Physician Code of Conduct in Women’s Reproductive Health

Preamble

In the midst of the sea of societal complexity float issues of reproductive health. Issues of human reproduction resurface time and again in virtually every setting where medicine touches research, government, religion and even economics. This is the case certainly in part if not in whole due to the fact that human reproduction represents the very foundation and definition of that for which medicine exists: the health of a single human. It is because of this fundamental reality that reproductive health issues and services must be handled without presumption or transference of belief (from clinician to patient) on a case-by-case basis with utmost delicacy.

Due to the influence of a pluralistic culture, the democratization of morality, and the pressure of consumerism western medicine may be on the verge of losing its high moral status and social trust. For western medicine to sustain its status as an independent and self-governing profession it will need to clarify the beliefs and behavior that define good physicians. This code internal to the profession defines those clinicians who intentionally think and act according to an agreed upon and comprehensive moral code of conduct. In the tradition of Thomas Percival, the Commission for Reproductive Health Service Standards has been formed to identify and interpret traditional medical ethics generally in order to assist and encourage medical clinicians to protect the patient and their true autonomous decision-making ability for women facing unplanned pregnancy specifically. Clinicians, those Physicians, Physicians Assistants, Nurse Practitioners, and any other members of the health care team who may be in a position to educate, diagnose, and treat a patient, are invited to use this code as a tool designed by medical professionals to protect the clinician’s integrity, the profession’s credibility, and above all the patient’s dignity.

I. Duties to the Patient

Much of the physician’s duty to a patient requires clear and open communication. Most patients seek out medical care to help them understand their condition. As such the patients are typically at a loss to know even what questions to ask of a clinician to both understand their condition as well as which treatment option would be most consistent with their beliefs and goals. To safeguard the patient from the violation of their dignity and self-determination three traditional ethical concepts should be employed by the clinician to govern the relationship with the patient.

1. Patient Autonomy: Patient Autonomy does not mean the facilitation of any legal choice of medical services on-demand. Patient autonomy carries with it the notion of self-determination and dignity which informs the manner and depth of communication between the physician and patient.
   • A clinician must hold the highest regard for the nature and purpose of humanity represented in the form of a single human being (dignity).
   • A clinician’s primary aim for the patient must be informed self-rule (self-determination).
   • A clinician must always attempt to understand a patient and insulate a patient from coercive pressure.
   • A clinician must always provide all the information about a patient’s condition as well as all treatment options.
   • A clinician, especially a specialist who has no long-term relationship with the patient and who stands to financially benefit from a patient’s choice, must rarely if ever omit information because he/she has invoked the justification of therapeutic privilege.
   • A clinician must never manipulate or knowing withhold information including downplaying the remotest side-effects.
2. Beneficence: To act solely for the benefit of the patient. Continuity of care, and conflict of interest disclosure are key concerns in upholding this commitment.
   • A clinician must be dedicated to seeing the patient as a whole person by understanding a patient’s past health history, current socioeconomic circumstances, personal beliefs, and future health goals.
   • A clinician who acts primarily as a specialist in non-emergent, elective circumstances, such as an abortionist, must be aware that they are most susceptible to violating the principle of beneficence and must be even more vigilant to take the necessary precautions.
   • A clinician who acts as a specialist must attempt whenever possible to work as a consultant for and in conjunction with the patient’s primary care provider.
   • A clinician should take independent patient requests for specialized medical services as a cue that the patient’s circumstances are coercive and reflect an ethical dilemma.
   • A clinician must always encourage the least invasive treatment options first.
   • A clinician must be committed to protecting the patient from any intentional or unintentional clinician self-interest. This is especially salient when presenting treatment options as a specialist, such as an abortionist. This would include anything from propagating a political belief implicit in a particular treatment option to financial remuneration from a particular treatment option.
   • A clinician must disclose any potential conflicts of interest when presenting treatment options to the patient.
3. Non-maleficence: Avoiding any act or treatment plan that would harm the patient or violate the patient’s trust.
   • A clinician must be committed first to prevention through good health and avoidance of behaviors leading to deteriorating conditions. Examples of reproductive health preventive medicine would be encouraging abstinence and/or mutual monogamy or if recommending high risk measures such as pregnancy termination to include STD testing and treatment prior to the procedure in order to protect the patient from infection thereby safe-guarding the patient’s future reproductive health.
   • A clinician must be committed to maintaining patient confidentiality in an effort to safe-guard the trust required for effective patient communication.
   • A clinician must be committed to facilitating the free and open communication with the patient which alone will yield appropriate prevention and treatment plans informed and freely chosen by the patient.

 II. Duties to Society

Because the practice of medicine happens within a changing culture and is performed by men and women who are a product of that culture it is paramount that physicians and other medical practitioners understand and teach society how the practice of medicine can and must occur in the context of differing personal or political beliefs. This is done by understanding the concepts that govern the relationship a doctor has with society. Those concepts have traditionally been personal integrity, distributive justice and education.

1. Personal Integrity: A clinician’s commitment to personal integrity is essential for the medical community to maintain its credibility with the society it serves.
   • A clinician recognizes that a patient’s lack of knowledge places her in a position of extreme vulnerability to clinician manipulation.
   • A clinician is dedicated to virtuous personal character if only to protect their patients from exploitation and victimization which comes with a lack of personal character.
   • A clinician is dedicated to understanding and practicing wisdom, empathy, temperance, courage, and justice both privately and professionally.
   • A clinician is dedicated to holding other clinicians accountable to these high moral standards even with the use of this code of conduct.
   • A clinician must maintain integrity to his personal convictions in the face of increased government regulation, as well as encroaching consumerism in the form of on-demand request for services.
   • A clinician is committed to maintaining his integrity through the exercise of a right to refuse treatment or recommend treatment at odds with his conscience.
2. Distributive Justice:Since there are always more patient needs to serve than medicine can accommodate, clinicians must make decisions about how to spend those resources day by day in a way that is equitable.
   • A clinician must be committed to understanding the true health needs of the community he serves taking care to distinguish those from political agenda.
   • A clinician must be committed to resisting government regulation.
   • A clinician must be committed to placing the health needs of a single patient over general notions of regulated care.
   • A clinician is committed first to serving the best interest of the patient and secondarily the policy and regulation of a hospital or government.
   • A clinician is committed to protecting society’s most vulnerable: the sick, demonized, and disenfranchised.
3. Education:Education involves both informing society at large as to how medicine should be applied and also teaching the next generation of clinicians the art of medicine.
   • A clinician is committed to participating in the education of the next generation of clinicians about the nature and practice of the craft.
   • A clinician is committed to professional accountability willing to act as expert witness for judicial and legislative matters.

 

Reference Notes: The Commission is indebted to the following authorities for the general framework and philosophy of the preceding Code of Conduct.

American College of Physicians. Ethics Manual. 4^th ed. Ann Intern Med. 1998; 128(7):576-94.

Hippocrates. The Hippocratic Oath. Trans. in Kass, L. R. Toward a More Natural Science. New York: Simon and Schuster; 1988:228-9.

Percival T. Medical Ethics; Of a Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons. Manchester: S. Russel; 1803.

President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making Health Care Decisions: The Ethical and Legal Implications of Informed Consent in the Patient-Practitioner Relationship. Vol. 1. Washington: GPO; 1982.