Chapter 4: Professionalism, Elitism and Health Care

Section 2.  Social Context

LAWS, CODES, OATHS

What determines how health care providers will act? Are there not a variety of laws and codes for them to follow? Don't they take oaths that they must keep?

Well there area variety of guides for the conduct of health care professionals, including:

Law

Statutes

Administrative regulations

Common law

Constitutional law

However, LAW does NOT equal Morality

LAW and MORALITY: the relationship

Morality- rules of right conduct concerning matters of greater importance. Violations of such can bring disturbance to individual conscience and social sanctions.

Law- rules which are enforced by society. Violations may bring a loss of or reduction in freedom and possessions.

What is the relation of law to morality? They are NOT the same. You can NOT equate the two. Just because something is immoral does not make it illegal and just because something is illegal it does not make it immoral.

You can probable think of many examples to support this view once you think about it.

Things that are illegal but are thought to be moral (for many)!

Drinking under age.

Driving over the speed limit.

Smoking marijuana.

Cheating on a tax return.

Splitting a cable signal to send it to more than one television.

People do not think of themselves or of others as being immoral for breaking these laws. Can you think of other examples??

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Things that are immoral (for many) but are not illegal.

Cheating on your spouse.

Breaking a promise to a friend.

Using abortion as a birth control measure.

People can not be arrested or punished with imprisonment or fines for doing these things. Can you think of other examples??

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What is the relation of morality to law? Well, when enough people think that something is immoral they will work to have a law that will forbid it and punish those that do it.

When enough people think that something is moral, they will work to have a law that forbids it and punishes those that do it repealed.

So it is established that: Legal Standards are NOT the same as Moral Standards

In Health Care and Medicine there is, for example:

Deciding whom to treat

Deciding how much to charge

Using drugs to increase submission

Denying drugs to those in pain

These questions involve moral issues but the law does not specify a particular course of conduct.

LAW codifies customs, ideals, beliefs and moral values in society.

LAW does not establish moral criteria or standards.

OATHS and CODES

Health care providers belong to professional organizations. They take oaths at graduation ceremonies and at inductions into professional societies. Are these effective in providing guidance for health care providers confronted with moral dilemmas and problems? Apparently not.

Health care providers have codes of conduct issued by professional societies and organizations and even by state authorities. Are these not effective in resolving moral dilemmas and providing a moral guide? Apparently not.

Oaths and codes are products of a pre- technological age. they hearken back towards the medieval guilds. They focus on the welfare of the guild and its members above all else and then on the accomplishment of that for which members of the guild are trained to do.

In health care the problems with such codes are numerous:

1. There is a marked emphasis on cures and no attention to other goals for health care. In this they are out of date in not considering let alone providing guidance for rendering care and for social responsibility.

2. They are issued in language which is quite general. The generality is associated with both ambiguity and vagueness and in need of interpretation in order to determine a meaning precise enough and relevant to particular situations.

3. They do not anticipate changes in practice and organizational patterns and leave the problem of how to resolve conflicts unanswered.

4. They do not acknowledge the underlying values upon which they rest. They give no insight into the basic ethical principles from which moral rules and guidance can be derived.

In examining the codes for various groups of physicains and nurses and technicioans involved in health care it is fairly easy to realize a number of problems exist with them:

1. Conflict with one another and even internally

2. The professional code often conflicts with the individual professionals own moral beliefs with no guidance for resolving the conflict

3. The codes do not cover all situations and dilemmas

4. The professional codes do not contain moral principles at all

PURPOSE of OATHS and CODES

As the "moral" codes or "ethical" codes of conduct for professional groups are not really ethical codes at all just what are they? They appear to be codes of conduct intended to produce a particular set of results.

They are intended to bind social groups together . They bring the professionals into a close knit group.

They express aims and aspirations of the group.

They promote integrity, dedication and principled behavior in accord with the goals and aims of the group.

The earliest of the codes are thus more oriented towards the group and not towards anyone served by the group. It is no surprise then that members of these groups feel a greater allegiance towards one another than to those whose interests they ostensibly are to serve.

As modern science and technology have drastically changed the nature of health care in the last one hundred years there has been a great need to reexamine the very nature and value of such codes.

In a number of ways the impact of technology has been to cause people to question the basic values involved with health care and the practice of medicine. This questioning naturally leads to an examination of Ethical Principles.

Professional Codes of Conduct and Common Sense are insufficient to handle the problems that arise.

There are the problems of:

  • Application of the Codes to actual situations
  • Variety of codes from various professional organizations that have no order of priority
  • Vagueness of codes making it difficult to determine the precise meaning
  • Inconsistency, conflicting guidance in and between codes
  • Questionable morality of the codes , e.g., on abortion, euthanasia, lies

The Professional codes have more to do with etiquette, social and economic niceties and maintaining a monopoly than with morality.

Codes are not normative, they are anachronistic and are thus objectionable.

Consider this shortened form of the most famous of the oaths.

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Hippocratic Oath By Hippocrates Written 400 B.C.E Translated by Francis Adams

I SWEAR by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation- to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!

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We will return to this oath in the next section but for now please notice in this ancient oath that the physician enters the profession acknowledging debts owed to those who trained the practitioner and to their families.  This oath establishes a special relationship amongst those who take it that sets them apart from the general public.  It establishes a relationship of debt and obligation amongst the professionals.  Towards the recipients of their care the oath establishes a relationship of largess.

There is the need for moral principles grounded in ethical theory and not in some form of social etiquette or set of voluntary arrangements.

Oaths and codes cannot take the place of ethical theory and principle as providing a foundation for moral decision making and action.

Therefore, there is the definite and pronounced need for ethical theory and guidance in applying ethical theory to specific moral dilemmas and problems.

This is the subject matter of BIOMEDICAL ETHICS.

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Copyright Philip A. Pecorino 2002. All Rights reserved.

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