The topics of Ethics is not one commonly brought up in the litany of rhetoric of educational systems along with subjects like math and science– often placing the role of molding the growing child’s moral code to the parents or religious institutions. Typically, many of these values are learned in life lessons through trial and error, pit falls and triumphs, or childhood fables which are espoused to be used as models for future behavior. As we age these lessons are reinforced by experiences and the role of adapting and molding one’s one core of ethics is often subjective to the experiences we face. Experiences, however are subjective. Ethics, in a sense, should be an infallible core which is shared by all and it is at this crossroad of subjective learning and experience driven understanding and what is to be understood as a common core for which all can utilize in a diversity of situations.
Since the dawn of time there have been stories used to help teach the values of ethics. Whether these be from religious texts such as the Bible and the Quran which, at their core, are meant to reflect values of respect, love for thy neighbor, justice and fidelity or other forms of literature. As we start this conversation on the topic of Ethics, it is only appropriate to begin where the word originated. The English word 'ethics' is derived from the Ancient Greek word ēthikós, meaning 'relating to one's character', which itself comes from the root word êthos meaning 'character, moral nature.'1 As far back as Ancient Greece in the 5th century BC there were writings of Aesop we have tales which were used in the forum of thought. In this center of culture and learning there were professors of philosophy who used these texts to flesh out morals. Thus by doing so, would therein help create a dialogue of common core values which they could raise above and set as examples in this rapidly expanding and developing part of the world. These tales, expanded upon by his flock of philosophers, were later translated into Latin by Phaedrus, and soon by countless others throughout the world.
The first printed version of Aesop's Fables in English was published in March 1484, by William Caxton.2 Around this time, and up into the 18th century, these fables were primarily used by those such as preachers and teachers in the school houses. It was the philosopher John Locke in his writings Some Thoughts Concerning Education (1963) which he offered a new way to view these stories. Writing that while Aesop’s fables are “…apt to delight and entertain a child. . . [they] afford useful reflection to a grown man. And if his memory retain them all his life after, he will not repent to find them there, amongst his manly thoughts and serious business.”
Similarly, the church had also latched onto the idea of standardizing a set of stories which children could share when wading into the world ahead – corrupt, full of sin and abound with ethical perils and pitfalls. The Centum Fabulae composed by Gabriele Faerno was commissioned by Pope Pius IV in the 16th century 'so that children might learn, at the same time and from the same book, both moral and linguistic purity'.3 This concept of standardization was one which flourished in this time in stark contrast to the Greek and Latin originators which used their stories as igniting sparks for conversation and debate.
Thus, on and on the history continues but from an early time people were cognizant that the process of ethics is something which need to be shaped, directed and reinforced as we grow. As times progressed, the focus turned to standardization and countless took on the mantle of the cause to formulate a core set and agree on a series of ethics which could be used as a model. Models which not only can guide the individual as they grow and enter society, but also various established sectors of society such as politics, finances, law and medicine. It is here where we will narrow the scope of our talk, as there is no more stigmatized field to exemplify the utilization of structure and model as the medical field.
Fittingly, there was an ethicist by the name of Rushworth Kidder, founder of the Institute for Global Ethics in 1990, who wrote of ethics as ‘'the science of the ideal human character' or 'the science of moral duty.” 4 This is a striking statement, as the term science is often not paired with the study of philosophy. Nevertheless, there is no better union of science and the study of man than medicine itself – if anything, that is the very definition of the vocation. The medical field has indeed adapted a core of ethics. The branch of ethics that directly relates to medicine and biology is referred to as bioethics, or biomedical ethics, and have had champions to formulate their own models for aspiring and acting physicians to look towards. Of note this paper will often discuss the physician, but in this age one may include nurses, nurse practitioners, Physician Assistants amongst the umbrella of health professionals which these values all apply. One such model has been Beauchamp and Childress (2008)5, which describe health care ethics:
The Principle of respect for autonomy
Principle of Justice.
Principle of beneficence
Principle of non-maleficence
The four principles listed above are non-hierarchical- meaning that no singular principle outweighs another in importance. These four principles are taught to many an endeavoring physician in the attempt to create a collective with shared standards to hold themselves to. Without a common groundwork from which to tread, the uneven footing can cause even the most stable around us to trip and stumble – possibly falling irreparably behind.
With any type of standard, defining and understanding each component is necessary in order to propagate its influence; for without understanding we cannot hope to practice. The first term we run across is Autonomy, with the principle stressing respect for the patient’s right to making their own autonomous decisions and our ability as physicians to give them the tools and environment with which they are free and capable of doing so. From this is where the derivation of a standard protocol and documentation – the informed consent – originates. This allows for a physician to maximize the loss of patient’s ability to develop their own life plan. Pitfalls may arise if the patient’s “life plan” differs from the one which years of science and experience may suggest to the physician’s eye, but as long as information is given to the patient simply (avoiding jargon and terminology which may distract, confuse or mislead) and thoroughly, the physician must relinquish the choice of treatment to the patient. This is with the understanding that as a physician, it is an ethical prerogative to utilize the knowledge and experience which has been garnered to guide in the decision making of the patient, who has an innate right to their own opinions, perspectives, values and beliefs. Medical paternalism is the term applied when this is not upheld, and the physician acts without consent or overrides a person’s wishes, wants, or actions. 6
Next is the Principle of Justice, which emphasizes a fairness and equality amongst individuals. As Aristotle is famously quoted to have said, 'giving to each that which is his due.' Whether that be in the level/acuity of care they are given, the types of resources available or the standards of treatment which are offered – the resources should be dispensed fairly, so that people with similar needs and in similar circumstances will be treated with fairness. Care must be fairly, justly, and equitably distributed among a group of patients, and cases must be treated equally with a blind eye to race, gender or religion (unless clinically relevant, and without violating the above principle of Autonomy). John Rawls, in his work A Theory of Justice7 he discusses this very topic – how to ensure justice is given to patients in the face of such disparities. He writes that mankind unfortunately experiences a “natural lottery” for which those slotted to various levels of society are often not to blame for their place. Therefore, he suggests society ought to help even the playing field of this lottery by providing resources to help overcome the disadvantaged situation.
This is where the question and debate of “rights to heath care” enter the stage, asking for changes in the laws and policies of society that govern the access of a population to health care. This is where the concept of Medicare entered in the United States – having a population of a shared characteristic (ie: age over 65) have equal access to a level of care, regardless of their place in the lottery. While this system is not without its flaws, this is a start to a very long journey which is still being actively worked in. These reforms are beyond the scope of an individual health care provider trying to navigate patient justice alone, however keeping in mind the basic tenant is imperative to make any strides forward in this sphere. The focus can be narrowed to the town or even the hospital which an individual is working under and start within this hub of interest to strive for justice in care for those under their care.
The next sector to cover under Ethics in Medicine is Beneficence, which at its core is doing good and the right thing for the patient; taking steps to also prevent and remove harm for the patient in the process. It’s an ethical commitment to act for the good of the patient, and is at the very heart of the relationship society entered with a medical professional. We aim for healing and care of the patient, looking to not only aid with physical ailments, but also with mental and social impediments to health. This involves the care team working on helping the patient advance his/her own good by striving to provide them with resources to better themselves – education, materials (ie: medicine, assisted devices, therapy), and support.
On the counter-end is Nonmaleficence which is doing no harm- intentional or unintentional. This may appear as one of the more “Common sense” elements to the conversation, however nonmaleficence is more complex than what appears on the surface. At times, this is in conflict with the other spheres. For example, let us consider a patient whom is diagnosed with an acutely infected appendix. Medically, the goal is Beneficence – utilizing our knowledge to ascertain the greatest good for the patient which in this case would mean immediate removal of the appendix via surgery. However, this is a procedure which is not without risks – general anesthesia and open wounds in an otherwise healthy patient. Fortunately, these four core elements work together rather than stand alone in isolation, and can help guide the physician in the process. One can utilize Autonomy to explain these risks to an informed patient, and how the benefit is one which falls under a justly standardized treatment to bring about the most good while mitigating very real risks the best that is possible. In this way we can see how all these elements of medical ethics as written work together to ensure the patient has the best possible outcomes in their personalized situations.
The process of working through an ethical problem such as the above (a minor one, but nonetheless with questions) is multifold and not unlike problem solving in any other context. First step is to identify the core problem in the situation, and to obtain a clear description of the circumstances surrounding. Collecting this data from the patient, the families or those involved in the care, as well as the core issue which is being discussed. Once the problem is identified, it comes to the exploration and generation of possible solutions, and the implications which may arise from each proposed solution. Once these are weighed out, the most ethical (respecting Autonomy, balancing Beneficence and Nonmaleficence and Justice) is to be taken. If necessary, calling upon those who train in these areas (ie: an Ethics committee) who can review ethical codes, published evidence based practices, declaratory statements, professional position papers and the professional literature, may also be crucial in coming to a decision which is best for the patient and their families.
What now if we turn the medical ethics however to the welfare of not only the patient, but also the healthcare professionals themselves. Entering into this field, many providers will immediately, and honestly say that they chose the profession in order to try and help as many people around them as possible. This at its base is what medicine means to many professionals – the act of healing those around them. Unfortunately, in doing so there are many physicians who are unable to care for themselves in the same rigorous and thoughtful manner – spending much of their time and energy in the diligent care of those around them. Members of a health care team may, inadvertently, do patients harm by not being beneficent to themselves. Whether this is from the strenuous work hours, failure to address their own health issues for fear of stigmata or stressors which are either inherent to the job itself or part of their personal lives which they are often forced to place on the back burner. Safety and welfare of the patient are stressed – but not always that of the physician or residents.
The statements of medical ethics require the physician to do what is best for the patient and place the patient's interests before the interests of the physician. This is where there may lie a fundamental problem: if by doing so we harm the physician, are we not doing harm to thy self? Does the medical code of ethics protect the physician aside from a roundabout way of not doing harm to the patient?
Looking into the cornerstone of up to date information on health, the World Health Organization defines health as an optimal state complete physical, mental and social well-being and not merely the absence of disease or infirmity.' 8 Social health advocate Marandi Taylor has proposed that health also be defined as the ability to adapt and manage physical, mental and social challenges throughout life. 9 It is unfortunate that medical training has historically acculturated physicians to deny their own self-care and pursuit of achieving a state of health for themselves in lieu of giving oneself to the service of others. A majority of interventions and research related to physician wellness have focused on personal resilience (e.g., mindfulness), while organizational interventions have come about more slowly and with more resistance. These interventions have included attempts to streamline electronic medical records which physicians these days spend chained to more often than getting to connect with their patients or peers, along with adequate staffing (allowing physicians to spend more time doing work for which they are uniquely trained), as well as changes in policy and legislature (which will be touched on shortly).
When the practice of medicine can be performed efficiently, it positively affects the physician’s ability to improve their own personal resilience by engaging in positive health behaviors. As their well-being improves, they can also better contribute to their organization’s culture of wellness through healthier interpersonal interactions and by encouraging others to care for their own wellness. We do not live in a bubble and must not continue to propagate this forward. Unfortunately, streamlining productivity is hardly half the battle when it comes to facing the struggle which some physicians are facing behind the curtain as they work tirelessly to care for and bring beneficence, justice and autonomy to their patients – all while avoiding harm.
The fallacy which needs to be addressed and changed in how not only society views physicians but also how peers view one another is the rigidity of the “iron doc” – the unflinching, never tiring physician who has melding with the technology they are attached to; to become more than the metaphor of a machine. Clinical leaders and those with administrative powers can start this process but encouraging an environment which allows physicians to extend to their peers and themselves the same natural compassion they show to their patients. Leaders should expect physicians to attend to their own well-being and should view self-care as a professional core competency, abandoning the antiquated and dangerous misconception that self-care and patient care are competing interests.
It is essential to build a culture of appreciation, support, and compassion along with a deep sense of community amongst healthcare teams. For example, peer support programs that train clinicians to provide emotional support to colleagues may be effective ways to prevent harmful stress while contributing to a culture of compassion and a sense of community. Medical teams also can reduce harmful stress by ensuring that all team members feel safe when pointing out problems rather than fearing retaliation or other negative reactions from colleagues or superiors. In the same vein, they must also feel comfortable disclosing issues they are actively trying to work on or are suffering with in order to continue to improve their resilience.
In a 2017 article entitled, “Doctors fear mental health disclosure could jeopardize their licenses” that very topic was explored and discussed.10 One paper they cite for example11 found that an average of 1:15 surgeons admitted to experiencing suicidal thoughts, but over 60 percent were reluctant to seek help because of concerns that it might affect their license. While it is illegal under the Americans with Disability Act, there are countless reports of physicians who have been turned down from job opportunities based on stigmata of mental illness. The article quotes Mayo Clinic professor and internist Dr. Liselotte Dyrbye: The ironic thing is that if a doctor is impaired but is discouraged from seeking help, the patients are not being protected. We want doctors to get help before they are unable to do their jobs.
In 2003, the American Medical Association released a statement recognizing the lack of priority given to physician mental health within the culture of medicine and in the same statement identified barriers to treatment, including discrimination and licensing.14 While this was a large step forward for an issue which had largely been in the shadows, the decade which followed did not bring with it much change. The culture stagnated until 2013 when the AMA again took an initiative to have the wording changed in licensing forms across the country, attempting to reduce the stigma that was inherent in the questions asked. The new policy urges to any state medical boards that wish to retain questions concerning the health of its applicants on the medical licensing applications to instead utilize a language recommended by the Federation of State Medical Boards. This language reads, “Are you currently suffering from any condition for which you are not appropriately being treated that impairs your judgment or that would otherwise adversely affect your ability to practice medicine in a competent, ethical and professional manner? (Yes/No).” 14 Unfortunately, two-thirds of state medical boards remain non-compliant with these recommendations and continue to be a source of fear and stigma to those suffering from any mental health condition.
Most mental health problems can be effectively managed, but real and perceived barriers— such as confidentiality concerns and fear of negative ramifications on one’s reputation, licensure, or hospital privileging — keep many physicians from addressing their mental health needs. Unattended distress has ramifications for physicians as well as the health care industry and patient safety, and can violate without intention the ethical code which was set forth and previously detailed. There are many contributing factors which we have touched upon, in addition to individual risk factors and stress load, institutional culture plays a critical role in leading physicians to rationalize and internalize distress as part of their professional identity: its, “part of the job.” a stoic culture of self-sufficiency alongside real and/or perceived barriers to help-seeking allow deterioration in wellbeing to go unaddressed and to potentially spiral into more severe, entrenched mental health problems.
According to estimates, 300 to 400 American physicians take their lives each year. 12 A meta-analysis by Eva Schernhammer that included U.S. and international studies, which supported the finding of elevated rate of suicide risk for male physicians versus the general male population (OR 1.41), additionally showed that the risk of suicide for female physicians is even higher: two to four times higher than non-physician females (overall OR 2.27).13 Physicians commonly mask their personalized experiences of anxiety, worry and shame; rationalizing significant feelings of distress as part of their identity as physicians - loathe to draw attention to self-perceived weakness.
One key factor shaping physicians’ behavior surrounding these issues of seeking help and speaking out about their conditions is fear— the fear of punitive consequences or loss of colleagues’ esteem as a result of acknowledging mental health struggles. Education must target peers and mentors to play an active role in noticing, encouraging and supporting individuals in distress to get help when needed. Education plays a key role, but policies and procedures that make it safe for individuals to seek support. Just as we have attempted and succeeded in the standardization of core ethical principle to guide us with care, we need to have a way to help physicians who are struggling to maintain their own health. Perhaps this is another fable we can add to the list of our ancestors. The culture surrounding physician mental health must be revised such that those struggling can comfortably seek treatment with the same privacy and dignity with which we are expected to treat our patients. “Physician, heal thyself” is a proverb easier said than done.