Medicine is an inherently moral profession. In everything that physicians do, we are guided by our promise to help patients and to avoid harming them. We came to the profession because we wanted to make a difference in the lives of other men and women. We value the relationships we have with our patients, their families, and our colleagues. Moral dilemmas are part of the life of every physician, and we look to the rich medical ethical tradition for guidance when facing them. Whether it be responding to requests for nonbeneficial interventions or resolving conflicts of interest, the ethical principles of medicine provide us with wisdom. At ProNobis Health, we place great value on medicine’s ethical tradition. We believe that understanding the ethical principles on which medicine is founded, particularly their application to some of the difficult situations we commonly face, gives us moral courage. Furthermore, we believe that this can reduce the likelihood that moral dilemmas will lead to moral distress, injury, or burnout. We also believe that much of the art of medicine can be found in its ethical principles, which distinguishes us from other professions.
We know that many physicians feel called to the profession. For us, medicine is more than a job; it is a vocation. We value the science as well as the art of our profession. However, technology, the need for efficiency, cost-cutting measures, and unrealistic expectations have made practicing the art of medicine difficult. Advances in science and standardization of treatment have certainly led to improved quality of patient care, but they have also taken some of the intellectual stimulation out of the practice of medicine. As many have observed, doctors are suffering from a moral crisis. Many solutions have been proposed, including practicing mindfulness, giving and receiving gratitude, and finding joy and meaning in practice. While each of these is worthwhile and useful, at ProNobis Health we believe that moral injury can in part be addressed by increasing moral courage and resilience. We believe that by helping physicians rediscover the ethical foundations of medicine and giving them tools to apply these principles to some of the most value-laden patient care situations, moral dilemmas will be less burdensome to physicians, and we can be confident in the difficult decisions that we have to make. The forces at play in medicine are unlikely to reverse course, and some of the threats to depersonalization may increase. However, we believe that moral resilience will lead to moral courage.
Medical Ethics Overview
We present here a careful review of the Hippocratic Oath as well as a discussion of the major biomedical theories. We recognize that sometimes ethical commitments compete, such as when our commitment to maintain patient confidentiality competes with our obligation to protect the public. This can occur if we learn of a credible threat to public well-being during a patient encounter. We propose a model for resolving conflicts. At ProNobis Health, we believe that beyond the moral dilemmas inherent in the profession, the core values of medicine are sometimes challenged by the systemization of health care, and that physicians are often caught in the middle. We believe that this causes injury to the very conscience of the physician. These situations can be lonely and isolating. By re-engaging with the ethical foundations, particularly the Hippocratic Oath, we want to help restore not only the art of medicine but also physicians’ moral courage. We believe that the physician’s conscience is as important as his or her intellect, and we want to help nourish this part of the self equally with the intellect and body.
Responding to Requests for Nonbeneficial Interventions
As physicians, we frequently have to respond to requests for nonbeneficial interventions. Previously referred to as futile treatments, or simply “futility,” the definition of these terms has proven elusive. As well, these terms suggest a lack of respect for the diverse perspectives of stakeholders. These requests can run the spectrum of severity from a request for a low-risk medication that is unlikely to remedy the patient’s problem, to a request for a potentially life-sustaining treatment. Because physicians value harmony in relationships with our patients, responding to these requests can be very stressful. It can at times be easier to “say yes” rather than explain why the requested intervention is not indicated. Sometimes patients become angry, file complaints, or try to find another physician who will agree with them. The most dramatic cases, involving high stakes interventions, can even go to court for resolution. It is important for physicians to understand how to respond to these requests, and ProNobis Health can help. In this section we discuss how to respond to requests for nonbeneficial interventions, particularly the importance of communication. We acknowledge respect for patient autonomy, and also the commitment we have to our own professional autonomy.
Conflicts of Interest in Medicine
Based on the frequency of diverse relationships and roles in medicine, conflicts of interest seem to be everywhere. Several high-profile cases have made physicians sensitive to the conflicts, especially when public trust is at stake. At ProNobis Health, we value high-quality patient care, rigorous scientific research, objective medical education, and loyal organizational service. We also place a premium on public trust. In this section, we describe a system for evaluating conflicts of interest, based on severity, which forms the basis for resolving the conflict. We recognize that addressing conflicts of interest involves assessing both the risk of bias, as well as the harm that could result. We offer a standardized template for assessment that emphasizes both the facts of the conflict, and the art of judgment in proposing a resolution.
Addressing Unintended Adverse Events
Every physician fears an unintended adverse event. We take seriously our promise in the Hippocratic Oath to help patients and avoid harming them. When harm does occur, it can be traumatizing for the physician. At ProNobis Health, we can help physicians respond to these events in a manner that cares for the patient and family but also recognizes the emotional needs of the physicians involved. When these events occur, it can be difficult to think clearly and our judgment can be affected. We propose a systematic way of responding, one step at a time. We also emphasize the importance of a “just culture” in responding to adverse events, and recognition of the physician as a “second victim.” We believe that thinking in advance about how you will respond to these events if they occur will lead to increased moral clarity in the moment, and greater long term resilience.