Doctors and hospital infection prevention – is medical professionalism the solution or the problem?

Gwendolyn L Gilbert1, Ian Kerridge1,

1 Centre for Values, Ethics and the Law in Medicine and Marie Bashir Institute for Emerging Infections and Biosecurity, University of Sydney, NSW 2006 (lyn.gilbert@sydney.edu.au)

There is ample evidence that doctors comply relatively poorly with hospital infection prevention and control (IPC). Many strategies can improve performance temporarily, but rarely achieve sustained behaviour change. In this study we interviewed senior medical consultants at a Sydney teaching hospital to gain insight into their attitudes to, and perceptions of, doctors’ roles and responsibilities in healthcare-associated infection (HAI) prevention. “Medical professionalism” is, prima facie, a potential framework for improving doctors’ practices, for patients’ benefit, but analysis of interview transcripts suggests that some aspects of medical professionalism are barriers to, rather than incentives for, compliance with IPC protocols. Specifically:

  1. Participants noted that doctors’ privileged professional autonomy and their ‘right’ to make independent judgments, based on clinical experience – meaning that they could justify disregarding “rules”, themselves, often whilst acknowledging the need for compliance (by others).
  2. While all participants noted the importance of senior leadership in training junior doctors in the “rules of the game” they disagreed about whether senior consultants were more likely to be positive or negative role models for IPC compliance or whether junior doctors are more likely to be aware of, and comply with, IPC protocols.
  3. HAIs become the focus of doctors’ attention only when they cause serious, identifiable, proximate mortality or morbidity; HAI prevention and adherence to IPC protocols are regarded as of limited interest and relevance or ‘nurses business’.
  4. Many doctors have limited cultural commitment to the (public) hospitals in which they work or, therefore, to organisational responsibilities, like IPC. Many believe that hospitals don’t value their work; they have no control over budgets, work practices, operating lists or even patient care. As one participant said: ‘they have no ”skin in the game”’.

Conclusion: Our results suggest that “medical professionalism” works against IPC adherence because it focuses mainly on the profession, itself, and doctors’ relationships with individual patients, and less on doctors’ role in, and responsibilities to, the (hospital and wider) communities they serve. A critical examination of doctors’ roles in IPC illustrates how “medical professionalism” is not synonymous with ethics in health care.


Biography

Lyn GIlbert is an infectious diseases physician with a particular interest in prevention and ethics of communicable diseases of public health importance, including healthcare-associated infections

Institutional values and patient rights

Dr Nicole Gerrand1

1Conjoint Fellow, School of Humanities and Social Science, University of Newcastle,  nicole.gerrand @bigpond.com

Under what conditions is it acceptable for institutions to adopt  and operate according to values that conflict with fullest realisation of the institution’s ultimate purpose? In particular, under what conditions may the code-of-conduct of a healthcare facility restrict patients’ access to information or treatment options? Such codes are sometimes underpinned by religious belief, but it is not difficult to imagine other values (e.g. economic values) that could lead to similar restrictions. Focussing on the issue of restricting patient information in clinical trials, this paper will draw out the implications of such restrictions for patients’ rights and healthcare generally, and point to possible solutions that can be explored in such circumstances.


Biography

Dr Nicole Gerrand is a Conjoint Fellow at the School of Humanities and Arts, University of Newcastle. She is employed as the Manger of Research Support and Development Hunter New England Local Health District. She has over 20 years experience in working in research ethics, bioethics and recently Clinical Ethics and has published in several peer reviewed journals. The views to be expressed in this paper are her own.

Expectations of information sharing in Primary Care and the role of trust

Samantha Fitch1

1 The University of Auckland, Private Bag 92019, Auckland 1142 s.fitch@auckland.ac.nz

Trust is a defining characteristic that gives the doctor-patient relationship meaning, importance and substance. Trust is said to promote honesty, disclosure and compliance between doctors and their patients. High profile scandals concerning medical competence, malpractice, breach of confidence and data breaches highlight individual and system failures that can undermine patient trust in health care providers and health care organisations more generally. Beitat et al. (2013) propose a dynamic model of trust where a patient’s trust in a practitioner is influenced by expectations, information/knowledge and outcomes/actions, which are all mediated by communication. These factors are seen to influence the building and break down of trust.

In primary care, a call for increased information sharing needs to be balanced with the interests of privacy and confidentiality. Where information is shared beyond the patient-GP dyad this study contends that trust is an important factor. Information sharing and trust were examined in an empirical ethics, multi-method study examining the role of trust in information sharing in Primary Care in New Zealand.  A theoretically driven survey was formulated to evaluate how expectations, information/knowledge, outcomes and communication influence patient trust in GPs concerning information sharing. The multi-format survey of New Zealand Adults, (n=449) was analysed using regression analysis, and thematic analysis of text questions. Qualitative interviews (n=40) with Auckland-based patients, utilised vignettes and follow up questions to ask about trust, information sharing practices and a data breach were analysed using thematic analysis.

Preliminary findings, show differences in general and particularised trust, though overall trust in GPs was high. Expectations of GPs concerning information go beyond privacy and confidentiality. Responses are consistent with the Beitat et al (2013) model outlined earlier. The findings may contribute to our understanding of trust as an aspect of ethical information sharing for GPs and generate recommendations for practice.

References

Beitat, K., Bentele, G., and Iedema, R. (2013). Trust after medical incidents. In Candlin, C. and Crichton, J., editors, Discourses of trust. Palgrave Macmillan, Houndmills, Basingstoke, Hampshire.


Biography

PhD Student at the University of Auckland, supervised by Dr Monique Jonas and Dr Rob McNeill from the School of Population Health. Topic: The role of trust in information sharing between Patients and GPs.

Resource allocation in intensive care units: Three arguments against prematurely discharging one patient to admit another who can benefit more

Drew Carter1, Andrew McGee2, Annette Braunack-Mayer3, Adam M. Deane4

1 School of Public Health, University of Adelaide, SA, 5005, drew.carter@adelaide.edu.au
2 Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, QLD, 4001
3 School of Public Health, University of Adelaide, SA, 5005
4 Discipline of Acute Care Medicine, University of Adelaide, SA, 5005

Intensivists routinely discharge patients only when they judge that a patient no longer has the capacity to benefit from intensive care. However, some ethicists and clinicians are advocating change, arguing that ICUs ought to maximise aggregated benefits (for example, save as many lives as possible) by discharging a patient early when the resources freed up by doing this can be allocated to another patient with a greater capacity to benefit. Under pain of being simplistic, proposals to transform ICU practices ought to reflect serious consideration of three arguments that we develop.

First, premature discharge indicates a type of care that is highly conditional. To avoid this, namely to uphold what it means to accept a patient into one’s care, we should be willing to forego some aggregated benefits.

Second, justice is better served by considering, not how to maximise aggregated benefits, but instead what we are each morally prepared to do for, and ask of, one another.

Finally, it is morally worse to withdraw beneficial treatment than to withhold it.  This is because withdrawing beneficial treatment from one patient to provide it to another involves upturning a first-come-first-served arrangement, and such an arrangement ought not to be upturned insofar as it constitutes an exercise in procedural justice.  Furthermore, to withdraw beneficial treatment is to act against a patient’s best interests.  It therefore violates the doctor-patient relationship and, in particular, the implicit promise and trust that partly comprise it.  The idea that withdrawing and withholding treatment are morally equivalent has been dubbed the Equivalence Thesis.  We thus explain why the Equivalence Thesis is false in the case of beneficial treatment.


Biography

Drew Carter is a moral philosopher and health services researcher who works mostly at the interface of ethics and health economics. He is particularly interested in identifying what is important besides gaining the maximum possible health for a population. Philosophically, he works to extend and apply insights made by the philosophers Ludwig Wittgenstein, Iris Murdoch, Raimond Gaita, and Christopher Cordner. He teaches ethics to medicine and public health students at the University of Adelaide, along with a short course open to the public: https://health.adelaide.edu.au/public-health/short-courses/ethics.

Practice makes perfect: Evaluating the conflict between aesthetic interventions and the ethos of medicine

Yves Saint James C. Aquino, MD, MSc, MRes1

1 Department of Philosophy, Faculty of Arts, Building W6A, Level 7 Room 704, Macquarie University, Balaclava Road, North Ryde, Sydney, Australia 2109; yves-saint-james.aquino@hdr.mq.edu.au

Aesthetic medical and surgical interventions, which seek to modify physical appearance, remain controversial as they challenge the professional ethos of medical practice. Professional ethos is typically interpreted, at least in clinical medicine, as the use of clinical knowledge, skills, values and judgments to benefit the individual patient. Further, the benefit should be aligned with the accepted medical goals of treatment that promote health and manage disease. Given this interpretation, reconstructive procedures, or aesthetic interventions that aim to restore ‘normal’ features, are considered compatible with the professional responsibility of physicians. However, purely cosmetic procedures, or aesthetic interventions that aim at creating extraordinary or beautiful appearance, can be criticised for aiming at enhancement rather than treatment. In this presentation, I argue that cosmetic enhancement is a questionable application of clinical knowledge, values and judgement of medical professionals. I will discuss how with purely cosmetic aims, some aesthetic interventions tend to conflate ‘ugliness’ with pathology—and beauty with health. This problematic conflation requires further investigation as to whether medical professionals should have responsibility for defining the concepts of beauty and ugliness. I propose that one way of examining this issue is by appealing to different accounts of health and disease. Naturalist accounts define health and disease descriptively, as objective concepts based on biological functions; while normativist accounts consider human values and judgments, not biological functions, as the bases of defining health and disease. Using the naturalist and normativist account may provide a fruitful way of investigating links between appearance and health, and is useful in understanding how aesthetic interventions with purely cosmetic goals can distort the professional ethos of medicine.


Biography

Yves Saint James Aquino is a first year PhD student with the Department of Philosophy at Macquarie University. He received a bachelor’s degree in philosophy and a medical degree from the University of the Philippines, an Erasmus Mundus master’s degree in bioethics from partner universities that included KU Leuven in Belgium, University of Nijmegen in the Netherlands and University of Padua in Italy. Before starting his PhD, he received a master of research degree from Macquarie University. His research interest is on the role of physical appearance in defining health in the context of contemporary medicine.

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About the Association

The Australasian Association of Bioethics and Health Law (AABHL) was formed in 2009.

It encourages open discussion and debate on a range of bioethical issues, providing a place where people can ask difficult questions about ideas and practices associated with health and illness, biomedical research and human values.

The AABHL seeks to foster a distinctive Australasian voice in bioethics, and provide opportunities for international engagement through its membership, journal and conferences.

Members come from all the contributing humanities, social science and science disciplines that make up contemporary bioethics.

Many members have cross-disciplinary interests and all seek to broaden the dialogues in which all members of the wider community ultimately have an interest.

The AABHL is a supportive, creative and challenging community that provides a rich source of continuing academic refreshment and renewal.

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