ETHICS AND

PROFESSIONALISM By

EMMANUEL RUDAKEMWA, MD, FCRAD (SA)

Associate Clinical Professor, Radiology and radiation

sciences

Chairman of Rwanda Medical and Dental Council

INTRODUCTION

In Rwanda, all stakeholders expect the best quality care; it is also

a worldwide concern. Medical & Dental profession under

increased public scrutiny, public health information available to

more people, request for evidence-based practice and better

standards of care, new medical insurance law, etc. In the medical

and dental school, we study essentially basic science, clinical

skills with little time left for other required skills for quality care

(professionalism, leadership, communication, etc.) and ethics.

Patients are entitled to good standards of practice and care from

their Doctors. Essential elements of this are professional

competence, good relationships with patients and colleagues and

observance of professional ethical obligations.”

LAYOUT AND APPROACH

I do not intend to talk about the principles as they appear in the

1847 Code of Ethics

I want us to examine whether or not ethics are still relevant to the

medical profession, so that if they are relevant, examine further

whether they are effective and suggest a way forward

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DISAMBIGUATION OF ETHICS

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Ethic refers to a set of moral principles (origin:

from Old French éthique, from Latin ethice, from

Greek (hē) ēthikē (tekhnē) ‘(the science of) morals’, based on ēthos)(Concise

Oxford English Dictionary.2011, twelfth ed,

Oxford University Press: 490)

Moral refers to the principles of right and wrong behavior, it also

means that which is based on adhering to the code of behavior that is considered socially right or acceptable (Oxford Dictionary supra:

929)

Principle refers to a fundamental truth or

proposition serving as the foundation for belief or

action. It also refers to a rule or belief governing one’s behaviour (Oxford Dictionary supra: 1140)

Ethics refers to the moral principles governing or

influencing conduct (Oxford Dictionary supra: ibid)

Ethos means characteristic spirit of a culture, era, or

community as manifested in its attitudes and aspirations

(Oxford Dictionary supra: ibid), e.g. Ubuntu is

therefore the Ethos of the African traditional culture.

OUTLINE

1. What is ethics in healthcare

2. Different types of Ethical tensions/Issues :

o Ethical dilemmas

o Ethical distress

o Ethical uncertainty

o Ethical principles

3. Professional values

4. Client’s rights and responsabilities

5. Health systems and ethical challenges

6. Ethical deliberation Models:( 6-Steps)

7. Medical Professionalsm

8. Medical Malpractice Management

9. Conclusion

I. WHAT IS ETHICS IN HEALTHCARE?

What does ‘ethics’ mean to you?

World Health Organization: “ethics is concerned with moral

principles, values and standards of conduct” (WHO, 2016)

The “best” thing to do (Storch, 2004)

Questions about “should I or shouldn’t I”?

Weighing potential impact of decisions or actions

Healthcare professionals’ conduct and choices given multiple

considerations and competing demands

II. Ethical Tension/ Competing Demands

What are some competing demands that you face in your everyday

practice?

How do you experience ethical tension?

Importance of attending to those sensations

Ethical tensions – feeling pulled

between multiple competing demands

3 TYPES OF ETHICAL TENSIONS

1. Ethical dilemmas(Urungabangabo) – 2 or more

mutually exclusive potential courses of action, each

with negative implications

2. Ethical distress(icyera gati) – Know what is

‘best’ thing to do, but are constrained from doing

that

3. Ethical uncertainty(Amayobera) – Not knowing

IF there is an ethical tension, WHAT it is, or WHAT

principles or values are in conflict

(Jameton, 1984)

III. Ethical Principles and Professional Values

Four ethical principles o Autonomy

o Beneficence

o Non-maleficence

o Justice

Professional values o Veracity, Fidelity, empathy

o Privacy and confidentiality

III.1 AUTONOMY

Varying definitions: Self governance and self-determination

o the capability to have input into determining your own well-being (Purtilo & Doherty, 2016)

o ‘self-rule that is free from both controlling interference by others and limitations that prevent meaningful choice’(Beauchamp & Childress p.101)

Upholding autonomy - Supporting self-determination in others and their freedom to choose what constitutes a good quality of life for them (Sasson, 2000)

III.2 RELATIONAL AUTONOMY

1. Individuals live in contexts, are

socially and politically embedded

2. Contexts have shaped, and

continue to, shape individual

identity, capacities to enact

autonomy (Mackenzie & Stoljar,

2000; Sherwin, 1998)

Varying definitions: two main premises

Relational Autonomy – Individual Contexts

What shapes individual autonomy?

“The nurse promotes an

environment in which the

human rights, values,

customs and spiritual

beliefs of the individual,

family and community are

respected.” (ICN, 2012, p.3)

Beneficence – ‘all forms of action

intended to benefit others’

Non-maleficence – intentionally refraining from actions

that contribute to harm (p.197)

(Beauchamp & Childress, 2013; Purtilo & Doherty, 2016)

III.3 Beneficence & Non-Maleficence

Beneficence and

Non-Maleficence

In healthcare, there are multiple and possibly competing

‘best’ interests, and potential benefits or harms

What might be patients’ best interests?

Harms?

Benefits?

III.4 JUSTICE

Multiple applications:

Distributive– allocation of resources

Substantive – distribution based on need, skills,

capacities

Procedural – rules guide distribution (e.g. first

come first served)

In codes of conduct:

Non-discrimination in provision of care

Fair allocation of resources considering need, priorities and availability

to provide good quality and effective healthcare

How is justice applied or enacted in your own settings? How might

injustice appear? In the case discussed, is there an issue with this

principle?

IV. PROFESSIONAL VALUES

o What does this value mean?

o What does it mean to you?

o How does it apply to (your) healthcare context?

o What barriers exist to its application in healthcare contexts?

‘Veracity’, ‘Fidelity’, ‘Privacy and Confidentiality’, ‘Empathy’

IV.1 Veracity

What does this value mean?

What does this value mean to

you?

How does it apply in healthcare

contexts?

What barriers exist to its

application in healthcare

contexts?

IV.2 FIDELITY, EMPATHY

What do these values mean?

What do they mean to you?

How do they apply in healthcare

contexts?

What barriers exist to their

application in healthcare contexts?

IV.3 Privacy and Confidentiality

What do these values mean?

What do these values mean to you?

How do these apply in healthcare contexts?

What barriers exist to their application in healthcare

contexts?

V. PATIENT RIGHTS

Differ based on various attributes such as country, jurisdiction, healthcare

setting, culture or religion

Depend on social norms and cultural beliefs

May vary in relation to patient population

Important considerations

Do the patient and family (if relevant)

know their rights?

Are these clear and easy to access or

understand? (e.g. language, where

posted etc.)

Charter of Patient Rights and

Responsibilities for Rwanda

Patient right to:

o Care

o Privacy

o Information

o Choices

o Respect

o Complain

Patient responsibility to:

o Take care of own health

o Access and use properly and not abuse

health system

o Respect rights of HCPs

o Provide relevant information about their

health

o Follow instructions

o Ensure they have means to pay

PATIENT RIGHTS

Are patient rights visible and accessible to patients in healthcare settings?

Do you feel that patients understand their rights? What makes you think this?

As Medical/dental practitioners are you aware of patients’ rights? If Not Why?

What can or do you do to help increase patients’ understanding of their rights?

VI. HEALTH SYSTEM AND ETHICAL

CHALLENGES

Can health system policies and or challenges contribute to, or even set up, situations of ethical challenges? If Yes, please explain more using your own experiences in your respective discipline

HEALTH SYSTEMS AND ETHICAL CHALLENGES

Yes, health system policies or challenges can sometimes contribute to, or even set up, situations of ethical challenges

Examples:

o Shortage of healthcare professionals

o Large number of patients

o Health insurance payment structure

• patients’ lack of health insurance or money

• delays in payments to hospital

o Inequity in distribution of equipment and materials, etc.

(These situations can be the source of ethical distress for example)

HOW TO HANDLE ETHICAL ISSUES

Ethical Deliberation Models

Ethical Deliberation Model Durocher, Kinsella & Mazer (2017)

Six-step model developed by

collating and summarizing a

variety of published models

(see bibliography)

Steps 1-4 are a process, can

be, and may need to be

repeated

26

Ethical Deliberation Model

Step 1: Identify the ethical issue

Is there an ethical

issue?

If so, what is it?

Is there more than one

ethical issue?

27

Ethical Deliberation Model

Step 2: Gather relevant information

Who are the individuals involved

in the situation?

What are their roles and

responsibilities?

What is their perspective?

What are the needs, preferences

and skills?

What are the different contexts or

contextual elements that need to

be considered?

28

Ethical Deliberation Model

Step 3: Identify and apply ethical

principles and professional values

What principles and values may

be discerned or relevant in the

situation?

o Relational autonomy

o Beneficence and non-maleficence

o Justice

o Veracity

o Fidelity

o Privacy and confidentiality

o Patient rights

29

Ethical Deliberation Model Step 4: Identify potential courses of action

What are the potential courses of action?

Is that it?

Be creative, think outside the box

What are potential benefits, risks and/or harms associated with each option?

How might each option affect each of the individuals involved?

30

Ethical Deliberation Model

Remember, Steps 1-4 are a process…

o Are you happy with the information uncovered in each step?

o Do any of the steps need to be revisited?

31

Ethical Deliberation Model

Step 5: Decision and action

Identify which option

you wish to pursue

Decipher all actions

required to move

forward with this choice

Take all actions

required to move

forward towards this

choice 32

Ethical Deliberation Model Step 6: Evaluate process and outcomes

Aim is to learn from the situation

Can occur immediately following or may be benefit to allowing a little bit of time to pass before evaluation

What went well?

What was difficult?

What could be improved?

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PART II:

PROFESSIONALISM

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Unit I. Ethics in Health care settings

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MEDICAL MALPRACTICE MANAGEMENT

Investigating into the case:

Receiving complaints of alleged misconduct

Prompt investigation into the allegation of misconduct of the health care provider

Establishing facts, the type and gravity of the alleged misconduct (analysis of the report)

Receiving and protection of the reporter or whistle blowers;

Referring the offender to the judiciary when necessary

MALPRACTICE MANAGEMENT (CONT’D)

Facilitating professional misconduct hearing process

Fair due process

Right to be heard

Right to appeal

Determining appropriate sanction

MALPRACTICE CASES PER YEAR

From January 2008 to 2018

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41

4 5

6

13

8

12 12

27

34

37

31

0

5

10

15

20

25

30

35

40

Year 2008 Year 2009 Year 2010 Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016 Year 2017 Year 2018

Malpractice cases per year ( from 2008- to 2018)

Total Case

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MALPRACTICE CASES PER SPECIALITY

From 2008 to 2018

0

10

20

30

40

50

60

70

80

90

Anesthesia InternalMedicine

Obstetrics andGynecology

Pediatrics Surgery Fraud Otherspecialities

6 10

82

29 24 25

10

3 5

44

16 13 13

5

Frequency Percentage

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DISCIPLINARY MEASURES TAKEN AGAINST

INVOLVED MEDICAL/DENTAL PRACTITIONERS

From 2008 to 2018

0

5

10

15

20

25

30

35

40

45

50

Warning One Monthsuspension

Three MonthsSuspension

Six MonthsSuspension

Removal from theRegister

Number 13 34 46 24 1

13

34

46

24

1

Number

CONCLUSION

Stakeholders urged to collaborate and support health care

regulators and providers in their service provision through

increased dialogue in order to address professional issues

that affect the public we all serve.

Reporting a negative incident at the workplace in time can

save lives.

The Good Medical Practice principles are the guiding tools

for the day to day action of the Rwanda Medical and Dental

Council.

References

Beauchamp, T., & Childress, J. (2013). Principles of

biomedical ethics. New York, NY: Oxford University Press.

Doane, G. (2004). Being an ethical practitioner: The

embodiment of mind, emotion and action. In J. Storch, P.

Rodney & R. Starzomski (Eds.). Toward a moral horizon:

Nursing ethics for leadership and practice (pp. 433-446).

Toronto, ON: Pearson-Prentice Hall.

Drolet, M-J., & Hudon, A. (2015). Theoretical frameworks

used to discuss ethical issues in private physiotherapy

practice and proposal of a new ethical tool. Medicine,

Health Care and Philosophy, 18(1), 51-62.

References,

(Yiika Sejdiu, 2018). Population Health Improvements And Challenges In Rwanda.

Mackenzie, C. (2008). Relational autonomy, normative authority and perfectionism. Journal of social philosophy. 39(4), 512-533.

Mackenzie, C., & Stoljar, N. (2000). Introduction: Autonomy refigured. In C. Mackenzie & N. Stoljar (Eds.), Relational autonomy: Feminist perspectives on autonomy, agency, and the social self (pp.3-34). New York, NY: Oxford University Press.

Ministry of Health.(2009) Charter of patient rights and responsibilities for Rwanda. Kigali, RW: MOH.

Purtilo, R., & Doherty, R. (2011). Ethical dimensions in the health professions. St. Louis, MI: Elsevier.

Reis, V., Deller, B., Carr, C., & Smith, J. (2012). Respectful maternity care: Country experiences. Survey Report. Washington DC: United States Agency for International Development.

Sasson, S. (2000). Beneficence versus respect for autonomy: An ethical dilemma in social work practice. Journal of Gerontological Social Work, 33 (1), 5–16.

References, Cont’d….

Sherwin, S., & Winsby, M. (2010). A relational perspective on autonomy for older adults residing in nursing homes. Health Expectations, 14, 182-190.

WHO (2016a) Ethics. Retrieved from: http://www.who.int/topics/ethics/en/, September 16, 2016.

WHO, (2016b), Patient Rights. Retrieved from: http://www.who.int/genomics/public/patientrights/en/, November 55, 2016.

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References, Cont’d….

Thank you

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