1. The Culture of Healthcare
Ethics and Professionalism
Welcome to The Culture of Healthcare, Ethics and Professionalism. This is Lecture (a).
The component, The Culture of Healthcare, addresses job expectations in healthcare settings. It discusses how care is organized within a practice setting, privacy laws, and professional and ethical issues encountered in the workplace.
Lecture a
This material (Comp2_Unit8a) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC

2. Ethics and Professionalism Learning Objectives
Provide an orientation to ideas about medical ethics and professionalism (Lecture a)
Explore the relationships among ethical ideals, professionalism, and legal duties (Lecture a, b)
Apply the general principles of ethics and professionalism to specific topics (Lecture c, d)
Examine ethical issues in health informatics (Lecture d)
The objectives for Ethics and Professionalism are to:
Provide an orientation to ideas about medical ethics and professionalism
Explore the relationships among ethical ideals, professionalism, and legal duties
Apply the general principles of ethics and professionalism to specific topics
Examine ethical issues in health informatics
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The Culture of Healthcare Ethics and Professionalism Lecture a

3. What Is Meant by Ethics and Professionalism?
Ethics is the study of what people think is right and wrong
Professionalism means that a person acts in a way that meets the standards of their profession
Training and skills
Ethical principles
This lecture discusses ethics and professionalism. These topics are very broad and can include many ideas that are not clear-cut. This unit approaches the subject of ethics and professionalism by starting with some basic ideas, then showing how these ideas apply to the complicated situations that can occur in healthcare settings.
Generally speaking, ethics is the study of beliefs about what is right and wrong and how people go about making those kinds of decisions. Professionalism is a term that describes generally accepted ideas of appropriate conduct within a specific profession.
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The Culture of Healthcare Ethics and Professionalism Lecture a

4. 4 Basic Principles
Plus concern for the scope of application of these principles
Many people who study medical ethics say that the basics of healthcare ethics can be captured by four principles: respect for autonomy, beneficence [buh-niff-fuh-sense], non-maleficence [non-muh-liff-fuh-sense], and justice. Some experts are critical of this approach as each of the broad principles is open to a variety of interpretations. However, the concept of these four basic principles is widely used and serves as the starting point for many discussions of healthcare ethics.
The following slides define each of these principles and show how they are applied in healthcare settings.
8.1 Figure: Four basic principles of healthcare (CC BY-NC-SA 3.0, 2012).
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The Culture of Healthcare Ethics and Professionalism Lecture a

5. The Culture of Healthcare Ethics and Professionalism Lecture a
Respect for Autonomy
Autonomy = self-governance
Respect for autonomy = patients have the right to make their own decisions without undue influence
Healthcare decisions are voluntary
Foundation of “informed consent”
Generally, autonomy means people have the right to make their own decisions. This concept is often called “self-governance.”
In the healthcare setting, respect for autonomy means that healthcare professionals must recognize that patients have the right to make their own treatment decisions based on their individual preferences and beliefs. Respect for autonomy also includes the idea that healthcare decisions are entirely voluntary. Healthcare providers must not put excessive pressure on patients to make a particular choice or submit to treatments.
The principle of respect for autonomy is the ethical basis for the concept of informed consent. Informed consent means that the patient knows, understands, and accepts the risks and benefits of treatment. This concept is discussed in more detail in a later lecture.
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6. The Culture of Healthcare Ethics and Professionalism Lecture a
Beneficence
The idea that actions of healthcare providers should benefit people
Prevent problems that may occur
Treat problems that have occurred
Widely accepted as an appropriate goal of healthcare
Applied at individual level and population-wide level
The principle of beneficence simply means that healthcare providers should do things that benefit the patient. This includes both actions meant to prevent problems and actions to address problems the patient is already experiencing.
The idea of beneficence is commonly recognized as one of the main purposes of healthcare. The idea is applied at the level of individuals and the level of populations. For example, giving antibiotics to a patient with pneumonia applies the principle of beneficence at the individual level. Giving elderly patients the opportunity to be vaccinated against pneumonia applies the principle at a population level.
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7. The Culture of Healthcare Ethics and Professionalism Lecture a
Non-Maleficence
The obligation not to intentionally create unnecessary harm or injury to the patient
Applies to both commission and omission
Commission
Omission
Act that causes harm
For example, performing needless surgery
Failure to act when one should act
For example, intentionally withholding a helpful drug
Non-maleficence is the expectation that healthcare professionals will not intentionally injure a patient. Medical students learn the famous saying that doctors should, “First, do no harm.”
There are two types of non-maleficence acts: acts of commission and acts of omission. An example of an act of commission is giving a patient a drug for the sole purpose of harming them. Acts of omission might not be as obvious. An example is intentionally withholding a drug from a patient who is expected to benefit from the drug.
8.2 Table: Non-Maleficence (CC BY-NC-SA 3.0, 2012).
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8. The Culture of Healthcare Ethics and Professionalism Lecture a
Justice
Justice in the medical ethics setting means fairness
Includes the concepts that:
All people have the right to be treated equally
If there is not enough to go around, what is available should be distributed fairly
In discussions of medical ethics, the term justice is often used as a synonym for fairness. The concept of justice includes the idea that all people have the right to be treated equally.
Distributive justice is the idea that if resources are scarce, they will be allocated in a fair manner. How distributive justice should be implemented is controversial in our society, and it is discussed in more in a later lecture.
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9. “Concern for the Scope of Their Action”
Who are healthcare professionals responsible to?
Everyone in their community?
Everyone in the country?
How far does respect for autonomy go?
Do animals have rights?
Does the environment have rights?
Healthcare professionals have an obligation to consider difficult questions about how far and wide their ethical duties extend. Obviously, it is not reasonable to think that every individual healthcare professional is responsible to care for every individual in the world. But is each healthcare professional responsible to everyone in their community? How about everyone in the country? Furthermore, does the healthcare profession as a whole have a duty to society as a whole? Do healthcare professionals have to respect the rights of laboratory animals, or the whole natural environment?
These are difficult questions, and well-meaning people can have fundamentally different beliefs about the answers. The phrase “concern for the scope of their action” means that when healthcare professionals are confronted with these kinds of difficult questions, they are obligated to think about them.
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10. The Principles in Action
Respect for autonomy
Informed consent
Medical confidentiality
Beneficence and non-maleficence
Requires that treatments be designed to maximize benefits and minimize risks
Justice
The risks of medical research should not fall disproportionally on one group of people
The general principles of respect for autonomy, beneficence, non-maleficence, and justice have many specific applications in the healthcare setting.
As previously mentioned, informed consent is a major duty that flows from respect for autonomy. Another duty based in respect for autonomy is confidentiality. In general, a person has no obligation to keep the secrets of another. However, in the healthcare setting, confidentiality is both a legal and ethical duty.
The principles of beneficence and non-maleficence are closely related. One implication of these duties is that healthcare treatments must be designed to maximize benefits and minimize risks.
The principle of justice obliges the healthcare profession to ensure that the risks of medical research do not fall disproportionally on one group of people. As previously mentioned, another implication is that healthcare will be distributed fairly among patients.
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11. The Culture of Healthcare Ethics and Professionalism Lecture a
Prima facie Duties
Prima facie = “at first view” or self-evident
Each ethical principle is binding unless it conflicts with another principle
When the principles conflict, a person must decide which one to act on
The theory of the 4 principles does not give guidance about which one to choose or how to prioritize them
Experts in medical ethics say that each of the four principles is a prima facie [pree-muh fay-shee] duty. Translated from the Latin, prima facie means “at first view.” In the context of ethics, this term means it is self-evident that an ethical principle is binding unless it conflicts with another principle.
As an example of a conflict in principles, imagine a situation where there is only enough medicine for one patient, but two patients need to be treated, and half the medicine would do no good for either patient. This situation represents an ethical conflict between the duties of beneficence, non-maleficence, and justice. Unfortunately, the concept of the four principles does not give guidance about how to choose between the principles when they conflict.
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12. The Culture of Healthcare Ethics and Professionalism Lecture a
Ethical Dilemma
Justice
Occurs when someone must choose between conflicting ethical principles
A conflict between ethical principles is called an ethical dilemma. People working in the healthcare field are often faced with ethical dilemmas, and although the four principles are a guide, they do not always provide an answer.
For example, a doctor may be unsure whether to recommend withdrawing life-sustaining treatment from a very premature infant who is not expected to survive. Another example of an ethical dilemma is how to decide which patient should receive a kidney that has become available for transplant.
8.3 Figure: Ethical dilemma (CC BY-NC-SA 3.0, 2012).
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13. Obligation and Aspiration
Obligation = minimum standard necessary to meet professional obligation
Provide competent medical care to individual patients
Make sure patients understand the risks and benefits of treatment
Aspiration = standard that one should strive to achieve, but is not always attainable
Providing equal worldwide access to healthcare
Find cures for currently incurable conditions
Sometimes, ethical issues are divided into those that are professional obligations and those that are aspirational.
An obligation is a standard that must be met, the minimum of care that must be provided. Some examples of ethical obligations are to provide competent healthcare to individual patients, and to make sure patients understand the risks and benefits of treatment.
In contrast, an aspirational goal is a standard that would be met in an ideal world but is not currently achievable in the real world. Some examples of aspirational goals are providing equal worldwide access to care, and finding cures for diseases that are currently incurable.
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14. The Culture of Healthcare Ethics and Professionalism Lecture a
Ethics Committee
Group of people who meet to discuss ethical dilemmas
All accredited hospitals must have a process for resolving ethical questions
Membership is usually diverse and may include:
Doctors and nurses
Social workers and lawyers
Religious professionals
Members of the community
A common way for healthcare professionals to resolve ethical dilemmas is to consult with others. This can be accomplished by having an ethics committee that is consulted to make ethical decisions. In the United States, all accredited hospitals must have a process for resolving ethical questions, and this usually takes the form of an ethics committee. Many long-term-care facilities and home healthcare organizations also have ethics committees.
The members of the ethics committee usually represent the many kinds of people who have a stake in resolving ethical questions. This can include doctors, nurses, social workers, lawyers, members of the clergy, and people from the community who are not healthcare professionals.
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15. The Culture of Healthcare Ethics and Professionalism Lecture a
Codes of Ethics
Examples:
American Medical Association
International Council of Nurses
American Health Information Management Association
American Medical Informatics Association
Another way in which healthcare professionals may get guidance about a difficult ethical situation is to consult a code of ethics created by an organization related to their specific profession. For example, the American Health Information Management Association has a code of ethics that is discussed in a later lecture.
When doctors in private practice have ethical questions, they might consult the American Medical Association Code of Ethics. In addition, they might talk the situation over with their co-workers. In some cases, they might even consult a medical ethicist [eh-thih-cyst], a person who is specially trained to deal with ethical questions.
Codes of ethics can be statements of current professional standards, or they can be aspirational, seeking to raise the standards of the profession. Some codes of ethics contain both obligatory and aspirational statements. A code that contains both kinds of provisions should identify the statements that are intended to be aspirational.
A code of ethics may also be called an ethical statement, statement of professional conduct, or something similar.
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16. The Culture of Healthcare Ethics and Professionalism Lecture a
Hippocratic Oath
A historical foundation of medical ethics
States a moral obligation to maximize benefits of treatment and minimize harms of treatment
Much of the original oath is not relevant today
Modernized versions of the oath are used at some, but not all, medical schools
The Hippocratic [hip-po-crat-ick] oath is one of the historical foundations of medical ethics. Generally interpreted, it states that doctors have a moral obligation to maximize the benefits and minimize the harms of treatment. Those core values are still held today, as discussed in this lecture.
However, other provisions in the oath reflect the beliefs of ancient Greek culture and are no longer relevant. Some, but not all, medical schools have new doctors take a modernized version of the oath.
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17. The Culture of Healthcare Ethics and Professionalism Lecture a
Profession = an occupation that:
Requires special knowledge and training
Has standards for behavior
Healthcare professional = a person who, by training and experience, has the knowledge to provide some aspect of healthcare delivery
Professionalism means:
Acting in a way that meets standards
Knowing ethical obligations and trying to meet them
There are many definitions of the word “profession.” In this unit, it means an occupation that requires special knowledge and training. In addition, a profession has standards that must be met.
A healthcare professional is a person who, by training and experience, has the knowledge to provide some aspect of healthcare delivery.
Professionalism means acting in a way that meets the standards of the profession. In addition, professionals are aware of their ethical obligations and strive to fulfill them.
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18. Core Medical Professional Responsibilities (1 of 2)
Professional competence
Honesty with patients
Patient confidentiality
Appropriate relations with patients
Improving quality of care
A charter created jointly by several medical societies states ten core principles of medical professional responsibilities. The first five are as follows:
(1) Commitment to professional competence. Individual doctors must do what it takes to keep up with new discoveries in their field and keep their skills at the level needed to deliver appropriate care. The medical profession must monitor its members and provide ways for doctors to meet this goal.
(2) Commitment to honesty with patients. This principle includes the duty of informed consent. In addition, this principle requires doctors to be honest when medical errors occur.
(3) Commitment to patient confidentiality. Doctors must take steps to protect patients’ private information.
(4) Commitment to maintaining appropriate relations with patients. Because patients are often vulnerable and dependent on their healthcare providers, “physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose.”
(5) Commitment to improving quality of care. .
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19. Core Medical Professional Responsibilities (2 of 2)
Improving access to care
Fair distribution of limited resources
Scientific knowledge
Managing conflicts of interest
Maintaining professional responsibilities
The remaining five principles are as follows:
(6) Commitment to improving access to care. Doctors should work to reduce barriers and achieve a fair healthcare system.
(7) Commitment to fair distribution of limited resources. This principle requires that doctors provide cost-effective healthcare and avoid unnecessary tests and procedures.
(8) Commitment to scientific knowledge. Doctors have a duty to “uphold scientific standards, to promote research, and to create new knowledge and ensure its appropriate use.”
(9) Commitment to maintaining trust by managing conflicts of interest. Doctors should not “compromise their professional responsibilities by pursuing private gain or personal advantage.” An example is that doctors should report any relationships they have with pharmaceutical companies when they are conducting research or reporting the results of their research in journal articles.
(10) Commitment to professional responsibilities. Medical professionals should work together to get the most out of patient care, treat each other respectfully, and take part in the regulation of the profession.
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20. Ethics and Professionalism Summary – Lecture a
People in the healthcare profession have duties based in the 4 core principles of medical ethics:
Respect for autonomy
Beneficence
Non-maleficence
Justice
Healthcare professionals must consider how broadly their ethical duties extend (“scope of their action”)
Professionalism requires that people in the healthcare industry act in accord with certain standards
This concludes Lecture (a) of Ethics and Professionalism. In summary, people in the healthcare profession have duties that are based in the core principles of medical ethics: respect for autonomy, beneficence, non-maleficence, and justice, plus concern for the scope of their action. Professionalism requires that people in the healthcare industry act in accordance with the standards of their profession.
The proper applications of ethical principles and standards of professionalism are not always clear. Individuals can find guidance in codes of ethics, statements of professional standards, and consultations with colleagues, ethics committees, and ethics experts.
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21. Ethics and Professionalism References – Lecture a
American Board of Internal Medicine Foundation [Internet]. Cassel CK. 21st century medical professionalism: renewing the social contract [13 pages]. Available from:
American Board of Internal Medicine Foundation [Internet]. Undated [cited 2011 Dec 20]. Medical professionalism in the new millennium: a physician charter [2 pages]. Available from:
Aulisio MP, Arnold RM. Helping to address value conflicts or uncertainties: role of the ethics committee. Chest. 2008;134;
Ethics Resource Center [Internet]. Ethics glossary. May 29, 2009 [cited 2011 Dec 19]. Ethics glossary [5 pages]. Available from:
Gillon R. Medical ethics: four principles plus attention to scope. BMJ. 1994;309(6948):
Gillon R. Ethics needs principles: four can encompass the rest—and respect for autonomy should be “first among equals.” J Med Ethics. 2003;29(5):
References slide. No audio.
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22. Ethics and Professionalism References – Lecture a (continued)
References (continued)
The Hastings Center [Internet] [cited 2011 Dec 20]. Jennings B, Baily MA, Bottrell M, Lynn J, eds. Health Care Quality Improvement: Ethical and Regulatory Issues [188 pages]. Available from:
History of Medicine Division, National Library of Medicine, National Institutes of Health [Internet]. Updated June 24, 2010 [cited 2011 Dec 20]. Greek medicine: the Hippocratic oath [1 page]. Available from:
Kirk LM. Professionalism in medicine: definitions and considerations for teaching. Proceedings (Bayl Univ Med Cent). 2007;20:13-16.
University of Washington School of Medicine [Internet]. Updated April 11, 2008 [cited 2011 Dec 19]. McCormick TR. Ethics in medicine: principles of bioethics [4 pages]. Available from:
University of Washington School of Medicine [Internet]. Updated November 1, 2010 [cited 2011 Dec 19]. Pearlman RA. Ethics in medicine: ethics committees and ethics consultation [3 pages]. Available from:
References slide. No audio.
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23. Ethics and Professionalism References – Lecture a (continued)
Charts, Tables, Figures
8.1 Figure: Four basic principles of healthcare (CC BY-NC-SA 3.0, 2012).
8.2 Table: Non-Maleficence (CC BY-NC-SA 3.0, 2012).
8.3 Figure: Ethical dilemma (CC BY-NC-SA 3.0, 2012).
References slide. No audio.
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Ethics and Professionalism Lecture a