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Conscience and moral obligations of physicians

2017; Wiley; Volume: 53; Issue: 8 Linguagem: Inglês

10.1111/jpc.13647

1440-1754

David Isaacs,

Clinical Reasoning and Diagnostic Skills

While teaching young doctors in Vietnam recently, I asked them to define conscience. One answered, ‘It is what is in your heart’. Her wonderful answer encapsulated some things for me. A good doctor is one who respects what is in the heart as well as in the head. Your conscience is your personal sense of right and wrong; it guides how you behave and makes you feel guilty if you do not behave as you would have wished. A moral obligation is different; it is how we feel all physicians ought to behave. There are some things the public might expect from any physician which could reasonably be considered true moral obligations, while there are other things which people might hope for from a physician, and could be considered aspirations rather than obligations. Probably, the first code of ethics for doctors was introduced by Hammurabi, King of Babylon, around 1750 BC. This code held doctors responsible if anything went wrong: ‘If a physician shall make a severe wound with the bronze operating-knife and kill him, or shall open a growth with a bronze operating-knife and destroy the eye, his hands shall be cut off.’1 Western doctors have preferred unsurprisingly to set their own rules. Hippocrates was born around 460 BC on the Greek island of Cos. He studied, practised and taught medicine all his life. He and his followers developed a code of ethics, expressed in the Hippocratic Oath, which is followed in Western medicine to this day.2 Hippocrates emphasised that a physician must learn skills from predecessors and should teach those skills to students. He urged a middle ground between over-treatment and therapeutic nihilism. Hippocrates saw medicine as an art as well as a science and stated that empathy: warmth, sympathy and understanding might be as important as any other intervention. He also praised humility and taught that doctors should not hesitate to consult colleagues when unsure. He said we should respect patient privacy. He told us never to forget we were treating a sick human being, not a fever or a cancer, and stressed the effect, including financial, of illness on the whole family and indeed on all of society.2 When trying to decide what is morally obligatory for physicians and what is aspirational, we may invoke the concept of medical professionalism. A profession, from the Latin word professio which means a public declaration with the force of a promise, is a group whose members promise to act in certain moral ways and which will punish or exclude members who transgress. The essential difference between a profession and a business is that professionals have a fiduciary duty to those they serve, that is a relationship built on trust. The professions (medicine, law, education and the clergy) have their own codes of ethics. They promise competence and have specific duties and responsibilities towards the individual and towards society.3 The profession offers a social benefit which society accepts, in the expectation of them fulfilling an important social goal.3 Attempts to define medical professionalism include those from US bodies, whose charter states that the three fundamental principles are primacy of patient welfare, patient autonomy and social justice.4 The professional responsibilities that follow from the above definition include a commitment to competence and knowledge, honesty with patients, confidentiality, appropriate relationships with patients, just distribution of resources and maintaining trust by managing conflicts of interests.3, 4 Advocacy for patients, giving a voice to those who cannot be heard, while not specifically addressed in the charter, is often cited as something we can expect of physicians.5 However, in extreme situations such as revealing what happens to children in immigration detention, advocacy may involve some personal risk.6 In such situations, when the safety of doctors and their families is a relevant consideration, the decision to expose iniquity is surely a matter of conscience, not obligation.5, 6 Doctors are in a position of power and they have a responsibility to use and not abuse that power. Of course, this is all well and good but what about the true story of the surgeon who, when you ask him to wash his hands and wear gloves before handling a baby colonised with a multiresistant organism, throws the gloves in your face? This is a surgeon with no conscience about his bad behaviour. Of course, the institution where he works should set strict rules about such behaviour, and should impose sanctions and threat of dismissal if the behaviour is ever repeated. The Department of Surgery should acknowledge and agree to uphold these standards. In practice, few institutions have the courage to stand up to surgeons who abuse their position of power. In trying to describe the obligations and values of a professional physician, others do not always distinguish clearly between the obligatory and the aspirational.7, 8 In a construct which, with a nod to Hippocrates, draws on a Greek temple model, the foundation of medical professionalism is clinical competence, followed by good communication and a sound understanding of ethics (Fig. 1).7, 8 Are good communication skills obligatory? When a general practitioner of my acquaintance was referring patients to an orthopaedic surgeon, he would ask if they wanted the best operator technically but one with no bedside manner or a kind, considerate surgeon who was good but not such a brilliant surgeon. Warning patients what to expect from a consultation was a nice ploy. It also implied the good technician with poor communication skills was not a bad doctor, just a different one. So although during medical training we emphasise good communication, it is perhaps aspirational rather than essential. Poor communicators can always work fulltime in laboratories or become orthopaedic surgeons. The pillars of professionalism in the model are accountability, altruism, excellence and humanism. Accountability means that a physician should take responsibility for patients and be accountable not only to their patients but also to society and to their profession. Altruism is described as a physician's obligation to attend to the best interests of patients rather than to self-interest, and conscience is surely relevant here. Excellence refers to a commitment to life-long learning. Humanism refers back to Hippocrates’ emphasis on treating a human being. Others have stressed that medical professionalism includes a duty or commitment to service within the profession and the community.3 Physicians should have honour and integrity: a commitment to being fair, truthful and straightforward in interactions with patients and the profession. Physicians should show respect for patients and their families, and indeed for other colleagues at all levels of training. These are values that should help guide us to behave professionally and to make difficult ethical decisions.3 Thanks to Phil Britton, Tom Isaacs and Henry Kilham for their helpful advice on earlier drafts.