© Springer-Verlag Berlin Heidelberg 2014
Ahmed Ammar and Mark Bernstein (eds.)Neurosurgical Ethics in Practice: Value-based Medicine10.1007/978-3-642-54980-9_1414. Workplace Ethics and Professionalism
(1)
Division of Clinical Public Health, Department of Family and Community Medicine, Clinical Research, Dalla Lana School of Public Health, Bridgepoint Health, University of Toronto, Toronto, ON, Canada
(2)
Division of Neurosurgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
14.1 Introduction
There was a time when the words and actions of the surgeon were paramount – life in the hospital was nondemocratic but simple. But the delivery of health care has undergone significant transformation in the past few decades. Health care has become more complex, delivered in multiple contexts by a growing number of recognized health professionals (Breitbach et al. 2013; Clark 2014). In the past health-care institutions were dominated by physicians and nurses, who, in addition to service delivery, also played most of the key administrative roles. Concerns for quality of care and patient safety have motivated initiatives to foster team-based care. This requires consideration of both interdisciplinary and interprofessional aspects of ethics, essential to the practice of value-based medicine. In addition, health-care institutions and their functions have become more complex. Health sciences centers often combine missions of service delivery, research, and education which brings additional human resources into the mix. Neurosurgeons are increasingly recognizing the importance of professionalism and teamwork (Apuzzo 2013; Bernstein 2005; Dacey 2013; Harnof et al. 2013; Kanat and Epstein 2010; McLaughlin et al. 2013; Sekhar and Mantovani 2013). There is also a recognition that the ethic of an institution percolates down to the workers and can positively influence workplace professionalism (Silva et al. 2008).
The reality of health care is that there are multiple health professions, administrators, and others involved in a complex web of relationships. The playing field has been leveled such that all members of the health-care team have voices that count, which is a good thing for patients. The advent of team-based care has forced health-care providers, educators, and administrators to rethink the roles and responsibilities of health-care providers in the context of teams. However, the bulk of the literature in bioethics focuses on specific and easily identifiable issues related to the extremities of life such as end of life decisions, intensive care unit experience, and neonatology. Much of workplace ethics will be of the everyday nature and deal with the interactions of the varied and heterogeneous providers. Each of these has their own codes of ethics and organizations which also instill particular cultures which influence ethical considerations.
Ethical issues are common in health care. The last two decades have witnessed increased attention to ethics training in the health-care professions. Many academic programs need to demonstrate proof of ethics training as a condition for accreditation. Similarly, many health-care institutions have devoted more resources to ethics services in terms of full time ethicists and support for ethics committees.
It is commonly thought that health professionals work from a well-established common ground of shared values. This, however, has been shown in numerous studies to be untrue (Bleakely 2006; Stiggelbout et al. 2006). Empirical studies have demonstrated that there are considerable intra- and interprofessional differences in how various ethical issues are understood and weighed (Miyashita et al. 2007). Personal and professional morality may also come into conflict in the conduct of daily work and may be particularly evident in interprofessional contexts (Upshur and Bernstein 2008). Formal effort is increasingly being directed at teaching professionalism (Hochberg et al. 2010; Parran at al 2013).
However, ethics training focuses largely on the roles and responsibilities of health-care providers with respect to the provision of care to individual patients. Ethics consultations also focus largely on issues related to the care of individual patients. This leaves a gap in terms of how to manage ethical issues that arise in the context of the workplace. This is particularly important in terms of addressing the ethics of interprofessional and team-based care. There is comparatively little literature and scholarship on this topic in the literature (Clark et al. 2007).
Despite the rapid move towards team-based care, the literature has not kept pace. It is clear that competency in workplace ethics is desirable as it is highly unlikely that health-care institutions will become simpler in the near future. As well, the days of physicians being the unquestioned leader and decision maker are likely in the past.
The well-known principles of autonomy beneficence, non-maleficence, and justice do not adapt easily to workplace ethics as they were specifically formulated to address issues related to care of patients by health-care providers. It may be necessary to draw from other ethical frameworks and theories (Bernstein and Fundner 2003) to assist in workplace ethics as it requires the framing and analysis of ethical issues in a manner that is not explicitly focused on the patient, but rather on the team or the organization.
Pearl
High-profile ethical issues like end of life conflicts and treatment of other vulnerables like neonates are actually relatively uncommon but get a lot of attention. Workplace ethics and breaches of professionalism are everyday occurrences, and continual vigilance is required by all members of the health-care team, mainly not only about their own behavior but also that of others.
14.2 Illustrative Case (Numerous Breaches of Professionalism)
A neurosurgeon is editing a multiauthored book and three of his chapter authors are late weeks after the deadline. When he e-mails them to find out what’s going on, two respond that they have been very busy and will get to it when they can, and the third does not respond at all. That night the neurosurgeon is on call and is paged in the middle of the night by an emergency physician at another hospital an hour away without neurosurgical services. The ER doctor has an 87 year-old woman, with a very small traumatic brain contusion following a fall at home; her GCS is 15. The neurosurgeon yells at the emergency doctor stating, “This is not an emergency – why are you bothering me? You could have called me later in the morning for some advice.” A few hours later at morning rounds, he tells his residents about the “stupid idiot” who woke him up in the middle of the night. An hour later he is performing an awake craniotomy in the OR and while doing so he chats with his residents about his other patients who are in hospital. Later that day on the ward, he shakes his head in desperation at a physiotherapist who is blocking his order to discharge one of his postoperative patients to her home. On the way home in the evening, he rides down in a full elevator in which two medical residents are animatedly discussing a complex patient, but says nothing to them.
14.3 Approach to the Case
As the vignette illustrates, lapses of professionalism and tensions often occur between health-care professionals in the conduct of everyday work. Examples of some which occur commonly and appear in our case include failure to respond to e-mails in a timely way (Bernstein 2006), violating patients’ privacy by speaking about other patients within earshot of patients or loved ones (Zener and Bernstein 2011; Howe and Bernstein 2014), and speaking disrespectfully to colleagues (Upshur and Bernstein 2008). While much of this may relate to the quite heterogeneous personalities, perfectionist temperaments, and multitasking skills of health-care providers, it would be a mistake to simply relinquish many of these issues to personality conflicts and/or personality flaws. The ability to be a good collaborator is often included in discussions of professionalism. Exemplary professional behavior would entail acting in a collegial manner, the manner in which one would want to be treated by others.
Personality conflicts may raise ethical issues particularly when they threaten patient safety. Some of these conflicts may legitimately arise from competing values between clinicians. It is seldom required of a physician that they be familiar and conversant with the codes of professional ethics of their colleagues. But ethics entails more than just considerations of etiquette and manners. Ethics drills deeper into the underlying value structure and addresses arguments to support or rebuff preferred courses of action.
Workplace ethics makes us reflect on the fact that our work is not carried out in isolation and that our behavior may have significant impact on those around us. The neurosurgeon in the case may be rightly frustrated by the actions of his professional colleagues, but this does not justify his actions to others and the implications of the behavior on team function.
It is easy to pass summary judgment on the surgeon. Yelling at colleagues is clearly not an acceptable behavior. Is it unethical though? To make this case we need an analytical framework that will help us determine where the ethical problems exist and how they can be interpreted.
Pearl
Surgeons will always have bad days, but a systemic culture of collegiality and tolerance must exist in the workplace so that occasional breakdowns do not have pervasive negative effects. This is not dissimilar to the patient safety culture in which systemic safeguards are in place to help prevent human errors from hurting patients.
14.4 A Framework for Interprofessional Teamwork Ethics
Ethical frameworks are commonly employed as a means of aiding in the explicit recognition of value issues in health care. The idea of a framework is a metaphor that directs attention to how we organize our thinking about a topic. Frameworks can take many formats and include substantive and procedural dimensions. It has been argued that the primary role of ethical frameworks is to aid in the process of deliberation about what ought to be done in a particular situation (Dawson 2009). Frameworks are not the same as overarching ethical theories in that they do not seek to justify actions on the basis of consistent theoretical considerations. It is argued: “…there is nothing wrong with a framework taking certain theoretical considerations for granted and concentrating upon aiding busy decision makers through the provision of a checklist of relevant considerations, principles and issues to keep in mind” (Dawson 2009). As such ethical frameworks are pragmatic and action oriented.
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