) prepare
the vials of drugs to be used for execution by lethal
injection.
Professional Standard: American Correctional
Health Services Association: “The correctional health
professional should not be involved in any aspect of
execution of the death penalty.”
Personal Standard: -??What does your conscience dictate with regard to
personal involvement with capital punishment?
Pharmacy #2
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Professional Standard: American
Pharmaceutical Association: “opposes laws
and regulations which mandate or prohibit the
participation of pharmacists in the process of
execution by lethal injection.” [Emphasis added]
The Cumulative Multiple
Sources of Professional
Responsibility
1. Duty of Beneficence
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To benefit others whenever we can
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prima facie duty, not absolute
perhaps fairly easily overridden
but a duty nonetheless
e.g., Walking past, I see a child fallen face-down
in a puddle. There may be no legal duty to
rescue, but I contend that there is a moral
duty.
2. Expertise Heightens Duty
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As I am walking with a physician, we both
see a person collapse clutching his chest.
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I have a moral duty to go to his aid. <from 1 above>
The physician has a greater moral duty, since she
has expertise that makes her help more effective.
3. Social contract
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Society subsidizes professional education – so
professional expertise cannot be said to be a
proprietary resource of the individual. (contra Sade)
Society grants deference to professionals in various
ways.
Society vests the professional with this body of
expertise – we don’t all bother to master it for
ourselves.
In exchange, we expect professional service.
Social Role
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“Professional” or “physician” or “<substitute
name for another professional role>” is a
social role
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Rule-governed behavior
Expectations for behavior
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Internal to the individual
Internal to the group
External to the group
You’re a dead duck, man! No way we can cure you!
I assure you, it’s a benign procedure!
<you supply the caption>
Professional Obligation
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i.e., obligation of professional qua
professional
Integral to social role / social contract
Professional Obligation / Core Professional
Values
As part of an appreciation of the ethical claims
of professionalism, physicians must be prepared
to set aside their personal values and morality, to
set aside what the legal system and their
employers want them to care about, and to take
up instead the question of what the responsible
physician ought to care about. The profession’s
core values inform those purposes that each
medical professional should have in common
with colleagues.
[Kipnis (2006), p. 11]
Professional Obligation / Core Professional
Values
As part of an appreciation of the ethical claims
of professionalism, physicians must be prepared
to set aside their personal values and morality, to
set aside what the legal system and their
employers want them to care about, and to take
up instead the question of what the responsible
physician ought to care about. The
profession’s core values inform those purposes
that each medical professional should have in
common with colleagues.
[Kipnis (2006), p. 11]
Professional Obligation / Core Professional
Values
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Professionalism can require that one set aside
one’s personal morality or carefully limit
one’s exposure to certain professional
responsibilities. . . . For some, it may be a
mistake to choose a career in medicine.
[Kipnis(2006), p. 10]
Professional Obligation / Core Professional
Values - CRITERIA
1.
2.
3.
4.
Consensus within the profession
Attention to these values forms part of
professional education
They are “goods that the rest of us want our
doctors to care about.”
An exclusive reliance upon the profession as
the means by which certain matters are to
receive due attention.
[Kipnis (2006), p. 12]
Where do we find the core
professional obligations and values?
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Starting Point: Codes of Ethics
Further source: client expectations
Additional Clues: popular culture
Professional Obligation / Core Professional
Values
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A sound code of ethics consists of a set of
standards that, if adhered to broadly by the
profession’s membership, will result in the
profession as a whole discharging its
responsibilities.
[Kipnis (2006), p. 12]
Primacy of Professional Duty
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Ed Pellegrino (& others) argue for an
overriding principle: “Doctors must not kill”
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e.g., A.M.A. policy opposing physician
participation in executions
physician-assisted suicide, euthanasia
Kipnis argues for an overriding principle:
“Doctors must not tell”
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An exceptionless principle of confidentiality
Personal Conscience /
Commitments
Miss. Code Ann. § 41-107-3 (2007)
(h) "Conscience" means the religious, moral or ethical
principles held by a health care provider, the health
care institution or health care payer.
For purposes of this chapter, a health care institution
or health care payer's conscience shall be determined
by reference to its existing or proposed religious,
moral or ethical guidelines, mission statement,
constitution, bylaws, articles of incorporation,
regulations or other relevant documents.
Miss. Code Ann. § 41-107-5 (2007)
§ 41-107-5. Rights of Conscience of Health Care
Providers
(1) Rights of Conscience. A health care provider has the
right not to participate, and no health care provider
shall be required to participate in a health care
service that violates his or her conscience.
However, this subsection does not allow a health
care provider to refuse to participate in a health care
service regarding a patient because of the patient's
race, color, national origin, ethnicity, sex, religion,
creed or sexual orientation.
James F. Childress
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. . . a state is a better and more desirable one if
it puts the presumption in favor of exemption
for conscientious objectors (not merely to
war). It is prima facie a moral evil to force a
person to act against his conscience.
(Childress, 1979, p. 330). Childress, J.F. (1979). “Appeals to conscience,” Ethics,
89, pp. 315-335.
Quoted in John F. Peppin, “The Christian Physician in the Non-Christian
Institution: Objections of Conscience and Physician Value Neutrality,” Christian
Bioethics 1997, Vol. 3, No. 1, pp. 39-54
However,
This cannot be taken as an
absolute principle.
Childress
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If my analysis of conscience is correct, a state
is a better and more desirable one if it puts the
presumption in favor of exemption for
conscientious objectors (not merely to war). It
is prima facie a moral evil to force a person to
act against his conscience, although it may
often be justified and even necessary.
P. 330
Duties to Employer
Ideal: congruence
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Professional code =
Employer mission =
Personal conscience
When these do NOT coincide,
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The first responsibility is to try to bring them
into congruence through reconsideration,
negotiation, and compromise.
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Institution, individual have an interest in
supporting professional code to extent possible.
Institution, profession have an interest in
honoring personal conscience to extent possible.
Profession, individual have a commitment to
institution.
For example, a pharmacy can tolerate a pharmacist who
cannot in good conscience dispense “Plan B” if (s)he:
is not the only pharmacist in town
 (or perhaps) is not the only pharmacist in the
store
 and is willing to refer requests to a pharmacist
willing to fill them.
I am not sure we can tolerate a total refusal to
have anything to do with the drug.
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First trained intensivist in town
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Ordered much larger doses of morphine than
this ICU had seen before
Nurses were uncomfortable administering
those doses – expressed their concerns
Intensivist came over – administered them
himself – kept this up for several days, until
Nurses came to understand that it was
aggressive treatment but not lethal treatment
No unilateral action is justified
Institution
 Profession
 Individual
Communication & negotiation essential on all
sides.
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Duty to treat
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When a physician visited the 1995 Ebola virus
outbreak in Kikwit (DRC), he found 30 dying
patients in an abandoned hospital, left to care for
themselves amid rotting corpses, sometimes in the
same bed. Was the last doctor justified in leaving the
patients, or should he or she have been obliged to
single-handedly treat the highly and dangerously
infectious Ebola patients?
Daniel K. Sokol, “Virulent Epidemics and Scope of Healthcare Workers’ Duty of
Care” Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 8, August
2006, p. 1240.
http://www.utoronto.ca/jcb/home/documents/pandemic.pdf
B1. Ten substantive values to guide ethical decisionmaking for a pandemic influenza outbreak
1.
2.
3.
4.
Individual
liberty
Protection of
the public
from harm
Proportionality
Privacy
Duty to
provide care
6. Reciprocity
7. Equity
8. Trust
9. Solidarity
10. Stewardship
5.
B1. Ten substantive values to guide ethical decisionmaking for a pandemic influenza outbreak
1.
2.
3.
4.
Individual
liberty
Protection of
the public
from harm
Proportionality
Privacy
Duty to
provide care
6. Reciprocity
7. Equity
8. Trust
9. Solidarity
10. Stewardship
5.
B1. Ten substantive values to guide ethical decisionmaking for a pandemic influenza outbreak
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Duty to provide care
Inherent to all codes of ethics for health care
professionals is the duty to provide care and to
respond to suffering. Health care providers will have
to weigh demands of their professional roles against
other competing obligations to their own health, and
to family and friends. Moreover, health care workers
will face significant challenges related to resource
allocation, scope of practice, professional liability,
and workplace conditions.
Four Key Ethical issues
C1. Health workers’ duty to provide care
during a communicable disease outbreak
C2. Restricting liberty in the interest of public
health by measures such as quarantine
C3. Priority setting, including the allocation of
scarce resources, such as vaccines and
antiviral medicines
C4. Global governance implications, such as
travel advisories
Four Key Ethical issues
C1. Health workers’ duty to provide care
during a communicable disease outbreak
C2. Restricting liberty in the interest of public
health by measures such as quarantine
C3. Priority setting, including the allocation of
scarce resources, such as vaccines and
antiviral medicines
C4. Global governance implications, such as
travel advisories
Four Key Ethical issues
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C1. Health workers’ duty to provide care
during a communicable disease outbreak
Recommendations
3. Governments and the health care sector should
develop human resource strategies for
communicable disease outbreaks that cover the
diverse occupational roles, that are transparent in
how individuals are assigned to roles in the
management of an outbreak, and that are
equitable with respect to the distribution of risk
among individuals and occupational categories.
ANA Position Statement: “Risk and
Responsibility in Providing Nursing Care”
http://www.nursingworld.org/readroom/position/ethics/RiskandResponsibility07.pdf
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“the most precious possession of this
profession is the ideal of service, extending
even to the sacrifice of life itself . . . .”
[Committee on Ethical Standards, 1926]
ANA Position Statement: “Risk &
Responsibility in Providing Nursing Care”
“A moral obligation exists for the nurse if all four of the
following criteria are present:
1.
The patient is at significant risk of harm, loss, or
damage if the nurse does not assist.
2.
The nurse’s intervention or care is directly relevant
to preventing harm.
3.
The nurse’s care will probably prevent harm, loss,
or damage to the patient.
4.
The benefit the patient will gain outweighs any
harm the nurse might incur and does not present
more than an acceptable risk to the nurse.”
Social Work – NASW Code of Ethics
Service: Social workers elevate service to others above self-interest.
3.09 Commitments to Employers
(a) Social workers generally should adhere to commitments made to
employers and employing organizations.
(d) Social workers should not allow an employing organization's policies,
procedures, regulations, or administrative orders to interfere with their
ethical practice of social work. Social workers should take reasonable
steps to ensure that their employing organizations' practices are consistent
with the NASW Code of Ethics.
6.03 Public Emergencies
Social workers should provide appropriate professional services in public
emergencies to the greatest extent possible.
Medicine – A.M.A. 1847
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When pestilence prevails, it is [physicians']
duty to face the danger, and to continue their
labors for the alleviation of suffering, even at
the jeopardy of their own lives.
(Baker, Caplan et al. 1999)
A.M.A. Declaration of Professional
Responsibility
We, the members of the world community of
physicians, solemnly commit ourselves to:
4. Apply our knowledge and skills when needed,
though doing so may put us at risk.
http://www.ama-assn.org/ama/upload/mm/369/decofprofessional.pdf
Reconciling
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Professional Obligations just stated
Personal concerns
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Personal safety
Family obligations
Institutional Mission
Communication & Negotiation
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C1. Health workers’ duty to provide care
during a communicable disease outbreak
Governments and the health care sector should
develop human resource strategies for
communicable disease outbreaks
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that cover the diverse occupational roles,
that are transparent in how individuals are assigned
to roles in the management of an outbreak, and
that are equitable with respect to the distribution of
risk among individuals and occupational
categories.
Professions & Individuals should
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Cooperate in developing these plans
Then honor them when the occasion arises.
Bibliography / Webography
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A.M.A. Declaration of Professional Responsibility.
http://www.amaassn.org/ama/upload/mm/369/decofprofessional.pdf

ANA Position Statement: “Risk and Responsibility in Providing Nursing
Care”
http://www.nursingworld.org/readroom/position/
ethics/RiskandResponsibility07.pdf
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Baker, R., A. Caplan et al. (1999). The American Medical Ethics
Revolution. Baltimore, MD: Johns Hopkins University Press.
Childress, James F. (1979). “Appeals to conscience,” Ethics, 89, pp. 315335.
Huber, S. J. and M. K. Wynia, (2004). When Pestilence
Prevails…Physician Responsibilities in Epidemics. The American Journal
of Bioethics 4(1): W5-W11.
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Bibliography / Webography
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Kipnis, Kenneth. (2006). "A Defense of Unqualified Medical Confidentiality,"
American Journal of Bioethics 6, no. 2: 7-18.
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NASW Code of Ethics.
http://www.socialworkers.org/pubs/code/code.asp

Peppin, John F., (1997) “The Christian Physician in the Non-Christian Institution:
Objections of Conscience and Physician Value Neutrality,” Christian Bioethics,
Vol. 3, No. 1, pp. 39-54

Sokol, Daniel K., “Virulent Epidemics and Scope of Healthcare Workers’ Duty of
Care” Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 8, August
2006, p. 1240.

Stand on Guard for Thee: Ethical considerations in preparedness planning for
pandemic influenza (November 2005) Joint Centre for Bioethics, University of
Toronto. http://www.utoronto.ca/jcb/home/documents/
pandemic.pdf