International Association of Medical Colleges
Ethics Committee

The IAOMC established an Ethics Committee to reflect the centrality of medical ethics to the practice of medicine. It is a Standing Committee that reports to the Board.

Physicians are confronted by ethical issues every day of their working lives so medical education and training must ensure they are equipped with the knowledge, skills and confidence needed to deal with clinical challenges in a trustworthy way.

The importance of a set of values that underpin the moral standards of physicians goes back to the beginning of medicine and has been reflected consistently in the many codes of medical ethics. Learning of medicine requires assimilating core values and acquiring the skills to implement those values in clinical practice. To cope with the increasing complexities posed by scientific advances the teaching of medical ethics has become more systematised and is now recognized to be an essential core component of the medical curriculum.

The Ethics Committee is composed of both practicing physicians and prominent scientifically trained academic teachers of medical ethics.

Committee Members

• Julia Frank MD Assoc Prof Dept of Psychiatry,
  George Washington University

• Haavi Morreim, JD, PhD Professor,
  University of Tennessee School of Medicine

• Barbara Schuster,
  MD Chair Dept of Internal Medicine Wright State University

• Roberta Sonnino MD, FACS, FAAP Assoc.
  Dean Creighton University

• James Appleyard MD FRCP,
  Past President World Medical Association

All members of the Advisory Council and other ‘Standing’ Committees of the IAOMC are ‘corresponding’ members.

The members are tasked to review and advise on the development of standards for medical ethics teaching within the medical curriculum

The Committee meets twice a year at the main meetings of the IAOMC and works though electronic correspondence and governed by the Associations e-mail voting by laws.

Comments from interested physicians and other associations of Physicians and Medical Ethicists are always welcome

To set the scene, a background paper on Medical Professionalism – Being a Physician has been presented to the IAOMC Council after widespread consultation and follows. The Committee aims to provide a common basis for more detailed discussion on the development of the standards expected in medical schools.

The Committee will also generate a platform for a dialogue on the core curriculum for medical ethics in undergraduate medical education including opportunities for ‘distance learning’.

The World Medical Association stresses the importance of medical ethics
As an essential part of medical Education

The World Federation for Medical Education has set a Basic Standard for Undergraduate Medical Education that ‘The Medical School must identify and incorporate in the curriculum the contributions of the behavioural sciences, social sciences, medical ethics and medical jurisprudence that ensure effective communication, clinical decision making and ethical practices’.

Of all the 44 standards required for a medical school to be accredited in the US, the Deans of US medical schools rank ethical behaviour the highest. The accrediting standard 21 of the LCME is; “Students must be encouraged to develop and employ scrupulous ethical principles in caring for patients''

The U.K. General Medical Council’s 1993 ‘Tomorrows Doctors’ stated two objectives for the medical curriculum

• to ensure that students acquire a knowledge and understanding of ethical and legal issues relevant to the practice of medicine

• to ensure that the students develop an ability to understand and analyse ethical problems so as to enable patients, their families, society and doctors have proper regard to such problems in reaching decisions

In 1998 the Journal of Medical Ethics (Ashcroft et al JME 1998 24 188-192) published a ‘consensus’ statement by teachers of medical ethics in the UK stressing that medical ethics and Law should be introduced systematically through out the entire clinical curriculum and each clinical discipline should address the ethical and legal issues of particular relevance to it. They did not suggest ‘rigid’ guidelines about how medical ethics should be taught.

Members of the Ethics Committee will bring their own and invite other experienced teachers experience to share in the discussion about differing methods of instruction and assessment to achieve our agreed objectives.

James Appleyard MD FRCP.
Chair

Haavi Morreim, JD, PhD.
Secretary

The essence of Medical Professionalism

Professionalism has been at the heart of the practice of medicine for over two millennia

Medical practice is by definition a “vocation whose core element is work based upon the mastery of a complex body of knowledge and skills and whose members ‘profess’ a commitment to competence, integrity, morality, altruism and the promotion of the public good within their domain.

These commitments form the basis of a social contract or covenant between a profession and society, which in turn grants the professions the right to autonomy in practice and the privilege of self regulation.

Professions and their members are accountable to themselves, those they serve and to society” (Oxford English Dictionary)

Society benefits by having those who control the knowledge and skills for providing essential services primarily for the good of others rather than personal gain or political advantage.

Thus, In exchange for the privilege and authority to be responsible for key aspects of their professional work including the setting of professional standards, education ,credentialing with a significant influence on the medical market and their working conditions society demands that professionals maintain and develop high standards of competence and moral responsibility.

By virtue of their autonomy and authority, physicians may at times be obliged to direct others in the care of their patients, to advocate for patients' interests against those of other social constituencies. In modern times, physicians must respect the wishes of competent patients, but in many instances they may exert considerable pressure on patients to take actions or accept interventions they would prefer to forego. The basis for physicians' persuasive power is their competence, skill and assurance of ethical conduct.

Public awareness of the professions’ ethical standards serves to maintain the professions’ devotion to medical science and to advocate for health care values in the context of competing social imperatives.

Historically noteworthy physicians of ancient Hindu, Confucian or Hippocratic Schools practiced ‘virtue based ethics. From this practice certain ‘codes’ have explicitly delineated the covenant between society, physicians and their patients. The code of Hammurabi provided gave detailed advice to practitioners of medicine, literally carved into stone. The Hippocratic Oath outlines key principles for medical practice, most importantly the exhortation to place concern for patient welfare above every competing demand.

After World War 2, World Medical Association’s Declaration of Geneva (1948) re-affirmed this ‘covenant’ between the world's physicians and all peoples specifying principles later incorporated into the WMA Document of the Duties and Responsibilities of Physicians Worldwide.


The Eight Characteristics of a Profession
There are eight characteristics of a Profession. While some may pertain to other endeavors, a true profession must adhere to all eight. The eight core elements are :

1. Morality and Integrity

2. Code of Ethics

3. Service

4. Altruism

5. Complexity of Knowledge

6. Autonomy

7. Accountability

8. Professional Associations

Present day circumstances challenge the expression of these values.

For instance with the vast increase in information available on the web, some no longer acknowledge the value of professional competence, believing that anyone can find information and follow a protocol – the ultimate in cook book medicine Others, especially Heath Service Managers feel it is possible to reduce medicine to its component parts, apply those parts in isolation and save money by deskilling the process.

The profession continues to exist because people, especially when ill, want personalized information from a trustworthy source. As Dr Mike Magee has shown, people still consult doctors for information. They are justifiably uncertain about the validity of the information on the web and are confused by its complexity and contradictions.

Patients need their physicians to help them interpret and apply that knowledge to their own individual circumstances. Providing coherent, well-informed care is the art of our profession.

Morality and Integrity
A fundamental characteristic of any profession is the expectation that its individual members and the associations and institutions representing them are ‘moral’ and carry out their activities with integrity

Code of Ethics
Code of ethics from the time of Hippocrates represent the applied morality of the Profession governing the behaviour of members.

The Hippocratic Oath was written in the language of 2,500 years ago but the principles underlying it are as valid today as them.

It has been updated by the WMA’s Declaration of Geneva and embraces many core principles of professional ethics. Even Hippocrates' invocation to Gods in which we no longer believe, has its modern analog in attention to the spiritual aspects of medicine, a dimension of professional care that commitment to rationality has not extinguished.

Service
Professional knowledge must be used in the service of others, individual patients and society in general

Altruism
The trust placed in the profession and medicine's privileged status are only justified if we consistently place the interests of individual patients and society above our own

Knowledge
Professions are given stewardship over their body of knowledge They are responsible for the integrity of the knowledge base. In medicine, this requires dedication to scientific evidence and clinical experience. The proper professional application of knowledge includes responsibility for its expansion –( promoting research and development) - and for its transmission to future practitioners –( medical education ). The profession must also apply its knowledge to the public good in order to improve public health and the health of nations.

Autonomy
Professions are granted autonomy in order that they may respect the autonomy of the individual patient, and act in the best interest of both their patients and society, in the face of competing social priorities.
The Profession's autonomy should be recognised under the broad heading of ‘self-regulation’

General respect for the personal autonomy of both physician and patient creates trust, ennobles and professionalizes the relationship. Essentially autonomy demands that individual patients have the right to choose both their physicians and their treatment.

Authoritarian governments continually undermine this right because of their concern about the influence the medical profession may exert by independently advocating for the health needs of individuals and society. In more democratic societies, medical autonomy is threatened by capitalist values that place efficiency and the generation and concentration of wealth over sometimes costly, seemingly irrational or apparently inefficient individual preferences and practices.

Accountability
Autonomy does not absolve the physician of accountability. Physicians are accountable personally to their patients and to their profession for adhering to medicine’s time honoured ethical principles
politically to the public as whole (political) and economically to third party payers.

Professional Associations
Professional collegiality establishes common goals and encourages all members of a profession to comply with them.

Independent associations and State sanctioned licensing bodies exist to set and maintain professional standards, discipline unethical behaviour, and establish. educational standards. At their best, they are custodians of the medical professions' conscience

The values of professionalism are expressed in the doctor patient relationship by seven principles, recognized around the world as essential to ethical practice. These are

Patient Autonomy
Patients' decisions about their care must be respected. They prevails long as they are in keeping with ethical practice and appropriate care. Physicians should empower patients to make informed decisions about their treatment.

Beneficence – Physicians must always aim to do good, look after patients' best interests and recognize circumstances where conflict of interest may compromise professional judgment.

Non Malfeasance – Physicians must endeavour to do no harm – ‘primum non nocere”-- avoiding unnecessary risks with treatments and refusing to take advantage of the intimacy of the patient physician relationship

Fidelity – Physicians' ‘duty of care’ is the free acceptance of a commitment to service. This commitment entails being available and responsive when needed, accepting inconvenience to meet the needs of patients, advocating the best possible care within the available resources regardless of ability to pay, seeking active roles in teaching and professional organizations, and volunteering skills and expertise for the welfare of the community. Medical professionals, therefore, should be encouraged to participate in professional organizations, community programs and institutional committees.
This duty also includes a commitment to competence and life long learning. Where appropriate, a physicians duty may require referring the patient on to those that have greater competence in a particular area to meet a patients needs.

Truthfulness – Physicians must ensure that patients are completely and honestly informed before consenting to treatment and after treatment has started. They must not mislead patients when medical errors have occurred. It implies keeping one’s word and meeting commitments. It also requires the recognition of possible conflicts of interest and avoidance of relationships that allow personal gain to supersede the best interest of the profession.


Confidentiality – Confidentiality is one of the foundations on which the trust between patient and physician is based. It may only be breached where there is a real and imminent threat to the patient or to others if this confidentiality were maintained

Justice – Physicians must treat all people equally according to their need. Physicians should work actively to eliminate discrimination based on race, gender socio-economic status, religion or ethnicity and promote justice in a health system based on individual and community clinical need. This effort demands a commitment to reduce barriers to access to medical care based on education, geography, finances and legal structures.

These ‘principles’ need to be ‘internalized’ and become a physician's professional conscience, a compass guiding the journey through the complex scientific and medico social scenes.

‘ The physician's individual conscience provides the foundation of the ‘trust’ given by the patient to the physician. The profession's collective conscience shapes the essential wider ‘contract’ between the medical profession and society in general.

The ‘Art’ of Medicine is the application of our knowledge and skills within this framework of our collective conscience to make judgments in the best interests of individuals seeking our help.

At times it is enormously difficult to balance these principles as they may internally conflict within the individual circumstances in which the physician finds him or herself. It is very rewarding to get the judgment ‘right’ for the individual patient but equally devastating for the physician if the judgment proves to be wrong . Physicians need to be called to account by their patients and their peers to justify their actions within a delegated professional regulatory framework which respects the difficulty and contradictions of professionalism. Imposition of a political, bureaucratic or business ethic would distort this accountability and work against the best interests of the patient.

Industries as well as professions acknowledge the importance of appropriately structured internal regulation. Any external regulation should re-enforce good practice rather than impose inappropriate unprofessional standards. Overregulation leads to poor professional morale when it conflicts with physicians' duties to their patients and diminishes research and innovation. An alienated profession spends much time attempting to circumvent regulations that interfere with, rather than promote, best practices.

Except in the case of research, reliance on strict imposed protocols outside may compromise independent professional judgment . Protocols are not necessarily designed to put the individual patient's interests first. Clinical guidelines may be helpful but they usually are ‘consensus’ documents which may not provide sufficient evidence to meet the needs an individual patient.

On the other hand, physicians always need to justify what action they take with their patients to the patients themselves and be able to do so to their peers through audit and peer reviews.

In his comparative study of relationship based Health Care in the US, United Kingdom, Canada, Germany South Africa and Japan Dr Mike Magee concluded that the patient physician relationship is a critical underpinning of stable societies second only in importance to family relationships in all the countries studied. The emancipation, empowerment and active engagement of patients as ‘health consumers has reinforced the high expectation in the humanistic, access to heath care and advocacy dimensions measured in the study. Physicians ability to align with and aspire to meet these expectations in support of patients continued evolution (as their advocates) will define the physicians future effectiveness as a health care leader. The design of different health care systems, including methods of financing, demonstrated significant difference in the positioning of patients and physicians as partners or adversaries’ within each system. This trend has already bean recognized based on many reports related to the experience and perceptions of physicians (12) It reinforces the need to instill the concept of professionalism at the start of medical training.

Instilling Ethics in Medical Education
All medical decisions need to be made on a case by case basis within the overall medical ethical framework.

The World Medical Association has exhorted all medicals schools in the world to ensure the teaching of medical ethics within their curricula . Of all the 44 standards required by the American Boards for a medical school to be accredited in the US, the Deans of US medical schools rank ethical behaviour the highest.

Undergraduate Medical Curricula have been developed to ensure that ethical issues are always reviewed in medical decision making.

The Arnold Gold Foundation of Columbia University in New York recognized the difficulties of fostering the medical conscience and initiated in August, 1993, the White Coat Ceremony in which medical students publicly committed themselves to the professions ethics. . The ceremony also reinforces the professional culture amongst the teaching faculty and administration of the School. Now 90% of US medical schools have introduced the ceremony, and it is spreading into Europe.

The Arnold P. Gold Foundation’s White Coat Ceremony welcomes entering medical students and helps establish a psychological contract for the practice of medicine. The event emphasizes the importance of compassionate care for the patient as well as scientific proficiency and includes several elements:

• Recitation or discussion of an oath (such as the Hippocratic Oath) which represents public acknowledgment by students of the responsibilities of the profession and their willingness to assume such obligations in the presence of family, friends, and faculty

• Cloaking of students in their first white coats

• An address by a eminent physician role model

• Celebration at a reception with students' invited guests

At the ceremony, students are welcomed by their deans, the president of the hospital, or other respected leaders who represent the values of the school and the profession the students are about to enter. The cloaking with the white coat—one of the mantles of the medical profession—is a hands-on experience that underscores the bonding process. It is personally placed on each student's shoulders by individuals who believe in the students' ability to carry on the noble tradition of doctoring. It is a personally delivered gift of faith, confidence and compassion.

An example of such an Oath of Commitment during a ‘White Coat Ceremony’ is taken at the University of Kansas School of Medicine:-

As I begin my training as a physician at the University of Kansas School of Medicine I pledge the following:

• I promise to earn the trust and respect of my teachers and to return them in kind, for only through mutual trust and respect can we learn the skills required of a physician.

• I will accept responsibility for those medical duties that I feel prepared for;

• I will hold back when I am not prepared; and I will seek the experience that I need to prepare myself.

• I will strive to preserve the dignity, the humanity and the privacy of all my patients, and through my openness and kindness I will seek to earn their trust in turn.

• I will treat my patients and my colleagues as my fellow beings and never discriminate against them for their differences; and I will ask that they do the same for me.

• I will value the knowledge, and the wisdom of the physicians who have preceded me;

• I will add to this legacy what I am able, and I will pass it on to those who come after me. As my skills and my knowledge grow so too will my awareness of my limitations and my errors;

• I will strive to recognize and understand my weaknesses;  And I promise never to put an end to my studying and learning that I might improve myself every day of my practice, in all the years to come.

The Association of American Medical Colleges have published a ‘Compact between Teachers and Learners of Medicine based on three guiding principles

The Duty of medical educators to inculcate the values and attitudes required for preserving the medical professions ‘social contract across generations

The need for integrity and role models who epitomize authentic professional values and attitudes
Respect as a fundamental part of the ethic of medicine for every individual

Some medical schools have found it helpful to link these concepts with the students ‘code of conduct’ and the disciplinary procedures required to re-enforce them

This is important because the social milieu or ‘informal’ curriculum of a medical school has a great influence on the values and professional identities acquired by its students

The University of Chicago, USA emphasizes six principles (Their six Cs) in teaching clinical ethics namely
Clinically based – for relevance
Cases (real) – narratives for fidelity and effectiveness
Continuous – the reinforcement of learning outcome
Coordinated – an integrated approach to all issues pertaining to the ‘case’
Clean (i.e. simple case) for clearer take home messages and better impact and
Clinicians as Instructors – for source credibility and all round case discussion

The Guy’s, Kings an St Thomas Hospital’s problem based undergraduate medical curriculum ensures that ethical aspects were always considered during discussion of each clinical problem which reinforces to the student the ethical structure within which medicine should be practiced

During their preclinical courses, students are introduced to medical decision making. As they progress, some clinical tasks delegated to them, within the ethical framework described above. They come to understand through their teachers , mentors and role models that the unifying umbrella of medical ethics does not mean uniformity. It is the very diversity of the clinical problems faced by their patients and the issues surrounding them that make medicine not only such a fascinating and interesting career. but a vocation where their individual conscience as a physician is key to the application of their knowledge and skills in the best interests of their patients

At Graduation publicly professing of the same ethical principles helps to reinforce the importance of maintaining and developing the ethical standards expected of members of the medical profession.

These principles are embedded in the WMA’s Declaration of Geneva and some Medical Schools use these words as an updated version of the Hippocratic Oath.

Declaration of Geneva

• 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 respect the secrets which are confided in me, even after the patient has died

• I will maintain by all the means in my power, the honour and the noble traditions of the medical profession

• My colleagues will be my sisters and brothers

Medical Graduates surveyed in the British Medical Association’s 1995 Cohort study placed Competence, Caring and Compassion as the most important three core professional values with integrity 5th. In 2004 with nine years experience as a physician the leading three values became Competence, Integrity and caring.

In our process of Accrediting Medical Schools we will need to assess the cultural environment within which medicine is being studied and re-enforce and develop the current standards expected by the WFME and LCME

(Further comment and advice on this will be welcomed)

References.

1. The Short Oxford English Dictionary 3rd Edition 1979.

2. ‘Medical Professionalism in the New Millennium: a physicians charter’ Medical Professionalism Project, Lancet 359 520-522, 2002

3. ‘Core Values of the Medical Profession in the 21st Century’ British Medical Association Conference 1994

4. ‘Professionalism in Medicine’ Canadian Medical Association 2001

5. ‘International Code of Medical Ethics’, World Medical Association Pilanesberg, South Africa 2006

6. On the importance and validity of Medical Accreditation Standards Kassebaum DG Cutler ER Engle RH Academic Medicine 74 553- 563 1998

7. Ethical Practice of Medicine – Education and training ‘Medical Ethics Today’ BMA/BMJ 2004

8. Compact between Teachers and Learners of Medicine Association of American Medical Colleges 2006

9. Medical Professionalism in the New Millennium – A Physical Charter ABIM and ACP Foundations and The European Federation of Internal Medicine

10. ‘Medical Graduates’ BMA Cohort Study , Health Policy and Economic Research Unit , BMA London WC1H 9JP 2005

11. Silver HK Medical Students and Medical School JAMA, 247(3) 309-310 1982

12. The “Dean’s Advisory Group on Professionalism” The University of Kansas School of Medicine, Roberta E Sonnino MD (Chair) July 2000

13. “ Relationship Based Health Care – a Comparative Study of patient and Physicians perceptions worldwide” .Mike Magee MD, World Medical Association Helsinki 2003

14. ‘Professionalism in Medicine’ K.R Sethuraman MD Regional Health Forum 10 1 2006

15. ‘Doctors in Society – Medical Professionalism in a changing world’ Report of a Working Party Royal College of Physicians 2005

16. The meaning of Professionalism in Medicine’ SR Benitar SAMJ 87 427- 31 1997

Declaration of Geneva

• 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
  Declaration of Geneva

• The Health of my patient will be my first consideration

• I will respect the secrets which are confided in me, even after the patient has died

• I will maintain by all the means in my power, the honour and the noble traditions of the medical profession

• My colleagues will be my sisters and brothers

• I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, or social standing to intervene between my duty and my patient

• I will maintain the utmost respect for human life from its beginning even under threat and I will not use my knowledge contrary to the laws of humanity

• I make these promises solemnly, freely and upon my honour

Declaration of Helsinki 1964
In Biomedical Research introduced concepts of:-

• Potential benefits must outweigh hazards

• The need for informed consent

• The need for research protocols to be scrutinized by ‘Ethics Committees

• A distinction between Scientific and Clinical Research

Declaration of Tokyo 1975

• The doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offense of which the victim of such procedures is suspected, accused or guilty, and whatever the victims beliefs or motives, and in all situations, including armed conflict and civil strife

Declaration Of Ottawa

• Health Data Bases - Ethical considerations
  
  The Right of a Child to Health Care , Specific Principles
  
  Quality of care
  Admission to hospital
  Freedom of choice
  Religious assistance
  Consent & self-determination
  Dignity of the patient
  Access to information
  Health Education
  Confidentiality
  Child abuse

The Right to privacy - entitles people to exercise control over the use and disclosure of information about them as individuals

The privacy of the patients personal health information is secures by the physician’s duty of confidentiality

Confidentiality is at the heart of medical practice and is essential for maintaining trust and the integrity of the patient-physicians relationship

Knowing that their privacy will be respected gives patients the freedom to share sensitive personal information with their physician

Principles
Access to information by patients
De-identified data
Confidentiality
Data integrity
Patients’ consent
Documentation
Authorization and use of data
Management procedures

Access
Patients have the right to know what information physicians hold about them, including information held on data bases.

Patients should have the right to decide that information about their health in a data base be deleted

Confidentiality
All physicians are individually responsible and accountable for the confidentiality of the personal health information they hold. Physicians must also be satisfied that there are appropriate arrangements for the security of personal health information when it is stored, sent, or received, including electronically.

Confidentiality
Medically qualified person (s) should be appointed to act as a guardian of a health data base, to have the responsibility for monitoring and ensuring compliance with the principles of confidentiality and security

Patients consent
Patients should be informed if their health information is to be stored on a database and of the purposes for which their information may be used.

Patients consent is needed if the inclusion of their information on a data base involves disclosure to a third party or would permit access by people other than those involved in the patients care, unless there are exceptional circumstances as described in paragraph 11

Authorization and use of data
Authorization from the guardian of the health data base is needed before information held on data bases may be accessed by third parties. Procedures for granting authorization must comply with recognized codes of confidentiality.

Approval from a specially appointed ethical review committee must be obtained for all research using patient data, including new research not envisaged at the time the data was collected.

Data accessed must be used only for the purposes for which authorization has been given

“We hold these truths to be self evident, that all men were created equal; that they are endowed by their Creator with certain unalienable rights; that among these are life, liberty and the pursuit of happiness.” Thomas Jefferson

“Care more for the individual patient than for the special feature of the disease.” Sir William Osler

“Wherever the Art of Medicine is loved, there is also the love of Humanity. Hippocrates 400 BC