ASDIN 9th Annual Scientific Meeting

Outline

True Lies: • Ethics in the profession of medicine Ethical behavior when a patient has not received optimal care • Responsibility when we observe bad care • Practical suggestions for what to do Timothy A. Pflederer, MD Chair, ASDIN Public Policy Committee

Nothing to disclose

What is a Profession?

• A group of persons who have expertise as a “Medicine is not a trade to be learned result of mastering a particular body of but a profession to be entered” knowledge and developing the skills to apply that knowledge to concrete cases – Society is willing to acknowledge a profession and Francis Peabody, MD hand over the social power to make final 1881-1927 determinations on matters in which the Harvard Medical School professionals are experts, because without the profession, certain benefits would not be available to society’s members

JAMA 1984 Aug 10;252(6):813-8 Ozar, et al. CJASN 2012. Nephrologists professional ethics in dialysis practices

What are professional ethics? Core professional ethics in healthcare

• A set of societal expectations regarding the ABSOLUTE QUALIFIED exercise of professional expertise • Autonomy • Confidentiality – Created by society and affirmed by the profession – Personal liberty – Within boundaries of the “harm principle” – For the purpose of avoiding the risk that the • Veracity profession might use their social power for their – Truthfulness • Justice own benefit • Non-maleficence – Non-discrimination, equality – Do no harm • Role fidelity • Beneficence – Act with defined role – Do good and licensure

Edge, RS. Ethical and legal implications of practice, in Ozar, et al. CJASN 2012. Nephrologists professional ethics in dialysis practices Egan’s Fundamentals of Respiratory Care , 6 th Ed. 1995

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Marketplace vs. Professional ethics ACP statement on physician obligation

• Marketplace ethics focus on the “well being of • Physicians must base their counsel on the the seller” with obligations to the consumer for interests of the individual patient, regardless of respecting autonomy, veracity and non- the insurance or medical care delivery setting. malficense Whether financial incentives in the fee for service Do not force, lie or harm • system prompt physicians to do more rather than • Professional ethics place a primacy on the “consumer’s good” less or capitation arrangements encourage them – Physicians have a particularly stringent duty to assure to do less rather than more, physicians must not that their decisions and actions serve the welfare of allow such considerations to affect their clinical their patients or clients, even at some cost to judgment or patient counseling on treatment themselves” (RPA position paper on ESRD patient solicitation) options, including referrals. • Always act for the benefit of the patient

Ozar, et al. CJASN December 2012 ACP Ethics Manual. 6 th edition

What is “bad practice or care”?

What should I do if I see a physician • Impairment providing bad care? • Incompetence • Unethical conduct

AMA code of medical ethics: Opinion 9.031

Bad practice should be reported Bad practice should be reported

• Nephrologists must strive to be in compliance • Professionalism entails membership in a self- with their state’s medical practice acts or correcting moral community other relevant state statutes. According to • Every physician is responsible for protecting state law, nephrologists conduct that is not in patients from an impaired physician and for assisting an impaired colleague compliance with these state regulations • A physician has a duty to patients, the public and should (or must, if required by state law) be the profession to report to the appropriate reported to the appropriate state licensing authority any well-formed suspicions of fraud, board professional misconduct, incompetence, or abandonment of patients by another physician RPA and Forum of ESRD Networks: Position on ESRD patient solicitation: www.renalmd.org ACP Ethics Manual. 6 th edition

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Bad practice should be reported So we agree, by virtue of our membership in • A physician shall uphold the standards of this profession, not only to be ethical but to professionalism, be honest in all professional ensure that the other members of the interactions, and strive to report physicians profession are ethical deficient in character or competence, or engaging in fraud or deception, to appropriate entities Our obligation is driven by our duty to: • Non-maleficence – Do no harm • Beneficence – Ensure the patient’s good

AMA code of medical ethics: Principles of Medical Ethics

Our ethical conflict What to do

• Uncertainty • Be careful about the facts – How good is the evidence? • Evaluate your motives • Conflict of interest • Report to an appropriate 3 rd party – Am I biased? • Have concern for the colleague • Personal impact • Don’t fail to act – Will reporting affect me? – Rapidly if imminent patient risk – Slow and cautious if no immediate risk Honesty, humility and wisdom

Where to report How to report

• Peer review • Impairment – Directly encourage impaired physician to stop practice and get • Supervisor help – Report if refuses to comply Corporate administrator • Immediate authority (supervisor, peer review, etc) or State licensing • board • Medical director • Incompetence – Report those physicians with a hospital affiliation to their clinical • Professional medical society authority and peer review – Report those physicians without a hospital affiliation to local or • State licensing board state medical society and/or state licensing board • Unethical behavior – Report to the authority responsible for the area of ethical violation

AMA code of medical ethics: Opinion 9.031 – Reporting impaired, incompetent, or unethical colleagues

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Summary

• Being part of the medical profession entails responsibility to practice ethically and police ourselves • Observed behavior demonstrating impairment, incompetence or unethical acts should be reported • Recognize that our own perceptions and biases may taint the accuracy of our interpretation

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