Professional and Ethical Matters

 

 

PROFESSIONAL AND ETHICAL MATTERS

 

The Newfoundland and Labrador Council of Health Professionals (NLCHP) registers a number of health professions in the province of Newfoundland and Labrador. One of the responsibilities identified in the Health Professions Act (2010) is for the discipline specific Colleges to develop and approve a code of ethics for the health profession that they represent. Codes of ethics for the individual Colleges are to be placed on the College’s web sites. The Newfoundland and Labrador Council of Health Professionals (NLCHP) Complaint Authorization Committee has reviewed  documents from the individual Colleges that make up the Council and has developed the following material  to supplement College codes of ethics and to provide additional information to practitioners and the public.

Information regarding the Complaints Authorization Committee’s role and responsibility is outlined under the Regulation/Registration section, drop box Complaints Authorization Committee of the NLCHP website. The following material is directed to both practitioners and the public.  The document focuses on considerations for ethical and quality care that can help practitioners avoid complaints.  Effective therapeutic relationships depend not only on the available services and treatments, but also on the manner of their delivery.

I           PROFESSIONAL/ETHICAL RESPONSIBILITIES

a.         Preamble

Health care ethics, influenced by patients’ concerns over their rights, underscore the need to respect patients’ autonomy and dignity. 

One consequence is the recognition that individuals have a right to make decisions about their health care and that an ideal patient-health practitioner relationship is a partnership.  However, this can be undermined by the vulnerability of patients and by a practitioner’s special knowledge, language and authority.  Patients may feel that their autonomy, even dignity, is ignored in ways that ultimately affect trust in a relationship.

b.         Professionalism

i.          Responsibilities to the public

Although a diversity of views have been expressed over the nature of professionalism in health care, a consensus exists that it must include:

œ          an acceptance of standards of practice that recognise the principles and values in codes of ethics, and the laws and regulations that govern a profession.  

œ          a commitment to improve the quality and effectiveness of current practices in appropriate ways such as through education, research, and multi-disciplinary collaboration.

œ          a response to the wants and needs of the public in accordance with an implicit, if not explicit, social contract with society.

Public expectations.    Practitioners, however, need to be aware that patients and the public in general not only perceive professionalism through what is written in codes, but also through such practitioner roles as communicator, healer, scientist (at least utilizing the best evidence), health advocate, and team member, as well as being a person with whom they can share their feelings and concerns. Complaints often stem from lack of role clarity particularly that of communicator.

ii.         Responsibilities to one’s profession

Codes of ethics, aside from responsibilities to patients, often notice responsibilities to professional colleagues.  As such they can be self-serving for the profession as a whole, rather than being oriented toward patient care.

Practitioners must recognize, for instance, that upon witnessing unprofessional behaviour by a colleague they have a responsibility to the integrity of their profession and to the public by acting lawfully.

iii.        Ethical principles

As medical ethics developed into a scholarly discipline, widespread consensus emerged that ethical practice must take into account four principles that protect the rights of patients to receive quality care. 

The principles are commonly listed as autonomy, beneficence, non-maleficence, and justice.  While it is a professional responsibility to have had formal education on current ethics and the nature of professionalism, some key features of the principles are noted here, in part to help the public recognize the responsibilities of practitioners.

Autonomy:  

Autonomy can be defined as self-governance or self-determination by the individual patient.  In practice, a practitioner has the responsibility to ascertain what information patients need or want, so that they can make their own decisions or participate fully in decision-making. 

A critical responsibility is ensuring patients have adequate information to understand fully the rationale of any treatment or procedure, including physical examination, before they provide their informed consent.

Beyond the capacity to give consent, practitioners have a responsibility to ensure a patient is sufficiently informed and does not feel the need for further details.  This may include, aside from outline details of a procedure, information on the practitioner’s qualifications and experience, the risks versus benefits and uncertainties of a procedure or treatment, alternative choices, the evidence for effectiveness, and the role of second opinions.

Depending on the professional situation – either a routine consultation for an existing problem requested by a patient, or a new problem – the appropriate manner of consent must be considered.  This may be documenting a verbal consent on a patient’s record, or obtaining written, signed consent using a form that will highlight points already discussed with a patient.

Beneficence:

The concept of beneficence directs practitioners to avoid ways of injuring others.  As health care today strives to be more holistic, this extends beyond avoidance of physical injury to ensuring that a patient’s well-being is not harmed, perhaps by raising, maybe incidentally, events from the past such as abuse or addictions.

Non-maleficence:

While non-maleficence, to do no harm, seems to have the same consequences as beneficence, it helps to focus attention on some important considerations.  For instance, tendencies to stress benefits while minimising side-effects of tests and treatments.  Furthermore, benefits might be minimal compared with less expensive alternative treatments.

Justice:

This includes the notion of fairness.  It is a complex idea but involves treating people equally regardless of race, gender, socio-economic status, with respect to allocation of health care resources.

With regards to everyday practice, fees are invariably problematic for patients with low incomes.  Professionals may need to justify fees on the basis of fairness.  That includes full disclosure to patients of total costs of treatment and the possibility of unanticipated expenses.

The principles in practice

Although public and professional attention to these four principles often focuses on “difficult” cases, they are equally relevant to everyday health care decisions.  However, it must be appreciated that, at times:

œ          tensions may arise between two or more principles;

œ          patients themselves in our multicultural society may not always be accepting of the principles;

œ          interpretation of the principles can differ between practitioners depending on philosophical precepts and personal values. 

Nevertheless, in all decision-making the principles demand careful evaluation.

 

II.        SEXUAL MISCONDUCT

a.         Preamble

Given the ethical responsibility to respect the autonomy and dignity of patients, and the place of trust in patient-practitioner relationships, any sexual misconduct on the part of practitioners is an ethical violation.

The notes that follow remind both those registered under the Health Professions Act and the public of types of behaviours and expressions that can lead to complaints.

Health professions take a zero-tolerance view toward sexual misconduct as violating trust and the dignity of a patient.  This is the position of the Newfoundland and Labrador Council of Health Professionals.

Unfortunately, occasions arise when a practitioner, unknowingly perhaps, makes patients uncomfortable so that they perceive sexual boundaries have been breached.  This may happen, for example, if a patient recognizes that matters of sexuality fall outside the scopes of practice of a health professional.

b.         Some specific situations

i.          Clear violations for practitioners with direct patient care include:

œ          Intercourse or other conduct with a patient that may reasonably be interpreted as sexual.  This also applies when it is initiated by a patient.

œ          Intimate relationships with current patients. 

ii.         Potential lapses of professional standards

Aside from transparent violations, various situations that can lead to complaints maybe overlooked by practitioners, for instance:

œ          Practitioners must ensure that any exploration of sexual matters falls clearly within the scopes of their practice. If not, practitioners must inform patients if questions are asked of a sexual nature.

œ          The authority to discuss sexual issues must be backed by professional education.  This should include such topics as (i) care of patients who have suffered past sexual abuse, and (ii) insights into one’s own sexuality and values, maybe past abuse that can affect personal attitudes.

œ          History-taking              Questions on gender preferences, sexual performance, and related considerations can be misunderstood unless a patient sees clearly that they are not discriminatory and that they are relevant to the presenting concern.         

œ          Physical examination  When a patient is asked to undress either for a physical examination or for treatment, special provision should be made such as (a) behind a screen and offering a johny-coat or other suitable coverings, (b) presence of a third party, (c) verbal consent, particularly if (a) and (b) are impractical.

It is always good practice, as an examination continues, to request repeatedly verbal permission to touch, examine or treat a breast or genital area.

œ          Behaviour        Off-hand sexual remarks can cause offence.  Jokes of a sexual nature are always inappropriate, unprofessional and often open to misinterpretation.

œ          Touching         Touching outside a scope of practice can be open to misinterpretation.  While a practitioner’s intent of a light touch, perhaps on a hand or shoulder, may be a gesture of sympathy, even encouragement, for a patient, a responsibility exists that it is not seen as more than this. 

iii.        Patients’ responsibility

It is important to recognize that, knowingly or unknowingly, patients may use their sexuality to gain some sense of a balance in situations where they perceive authority to be solely in the hands of a practitioner.

III.        PROCEDURE TO FILE A COMPLAINT AND THE DISCIPLINARY PROCESS.

To learn more about the NLCHP’s Complaints Authorization Committee and how to file an allegation (complaint) with the NLCHP, please go to the Registration/Regulation section, drop box Complaints Authorization Committee.