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Module 2: Approach to PT Care

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

  1. Describe, in outline, the evolution of differing models of the patient-physician relationship.
  2. Describe and evaluate different models of the patient-physician relationship.
  3. Describe, contrast, and evaluate differing approaches to ensuring that the practice of medicine by physicians is ethical-i.e., virtue-based, duty-based, and principle-based approaches.

Module: 2 / The Urologist-Patient Relationship: The Role of Virtue, Duty, and Principle

Contents

  1. Framing the Challenges: Clinical Scenarios
  2. The Historical, Legal, And Ethical Background
  3. Exercise: Conducting an Ethical Analysis of The American Urological Association's Code of Ethics
  4. Questions for Discussion, Analysis and Reflection

Framing the Challenges: Clinical Scenarios

You are a third-year resident who has been appointed to your hospital ethics committee. One of your peers, a third-year resident in general surgery, asks you for a “curbside” consultation, i.e., he seeks your advice and counsel on one of his patients. The patient is a 68-year old woman with a long, extensive history of diabetes and cardiovascular disease. She has developed a bowel obstruction that can be readily treated with surgery; she has, however, refused the surgery, explaining that she is “tired” of battling ill health and has no interest in undergoing—and recovering—from a surgical procedure. After repeated attempts to convince her to undergo the surgery, she remains adamantly opposed. His question to you is this: “what if I just put on the gurney, wheel her into the OR and do the surgery?” And he adds, “I know she’ll thank me in the end; after all, she obviously doesn’t know what’s in her best interests.”

You overhear a colleague talking, in an off-handed way, about his “basic philosophy” with certain male patients who seek him out—i.e., patients without erectile dysfunction but who ask him to prescribe “a little pharmacologic boost” for their sexual performance: “What’s wrong with a little enhancement?” your colleague asks rhetorically.

One of the attending urologists on your service is giving a “mini-lecture” on the scope and limits of the physician’s role in relationships with patients. She states “job number one” for the urologist is to determine what’s wrong with the patient and to inform the patient of the various ways of treating the problem—but to stop short of making and arguing for a particular recommendation. “Doctors are on the surest, safest ground in providing the patient with the scientific and technical information that they need in order then to figure out how their (i.e., patients’) preferences and values apply. We are technical advisors to our patients—but not decision makers. Respecting the autonomy of our patients means yielding the power to decide entirely to them.”

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Historial, Legal, and Ethical Background

How should the relationship between a patient and a physician be conceived, understood, and described? Perhaps more importantly, how should this relationship be lived? How are the ethical dimensions of that relationship to be conceived and described? More precisely, what provides the most secure basis for the ethical practice of medicine? Should we seek such security in the character of the physician, i.e., the degree to which he or she possesses, cultivates, and exemplifies such clinical virtues as honesty, integrity, excellence, temperance, and compassion? Should we look to some set of duties or obligations that are conceived as fundamental or inherent in the nature of medicine or medical practice – for example, to “do no harm” or, always and ever, to seek the patient’s good? Or, should we take our ethical bearings in the patient-physician relationship from some set of principles—e.g., from the principles of respect for autonomy, beneficence, non-malfeasance, and justice?

This module, which builds on the content of module 1, is devoted to an exploration of these as well as other related questions. In it, we will turn first to various ways of conceiving the patient-physician relationship, that is, to various models of the patient-physician relationship. Then, we will turn to various ways of ensuring that the practice of medicine—of urology—is ethical and in so doing, we will explore the respective roles of principle, duty, and virtue in explaining, justifying, and informing ethical practice.

Models of the patient-physician relationship: We begin with the history of the physician-patient relationship. Module 1 reviewed a series of statements of professional morality in medicine, beginning with the Hippocratic Oath. The brief analysis following the Oath threw into relief the ethical precepts that comprise the Oath; it did not, however, draw attention to what the Oath does not say or mention. For example, unlike more modern statements of professional morality, the Oath contains no references or appeals to patient rights or to the idea of patients as autonomous, self-determining individuals. Although this is not explicit, the implication of the Oath’s precepts regarding the primacy of patient benefit is that the physician decides what is of benefit to the patient. In general, the idea that physicians are the principal decision makers in their relationships with patients has been dubbed “paternalism.” The various forms of paternalism (“strong” vs. “weak”) need not be of concern in this context; suffice it to say that “paternalism” dominated the practice of medicine in the West until, in relative terms, very recently. In the mid- to late 1960s, the United States and other countries in the West were swept by social movements that challenged various forms of authority (i.e., governmental, institutional, professional) and championed the rights, values, and prerogatives of individuals—regardless of race, ethnicity, gender, age, and sexual orientation. Such movements valorized an idea of cherished American vintage: the idea of individuals as autonomous, as gifted or endowed with the capacity for, and the moral right to self-determination. Especially, in the United States the idea of respect for autonomy began to undermine the dominance of paternalism in medical practice and was enshrined in medical ethics as a principle. Although there is controversy over this claim, some read the modern history of bioethics in this country as a history of the triumph of autonomy—a complete swing of the pendulum away from paternalism and toward autonomy: whereas, heretofore, the physician was sovereign in decision making, now the patient has supplanted the physician.

More recently, however, the pendulum has come to rest at a mid-point between the extremes of paternalism, on the one hand, and patient autonomy, on the other hand. Whether in theory or practice, the argument that one party to the relationship, either physician or patient, should possess pivotal authority has given way to the ethical ideal of shared decision making between physician and patient. It is important to be clear on what is implied in this ideal. Some have argued that there is a division of labor between physician and patient in terms of what each contributes to the process of clinical decision making: the physician offers expert knowledge and skill, grounded in biomedical science and technology, and thereby insures that the options for intervention and care are scientifically, clinically sound; the patient contributes her preferences and values, which are essential to the process of determining which option will be pursued. There is, however, another perhaps more compelling way of understanding what physician and patient can and should contribute to the process of clinical decision making—a way that does not confine the physician to the role of being a mere purveyor of technical advice and yet avoids the pitfalls of paternalism. Pellegrino has argued that the telos of the healing relationship between patient and physician—the end for which and toward which the relationship is, by its very nature, ordained to move—is a right and a good healing action for the particular patient. Such an action is right to the extent that it is based on secure scientific and clinical evidence; such an action is good to the extent that it is in accord with the patient’s preferences and values and consistent with the integrity of the clinician’s judgment. “Consistent with the integrity of the clinician’s judgment”: in recommending a particular course of therapeutic action to a patient, a physician is not simply selecting one possibility from a menu of equally appropriate possibilities. The course of action presented to the patient by the physician is one that reflects the best of biomedical science and technology and is attuned and tailored, by the physician, to the best interests of this patient. As Module 6 will discuss, whether the recommendation is followed is a matter for the consent or the refusal of the adult patient with decision making capacity or a surrogate: this is a principle that is now well established in the ethics and the law of clinical decision making with patients and their physicians.

Thus, from a historical perspective, one could argue that the evolution of the patient-physician relationship has yielded three distinct models of the relationship: (1) the physician-paternalism model, (2) the patient sovereignty or autonomy model, and (3) the shared decision making model. This is not, however, the only typology of models of the patient-physician relationship. Another influential typology has been developed by Ezekiel and Linda Emanuel, who focus on four different dimensions of the relationship, i.e., patient values, physician obligations, patient autonomy, and physician role, and argue that there are four basic models of the patient-physician relationship (see Emanuel, E.J., and Emanuel, L.L. (1992). Four models of the physician-patient relationship: Journal of the American Medical Association, 267, 2221-2226):

  • In the paternalistic model, the patient’s values are assumed, by the physician, to conform to the values of the physician and the physician’s fundamental obligation is to achieve the patient’s biomedical good, regardless of whether this good is consistent with the patient’s preferences; the patient’s autonomy consists in his or her compliance with the physician’s recommendations and the physician’s role is that of a parent or guardian who acts for and on behalf of the patient.
  • In the informative model, the patient’s values are well defined and relatively fixed and the physician’s obligation is, first, to provide the patient with factual information about his or her diagnosis and therapeutic possibilities and, then, once the patient has selected his or her preferred course of therapy, to implement the selected the intervention; as for the patient’s autonomy, the patient is sovereign over all decision making and the physician’s role is that of a competent, technical expert.
  • In the interpretive model, the patient’s values are not well defined and may, indeed, be ill-formed and in conflict, while the physician’s obligation is to assist the patient with the aim of clarifying his or her values and preferences and, having accomplished this, to implement the patient’s chosen intervention; the patient’s autonomy, in this model, is optimized through improved self-understanding as this understanding relates to medical care and the physician’s role is that of a counselor or advisor.
  • In the deliberative model, the patient’s values are open to clarification and, perhaps, further development through dialogue with the physician and the physician’s obligation is not just to implement the patient’s selected intervention—the physician’s obligation also consists in articulating those values that are most conducive to the patient’s well being and using moral persuasion, if necessary, to encourage the patient’s adoption of these same values; the patient’s autonomy is conceived, here, as the achievement of moral self-development in relationship to physical, emotional, and mental well being and the physician’s role is that of a friend or teacher.

One additional typology of models of the patient-physician relationship will be considered here: this typology contrasts covenantal and contractual concepts of the relationship. The idea that the relationship between patient and physician is best conceived as a contractual relationship is almost intuitively appealing, especially in the contemporary context of consumer-oriented health care. According to this idea, physician and patient encounter each other as equals, who freely enter the relationship to achieve their respective self-interests—the one, to make his or her knowledge and skill available to those who need it and to receive, in return, some recompense for this knowledge and skill; the other, to utilize the physician’s knowledge and skill to achieve one’s own aims, be those aims to return to health or, perhaps, to realize some enhancement in one’s sense of well being—indeed, one of the key attractions of a contractual relationship is that its ends are entirely and freely negotiable. A contractual relationship between a physician and a patient is a relationship of mutuality and symmetry; moreover, as a contract, it is legally enforceable; and finally, it appeals to that trait of individuals that the Anglo-American tradition of political, economic, and legal theory enshrines as basic—the trait of being self-interested (to the exclusion of any other, perhaps equally salient traits). In this respect, it is interesting to note that contemporary discourse about professionalism in medicine often refers to the idea of a social contract between the profession of medicine and the society at large, i.e., some “implicit” agreement between physicians and society spelling out what the latter will grant to the former (professional autonomy and self-regulation) and what the former, thereby, owes to the latter.

Critics of this model of the patient-physician relationship argue that the concept of a contract is inappropriate, either as a description of, or as a prescription for the clinical encounter. Some cite the inequalities or imbalances of power that inevitably mark the relationship: physicians are sought out by patients precisely because they have superior knowledge, skill and experience—mutuality, in this respect, is and will remain, necessarily, a fiction. Others also criticize the claim that the end, the goal, or the aim of the relationship can be freely negotiated: they argue that that aim or goal is and should be the healing of the patient and many would confine the means to such healing to interventions that are strictly therapeutic and that are not simply enhancements to physical or emotional well being.

Some critics of the contractual model would turn, instead, to the covenantal model. The argument that the patient-physician relationship should be conceived as a covenantal relationship is inspired, in part, by the Judeo-Christian tradition and, specifically, the covenant formed between God and the Jews following their exodus and deliverance from Egypt. A covenantal relationship is distinguished by three structural elements. First, there is the giving of some gift between the partners to the relationship. Second, there is a promise based on this gift. Together, this giving of a gift and the promise that it inspires alter the being of partners to the covenant. Third, the parties to the covenant pledge to live their lives in accord with a set of moral obligations—obligations whose observance maintains and preserves the covenant. In exploring the significance of the idea of covenant for medicine and for the patient-physician relationship, we may be puzzled at first, wondering in what does the original gift consist? The gift, in this sense and context, is the gift of human experience—the human experience of health and illness and, eventually, of mortality. Physicians are witnesses, in a unique way, to this primordial drama, which is enacted in the life of every individual—in the life of every patient. To observe this drama—nay to participate in it and to experience its joys and its sorrows—is a privilege, an entering into a sphere that is both common (to the extent that it is shared by every other human being) and unique (to the extent that it is the sphere of this, ineluctably particular individual). Just as the needs of an infant, of a child, call for and, indeed, demand the responsiveness of the parent to those needs, the needs of the healthy and of the sick elicit from the physician the promise and the pledge to tend to—to care for—those needs. Parents respond to the child’s need for physical and emotional nurture; teachers, to the individual’s need for learning; clergy, to the individual’s need for God; and physicians, to the need for healing. Finally, being transformed by this gift of the human experience of illness and health and by the responsive promise to heal, physicians profess—they declare and promise—to live their lives and practice their profession in deference to a set of definitive obligations or duties.

In what, however, do these duties consist? Are these duties absolute: in other words, are they incumbent upon the physician at all times and in all circumstances? Or are they imperfect duties, which hold, for the most part, but may be abridged or relaxed in given circumstances? Is the ethical life of the physician best conceived as a life lived in performance of one’s duties? Are there other ways of envisioning the ultimate source of ethics in medicine? It is to these questions that we will now turn. As a means of becoming oriented to the ensuing discussion of the ethics of virtue, duty and principle, it is useful to analyze the various dimensions of the moral life—whether we are talking about life in general or life as it is lived in the specific context of the patient-physician relationship. These dimensions are graphically illustrated below:


Thus, the principal dimensions of the moral life include: (1) moral agents, including their character, motivations, and intentions; (2) the acts or actions of moral agents; (3) the consequences or effects of the acts and actions of moral agents; and (4) the specific context and circumstances in which moral agents act or are called to act. Although this “rule of thumb” admits of many exceptions, by and large, the differences between and among ethical theories often turn on the differences in the emphasis each assigns to one or more of these dimensions. Consequentialists argue that the consequences of acts or actions provide the only reliable measure for ethical evaluation; consequentialists tend, as well, to neglect moral agents and their character as well as the specific acts as means by which consequences and effects are generated. With respect to the three ethical theories (or approaches) that are the focus of this module, the following can be said. The approach that looks to the virtues of the physician as the most secure foundation for the ethical practice of medicine focuses on moral agents. This is not to say that it completely neglects or cares nothing for the acts or actions of moral agents; rather, it will see acts and actions as the outward manifestations of virtue or vice, as the case may be. The approach that conceptualizes the moral life as a life of duty tends to emphasize acts or actions—often to the neglect of the motivations or intentions of the moral agents who perform the highlighted acts or actions, as well as to the neglect of the actual consequences or effects of these acts. Finally, the approach that takes its bearings from ethical principles will also tend to focus on acts or actions, but in ways open to considerations of both character and intentions, on the one hand, and consequences and effects, on the other hand.

Virtue: Of all the various approaches to ensuring the ethical practice of medicine, that which emphasizes the virtues of the physician is one of the most enduring. When we speak of the character of an individual—including the character of a physician—we speak of his or her virtue. The nature of virtue and the capacity of human beings to be virtuous were prominent themes in the works of Plato and Aristotle, both of whom looked to the emerging theory and practice of rational medicine as a fertile field for exploring not only the nature of our knowledge of the world and of living beings but also the nature of various forms of human action whether that action is directed to the formation of states or to the achievement of health. For Aristotle, in particular, a virtue is a demonstrable disposition to choose what is good, what is right, what is just, whenever one is confronted with a choice: in the concrete circumstances of an ethical dilemma, a dilemma that compels us to make a choice as to what to do, a virtue is that by which we are habitually oriented to do—not just think—the humanly good thing to do. The individual virtues, as such, are not simply intellectual states; they are not a function of simply knowing, in a dispassionate way, what to do. In the exercise and demonstration of virtue, we engage not only mind, but also heart: the virtues, thus, have an emotive component and entail a responsiveness of one’s whole being to the demands of the concrete situation.

The challenge confronting a virtue ethic in medicine is that of determining which virtues are fundamental to the patient-physician relationship and to the work of healing that provides the ultimate rationale for that relationship. Edmund Pellegrino has argued that the following are core virtues in the practice of ethical medicine:

  • Fidelity to trust and promise: we have already encountered the claim that the patient-physician relationship is a fiduciary relationship, i.e., a relationship in which trust is absolutely pivotal. This particular virtue is critical: with it, the physician demonstrates his or her faithfulness to that trust – his or her awareness of the importance of those behaviors and actions that invite and secure the patient’s trust.
  • Benevolence: This virtue—literally, to will the good—is the motivational correlate of the principles of beneficence and non-maleficence (see below for a description of these principles). With it, the physician is habitually predisposed and oriented to seek the patient’s best interests in the concrete situation of the patient’s needs.
  • Effacement of self-interest: It is inherent in the nature of the patient-physician relationship that patients are vulnerable to one degree or the other. Illness renders patients vulnerable. The superior knowledge and skill of the physician renders the patient vulnerable. The imbalances of power between physician and patient render the patient vulnerable. As a result, the risk of exploitation of the patient by the physician is an omnipresent reality. And also as a result, and to secure the patient’s trust, the physician must, always and ever, place the patient’s interests at the forefront of his or her concern. The advancement of knowledge, the reaping of profit, the satisfaction of one’s own personal needs should never be inducements for assigning a lower priority to the patient’s individual good.
  • Compassion and caring: Our word, compassion, is derived from the Latin, compassio, which means “to suffer with”. Effective healing depends, in part, on the physician’s inclination and ability to experience the patient’s experience of illness, at least to some degree: this is what is meant by compassion. Feeling compassion for one’s patients is a prelude to caring in the full sense of this word—to having concern and empathy for the patient and giving due consideration to those individuating aspects of the patient’s illness that make that illness his or her illness.
  • Intellectual honesty: In light of the breadth of biomedical knowledge and complexity of any one biomedical fact, it is impossible for any one physician “to know it all” – or, to be able “to do it all.” Being conscious and transparent about the scope and the limits of one’s knowledge and skill is fundamental to securing the patient’s trust.
  • Justice: In the context of the patient-physician relationship, the virtue of justice moves the physician to render unto the patient, what the patient requires and needs. This is often termed “commutative justice.” Commutative justice differs from distributive justice, which is justice applied to allocation of resources among many.
  • Prudence: This is often described as the “capstone” virtue, i.e., the virtue that enables the physician to deliberate well and to discern how best to fulfill this patient’s need for healing in these circumstances. It is the virtue upon which all other virtues turn, so to speak: it enables the physician to discern how to demonstrate compassion, intellectual honesty, justice, and benevolence with this patient in this situation. (See Edmund D. Pellegrino, Toward a Virtue-Based Normative Ethics for the Health Professions. Kennedy Institute of Ethics Journal, Vol. 5, No. 3, 253-277.)

Other “catalogs” of the clinical virtues have been proposed. For example, reflecting, in part, the revival of virtue ethics in medicine, the American Board of Internal Medicine’s Project Professionalism has defined “professionalism” as consisting in the demonstration of the following character traits or virtues:

  • Altruism, i.e., the habitual practice of placing the patient’s interest first—never one’s self-interest
  • Accountability, i.e., the virtue of holding oneself responsible for one’s behavior and actions and responsive to the needs of patients, the profession, and society
  • Excellence, i.e., the virtue of conscientiously striving to improve one’s knowledge and skill and to bring the fruits of this ongoing effort to bear on the care of one’s patients
  • Duty, i.e., the virtue of freely accepting the commitment that the practice of medicine requires—the commitment to excellence, to the patient’s best interests, and the advance of medicine and the well being of humankind
  • Honor and integrity, i.e., the virtues of acting in accord with one’s personal and professional code of conduct, of keeping promises, telling the truth, and avoiding any compromise of the ideals critical to the ethical practice of medicine
  • Respect for others, i.e., the virtues of acting in recognition of the inherent worth and dignity of patients, their families, other physicians, and health professionals

The contemporary concerns about how to select applicants of “good” character, to teach and foster the “learning” and assessment of professionalism, and to ensure the lifelong cultivation of altruism, honesty, and other traits are implicit acknowledgements of the critical import we assign to virtue as an anchor for the ethical practice of medicine.

Duties: The concept of “duty” is common to discussions of medical ethics: one often hears that “it is the physician’s duty to do X, Y, or Z.” The implication is that the action at issue is required or mandatory; the action is prompted by an imperative and responding to the imperative—doing one’s duty—has little to do with concerns about motivation or consequence. Duty- or obligation-based medical ethics is a form of what philosophical ethicists call deontology: deon is the ancient Greek word for “duty.” The history of this approach to ethical explanation and justification is rich and complex. Two chapters from that history will suffice to illuminate it. The first has to do with the ancient Stoics who claimed that moral rules in the realm of human affairs are simply the correlates of the laws of nature that govern the cosmos. As rational beings, human beings must act in ways consistent with these laws or rules: we are, that is to say, duty-bound to act in this way. To act otherwise is not only irrational; it is negligent of duty. The second chapter was written, largely, through the philosophizing of the 18th century German idealist philosopher, Immanuel Kant. In formulating his categorical imperative, Kant developed several different but interrelated expressions of what he conceived as the fundamental duty incumbent on all rational beings. One such expression is “Act only on that maxim whereby you can at the same time will that it should become a universal law or a universal law of nature.” The more readily accessible—and ethically applicable—formulation reads: “Act as to treat humanity, whether in your own person or in that of any other, never solely as a means but always also as an end.” All other duties are simply specifications of this categorical imperative.

In the realm of medical ethics, however, the difficulty is reaching agreement on what it is that physicians are “duty-bound” to do. Some have argued, for example, that physicians are duty-bound to respect and protect life, which yields a so-called “negative duty” never to kill or be complicit in killing. Physician-assisted suicide and euthanasia would thus be practices in violation of this negative duty. Others argue that, in particular circumstances, these practices could be consistent with the clinical virtues of compassion and caring—or at the least, with the principle of respect for autonomy in the case of an adult who has decisional capacity and has requested direct aid in dying. The injunction found in the Hippocratic Oath and other statements of professional morality to maintain confidentiality is often conceived as an example of duty—albeit not an absolute duty holding in all times and places but rather an imperfect duty that may be overridden in unique circumstances.

Principles: In the Anglo-American West, medical ethics is often conceived as an exercise in the identification and application of principles and of four principles, in particular:

  1. the principle of beneficence, i.e., the obligation to seek the patient’s benefit or good
  2. the principle of non-maleficence, i.e., the obligation to avoid or minimize harms to the patient
  3. the principle of respect for autonomy, i.e., the obligation to respect the capacity and outcomes of self-determination by autonomous individuals
  4. the principle of justice, i.e., the obligation to seek and achieve fairness in the distribution of benefits and risks

Sometimes referred to as “principlism” (whose followers are thus dubbed “principlists”), this approach is, in part, the evolutionary product of a developmental process that was inaugurated with the writing and publication of the Belmont Report in 1979. The report was issued by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research and articulated a set of ethical principles and guidelines intended to prevent abuses of often vulnerable subjects unwittingly used for the purposes of human experimentation. One of the report’s principal authors was Tom L. Beauchamp who, along with James Childress, wrote one of the most influential texts in the history of modern bioethics, The Principles of Biomedical Ethics.

Two of the principles, the principles of beneficence and non-maleficence, have roots deep in the history of Western medicine. The Hippocratic Oath is one of the earliest expressions of both principles, which together enjoin the physician always to act to secure the best interests of the patient. The other two principles have different origins. Respect for autonomy has long been central to the liberal tradition in the West, a tradition that privileges individual freedom in political life and self-determination in the sphere of personal life. Despite this centrality, the principle of respect for autonomy did not triumph in the sphere of medicine and health care until the social movements of the 1960s. Those same social movements—as well as the evolution of bioethics itself—also played in important role in the ascendancy of justice as a principle in medical ethics.

According to Beauchamp, the four principles are not “rules of thumb,” nor are they “absolute prescriptions”: each is a prima facie principle, that is, it is always incumbent and binding on the physician unless it conflicts with obligations inherent in another moral principle, in which case it is necessary to balance the demands of the two principles. Ultimately, the question of which principle takes precedence or priority can only be answered in the concrete circumstances of the particular case. This is accomplished through a process of specification. Consider the principles of beneficence and non-maleficence, which as suggested above, join in the ethical injunction to place the interests of the patient first and foremost in one’s thinking and action. What if the concrete case is such that the only way to secure the patient’s interests is through some illegal means – for example, through fraud and deception. The ethical injunction alone offers little practical guidance for how to resolve the conflict between the law and ethics in this situation – unless, that is, the injunction is further specified, for example, by elaborating on the injunction as follows: the physician must place the interests of the patient first and foremost in his thinking and action but do so only by utilizing means that are both legally and morally sound. (For a complete but succinct description of the four principles, see Tom L. Beauchamp, “The Four Principles Approach” in Meaning and Medicine: A Reader in the Philosophy of Health Care, edited by James Lindemann Nelson and Hilda Lindemann Nelson New York: Routledge, 1999.)

As previously noted, there are other approaches to informing, explaining and justifying ethical action beyond the three upon which we have focused. For example, there is the “rights” approach, which is reflected in the statements of “patients’ rights” that are found in every hospital patient’s room in the country. Rights are claims to particular private and social goods that are conceived as creating an obligation on the part of others to respect and, in specified ways, be responsive to those rights—hence, there is some resonance between this approach and the approach that conceives of ethical behavior as behavior in deference to duty. There is, as well, the feminist approach, which tends to focus on the ways in which gender—as well as other individuating characteristics, such as race, socioeconomic status, sexual orientation—is often tied to imbalances in power in any relationship, including the patient-physician relationship.

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Exercise: Conducting an Ethical Analysis of The American Urological Association's Code of Ethics

Most of the modules in this on-line curriculum culminate in a case for individual or group analysis, discussion and reflection. Module 2 is an exception. Instead of delving into the ethical complexities of a clinical case, this module challenges you to analyze the American Urological Association’s Code of Ethics, which was approved by the AUA board of directors in 1999. First, read the Code of Ethics carefully—perhaps repeatedly. Then, respond to the questions posed in the text after the Code.

  1. Recognizing that the American Urological Association seeks to exemplify and develop the finest standards of urologic care, I hereby pledge myself, as a condition of membership, to live in strict adherence with its principles and regulations. I pledge myself to pursue the practice of urology with honesty and place the welfare and rights of my patients above all else. I pledge to deal with each patient as I would wish to be dealt with myself. I will render services to humanity with full respect for human dignity, giving full measure of service and devotion, and using my skills to the very best of my abilities. I pledge myself to cooperate in advancing and extending the art and science of urology by my attentive diligent membership in the American Urological Association.
  2. I will maintain my qualifications by continued study using the scientific basis of evidence and proof, for medical knowledge must continuously be maintained and improved. All this so that I may select the best alternative for a particular patient's care. I will advance my knowledge and skills, respect my colleagues, seek their counsel when in doubt about my own abilities, and assist my colleagues whenever requested. I will accept that "competence" includes having adequate and proper knowledge to make professionally appropriate and acceptable decisions regarding management of the patient's problems, as well as the ability and skill to perform what is necessary to be done and to ensure that the aftercare is the best available to the patient.
  3. I will safeguard the public and the profession from physicians deficient in moral character or professional competence, and will expose to the proper authorities without hesitation any illegal or unethical conduct of fellow members of the profession, or of those who engage in fraud or deception. I will encourage impaired physicians to seek help and to withdraw from those aspects of practice affected by their impairment. I will report to appropriate authorities suspected abuse or neglect of patients, sexual harassment and exploitation, and/or sexual misconduct in patient-physician relationships.
  4. Physician-patient confidences will be safeguarded within the constraints of the law.
  5. Pre- and post-operative care of my surgical patient and continuing care of my medical patient will be my personal responsibility unless specifically designated to a competent substitute. Any delegation of my services will be to appropriately trained physicians or physician-extenders (PAs or NPs). I will accept income only for medical services actually rendered or supervised by me, and my remuneration will be commensurate with services rendered, regardless of who pays the bill.
  6. Any advertising I use will be honest and straightforward, not false, misleading, fraudulent, extravagant, or deceptive. My communications with the public will be accurate, and I will not misrepresent my training, my credentials, my experience, or my ability. When asked or when presenting data that may involve a conflict of interest, I will disclose any personal commercial interests, including any gifts of more than minimal value from commercial firms or significant stock and security investments in commercial firms if there may be any effect on patient care, research, medical decisions, etc. I recognize that failure to do so will invite disciplinary action. I will be truthful, honest, and fair in dealing with patients and colleagues. If I am asked to give expert testimony in the courtroom or outside the court, my testimony will be based on recent and substantive experience in the region in which it is given. I will thoroughly review the medical facts and testify to the content fairly, honestly, and impartially, to the best of my knowledge, ability, and experience, neither condemning practices clearly within accepted standards nor excusing performances clearly outside such standards.
  7. I will conduct my research and perform my academic activities in an honest, fair, truthful, and complete fashion, recognizing my responsibilities to myself, my reputation, my colleagues, my institution, society in general, and to posterity to do so. The dissemination of information is inherent in the pursuit of investigation. Timely and appropriate reporting of results is a responsibility I accept in doing research of any kind. As an author I will verify that I and my associates in the research are familiar with and have adhered to the guidelines for responsible ethical research. I will assure that the use of clinical trials or investigative procedures follow the accepted guidelines and standards as drawn up by local Institutional Review Boards that monitor investigations or by the similar Institutional Review Boards at the National Institutes of Health. Any support by commercial firms for my research will be completely disclosed by all involved in a written statement when reporting such research in any forum whatsoever.
  8. I will acknowledge that my commitment to a patient is total once I accept the case, and if I withdraw from providing that care, I will endeavor to assist in obtaining an adequate substitute. I will condemn unnecessary surgery as an extremely serious ethical violation, and will not engage in fee splitting or itinerant surgery---surgery anywhere without appropriate preoperative evaluation or adequate and skilled postoperative care.
  9. I will consider informed consent integral to providing appropriate medical or surgical care. I recognize that my patient must be provided with all of the information necessary to consent and to make his own choice of treatment, regardless of my own advice or judgment. The information provided must include known risks and benefits, costs, reasonable expectations and possible complications, available alternative treatments and their cost, as well as the identification of other medical personnel who will be participating directly in the care delivery. Wherever feasible, I will respect my patient's rights and be limited by the scope of my patient's consent.
  10. I will obey the law. I will seek to change laws that are contrary to the best interests of the patient. I will accept the profession's self-imposed discipline.
  11. I believe my responsibilities to the community and to society are part of a physician's code and that a physician must safeguard the public.
  12. I will work constantly to improve this Code of Ethics, thereby improving the care I deliver and its value to society. I recognize that there will be a need from time to time to amend or change some portions of this Code. Emerging issues inevitably will appear involving "Ethics." Those must be judiciously considered in the light of the best interests of the individual, of society, and of the yet-unforeseen consequences of the various alternative actions. Hopefully this Code of Ethics will serve as a framework for evaluating and deciding on these emerging issues.

These I pledge, (AUA Member Signature)

Last updated: Dec 12, 2004
Content provided by: Ethics Standards

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Questions for Discussion, Analysis and Reflection

  1. What is the ultimate source of authority for AUA Code of Ethics? What endows the Code with its ethical force? What mechanisms are present within the Code for enforcing adherence by urologists who are members of the AUA?
  2. What are the main ethical precepts specified in the Code? In other words, what are those who pledge to uphold the Code pledging to do? What sort of physicians-urologists are they pledging to be?
  3. To what extent does the Code reflect a virtue-based, a duty-based, and/or a principle-based approach to securing the ethical practice of urology?
  4. What is missing from the AUA Code of Ethics? What are ethically significant aspects of the practice of medicine in general and urology in particular that are not addressed in the Code?
  5. What is the value of the AUA Code of Ethics to the practice of urology in general? What is the value of the AUA Code of Ethics to your professional life as a practicing urologist?

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Additional Resources


The National Institutes of Health has an exceedingly rich and helpful on-line resource of bioethics websites, including several devoted to the patient-physician relationship, at http://bioethics.od.nih.gov/physician.html

The Ethics Manual of the American College of Physicians is an excellent resource for physicians of any specialty.  Go to http://www.annals.org/cgi/content/full/128/7/576



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