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Presentation at UKM Faculty of Medicine on 3rd July 1997 by Prof Dr Omar Hasan Kasule, Sr Deputy Dean for research and Post-Graduate Studies at the Kulliyah of Medicine, International Islamic University PO Box 70 Jln Sultan Petaling Jaya Selangor 46700
1.0 INTRODUCTION
In this short presentation we shall discuss physician ethics as they relate to interaction with patients and professional colleagues. A central thesis of the presentation is that ethics must be based on a moral system. Ethics can not be divorced from morality. The current trend in the west is to define ethics as consensus guidelines that do not relate to any moral system. Guidelines are relative and are not absolute. Moral issues are absolute and are not always relative.
2.0 ETIQUETTES WITH PATIENTS
2.1 BEDSIDE VISIT
We are taught clear etiquettes for visiting patients (adab ‘iyadat al mariidh). A clinical visit is akin to a visit that is enjoined on every member of the community to visit the sick. These etiquettes include dua for the patient, asking the patient for dua, asking about the patient’s feelings, doing good/pleasing things for the patient (ihsaan), making the patient happy (tatyiib nafs al maridh), reminding the patient about his/her convenant with Allah, discouraging the patient from wishing death (tamanni al mawt), professional, competent and considerate care, listening to and resolving outstanding medical and non-medical problems. In all of this the physician should maintain confidentiality (hifdh al sirr), covering the nakedeness (satr awrat) except for necessity (dharurat). Dealing with patients of the opposite gender requires special considerations in order to avoid confusions (shubuhat). The best is for the patient of the same gender to be treated by a physician of the same gender. If this is not possible then a physician of the opposite gender can treat the patient preferably from the same culture so that sensibilities are minimized and there should always be a second professional from the same gender as the patient as a witness and assurance that no impropriety is committed.
2.2 CHOICE OF PHYSICIAN AND TREATMENT
The patient should have an opportunity to choose the physician he/she needs. It is not acceptable that patients be treated against their will unless there are extenuating circumstances. Even after choosing the physician the patient should still retain the freedom to accept or refuse treatment. A patient can not be forced to to take medication, to be treated with new/experimental drugs or procedures, or to undergo any procedure without informed consent. There are complications about treatment decisions for patients without legal capacity (ahliyyat) due to infancy or mentally incapacitating disease. The legal custodian (waliy) such a spouse, a parent or the administrative/political official can give consent for treatment decisions for mentally unfit patients or for those in coma.
2.3 MAKING THE DYING PATIENT CONFORTABLE
There are several measures that can be taken: narcotics for pain, drugs to allay anxiety & fears, talking with the dying, showing patience and empathy, dealing with complaints promptly, taking care of the patient’s hygiene such as cutting nails and shaving and providing clean clothes. The patient should be helped to make ablution (wudu) if possible.
2.4 MAKING A WILL
The physician should help the patient make a will. This implies that the physician himself should know the conditions of a valid and legal will (shuruut al wasiyyat). Sometimes the physician may have to write the document with the patient giving clear sign by nodding or using any other sign language. It is good to advise the rich patient to leave some property for charitable endowments (waqf). He should be advised not to will gifts more than 1/3 of the total estate because by law 2/3 must be for inheriting relatives. He should be advised to settle all debts before death.
2.4 THE LAST MOMENTS
In the last moments the physician should make sure of talqiin, that the last words of the patient are the 2 testaments: la ilah illa lah, Muhammad rasul Allah. The patient should be positioned facing the qiblat while reciting surat yasin. The eyes should be closed on death. The body should be covered. A dua should be made for the dead. Relatives and friends should be informed as soon as possible. They should be advised about the proper etiquette of mourning. Weeping with tears is a natural reaction and is allowed. Tearing garments, shaving the head, slapping the cheek, wailing, and crying aloud are not allowed.
3.0 ETIQUETTE WITH COLLEAGUES
GENERAL DUTIES AND RIGHTS OF BROTHERHOOD
The physician should understand that relations with professional colleagues extend beyond the narrow confines of the hospital. These include general duties of brotherhood such as returning greetings, following the funeral procession, accepting invitations, visiting the sick, responding to the sneezer, tolerance, forgiveness, helping those in difficulty, solving problems, fulfilling needs, compassion & kindness, protecting their honor and dignity in front of others, fulfilling promises and commitments, mutual respect, sincere advice (nasiiha ), avoiding underrating or humiliating them, and being grateful for their help and kindness.
3.2 COLLEAGUES OF THE OPPOSITE SEX
In a hospital environment there is very close contact in a small place. The general guidelines about awrat may be forgotten. The awrat of non-related person of opposite gender is not to be seen. The awrat of man is between the knee and the navel. The awrat of the woman is all her body except the face and the hands. The general conduct in the hospital setting should be to take care not to get into any emotional involvement or bonding. Even without adultery, such emotional bonding between colleagues of opposite genders weakens the marital relationship of both parties.
PERFORMANCE APPRAISAL
Senior colleagues or those in administrative positions may have to evaluate the performance of their colleagues and make some decisions. Performance has two components: competence and commitment. A competent worker lacking in commitment will not be productive. A committed worker lacking the necessary skills will make mistakes and end up costing the organisation a lot. Competence is determined by knowledge, skills, level of education, and amount of training. Commitment arises from self confidence and motivation. Inner intrinsic motivation is more important.
A worker may fail in performance for reasons that may be unique to him or the work environment. Expectations and standards of performance must be well defined. A worker will not perform competently if the goals, tasks, and activities are not clear or are poorly defined. Inadequate knowledge and deficient skills that are not remedied by appropriate education and training will impair performance. There must be a control system to monitor and detect failures early so that corrective action can be taken. Absence of such control will allow small mistakes to become big mistakes and eventually result in failure. In some cases failure is due to external circumstances over which the managers and the workers have no control.
People are evaluated for their suitability for appointment to certain tasks or for their performance. When evaluating people concentrate on results and not activity. Evaluation is not criticism. Appraisal can classify workers as: outstanding, very good, satisfactory, barely adequate, or inadequate. Trait appraisal looks at traits such as: appearance, self-confidence, ability of self-expression, alertness, ambition, initiative, energy, knowledge of organisation, ability to learn, accuracy, meeting deadlines, health, enthusiasm, attitude, acceptance of responsibility, efficient use of time, finishing tasks, adaptability, maturity, delegation, judgement, volume of work output, and forward planning. Performance appraisal looks at productivity, quality and quantity. An appraisal must not only look at performance indicators but must also consider the circumstances. A luck-luster performance may be judged outstanding if the surrounding circumstances were very difficult. The following are methods of recording of appraisal: essay, rating scale, forced distribution, critical incidents, and MBO (appraisal by achievement of targets). The common errors in appraisal are: (1) rater too lenient (2) rater is influenced by one or two good or bad traits (3) favorable rating of those who have traits like those of the rater (4) rating everybody the same way. Appraisals are used for: (1) promotion (2) salary reviews (3) placement (4) motivation (5) company planning. Participative is better than hierarchical appraisal. In participative appraisal, the negative and positive points are discussed with the worker and a strategy of improvement is worked out jointly. In hierarchical appraisal the manager alone makes the appraisals.
On-site inspections are one of the best control tools. The manager must wander around frequently to see what is going on. The Management Information System may not report all the relevant information needed for control. Workers get motivated when they see the leaders visiting them in the field. They feel that what they do is noticed and is important.
Do not confront in anger. Wait until you have had time to calm down and think through the problem. Do not procrastinate. Deal with problems promptly. Remember that worker problems will not go away on their own. Problem behaviours are likely to be repeated. Talk to the worker in privacy and avoid humiliating him. Criticize specific behaviour and actions and never give the impression that you are attacking the worker as a person. Give data to support your point. Make sure that the data is valid and is verifiable. Discuss solutions to the problems and listen carefully to the worker's own suggestions. Follow up the meeting and monitor behavioural changes. Some worker problems become chronic and call for more serious measures. The worker may not fit in the organisation and will be apathetic, destructive, or even move out. Sometimes you have to make the painful decision of firing in the interests of the organisation
Worker problems: There are situations when there is no fit between the individual and the job or the organisation. If he stays he will be apathetic and non-productive. He may be destructive in behaviour. Moving out of the organisation is the best solution in cases of persistent lack of fit. You must maintain a correct equilibrium between professionalism, friendliness, and brotherhood. Personally painful decisions may have to be taken in the best interests of the organisation
The following worker problems occur: not following instructions, chronic whining and complaining, an attitude of not caring, acting like he knows everything, 9-to-5 attitude, burned-out employee, prejudice, hard to get along, gossip, tension and hard feelings, too much sick leave, trying to be perfect and avoiding challenges, being a maverick loner who is non-conformist, under performing , being an egomaniac and autocratic, having poor human relations, setting unrealistic objectives, trying to be irreplaceable, conflicting with others and disloyalty
Attitude problems should be avoided preventively by discovering them during interview, trying to discover them at work while they are still below the surface, and counselling after employment. Some times you may have to change your management style since it could the cause of the problems. Maintain good documentation before firing.
As a leader you will be called upon to take hard decisions to solve an incompetence problem. You should not be afraid of being unpopular. You should remember that you will retain the respect of your followers if you are objective and fair. Criticism of employees should be done with care. Do not be emotional. Be constructive and maintain a problem-solving mode. Do not criticise in front of others. Criticise the behaviour and not the person. Do not push the employee to become defensive; this will destroy the whole purpose of the criticism exercise.