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Module 1: Codes of Conduct

Upon completion of this module, the resident should be able to:

  1. Identify and describe the principal ethical precepts of
    • The Hippocratic Oath
    • The Code of Maimonides
    • The Declaration of Geneva
    • The American Medical Association's Principles of Medical Ethics
    • The Patient-Physician Covenant
  2. Describe the arguments for and against oath-taking in medicine
  3. Analyze and critically evaluate the ethical precepts in various "statements" of professional morality in medicine
  4. Describe different approaches to defining a profession
  5. Identify forces contributing to the contemporary "crisis" in professionalism

Ethics & Professionalism

Module: 1 / History and Sources of Professional Morality in Medicine and Urology: Oaths, Codes, and Statements

Contents

  1. Framing the Challenges
  2. Historial, Legal, and Ethical Background
  3. What is a Profession? Consensus and Controversy
  4. Cases
  5. Case-Based Questions for Discussion, Analysis and Reflection

Framing the Challenges

With two exceptions, most of the modules in CLINICAL ETHICS FOR UROLOGISTS use brief clinical scenarios to frame the challenges inherent their respective topics. Module 1 is one of the two exceptions. If you began with the self-assessment, you should have an accurate view of your knowledge of some aspects of the topic that is the focus of this module, professional morality in medicine and urology. In order to frame some of the challenges encountered with this topic, instead of presenting you with brief clinical scenarios, this module poses the following reflective questions for you-questions that have to do with your own personal experience with oaths and codes and the broader topic of the formation of your identity as a member of the medical profession, particularly the moral and ethical dimensions of your identity:

At some point during medical school, did you swear an oath?
        o Yes
        o No

If so, when did you do so?
       o At the beginning of medical school
       o At the beginning of medical school during a white coat ceremony
       o At the end of medical school, i.e., at graduation
       o At the beginning and the end of medical school

If you did swear an oath during medical school, which oath did you swear?
       o The original Hippocratic Oath
       o A modified version of the Hippocratic Oath
       o Another oath (if you remember, please try to be specific about which oath)
       o A student-formulated oath

If you did swear an oath, describe the impact of that experience on your moral formation as a member of the medical profession:
       o Although I recall swearing an oath, I have no recollection of the specifics and no sense that the event has had a lasting impact on me
       o It was an exciting, moving event that has had no long-term impact on my identity
       o It was a moving event that caused me to reflect on my own personal orientation to morality and ethics in medicine
       o It introduced me to a set of ethical precepts that continue to shape and inform my practice of medicine today

Reflect on the values, the sense of duty, and/or the moral commitments that animate your daily conduct as a physician-with your patients, your patients' families, your peers, and your subordinates. Now, try to identify the forces in your life that have been, for you, most influential in shaping your conduct as a physician. If one were to develop a list of these forces, such a list would probably include the following. Finally, using the list below, place a "1" beside the force that has been most influential, a "2" beside the force that has been next to the most, and so on.


 

My parents and early upbringing

 

My friends

 

My faith

 

My professional peers

 

My mentors in medicine

 

My experience in medicine thus far

 

My evolving understanding of medicine as a moral endeavor

 

Other


I believe that there are things that physicians must always do, as well as things that physicians must never do.
       o Yes
       o No

If you answered "yes" to the previous question, list the things that physicians must always do, along with the things that physicians must never do-AND justify your response.

_______________________________

_______________________________

_______________________________

_______________________________

I believe that there are certain character traits that physicians must always possess.
       o Yes
       o No

If you answered "yes" to the previous question, list the character traits that physicians must always possess.

__________________________

__________________________

__________________________

__________________________

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Historial and Ethical Background

The argument that the medical profession is "in crisis" is an argument that has garnered both attention and support of late. Proponents of the argument point to signs and symptoms of a malaise that, for them, is fast approaching a state of acuity. Cynical and tired, many older physicians express regrets about having entered the profession, bedeviled as they are by allegedly frivolous malpractice suits and faceless bureaucrats in private insurance companies and the state and federal governments. Surveys indicate an erosion of trust in physicians on the part of the public. Some argue that economics and finance have introduced perverse incentives into clinical decision making. For various reasons, there is widespread concern, among medical educators, about the learning, teaching, and assessment of "professionalism." To appreciate the rich historical and ethical background to these concerns, and to evaluate the evidence for and against them, it is necessary to survey and analyze the principal oaths and codes of ethics for medical practice, to reckon with definitions of what it is to be a member of a healing profession, and to explore the forces generating the current "crisis" of professionalism in medicine.

Oaths, codes and other written (as well as spoken) statements of professional morality are historical fixtures of the practice of medicine-at least they have been since the inception of Western, rational medicine some 2,500 years ago on the Mediterranean island of Cos, home to the famed Hippocrates, whose name is joined to one of the most renowned codifications of medical morality, the Hippocratic Oath. Today, graduates at all of the 126 medical schools in the United States take an oath of some form-often a modified Hippocratic Oath-in conjunction with the awarding of their MD degrees. The public taking and swearing of an oath at this time marks the new physician's formal admission to the profession of medicine-a profession whose members practice in accord with certain ethical precepts specifying what they should and should not do, as well as the values and virtues that they should exemplify in their behavior. Oaths are not, however, the only formal expression of professional morality in medicine. There are, as well, prayers, statements of principle, covenants, declarations, and codes. And, in the last decade, in reaction to the ethically corrosive effects of economic, financial and cultural forces, physician groups have sought to develop and promulgate new more contemporaneous and "binding" statements of professional morality: witness, for example, the Patient-Physician Covenant , which below is reproduced and analyzed.

Below are different expressions of professional morality in medicine, spanning two and a half millennia. The code of ethics of the American Urological Association will be introduced in Module 2. Each of the following expressions of professional morality is preceded by a brief historical introduction and followed by a brief analysis of its ethical precepts. There are other statements of professional morality in medicine; thus, the following is not an exhaustive, but rather a representative catalog.

The Hippocratic Oath:

History: The Hippocratic Oath is one of the best known statements of professional morality in the history of Western medicine. Scholars of ancient medicine have traced its origins to the 4th century, B.C., but due to a lack of evidence, other aspects of its early history remain obscure. One prominent theory has been that it reflects the thinking of the rather ascetic, philosophical sect known as the Pythagoreans (named for Pythagoras, the renowned ancient mathematician and philosopher).

I swear by Apollo Physician and Asclepius and Hygeia and Panacea and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.

If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

Translation from the Greek by Ludwig Edelstein. From The Hippocratic Oath: Text, Translation, and Interpretation, by Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943.

Analysis: Contemporary critics of the Oath-i.e., those who are skeptical of its relevance or value today-argue that many features of the Oath are anachronisms that render it largely useless or ineffectual as a guide to the ethical practice of medicine. They cite, for example, the opening appeal to certain deities of ancient Greece as well as the now out-moded prohibition on surgery-and, in some cases, the second paragraph with its elaborate statement of what the initiate owes to his teachers and family members. There are others, however, who defend the Oath, especially insofar as it articulates, at the dawn of Western medicine, certain enduring ethical precepts that are now prized as definitive elements of the ethical practice of medicine. One such enduring ethical precept-perhaps the most important-is that which establishes patient benefit as the central obligation of the physician: in two places in the Oath, statements pledging fidelity to the principle of beneficence are married, first, to an accompanying commitment to non-maleficence (preventing and avoiding harm) and second, to an accompanying commitment to keep individual patients from injustice. Another enduring precept speaks to the boundaries characteristic of professional relationships and prohibits any form of sexual congress with patients. A third precept articulates the now-traditional duty to maintain and protect the confidentiality of patient information. And a fourth precept-perhaps more controversial in these days and times-places both abortion and assisted suicide outside the realm of ethical practice. The Oath closes with a statement of self-prescribed accountability: the swearer of the Oath accepts, indeed, welcomes the adverse consequences of violating his Oath.

It should be noted in this context that the idea that the injunction, "First, do no harm," is included in the Oath is a widespread misconception. It does appear to derive, however, from another text in the HippocraticCorpus-that is, from the Epidemics and specifically, from a passage that reads: "Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things-to help, or at least to do no harm."

The Code of Maimonides:

History: Maimonides was a Jewish rabbi, philosopher, and physician who was born in Spain in 1135. In 1148, he and his family were forced to leave their hometown of Cordoba; after living for intervals in southern Spain, Morocco, and Jerusalem, Maimonides settled in Egypt, where he died in 1204. Author of the well known Guide for the Perplexed, he is regarded as the most influential figure in medieval Jewish philosophy and was a decisive force in the intellectual development of Albert the Great, Thomas Aquinas, and Duns Scotus.

The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.

May I never see in the patient anything but a fellow creature in pain.

Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements.

Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.

Analysis: Like the Hippocratic Oath, the Code of Maimonides begins with an invocation of the divine-in this case, the God of Judaism-and proceeds with the recitation of a series of prayerful supplications denoted by such words as "may" and "grant." The Code thus anchors its ethical precepts in (1) the relationship between the physician and God and (2) the idea that the physician's abilities as well as his entire sense of his own profession is ultimately dependent upon divine guidance and grace. The Code then appeals to the orienting virtue of love as the primary impetus to the physician's actions and beliefs, as well as to the virtue of truth. In addition to stipulating critical elements of the physician's ethical grounding, the Code then articulates two principal precepts: with the first, the physician enjoins himself to remember, always and ever, that patients are "fellow" creatures with whom he shares the same possibilities of experience, i.e., the experience of health and pleasure, on the one hand, and the experience of disease and pain, on the other. The second principal ethical precept focuses on the physician's responsibilities for medical knowledge: the physician commits himself to ensuring the integrity of that knowledge by seeking to correct errors and advance its scope.

The World Medical Association
Declaration of Geneva (1948)
Physician's Oath

History: The Declaration of Geneva/Physician's Oath was adopted by the General Assembly of the World Medical Association in Geneva, Switzerland in September 1948 and amended by the 22nd World Medical Assembly, meeting in Sydney, Australia in August 1968. The oath is, first and foremost, a response to the atrocities committed by German physicians in Nazi Germany. In a parallel development, three months later, the United Nations General Assembly adopted the Universal Declaration of Human Rights.
       At the time of being admitted as a member of the medical profession:
       I solemnly pledge myself to consecrate my life to the service of humanity;
       I will give to my teachers the respect and gratitude which is their due;
       I will practice my profession with conscience and dignity; the health of my patient will be my first consideration;
       I will maintain by all the means in my power, the honor and the noble traditions of the medical profession; my colleagues will be my brothers;
       I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient;
       I will maintain the utmost respect for human life from the time of conception, even under threat, I will not use my medical knowledge contrary to the laws of humanity;
       I make these promises solemnly, freely and upon my honor.

Analysis: The Declaration of Geneva has been described as an "updating" of the Hippocratic Oath and there are clear parallels between the latter and the former. Like the Hippocratic Oath, the Declaration describes a certain debt that the newly admitted members of the medical profession owe to their teachers (i.e., "respect and gratitude") as well as the ways in which they are to treat other members of the profession ("my colleagues will be my brothers"). In similar ways, as well, the Oath gives pride of place to patient benefit-"the health of my patient will be my first consideration."  Unlike the Oath, however, the Declaration commits the physician to the broad goal of serving humanity and, more concretely and practically, "respect for human life, from the time of conception."   Also concretely and practically, with the Oath, the physician promises, implicitly, to respect the claims of equality in caring for patients: that is, to eschew any bias against or in favor of patients on the basis of their individuating characteristics. Finally, in a veiled reference to some German physicians under the Third Reich, the Oath commits to the physician to the beneficial use of medical knowledge-i.e., beneficial with respect to the particular patient.

The American Medical Association's Principles of Medical Ethics:

Preamble: The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.

Principles of medical ethics

A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.

A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.

A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.


A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.

A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.

A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.

A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

A physician shall, while caring for a patient, regard responsibility to the patient as paramount.

A physician shall support access to medical care for all people.

Adopted bythe AMA's House of Delegates June 17, 2001.

Analysis: The AMA Code of Ethics is one of the better known contemporary statements of professional morality. As the preamble makes clear, the ethical precepts that make up the code do not have legal standing and instead constitute "standards" of conduct defining the "essentials of honorable behavior." Hence, the precepts are not presented as having the ethical status of duties that are inherent in the nature of medicine and medical practice-in the sense of perfect moral obligations that hold in all circumstances, at all times. They are instead exhortatory guidelines that are intended to illuminate the path of ethical practice in medicine. Some of the "shall" statements, however, implicitly and explicitly appeal to other ways of explaining and justifying ethical conduct. For example, the first principle specifies the clinical virtues with which "competent medical care" should be provided, i.e.., with compassion and respect. The second principle also appeals to a clinical virtue, i.e., the virtue of honesty, while invoking one of the essential features of a profession, i.e., that the members are responsible for holding each other accountable. There is, as well, another prominent "language" or theory of ethics that is cited in the principles of the code: the language of rights. The fourth principle uses "rights" language in this respect, although it does not specify what rights. Two of the principles seem to urge that physicians have a sense of social responsibility, i.e., principles six and eight, but again, the exact substance of the precept is left unspecified. Finally, like the Hippocratic Oath and the Declaration of Geneva, the AMA Code of Ethics includes an emphasis, via principles three and eight, on the centrality of the patient and the patient's interests in clinical decision making and judgment.

The Patient-Physician Covenant

History: This covenant was formulated by five nationally prominent physicians who came together out of a shared concern about the way in which economic and financial forces have transformed the very nature of the physician-patient relationship. It was published in 1995 with the aim of having it "adopted" by educational institutions and professional organizations.

Medicine is, at its center, a moral enterprise grounded in a covenant of trust. This covenant obliges physicians to be competent and to use their competence in the patient's best interests. Physicians, therefore, are both intellectually and morally obliged to act as advocates for the sick wherever their welfare is threatened and for their health at all times.

Today, this covenant of trust is significantly threatened. From within, there is growing legitimation of the physician's materialistic self-interest; from without, for-profit forces press the physician into the role of commercial agent to enhance the profitability of health care organizations. Such distortions of the physician's responsibility degrade the physician-patient relationship that is the central element and structure of clinical care. To capitulate to these alterations of the trust relationship is to significantly alter the physician's role as healer, carer, helper, and advocate for the sick and for the health of all.

By its traditions and very nature, medicine is a special kind of human activity-one that cannot be pursued effectively without the virtues of humility, honesty, intellectual integrity, compassion, and effacement of excessive self-interest. These traits mark physicians as members of a moral community dedicated to something other than its own self-interest.

Our first obligation must be to serve the good of those persons who seek our help and trust us to provide it. Physicians, as physicians, are not, and must never be, commercial entrepreneurs, gateclosers, or agents of fiscal policy that runs counter to our trust. Any defection from primacy of the patient's well-being places the patient at risk by treatment that may compromise quality of or access to medical care.

We believe the medical profession must reaffirm the primacy of its obligation to the patient through national, state, and local professional societies; our academic, research, and hospital organizations; and especially through personal behavior. As advocates for the promotion of health and support of the sick, we are called upon to discuss, defend, and promulgate medical care by every ethical means available. Only by caring and advocating for the patient can the integrity of our profession be affirmed. Thus we honor our covenant of trust with patients.

Analysis: The Covenant is one of the more cogent and, from the perspective of medical ethics, coherent statements of professional morality ever crafted. It is clear and unambiguous in its appeal to various forms of ethical argumentation and justification-and in the way it marshals a sophisticated vision of what medicine is and relates it to the question of what physicians should and should not do. Its use of the notion of a "covenant" harkens back to the Old Testament, to the covenant established there and then between the God and the people of Israel and conveys, at the outset, the idea that the relationship between a physician and patient is not just any other relationship: it is one born of a fundamental human need-the need for healing. The Covenant also, in its second paragraph, provides an explanation of why it has been crafted: the moral center of medicine is under attack and must be defended-and defended by those who have the most to gain and the most to lose, physicians themselves. The third paragraph is a succinct statement of the importance of an ethics of virtue for medicine; the fourth paragraph builds upon an ethics of virtue by appeal to an ethics of duty or obligation-specifically, the core duty or obligation of medicine, which is to place the benefit, the interests, and the well being of the patient prior to all other considerations, especially considerations of self-interest. The Covenant closes by invoking an essential feature of the profession: that it is ultimately responsible for the security and maintenance of its own integrity.

Retrospective on Oaths and Codes: There are good reasons why oaths have the appeal and status that they enjoy, for example, in the context of medical school graduation, which marks a major milestone in one's membership in the profession. Unlike codes of ethics, oaths involve the public taking-in a public setting-of a promise or pledge. The very setting, the ceremonial occasion, and other aspects of context validate the oath in ways absent from codes of ethics. As a performative event, the swearing of an Oath engages the swearer deeply, in his or her very being, in a way that reading or "subscribing" to a code of ethics does not.

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What is a Profession? Consensus and Controversy

What is a profession? Today, this question is very much on the minds of members of the profession, medical educators, and non-medical observers of the professions. The reasons have been cited previously but several bear repeating: the ongoing economic and financial transformation of medicine and health care; the concerns about the trust traditionally invested by the public in the profession and by patients in individual physicians; the triumph of technology in medicine and the concern that this progress has also led to depersonalization of care.

Sociological commentators have tended to site certain descriptive features shared by all of the traditional, so-called learned professions: (1) the practice of the profession is "founded" on specialized knowledge and skill; (2) the profession exercises control over entrance to the profession and disciplines its members when they fail to uphold standards; (3) the profession is practiced in accord with certain standards of excellence, particularly standards of ethical excellence. Medicine still exhibits these descriptive features, despite contrary evidence with respect to some individual practitioners. Yet, there is still, for some, a crisis of professionalism-a crisis that compels some to argue for a deeper and more profound meaning of the word "profession" especially in terms of its application to medicine and medical practice. In this vein, some advocates of a renewal of professionalism in medicine point to the very roots of the word "profession": "to profess" means to declare and promise aloud-to declare and promise aloud, that is, the central duty of the physician, which is, always and ever, to seek the benefit of thisparticular, unique patient and to ensure that nothing-be it self or institutional interest-displaces the patient in the moral schema that is fundamental to the ethical practice of medicine. They argue, further, that despite trends in better educated patients (many of whom are keen observers of the Latin warning "caveat emptor," buyer beware), the men, women, and children who present themselves to physicians for treatment and care, ultimately, have NO choice but to trust their physicians: to trust their physicians to give pride of place to the patients' needs and to use their specialized knowledge and skill for patient benefit and nothing else.

How can patients and the public at large be assured that physicians are worthy of their trust?  How can trustworthiness and other traits of professionalism be discerned in applicants to medical school and assessed in medical students, residents, and practicing physicians. How is professionalism to be taught and learned along the continuum of medical education that extends all the way from pre-medical school well into the later life of the practicing physician?  Today, these questions are very much on the minds of medical educators-as well as licensing and credentialing authorities. There is a pronounced movement toward broadening the definition of professional competence to include not only knowledge and skill but also virtues and values: this is clear in the evolution of examinations for licensure in the United States, which now include not only assessments of knowledge but also assessments, using standardized patients, of such clinical skills as history taking, physical examination, and communication. It is probably only a matter of time before these methods of ensuring clinical competence encompass some method of determining whether the physician's character merits the trust of his or her patients.

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Cases

Please note: the following cases are not necessarily specific to the specialty and practice of urology. The cases have been developed to throw into relief questions about the scope and limits of those ethical precepts that are conceived as central to the profession of medicine.

One: You are a military physician, newly stationed in Iraq, specifically, at a facility for the detention of captured insurgents. You are charged with the care and treatment of the insurgents. After being at the facility for approximately four weeks, you are ordered to report to that part of the facility where interrogations of insurgents are conducted. Once there, you are informed of the nature of the task before you: to help interrogators determine just how far they can go in applying physical and emotional stress, without causing irreparable harm to a detainee. What should you do?

Two: Your religious denomination teaches that infertility and impotence are signs of God's displeasure and that they are states to be suffered through rather than treated or ameliorated through medicine. A young man with erectile dysfunction comes to you for treatment, but you are opposed to prescribing medication for him. What should you do?

Three: You are a first-year resident and you are about to assist in your first harvesting of a kidney from a living donor. You are troubled by this prospect because this operative procedure seems, on the face of it, to be contrary to the ethics of medicine, particularly to the Hippocratic precepts that enjoin physicians to benefit the patient while avoiding harm to the patient. What's the benefit to the donor of this procedure? And how well are the potential harms understood? What should you do?

Four: Citing the 46+ million Americans without health insurance, a colleague of yours asserts that it is impossible to practice medicine ethically in the United States health care "system." Is your colleague correct?

Five:A new, "revolutionary" technique has been developed, utilizing questions and biometric measures (e.g., of skin surface temperature, eye dilation, heart rate), to assess one's character. The new method will be used, on a pilot basis, in the process of identifying suitable candidates for admission to medical school. Would you submit to assessment of your character with this method?

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Case-Based Questions for Discussion, Analysis and Reflection

Regarding Case One:
       o If you are a physician in military service, do your military duties "trump" your duties as a member of the medical profession?
       o Does Case One present an ethical conflict or dilemma? If so, what is the conflict or dilemma? If not, why not?

Regarding Case Two:
       o Should a physician's personal beliefs and values play a role in patient care?
       o If you believe that a physician can refuse, on the basis of personal beliefs and values, to provide care to a patient, do you believe that there are any limits to, or constraints on this ability?
       o If you do not believe that physicians can refuse, what is the ethical grounding for your stance on this question of the significance of physician conscience?

Regarding Case Three:
       o In usual circumstances, surgery is undertaken because the patient has a therapeutic need that cannot be addressed in any other way; the risks inherent in the process of cutting people open are balanced-and usually outweighed-by the benefits of surgery.
         In retrieving kidneys from living donors, surgeons place these individuals at risk, in the absence of any direct benefit to them from the surgery. Is this ethically justifiable? If not, why not? If so, why?

Regarding Case Four:
       o Do physicians have duties beyond the immediate sphere of the relationship between a physician and a patient? If so, what are these duties? If not, why not?
       o Do physicians have any responsibility, whatsoever, for improving the contexts in which they practice?

Regarding Case Five:
       o Compared with scientific/clinical knowledge and clinical/technical skill, how important are considerations of character in the assessment and determination of competence?
       o Should licensed physicians be subjected to a formal re-assessment of character at various points in their careers?

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Additional Resources


The Kellogg Library at Dalhousie University maintains a fairly comprehensive on-line catalog of codes, oaths, guidelines and position statements at http://www.library.dal.ca/kellogg/Bioethics/codes/codes.htm

A similar resource, compiled by Robert Freitas, Jr., with many useful links, can be found at http://www.foresight.org/nanomedicine/Ethics.html

The Center for the Study of Ethics in the Professions at the Illinois Institute of Technology also has a comprehensive website on codes of ethics from multiple professions at http://ethics.iit.edu/codes/health.html

Charles Yanofsky, MD, has an interesting catalogue of physicians’ oaths, with commentary, at http://www.pneuro.com/publications/oaths/

Eric Matthews addresses the question of who needs codes of ethics at http://www.abdn.ac.uk/philosophy/endsandmeans/vol4no1/matthews.shtml



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