Ethics and Professionalism in Healthcare

Transition and Challenges

Sabine Salloch, Verena Sandow, Jan Schildmann, Jochen Vollmann

• Publisher: Routledge
• Year: 2016
• Print ISBN: 9781472479518
• eBook ISBN: 9781317141303
• Edition: 1
• Topic: Law
• Subtopic: Comparative Law
• Index: Law

Recent social developments, such as demographic change, skill shortages and new medical technologies, have necessitated a transition in the traditional roles of health-care professions. New forms of division of labour and inter-professional health-care education are emerging while at the same time ethical challenges, such as corruption and conflicts of interest, have to be mastered. This book addresses historical, conceptual and empirical aspects of professionalism and inter-professionalism in health care from an international and interdisciplinary perspective. The work is divided into five sections: historical and societal aspects of health care professions; learning and teaching medical professionalism; transformation of health care professions; professional leadership and team decision-making in health care; and ethical challenges to health care professionalism. The final chapter integrates the main ideas and perspectives on health-care professionalism which have been developed throughout the book and highlights how the work in the diverse disciplines is interrelated. The book will be a valuable reference for the many researchers and students with an interest in medical ethics, professionalism and comparative systems of healthcare.

1 Introduction

Sabine Salloch, Verena Sandow, Jan Schildmann and Jochen Vollmann

DOI: 10.4324/9781315580340-1

Ethics and professionalism in healthcare – a brief introduction

Physicians served for a long time as a paradigm example of an occupation that is distinguished by certain features which transform it from a ‘mere job’ into a profession. Members of a profession bear specific characteristics, such as a specialised academic education, working autonomy, professional bodies, self-government and codes of ethics (Carr-Saunders and Wilson, 1933; Dingwall, 1983; Freidson, 2001). Medical doctors, as highly qualified academics whose work is very much shaped by complex regulatory and organisational structures, can be regarded as indicative of the chances and challenges which are associated with professionalism in modern societies. Some of the key features of professionalism are closely linked to the basic principles of medical ethics, such as autonomy, beneficence and justice (Beauchamp and Childress, 2013), while other aspects (such as the establishment of a professional association or high compensation) do not refer directly to morally demanded tasks.

The notion of professionalism within medicine and healthcare has recently gained attention as a countermovement to forces and tendencies which threaten the independent judgement of physicians regarding the care of individual patients and for the sake of society (ABIM Foundation, 2002). Along these lines, a renewed sense of professionalism supports the efforts to ensure that healthcare professionals and healthcare systems remain committed to patient welfare and the basic tenets of social justice. Furthermore, professional judgement and behaviour have increasingly become part of undergraduate medical curricula (General Medical Council, 2005; CanMEDS, 2015; NKLM, 2015) and even play a role in the distribution of job opportunities in some countries. Professionalism is, thus, currently high on the agenda of medical education, healthcare providers and key players in the international reform of healthcare systems.

Despite this general tendency, the theoretical underpinnings of healthcare professionalism and its manifold appearance in everyday practice remain widely unexplored. In addition to the traditional profession of the medical doctor, a large number of other healthcare vocations have appeared on the scene and passed enormous processes of professionalisation during the last few decades. The spectrum of professionals has widened enormously from the beginning of professional nursing in the nineteenth century up to the development of more and more specialised assisting vocations, such as orthoptist or speech and language therapists. There are also considerable international differences in the training, role and status of non-physician healthcare professionals. While many countries have already established academic training for nurses and assisting vocations, there are other countries, such as Germany, in which the division between academic training for physicians and an apprenticeship for other healthcare staff still prevails (Friedrichs and Schaub, 2011).

This volume presents the results of an interdisciplinary conference on ethics and professionalism in healthcare which was organised by the Institute for Medical Ethics and History of Medicine at Ruhr-University Bochum, Germany. The conference took place in Bochum from 9 to 13 February 2015 and was funded by the German Federal Ministry of Education and Research (BMBF; 01GP1387). The topic of ethics and professionalism in healthcare attracted considerable attention and the organisers received the high number of 83 applications, which far exceeded the number of funded places available. Therefore, a selection was made of contributions which, on the one hand, promised innovative ideas on the topic of professionalism in healthcare and, on the other hand, included researchers from a wide range of countries (Belarus, Croatia, Germany, Great Britain, Romania and Ukraine), as well as participants with a more theoretical and practice-oriented approach to the topic. The outcome of this competitive selection process was a programme that sheds light onto various aspects of ethics and professionalism in healthcare from both international and multi-professional perspectives.

This book summarises the conference results and is structured into five main parts. Each chapter has undergone significant revisions following the conference and has gone through an extensive peer review process. The book concludes with a joint position paper which brings together the junior scientists’ main ideas on the status quo of, and future perspectives for, healthcare professionalism. The following paragraphs will provide an overview of the book's content.

Part I Historical and societal aspects of healthcare professions

In order to better understand the shifting requirements and dynamic roles of professionals in modern healthcare, a look at their historical development and social context is of great importance. The perspectives of history and medical humanities can help to set current questions into a new context and illuminate aspects that would have otherwise slipped the attention of the researcher. Consequently, the two contributions in the first part of the book highlight aspects of healthcare professionalism that are not often in the focus of modern discussions, but nevertheless, sharpen our view of the role of professionals in the clinical context.

Clemens Tangerding examines the role of religious institutions as hospital owners in his historical analysis. He focuses on the period of transition between the 1960s and the 1980s, in which many of these institutions handed over nursing care and clinic management to secular agencies. Tangerding shows how the first generation of secular nurses strongly advocated political awareness and a strengthening of their working rights, which led to increased employee representation. The author characterises these developments as ‘a shifting focus from patients to employees’ and discusses how far nursing in the twenty-first century can only be successful when it is still regarded as a profession.

The focus of the second contribution, by Katharina Fürholzer, is on physician–patient communication. She expands the oral doctor–patient communication on a written level by analysing the possible effects of the author–reader relationship on the doctor–patient relationship. Physician's letters, as a particular type of text, still lack systematic research and teaching, which can turn into an ethically relevant problem when the patient becomes the actual but unintended reader of their own pathography. Fürholzer argues that it is time to raise awareness of the possible correlations between written and spoken doctor–patient interactions, which are equally vital for today's understanding of medical professionalism.

Part II Learning and teaching healthcare professionalism

The dynamic interactions between the various healthcare vocations necessitate a better reflection on the learning and teaching of healthcare professionalism. Healthcare teams must function collaboratively and optimally utilise all the different competencies available for the care of individual patients. This brings about the need for new standards in the education of physicians and nonphysician healthcare professionals. Issues of interprofessional collaboration are increasingly integrated in the respective curricula.

Sarah Berger et al. provide an overview of existing models, such as shared decision-making, and propose a collaborative decision-making model for use in interprofessional healthcare teams. Collaborative decision-making is seen as a complex phenomenon which aims at reaching decisions amenable to all stakeholders, even in the event of varying objectives or conflicting interests. The authors highlight that equipping healthcare professionals to work together effectively is an important means to optimise patient care outcomes in complex healthcare environments.

Kirstin Fragemann et al. take up the example of pain management and introduce an integrated interprofessional pain curriculum for healthcare professionals (‘Pain Care Manager’). This postgraduate programme was designed by a six-step approach to curriculum development for clinically experienced healthcare staff, such as physicians, nurses, psychologists, physiotherapists, occupational health therapists and pharmacists. The programme evaluation suggests the acceptance of interprofessional learning approaches and encourages further activities in the field of ongoing education.

Part III Transformation of healthcare professions

Professional roles and expectations concerning healthcare professionals have undergone a significant change in the last few years due to societal and political developments. Post-Soviet countries in particular are currently experiencing a situation of instability which affects the working conditions of physicians heavily. In addition to that, the problem of the international ‘brain drain’ poses severe challenges to Eastern European healthcare systems.

Tetiana Stepurko et al., in their qualitative empirical study, analyse recent approaches of assuring professionalism among medical staff in the Ukraine. They identify a range of problems in the area of internal governance which affect physicians’ professionalism. According to their findings, professional development is perceived mostly as the personal responsibility of the physician. This poses multiple-nature barriers to the enforcement of healthcare professionalism and, therefore, challenges the adequate access to and quality of healthcare services in the Ukraine.

Andrei Famenka provides an overview of the situation of Clinical Ethics Consultation (CEC) in Belarus and analyses how it functions on the basis of a modified framework by Hyder et al. (2009). The current regulation of Healthcare Ethics Committees in Belarus is centralised and strict. Famenka argues that a number of factors of socio-political and economic post-communist transition in Belarus are responsible for creating an environment in which the operations of CEC services are adversarial to ethical reflection and democratisation. The notion of professionalism is used as a means to exercise control over the medical profession for the sake of certain societal and political interests.

Dorina Maria Stănescu discusses the right of healthcare professionals to free movement and emigration from their country of origin in her contribution on the international brain drain. Stănescu embraces Nozick's libertarian view that we owe others no more than that which the term of a formal contract signed in total agreement requires. She concludes that healthcare professionals have no moral duty to stay in their country of birth and education because they are not bound by any agreement with the citizens of their country of origin and that they have no moral duty to fix their respective healthcare systems.

Part IV Professional leadership and team decision-making in healthcare

Contemporary healthcare professionalism is executed in multidisciplinary teams. Therefore, team structures and leadership play a key role in ensuring high-quality patient care. Issues of professional leadership and team decision-making are discussed by three case studies from the UK, Croatia and Germany, respectively.

Gemma Clarke et al. report on a qualitative observational study on multi-professional team meetings concerning feeding interventions for patients at risk of lacking capacity. The authors found that the decisions concerning artificial nutrition and hydration are complex and multifaceted. The decision-making is not a one-off choice, but involves many different steps and decisions and includes discussions with relatives and other clinicians taking place both before and after the team meetings. The study further reveals that decisions in clinical practice may contain elements of both substituted and supported decision-making.

Regarding their questionnaire study, Martina Šendula-Pavelic´ et al. start from the idea of ethical leaders as role models, whose integrity, honesty and fair treatment encourage ethical behaviour within the organisation. The research was conducted on a convenience sample of Croatian healthcare teams and examined the relationship between healthcare team members’ perceptions of the ethical leadership of their supervisors and the team members’ own attitudes and behaviours. As a result, ethical leadership was positively related to all the desirable attitudinal, motivational and behavioural outcomes of the team members.

Management as a ‘third profession’ in healthcare is the subject of a qualitative interview study by Stephanie Rüsch. She analyses the cooperation between hospital managers and physicians in the context of strategy-making processes. Her findings reveal that chief physicians are considerably involved in strategic decision-making, while, at the same time, managers are gaining increasing control over medical services. Rüsch concludes that the traditional image of professional bureaucracy should be critically discussed and she provides suggestions regarding altered organisational structures within hospitals.

Part V Ethical challenges to healthcare professionalism

The classic notion of medical professionalism refers to the idea of the individual physician making treatment decisions based on the best available scientific evidence and for the sake of his patients. However, in clinical reality, this image gets shaken by organisational and hierarchical structures and societal developments which counteract the ideal picture of professional autonomy. Becoming and acting as a medical professional means more than exercising knowledge and competencies based on formal training. The two last contributions in this volume highlight the complex socialisation of junior doctors and the increasing importance of physicians in the context of public health.

Tim Wray et al. analyse the phenomenon of akrasia in situations where junior doctors, despite their belief, still carry out a senior's strategy against their own moral conscience. Starting from a clinical case example, the authors discuss psychological studies on conformity and obedience and link it to the workplace reality in hospitals. They come to the conclusion that a lack of senior support causes moral stress in the early training of physicians and ...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Table of Contents
• List of figures
• List of tables
• List of boxes
• Notes on contributors
• 1 Introduction
• Part I Historical and societal aspects of healthcare professions
• Part II Learning and teaching healthcare professionalism
• Part III Transformation of healthcare professions
• Part IV Professional leadership and team decision-making in healthcare
• Part V Ethical challenges to healthcare professionalism
• Index