ETHICS AND
PROFESSIONALISM By
EMMANUEL RUDAKEMWA, MD, FCRAD (SA)
Associate Clinical Professor, Radiology and radiation
sciences
Chairman of Rwanda Medical and Dental Council
INTRODUCTION
In Rwanda, all stakeholders expect the best quality care; it is also
a worldwide concern. Medical & Dental profession under
increased public scrutiny, public health information available to
more people, request for evidence-based practice and better
standards of care, new medical insurance law, etc. In the medical
and dental school, we study essentially basic science, clinical
skills with little time left for other required skills for quality care
(professionalism, leadership, communication, etc.) and ethics.
Patients are entitled to good standards of practice and care from
their Doctors. Essential elements of this are professional
competence, good relationships with patients and colleagues and
observance of professional ethical obligations.”
LAYOUT AND APPROACH
I do not intend to talk about the principles as they appear in the
1847 Code of Ethics
I want us to examine whether or not ethics are still relevant to the
medical profession, so that if they are relevant, examine further
whether they are effective and suggest a way forward
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DISAMBIGUATION OF ETHICS
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Ethic refers to a set of moral principles (origin:
from Old French éthique, from Latin ethice, from
Greek (hē) ēthikē (tekhnē) ‘(the science of) morals’, based on ēthos)(Concise
Oxford English Dictionary.2011, twelfth ed,
Oxford University Press: 490)
Moral refers to the principles of right and wrong behavior, it also
means that which is based on adhering to the code of behavior that is considered socially right or acceptable (Oxford Dictionary supra:
929)
Principle refers to a fundamental truth or
proposition serving as the foundation for belief or
action. It also refers to a rule or belief governing one’s behaviour (Oxford Dictionary supra: 1140)
Ethics refers to the moral principles governing or
influencing conduct (Oxford Dictionary supra: ibid)
Ethos means characteristic spirit of a culture, era, or
community as manifested in its attitudes and aspirations
(Oxford Dictionary supra: ibid), e.g. Ubuntu is
therefore the Ethos of the African traditional culture.
OUTLINE
1. What is ethics in healthcare
2. Different types of Ethical tensions/Issues :
o Ethical dilemmas
o Ethical distress
o Ethical uncertainty
o Ethical principles
3. Professional values
4. Client’s rights and responsabilities
5. Health systems and ethical challenges
6. Ethical deliberation Models:( 6-Steps)
7. Medical Professionalsm
8. Medical Malpractice Management
9. Conclusion
I. WHAT IS ETHICS IN HEALTHCARE?
What does ‘ethics’ mean to you?
World Health Organization: “ethics is concerned with moral
principles, values and standards of conduct” (WHO, 2016)
The “best” thing to do (Storch, 2004)
Questions about “should I or shouldn’t I”?
Weighing potential impact of decisions or actions
Healthcare professionals’ conduct and choices given multiple
considerations and competing demands
II. Ethical Tension/ Competing Demands
What are some competing demands that you face in your everyday
practice?
How do you experience ethical tension?
Importance of attending to those sensations
Ethical tensions – feeling pulled
between multiple competing demands
3 TYPES OF ETHICAL TENSIONS
1. Ethical dilemmas(Urungabangabo) – 2 or more
mutually exclusive potential courses of action, each
with negative implications
2. Ethical distress(icyera gati) – Know what is
‘best’ thing to do, but are constrained from doing
that
3. Ethical uncertainty(Amayobera) – Not knowing
IF there is an ethical tension, WHAT it is, or WHAT
principles or values are in conflict
(Jameton, 1984)
III. Ethical Principles and Professional Values
Four ethical principles o Autonomy
o Beneficence
o Non-maleficence
o Justice
Professional values o Veracity, Fidelity, empathy
o Privacy and confidentiality
III.1 AUTONOMY
Varying definitions: Self governance and self-determination
o the capability to have input into determining your own well-being (Purtilo & Doherty, 2016)
o ‘self-rule that is free from both controlling interference by others and limitations that prevent meaningful choice’(Beauchamp & Childress p.101)
Upholding autonomy - Supporting self-determination in others and their freedom to choose what constitutes a good quality of life for them (Sasson, 2000)
III.2 RELATIONAL AUTONOMY
1. Individuals live in contexts, are
socially and politically embedded
2. Contexts have shaped, and
continue to, shape individual
identity, capacities to enact
autonomy (Mackenzie & Stoljar,
2000; Sherwin, 1998)
Varying definitions: two main premises
Relational Autonomy – Individual Contexts
What shapes individual autonomy?
“The nurse promotes an
environment in which the
human rights, values,
customs and spiritual
beliefs of the individual,
family and community are
respected.” (ICN, 2012, p.3)
Beneficence – ‘all forms of action
intended to benefit others’
Non-maleficence – intentionally refraining from actions
that contribute to harm (p.197)
(Beauchamp & Childress, 2013; Purtilo & Doherty, 2016)
III.3 Beneficence & Non-Maleficence
Beneficence and
Non-Maleficence
In healthcare, there are multiple and possibly competing
‘best’ interests, and potential benefits or harms
What might be patients’ best interests?
Harms?
Benefits?
III.4 JUSTICE
Multiple applications:
Distributive– allocation of resources
Substantive – distribution based on need, skills,
capacities
Procedural – rules guide distribution (e.g. first
come first served)
In codes of conduct:
Non-discrimination in provision of care
Fair allocation of resources considering need, priorities and availability
to provide good quality and effective healthcare
How is justice applied or enacted in your own settings? How might
injustice appear? In the case discussed, is there an issue with this
principle?
IV. PROFESSIONAL VALUES
o What does this value mean?
o What does it mean to you?
o How does it apply to (your) healthcare context?
o What barriers exist to its application in healthcare contexts?
‘Veracity’, ‘Fidelity’, ‘Privacy and Confidentiality’, ‘Empathy’
IV.1 Veracity
What does this value mean?
What does this value mean to
you?
How does it apply in healthcare
contexts?
What barriers exist to its
application in healthcare
contexts?
IV.2 FIDELITY, EMPATHY
What do these values mean?
What do they mean to you?
How do they apply in healthcare
contexts?
What barriers exist to their
application in healthcare contexts?
IV.3 Privacy and Confidentiality
What do these values mean?
What do these values mean to you?
How do these apply in healthcare contexts?
What barriers exist to their application in healthcare
contexts?
V. PATIENT RIGHTS
Differ based on various attributes such as country, jurisdiction, healthcare
setting, culture or religion
Depend on social norms and cultural beliefs
May vary in relation to patient population
Important considerations
Do the patient and family (if relevant)
know their rights?
Are these clear and easy to access or
understand? (e.g. language, where
posted etc.)
Charter of Patient Rights and
Responsibilities for Rwanda
Patient right to:
o Care
o Privacy
o Information
o Choices
o Respect
o Complain
Patient responsibility to:
o Take care of own health
o Access and use properly and not abuse
health system
o Respect rights of HCPs
o Provide relevant information about their
health
o Follow instructions
o Ensure they have means to pay
PATIENT RIGHTS
Are patient rights visible and accessible to patients in healthcare settings?
Do you feel that patients understand their rights? What makes you think this?
As Medical/dental practitioners are you aware of patients’ rights? If Not Why?
What can or do you do to help increase patients’ understanding of their rights?
VI. HEALTH SYSTEM AND ETHICAL
CHALLENGES
Can health system policies and or challenges contribute to, or even set up, situations of ethical challenges? If Yes, please explain more using your own experiences in your respective discipline
HEALTH SYSTEMS AND ETHICAL CHALLENGES
Yes, health system policies or challenges can sometimes contribute to, or even set up, situations of ethical challenges
Examples:
o Shortage of healthcare professionals
o Large number of patients
o Health insurance payment structure
• patients’ lack of health insurance or money
• delays in payments to hospital
o Inequity in distribution of equipment and materials, etc.
(These situations can be the source of ethical distress for example)
HOW TO HANDLE ETHICAL ISSUES
Ethical Deliberation Models
Ethical Deliberation Model Durocher, Kinsella & Mazer (2017)
Six-step model developed by
collating and summarizing a
variety of published models
(see bibliography)
Steps 1-4 are a process, can
be, and may need to be
repeated
26
Ethical Deliberation Model
Step 1: Identify the ethical issue
Is there an ethical
issue?
If so, what is it?
Is there more than one
ethical issue?
27
Ethical Deliberation Model
Step 2: Gather relevant information
Who are the individuals involved
in the situation?
What are their roles and
responsibilities?
What is their perspective?
What are the needs, preferences
and skills?
What are the different contexts or
contextual elements that need to
be considered?
28
Ethical Deliberation Model
Step 3: Identify and apply ethical
principles and professional values
What principles and values may
be discerned or relevant in the
situation?
o Relational autonomy
o Beneficence and non-maleficence
o Justice
o Veracity
o Fidelity
o Privacy and confidentiality
o Patient rights
29
Ethical Deliberation Model Step 4: Identify potential courses of action
What are the potential courses of action?
Is that it?
Be creative, think outside the box
What are potential benefits, risks and/or harms associated with each option?
How might each option affect each of the individuals involved?
30
Ethical Deliberation Model
Remember, Steps 1-4 are a process…
o Are you happy with the information uncovered in each step?
o Do any of the steps need to be revisited?
31
Ethical Deliberation Model
Step 5: Decision and action
Identify which option
you wish to pursue
Decipher all actions
required to move
forward with this choice
Take all actions
required to move
forward towards this
choice 32
Ethical Deliberation Model Step 6: Evaluate process and outcomes
Aim is to learn from the situation
Can occur immediately following or may be benefit to allowing a little bit of time to pass before evaluation
What went well?
What was difficult?
What could be improved?
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PART II:
PROFESSIONALISM
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Unit I. Ethics in Health care settings
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MEDICAL MALPRACTICE MANAGEMENT
Investigating into the case:
Receiving complaints of alleged misconduct
Prompt investigation into the allegation of misconduct of the health care provider
Establishing facts, the type and gravity of the alleged misconduct (analysis of the report)
Receiving and protection of the reporter or whistle blowers;
Referring the offender to the judiciary when necessary
MALPRACTICE MANAGEMENT (CONT’D)
Facilitating professional misconduct hearing process
Fair due process
Right to be heard
Right to appeal
Determining appropriate sanction
MALPRACTICE CASES PER YEAR
From January 2008 to 2018
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41
4 5
6
13
8
12 12
27
34
37
31
0
5
10
15
20
25
30
35
40
Year 2008 Year 2009 Year 2010 Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016 Year 2017 Year 2018
Malpractice cases per year ( from 2008- to 2018)
Total Case
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MALPRACTICE CASES PER SPECIALITY
From 2008 to 2018
0
10
20
30
40
50
60
70
80
90
Anesthesia InternalMedicine
Obstetrics andGynecology
Pediatrics Surgery Fraud Otherspecialities
6 10
82
29 24 25
10
3 5
44
16 13 13
5
Frequency Percentage
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DISCIPLINARY MEASURES TAKEN AGAINST
INVOLVED MEDICAL/DENTAL PRACTITIONERS
From 2008 to 2018
0
5
10
15
20
25
30
35
40
45
50
Warning One Monthsuspension
Three MonthsSuspension
Six MonthsSuspension
Removal from theRegister
Number 13 34 46 24 1
13
34
46
24
1
Number
CONCLUSION
Stakeholders urged to collaborate and support health care
regulators and providers in their service provision through
increased dialogue in order to address professional issues
that affect the public we all serve.
Reporting a negative incident at the workplace in time can
save lives.
The Good Medical Practice principles are the guiding tools
for the day to day action of the Rwanda Medical and Dental
Council.
References
Beauchamp, T., & Childress, J. (2013). Principles of
biomedical ethics. New York, NY: Oxford University Press.
Doane, G. (2004). Being an ethical practitioner: The
embodiment of mind, emotion and action. In J. Storch, P.
Rodney & R. Starzomski (Eds.). Toward a moral horizon:
Nursing ethics for leadership and practice (pp. 433-446).
Toronto, ON: Pearson-Prentice Hall.
Drolet, M-J., & Hudon, A. (2015). Theoretical frameworks
used to discuss ethical issues in private physiotherapy
practice and proposal of a new ethical tool. Medicine,
Health Care and Philosophy, 18(1), 51-62.
References,
(Yiika Sejdiu, 2018). Population Health Improvements And Challenges In Rwanda.
Mackenzie, C. (2008). Relational autonomy, normative authority and perfectionism. Journal of social philosophy. 39(4), 512-533.
Mackenzie, C., & Stoljar, N. (2000). Introduction: Autonomy refigured. In C. Mackenzie & N. Stoljar (Eds.), Relational autonomy: Feminist perspectives on autonomy, agency, and the social self (pp.3-34). New York, NY: Oxford University Press.
Ministry of Health.(2009) Charter of patient rights and responsibilities for Rwanda. Kigali, RW: MOH.
Purtilo, R., & Doherty, R. (2011). Ethical dimensions in the health professions. St. Louis, MI: Elsevier.
Reis, V., Deller, B., Carr, C., & Smith, J. (2012). Respectful maternity care: Country experiences. Survey Report. Washington DC: United States Agency for International Development.
Sasson, S. (2000). Beneficence versus respect for autonomy: An ethical dilemma in social work practice. Journal of Gerontological Social Work, 33 (1), 5–16.
References, Cont’d….
Sherwin, S., & Winsby, M. (2010). A relational perspective on autonomy for older adults residing in nursing homes. Health Expectations, 14, 182-190.
WHO (2016a) Ethics. Retrieved from: http://www.who.int/topics/ethics/en/, September 16, 2016.
WHO, (2016b), Patient Rights. Retrieved from: http://www.who.int/genomics/public/patientrights/en/, November 55, 2016.
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References, Cont’d….
Thank you
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