search this site.

220628P - PROFESSIONALISM AND ETHICS FOR A HEALTHCARE PROVIDER FROM AN ISLAMIC PERSPECTIVE

Copyright 1995-2023 © by Prof Omar Hasan Kasule - Admin
Category:
Print Friendly and PDFPrint Friendly

Presented at a certificate course on essentials of ethics and professionalism in health care Pakistan Islamic Medical Association on June 28, 2022. By Professor Dr. Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Ex-Chairman, Human and Medical Ethics Committee, KFMC and Consultant Academic and Training Affairs, R2 Cluster

 

OVERVIEW

  • Define professionalism, its dimensions, and its teaching.
  • Describe the principles of medical ethics.
  • Case scenarios of professionalism and ethics.


ETHICS AND PROFESSIONALISM: The Inner and Outer Dimensions

  • Ethics and professionalism are closely interlinked in good patient care but they come from different conceptual backgrounds. Both are difficult to define exactly.
  • In my view, ethics is the inner dimension while professionalism is the outer dimension. Ethics is difficult to police but some consequences of lack of ethics can be detected.
  • Professionalism being an outer dimension would have been easy to police if it was easy to define.
  • The relationship between ethics (right vs wrong) and law (legal vs illegal) is complex and differs between the Islamic and Western perspectives. Is right = legal? Is wrong = illegal? How about exceptional circumstances (dharurat)?


CASE SCENARIO: Professionalism or Ethics?

  • Physician A called in for consultation assessed the patient and told physician B (the attending physician) that the patient needed an ultrasound to rule out the acute abdomen.
  • Physician B quoting official hospital policy disagreed insisting that if an acute abdomen is suspected general surgeons should be called in.
  • Physician A suddenly started to raise his voice with a high tone and shout in front of the patient with all staff and patients and visitors watching.
  • Physician A then left while Physician B was thinking ‘This attitude is affecting me as a health care provider. Shouting and disrespecting me in my workplace and I wonder, why he would do such an attitude to me.


DEFINITION OF PROFESSIONALISM AS ATTRIBUTES AND BEHAVIORS:

  • In general, professionalism is defined as attributes and behaviors expected of a healthcare provider.[1]
  • A fair level of agreement can be reached by physicians, nurses, and the public on tangible behaviors that constitute professionalism.[2],[3]
  • Behaviors are easier to observe and measure than attitudes and other intangibles that are acquired by apprenticeship or experience but which cannot be described in concrete terms.


DEFINITION OF PROFESSIONALISM AS INTANGIBLES:

  • Intangible aspects of professionalism can explain similar reactions of professionals to a situation without having to discuss or refer to a rule or code.
  • The intangibles could almost be called ‘trade secrets’ or practical wisdom (phronesis).[4]
  • Intangibles can be considered under the Islamic legal principle of custom, ‘urf, with various formulations such as: what is known as customary has the force of law, al ‘aadat muhakkamat (Majallat Article No. 36)[5] and what is known customarily is considered an agreed condition among the practitioners of a profession like trade, al ma’aruf ‘urfan ka al mashroot shartan (Majallat Article No. 43 and 44).[6]


DEFINITION OF PROFESSIONALISM AS SKILLS:

  • Professionalism can also be defined as skills: A professional who is engaged in the same activities on a daily basis develops special skills.
  • In earlier times with limited knowledge and technology, it was possible to list skills that a professional was supposed to have.
  • It is not possible to list comprehensively the skills of a professional today but the skill dimension is still assumed in attributes of professionalism such as ‘excellence’ because you cannot achieve excellence without being skilled.


6 DIMENSIONS OF PROFESSIONALISM - ABIM (AMERICAN BOARD OF INTERNAL MEDICINE)[7]

  • Altruism
  • Accountability
  • Excellence
  • Duty
  • Honor and integrity
  • Respect for others


NEGATIVE ‘DIMENSIONS’ OF PROFESSIONALISM - ABIM[7]

  • 5 attitudes, behaviors, and actions erode professionalism.
  • Abuse of power and sexual harassment.
  • Conflicts of interest.
  • Professional arrogance.
  • Physician impairment.
  • Fraud in research.


DISCUSSION OF THE ABIM DIMENSIONS OF PROFESSIONALISM:

  • The ABIM formulation is very practical and pragmatic by having both positive and negative definitions that leave little room for ambiguity.
  • The ABIM formulation is not exhaustive enough.
  • The ABIM formulation has no statement of an underlying moral theory that could be the basis for the intangibles of professionalism which as mentioned above exist but are not obvious.
  • Hence the attempt at a formulation from the Muslim perspective attempts to overcome these defects.


PROPOSED 7 DIMENSIONS OF PROFESSIONALISM - 1:

  • Faith (iman),
  • Consciousness (taqwat),
  • Best character (ahsan al akhlaq),
  • Excellent performance (itqaan al ‘amal),
  • Strife toward perfection (ihsan),
  • Responsibility (amanat),
  • Self-accountability (muhasabat al nafs).


PROPOSED 7 DIMENSIONS OF PROFESSIONALISM - 2:

  • Iman improves professionalism in two ways: holism and humility.
  • Iman motivates the practice of holistic medicine emanating from the integrative doctrine of monotheism.
  • Iman makes the physician more humble and less arrogant through the realization that he is an agent and not the cause of cure; cure is in Allah’s pre-determination, qadar.


PROPOSED 7 DIMENSIONS OF PROFESSIONALISM - 3:

  • Taqwat makes the physician conscious of his duties and meticulous in performance in the full knowledge that Allah is watching and knows all that is being done, unlike human observers who cannot see hidden mistakes and bad intentions.
  • Akhlaq ensures the best human interaction between the physician on the one hand and the patients and professional colleagues on the other hand manifesting as balance (tawazun), humility (tawadh’u), brotherhood (ukhuwwat), social respectability (muru’at).


PROPOSED 7 DIMENSIONS OF PROFESSIONALISM - 4:

  • Itqan and ihsan motivate the physician to improve his skills and knowledge to have the best outcome in his medical procedures.
  • The physician should take his work as a trust (amanat), involving: sincerity of intentions (ikhlas al niyyat); quality work (itqan & ihsan), and social responsibility (masuliyyat ijtima’iyyat).
  • Professionalism is part of the social contract involving the responsibility of the professional to society.[8]


TEACHING PROFESSIONALISM - 1:  Motivation

  • Growing awareness of the importance of professionalism and the horrors of the consequences of its failures have forced including professionalism in medical curricula at undergraduate and postgraduate levels.[9],[10]
  • Schools struggled to introduce a culture of professionalism using various strategies[11] including the integration of ethics and humanities.[12]


TEACHING PROFESSIONALISM - 2:  Approaches

  • The teaching should be done as early as possible in the medical course before students pick up bad habits.
  • The teaching of professionalism can be passive as an apprenticeship.
  • Apprenticeship remains the best method because it is one-to-one and teaches practical wisdom[13] and students learn from good role models.[14]
  • The disadvantage of apprenticeship is that students may feel deficient in professionalism if they do not get teachers who are good role models.[15]


TEACHING PROFESSIONALISM - 3: Methods

  • Ireland: professionalism in Ireland was taught as an interdisciplinary course assessed by a student essay.[16]
  • California: professionalism was taught as part of an integrated longitudinal program starting early in the medical course.[17]
  • Among teaching methods used were: use of simulated emails,[18] using movies,[19] medical television programs portraying hospital practice,[20] discourses on professionalism,[21] online programs,[22] and learning from malpractice suits and malpractice experiences.[22]


TEACHING PROFESSIONALISM: REVIVAL OF A HOLISTIC EDUCATIONAL TRADITION - 1:

  • Traditional Muslim education is based on a student being with the teacher all through the waking hours and being awarded permission to teach others, ijazah, at the end of a long apprenticeship.
  • The system was not only about transferring knowledge but also transferring ethics, behavior, and attitudes by actual observation and interaction with a mentor.
  • The mentor also had ample time to observe the student and correct any deviations.


TEACHING PROFESSIONALISM: REVIVAL OF A HOLISTIC EDUCATIONAL TRADITION - 2:

  • The Qur’an describes this system in the education of Musa (PBUH) who traveled with the righteous man Khidhr and learned deep ethical lessons from him.
  • The prophetic teaching at Dar al Arqam: one-to-one, observation.
  • Hadith literature: words, actions, and iqrar.


IMPLICATIONS OF REVIVING THE HOLISTIC EDUCATION TRADITION:

  • Relative separation of service from teaching.
  • Doing service while teaching vs. teaching while doing service.
  • Teaching is confined to only those who can / are willing to be good role models.
  • Teachers should have enough time to teach with reduced clinical loads.
  • The concept of a good/bad sunnat.


UNDERLYING ETHICAL PRINCIPLES:

  • The principle of intention, قاعدة القصد
  • The principle of certainty, قاعدة اليقين
  • The principal of injury, قاعدة الضرر
    • Autonomy of patient and physician
    • Beneficence
    • Non-maleficence
    • Justice
  • Principle of hardship قاعدة المشقة
  • Principle of precedent قاعدة العرف


OTHER PRINCIPLES:

  • Privacy and confidentiality
  • Truthfulness and disclosure
  • Fidelity


ROLES IN THE HOSPITALS:

  • Healer
  • Collaborator
  • Manager
  • Researcher


ROLES IN THE MINISTRY OF HEALTH:

  • Manager
  • Planner
  • Researcher


ROLES IN THE COMMUNITY:

  • Health educator
  • Advocate
  • Researcher
  • Healer


DUTY TO THE PATIENT - 1:

  • Treat your patient as a person, not just a body.
  • Respect your patient’s autonomy.
  • Treat all patients equally, without discrimination.
  • Fear God when dealing with your patients; show respect for their beliefs, religions, and traditions.
  • Ask only for the tests needed for the patient without adding any tests not justified by the patient’s case. A doctor should base his whole diagnosis and treatment on the best available evidence and data.


DUTY TO THE PATIENT - 2:

  • Explain honestly to the patient or anyone representing him/her the type, causes, and complications of the illness, and the usefulness of diagnostic and therapeutic procedures.
  • Relieve the patient’s pain and give him the feeling that the physician is eager to give him proper care and attention.
  • Respect Privacy.
  • Respect the patient’s autonomy.
  • Inform the patient about his/her condition.
  • Keep the patients’ secrets (confidentiality).


DUTY TO THE PATIENT - 3:

  • DO NOT hesitate to refer the patient to a more experienced doctor or to a doctor who has more effective equipment whenever the patient’s case calls for such a referral, nor to refer him to a doctor whom the patient wishes to consult.
  • Continue to give an emergency patient the proper treatment until it is no longer needed or until care for the patient is taken over by another doctor.


DUTY TOWARDS COLLEAGUES:

  • Deal with, and act towards his/her colleagues in a good manner and in the same way he/she would prefer to be treated.
  • Avoid direct criticism of his/her colleague in front of patients.
  • Do not indulge in defaming the honor of his/her colleagues.
  • Exert every possible effort to educate colleagues.
  • Respect the differences with colleagues (gender, culture, belief…).
  • Respect other non-physician medical professional colleagues, and appreciate their roles in the healthcare of the patient.
  • Report the incidence in which a colleague could be dangerous to the authority concerned.


CASE SCENARIO - 1:

The Ministry of Health issued a new policy that all doctors in its hospitals must be engaged in research and that research would be included in professional performance evaluation. There was a great protest by physicians who said they hardly had enough time for their patients where would they find the time to do research? How would you solve this problem?


CASE SCENARIO - 2:

The hospital manager disciplined a physician who was 2 hours late for his cardiac follow-up clinic because he was in a community program on the prevention of cardiovascular disease. What do you think about this? What principles will you use?


CASE SCENARIO - 3:

The hospital director wanted to discipline a doctor who refused to treat a patient with repeated myocardial infarction and had refused to give up smoking, and compliance with dietary and drug treatment with the result that he had to come to the emergency room 2 or 3 times a week.


CASE SCENARIO - 4:

An 80-year-old woman with severe coronary artery disease was in the ICU for the past 6 months with repeated episodes of MI and cardiac arrest always relieved by CPR. The physician wrote a DNR order to relieve her from further suffering.


CASE SCENARIO - 5:

A 70-year-old man was admitted with severe MI. After initial treatment and stabilization, the doctors decided to offer him a coronary graft operation. His sons told the doctors to go ahead with the operation without telling the patient the diagnosis because knowing he had a heart problem would depress him and he might refuse the operation.


CASE SCENARIO - 6:

Physician A called in for consultation assessed the patient and told physician B (the attending physician) that the patient needed an ultrasound to rule out the acute abdomen. Physician B quoting official hospital policy disagreed insisting that if an acute abdomen is suspected general surgeons should be called in. Physician A suddenly started to raise his voice with a high tone and shout in front of the patient with all staff and patients and visitors watching. Physician A then left while Physician B was thinking ‘This attitude is affecting me as a health care provider. Shouting and disrespecting me in my workplace and I wonder, why he would do such an attitude to me.


REFERENCES:

[1] N Z Med J. 2010 May 14;123(1314):123-32.
[2] Acad Med. 2009 May;84(5):566-73.
[3] Clin Med. 2010 Aug;10(4):364-9.
[4] J Med Philos. 2011 Apr;36(2):114-32.
[5] Majallat al Ahkaam al Adliiyyat Dar Ibn Hazm Beirut 2004 G / 1424H page 90
[6] Majallat al Ahkaam al Adliiyyat Dar Ibn Hazm Beirut 2004 G / 1424H page 91
[7] American Board of Internal Medicine. Project Professionalism was sponsored by the ABIM Committee on Evaluation of Clinical Competence in conjunction with the ABIM Clinical Competence and Communications Programs. For additional copies please call 215-446-3630 or fax 215-446-3470. First printing 1995, second printing 1996, third printing 1997, fourth printing 1998, fifth printing 1999, sixth printing 2000, seventh printing Philadelphia 2001.
[8] Perspect Biol Med. 2011 Autumn;54(4):455-69.
[9] Keio J Med. 2009 Sep;58(3):133-43.
[10] Eur J Intern Med. 2009 Dec;20(8):e148-52.
[11] P R Health Sci J. 2009 Jun;28(2):135-9.
[12] Acad Med. 2012 Mar;87(3):334-41.
[13] J Med Philos. 2011 Apr;36(2):114-32.
[14] Acad Med. 2009 May;84(5):574-81.
[15] Med Teach. 2011;33(10):840-5.
[16] Med Teach. 2011;33(9):710-2.
[17] Med Teach. 2009 Jul;31(7):e295-302.
[18] Acad Med. 2010 Oct;85(10 Suppl):S1-4.
[19] Med Teach. 2009 Jul;31(7):e327-32.
[20] BMC Med Educ. 2011 Jul 29;11:50.
[21]  Med Educ. 2011 Jun;45(6):585-602.
[22] Acad Med. 2010 Oct;85(10 Suppl):S68-71.

[23] Acad Med. 2011 Mar;86(3):365-8.