Individual Conscience, Institutional Mission, Professional Code: Which Allegiance is Primary

1
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

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Short Answer

• It Depends
• depends on . . . .

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Levels of ResponsibilityEngineering Ethics

• Irresponsibility
• Fulfilling ones job description
• Professional standard
• Personal standard

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EXAMPLE auto safety

• 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.

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EXAMPLE auto safety

• 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.

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EXAMPLE auto safety - PINTO

• 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.

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Pharmacy

• 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?

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Pharmacy 2

• 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

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The Cumulative Multiple Sources of Professional
Responsibility
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1. Duty of Beneficence

• To benefit others whenever we can
• 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.

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Judy Thomson disagreesJudith Jarvis Thomson, A
Defense of Abortion, Philosophy and Public
Affairs, vol. 1, no. 1 (1971)55.

• In some views having a right to life includes
  having a right to be given at least the bare
  minimum one needs for continued life. But suppose
  that what in fact is the bare minimum a man needs
  for continued life is something he has no right
  at all to be given? If I am sick unto death, and
  the only thing that will save my life is the
  touch of Henry Fonda's cool hand on my fevered
  brow, then all the same, I have no right to be
  given the touch of Henry Fonda's cool hand on my
  fevered brow. It would be frightfully nice of him
  to fly in from the West Coast to provide it. It
  would be less nice, though no doubt well meant,
  if my friends flew out to the West Coast and
  carried Henry Fonda back with them. But I have no
  right at all against anybody that he should do
  this for me.

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2. Expertise Heightens Duty

• As I am walking with a physician, we both see a
  person collapse clutching his chest.
• I have a moral duty to go to his aid. ltfrom 1
  abovegt
• The physician has a greater moral duty, since she
  has expertise that makes her help more effective.

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3. Social contract

• 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 dont all bother to master it for
  ourselves.
• In exchange, we expect professional service.

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Social Role

• Professional or physician or ltsubstitute
  name for another professional rolegt is a social
  role
• Rule-governed behavior
• Expectations for behavior
• Internal to the individual
• Internal to the group
• External to the group

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Youre a dead duck, man! No way we can cure you!
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I assure you, its a benign procedure!
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ltyou supply the captiongt
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Professional Obligation

• i.e., obligation of professional qua professional
• Integral to social role / social contract

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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 professions
  core values inform those purposes that each
  medical professional should have in common with
  colleagues.
• Kipnis (2006), p. 11

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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 professions
  core values inform those purposes that each
  medical professional should have in common with
  colleagues.
• Kipnis (2006), p. 11

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Professional Obligation / Core Professional Values

• Professionalism can require that one set aside
  ones personal morality or carefully limit ones
  exposure to certain professional
  responsibilities. . . . For some, it may be a
  mistake to choose a career in medicine.
  Kipnis(2006), p. 10

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Professional Obligation / Core Professional
Values - CRITERIA

• 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

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Where do we find the core professional
obligations and values?

• Starting Point Codes of Ethics
• Further source client expectations
• Additional Clues popular culture

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Professional Obligation / Core Professional Values

• A sound code of ethics consists of a set of
  standards that, if adhered to broadly by the
  professions membership, will result in the
  profession as a whole discharging its
  responsibilities. Kipnis (2006), p. 12

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Primacy of Professional Duty

• Ed Pellegrino ( others) argue for an overriding
  principle Doctors must not kill
• 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
• An exceptionless principle of confidentiality

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Personal Conscience / Commitments
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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.

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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.

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James F. Childress

• . . . 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

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However,

• This cannot be taken as an absolute principle.

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Childress

• 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

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Duties to Employer
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Ideal congruence

• Professional code
• Employer mission
• Personal conscience

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When these do NOT coincide,

• The first responsibility is to try to bring them
  into congruence through reconsideration,
  negotiation, and compromise.
• 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.

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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

• 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

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No unilateral action is justified

• Institution
• Profession
• Individual
• Communication negotiation essential on all
  sides.

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Duty to treat

• 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.

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http//www.utoronto.ca/jcb/home/documents/pandemic
.pdf
44
B1. Ten substantive values to guide ethical
decision-making for a pandemic influenza outbreak

• Individual liberty
• Protection of the public from harm
• Proportion-ality
• Privacy

• Duty to provide care
• Reciprocity
• Equity
• Trust
• Solidarity
• Stewardship

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B1. Ten substantive values to guide ethical
decision-making for a pandemic influenza outbreak

• Individual liberty
• Protection of the public from harm
• Proportion-ality
• Privacy

• Duty to provide care
• Reciprocity
• Equity
• Trust
• Solidarity
• Stewardship

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B1. Ten substantive values to guide ethical
decision-making for a pandemic influenza outbreak

• 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.

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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

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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

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Four Key Ethical issues

• 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.

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ANA Position Statement Risk and Responsibility
in Providing Nursing Care
http//www.nursingworld.org/readroom/position/ethi
cs/RiskandResponsibility07.pdf

• 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

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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
• The patient is at significant risk of harm, loss,
  or damage if the nurse does not assist.
• The nurses intervention or care is directly
  relevant to preventing harm.
• The nurses care will probably prevent harm,
  loss, or damage to the patient.
• 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.

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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.

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Medicine A.M.A. 1847

• 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)

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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/decofpro
fessional.pdf
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Reconciling

• Professional Obligations just stated
• Personal concerns
• 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
• 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.

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Professions Individuals should

• Cooperate in developing these plans
• Then honor them when the occasion arises.

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Bibliography / Webography

• A.M.A. Declaration of Professional
  Responsibility. http//www.ama-assn.org/ama/uploa
  d/mm/369/decofprofessional.pdf
• ANA Position Statement Risk and Responsibility
  in Providing Nursing Care http//www.nursingworld
  .org/readroom/position/ ethics/RiskandResponsibili
  ty07.pdf
• 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. 315-335.
• Huber, S. J. and M. K. Wynia, (2004). When
  Pestilence PrevailsPhysician Responsibilities in
  Epidemics. The American Journal of Bioethics
  4(1) W5-W11.

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Bibliography / Webography

• Kipnis, Kenneth. (2006). "A Defense of
  Unqualified Medical Confidentiality," American
  Journal of Bioethics 6, no. 2 7-18.
• 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