Potential conflicts in interprofessional relationships
Gonzalo Herranz, department of Bioethics, University of Navarra, Spain.
Session in Bioethics Course
Pamplona, Friday, June 21, 1991, 18:30 to 19:45.
General deontology of interprofessional relations.
On the inevitability of dissent in interprofessional relations
Autonomy and hierarchy in areas of shared responsibility
In what is supposed to be a long speech of mine this afternoon, we have to deal with a topic that needs that time and much more. Because the relationships between doctors, between nurses, between pharmacists, between assistants, between managers, among themselves and with each other, constitute that dense and complex network of stimuli and responses, of concerted and synergic actions, which maintains the health of the population and prevents and cures disease. But in the midst of this coordinated and peaceful joint activity, from time to time, sometimes with alarming frequency, conflicts and clashes of very different magnitude arise, which can endanger people's health and lives, or which, and this is what interests us most today, can threaten the freedom or moral integrity of colleagues and other health professionals.
In order to distribute in a reasonable way the subject to be considered, I will first deal with the general deontology of interprofessional relations. I will then analyze what place there is in them for dissent. I will end with some reflections on how individual autonomy and hierarchical organization can be combined in the performance of work as a team.
So let's move on to our first point.
General deontology of interprofessional relations.
Health professionals may, for reasons of socioeconomic (sub)development or professional demographics, work separately. A physician may be forced to act as a nurse and pharmacist, or a nurse may be forced to act as an assistant, a bureaucrat, or even a physician. But the ordinary, among us, is the work at partnership, creator of multiple and varied interrelationships. The physician needs other professionals to apply nursing care to the patient, to perform analyses of laboratory, to examine the patient under certain aspects, to dispense drugs. Although the physician plays a decisive role in patient care, if he/she were to remain alone, he/she would provide very deficient, fragmented care. He cannot be the exclusive health caregiver: he needs the partnership of the members of the other health professions. He certainly retains the ultimate responsibility towards his patient, which obliges him to coordinate the work of all, to point out to himself and to each of those who collaborate with him the objectives and limits of the individual work and of the cooperative task. Although in all this there must be some sense of organization and science of the management, what interests us is the ethics of interprofessional relations.
Following, as a vector thread, the ethical rules of the Codes of Ethics of nurses, pharmacists and physicians, I will summarize the notions that should govern interprofessional relations, which, in my opinion, are four: the ideas of ethical respect, territoriality of responsibilities, correctness in command, and delegation of functions.
Interprofessional relations must be attentive and respectful. Attention and respect should be understood here, as on the other occasions when dealing with deontological respect, not only as the set of gestures imposed by good Education, but something more profound: the recognition that those who collaborate in the care of patients are true professionals, who enjoy autonomy and skill, who have the right to be treated as responsible and knowledgeable persons in the corresponding subject. They are, after all, morally adult persons, whose convictions and dignity must be taken into account as much as their own.
This general obligation of respect for the professions that are at the service of human health must be applied concretely and directly to relations with immediate collaborators. The logic of this rule is evident, since the best service to the sick demands it, for whom it is good to be cared for by professionals who collaborate in good harmony and who mutually esteem each other. It would be a cause of concern for the sick and those close to them to see that there is misunderstanding among their caregivers and that there is no concealment of hostility or mutual contempt. It is inevitable that the sick suspect, in such circumstances, that neither one will inform the other with the necessary trust and loyalty, nor will they comply with enthusiasm and punctuality with the orders received.
It is also a common rule which imposes to respect the specific competences of each of the professions. This is what can be called the principle of territoriality. Each of the professions has its own traditions of professional quality and its own rules of ethics, which all must know and respect: not only their own, but also those of others. All must resist the temptation to encroach on the specific competencies of others. The boundaries of the responsibilities of each profession and of each person must be marked out - or, better still, set down in writing - as precisely as possible. And the criterion for drawing them is the best interest of the patient. If conflicts of competence should ever arise, they should be clarified and discussed amicably, but never discussed in the presence of the patient. agreement It is therefore necessary that everyone, before or at the very beginning of your partnership, negotiate the terms of the latter and agree on the issues (technical objectives, practical procedures, human style) to be agreed upon if the necessary harmony is to be achieved. skill And, once they have agreed on these points, they should never forget that good coexistence requires a certain amount of tolerance and trust in the honesty and professionalism of everyone.
This harmony is easier to achieve if instructions are given with clarity and moderation. The behavior of those who habitually dictate their orders in a blunt manner, with excessive energy, or those who continually introduce changes in the usual way of proceeding without justifying them with the appropriate reasons, or those who trivialize their authority by giving very detailed instructions for more or less routine tasks, would not be good. True trust in one's collaborators manifests itself in giving orders only when necessary and then doing so with humanity and in a precise and clear manner. This excludes any ambiguity or lack of precision in the orders, and includes the important obligation to write in legible handwriting (by everyone, not only by specialists in graphological interpretation) the recipes, orders or instructions that are transmitted to their collaborators.
It belongs to the common ethics that, ordinarily, each one has to fulfill the orders that are assigned to him. But if someone does not agree agreement with the moral or technical content of the order received, he must communicate the reasons for the disagreement to the one who gave the order, and the latter must listen to them and modify or maintain the order after calmly considering the data of the problem posed. No partner physician may ever be compelled to act against his or her own conscience or to do anything that seems unreasonable or unreasonable to him or her. In particular, no physician manager should feel confident in the work of collaborators who will always be obsequious and reduce their responsibility staff to an ethic of passive submission. And he will be very careful not to impose on his assistants a behavior of blind obedience. In today's medicine, no one can justify his conduct by invoking the fact that in his work he is simply following orders: such an attitude is professionally indefensible, both from an ethical and legal point of view.
The inter-territorial border must be clear, but it must be permeable. It is very human to lend each other a hand, and very necessary from time to time. It is precisely in this voluntary and supererogatory substitution that the human tone of interprofessional cooperation is decided. No one can be offended by substituting for another in a pinch in a seemingly humiliating task (the status of tasks depends on the human dignity of the one who performs them and the human dignity of the one who is served by them), nor can anyone be offended by being asked for an occasional financial aid to do something that is not included in the list of his or her duties. But there is nothing more odious in this field than to abuse the goodwill of others, to live parasitically from the efforts of others.
It may sometimes be necessary to formally institute the delegation of functions. In order to delegate functions to employees, to change the boundaries separating the fields of professional responsibility in a stable manner, it is necessary to proceed with very restrictive criteria and with a strong sense of responsibility. Only in this way will it be possible to derive maximum benefit from such cooperation. The physician remains the ultimate manager before the patient and, therefore, assumes before him the consequences of all his decisions, including those that may derive from having entrusted non-physicians to carry out certain procedures that he alone is responsible for performing. A hindrance to the delegation of functions to collaborators, even in the case of physicians, is the lack of due qualification, or the simple lack of experience. If the physician needs to delegate functions to non-medical collaborators, he/she will do so, under his/her responsibility, to persons whose skill and good judgment are clear to him/her, while remaining available to intervene, if necessary. The delegation of functions has its limits. By their very nature, medical acts that cannot be delegated are those that have to do immediately with the diagnosis (taking the medical history, physical examination of the patient), with the determination of the initial therapy and its subsequent modifications, and also those that must precede the extension of a medical certificate .
On the inevitability of dissent in interprofessional relations
A manifest fact in today's societies is pluralism, diversity. agreement People have taken it upon themselves not to agree with agreement, and this is manifested not only in the intimacy of consciences, in the field of political ideas, religious convictions and lifestyles, but also in professional activities. It is taken for granted that there is plenty of room for diversity in society, that differences of opinion and action must be compatible with peaceful social coexistence. Curiously, however, there is much less tolerance for dissent in interprofessional relations.
And yet, just as evident as the macro-social pluralism is the pluralism of the micro-society formed by doctor and patient, or that which constitutes the health care team, or that which is enclosed within the walls of a hospital. Let us look for a moment at what happens in a hospital.
There are people who deny that hospitals, especially public hospitals, can have, as an institution, a moral conscience or profess certain ethical convictions. They say that a hospital consists of bricks and mortar, and therefore lacks the capacity to raise ethical objections. But real life refutes such ethical nihilism. When someone feels that his or her ethical expectations are not being met or are being disappointed by a doctor or nurse, he or she turns to the institution's director to advocate on his or her behalf. The institution or its directors cannot fail to act as moral agents. It is unthinkable for them to refrain from intervening when disagreements on relevant ethical issues come into play.
I wanted to point this out to indicate that a hospital, an outpatient clinic, a simple doctor's office, are places of whose identity the ethical is part. Implicitly or explicitly, they all have, and must publicly manifest, a moral identity. This institutional ethical identity is constituted by a defined set of obligations that are assumed and published, which show, in congruence with the ethical pluralism of society, that such an institution, such a pharmacy, such a dispensary, sanctions such and such a specific ethical attitude to which it feels morally obliged, or is rather inclined towards a more open, unlimited pluralism.
The public manifestation of the ethical identity of institutions and individuals can do much to reduce the intensity and frequency of ethical disagreement between professionals and patients and among professionals themselves. Disagreement is a matter of ordinary administration. Physicians and patients often disagree on the therapeutic plan to be followed: disobedience in complying with medication regimens or in avoiding voluntary health risks can be found at agenda. The data, the criteria and the methods by which physicians make their decisions are incredibly diverse. The evaluations and recommendations of Consensus Conferences about preventive, diagnostic and therapeutic procedures are followed by a very small fraction of physicians. Despite the ongoing medical Education and the study staff of the bibliography, physicians continue to prescribe according to asystematic, intuitive, capricious guidelines. This has led some to consider that freedom of prescription is an alibi for caprice and intellectual laziness and that it should be ended.
It is not easy to find a solution. It is obvious that clinical freedom allows the scandal of doctors who practice medicine without a scientific basis, as is the case with many alternative practices that deliberately manipulate credulity; or that of practitioners who ignore the consolidated progress of recent years. But a medicine without clinical freedom would be even worse. The most advanced medicine, if it becomes a standardized, dogmatic system, where for each problem there is an official, universal, binding, immutable solution, is inexorably a dogmatic medicine, which, in a few years, becomes a superstition.
Medicine is, by its very nature, open, progressive: which means that it does not admit an end point. In the medical internship , everything is, in principle, provisional. There are very few definitive, non-negotiable, monolithic truths in medicine. These are things such as respect for the life and integrity of mankind, the obligation to seek the scientific improvement of medical acts, the struggle to provide quality professional care. In everything else, there is room for dissent.
I do not know if the above has served to justify the need and convenience of diversity of opinion and internship in Medicine. The problem with dissent lies precisely in how to practice it. Traditional deontology imposes the obligation not to make public place the discussion of disagreements between colleagues on scientific, professional or deontological issues, issues that should be discussed in the appropriate venue: in private, in sessions held within the profession.
This does not mean, by any means, that deontology limits the right to freedom of thought or free expression. The ethical maturity of professionals must manifest itself in tolerance for legitimate diversity, in calm criticism, in respect for people. The Hippocratic precept that the first thing is to do no harm has, in the circumstance of disagreement, an opportune field of application. Professional deontology not only does not impose ideological uniformity: it recognizes and promotes professional freedom by establishing precisely the obligation to practice it correctly and, specifically, not to harm the colleague who practices it, when we disagree with him. It reminds members that airing legitimate differences of opinion in public can have undesirable effects from an ethical perspective, such as generating confusion among those who follow the controversy, giving rise to undue publicity for procedures or persons, and creating occasions for mutual disrespectful attention . The heat of a controversy is not the most appropriate venue for informing or educating the general public or for maintaining correct relations with colleagues.
There are certain professional matters in which, if the interested parties do not reach an agreement at agreement, it is advisable to seek arbitration at high school. Only after this means of conciliation before the high school has been exhausted and a satisfactory and fair solution has not been reached in the opinion of both parties, is it ethical to appeal to the legal channel to settle the differences. However, experience shows that the distance between the demanding deontological standards of mutual respect and correctness and the lax judicial rulings that are incredibly tolerant of uncouthness and ideological aggression is growing. The gap between legality and morality as to what is to be understood as wrong in interprofessional relations has become too wide.
It is necessary to learn the internship of educated disagreement. The reasons for not polemicizing beyond what is reasonable come not from indifferentism or skepticism in subject scientific or professional, but from the notion that there are many open questions that admit several solutions, none of which possesses attributes that make it so superior to the others that one must feel urged to follow it and also to impose it on others. Since, in matters left to free discussion, no one can be compelled to go against his own best knowledge, it is necessary to conclude that the right thing to do is not to pursue the discussion beyond a point. It is irrational and inoperative to use violent language to try to persuade others.
All this may seem very ideal. And it seems so because, perhaps, a discussion about dissent cannot be disconnected from a permanent reality: the hierarchical arrangement of groups formed by health professionals. Disagreements among peers can sometimes be very complicated and harsh. But disagreement between superiors and subordinates tends to provoke a tremendous amount of pain and ingratitude. What does deontology tell us about autonomy and hierarchy in interprofessional relationships?
Autonomy and hierarchy in areas of shared responsibility
Hierarchical relationships play a very important role in the organization management assistant and function of medicine. It is enough to recall that the internal organization of health care institutions, whether public or private, has always had a hierarchical structure, they are "hierarchical". For its part, the nursing profession was born with an almost paramilitary structure and retains a strong hierarchical imprint. From a legal point of view, the hierarchical organization is the basis for the different types of subsidiary liability. But, on the other hand, and this is what interests us today, they are the cause of frequent and painful conflicts between colleagues. Physicians have quite different opinions about what are the attributes and limits of hierarchy within the groups of work.
The current Code of Medical Ethics and Deontology is the first that has dared to introduce an initial deontological regulation of hierarchical relationships. It tells us that the hierarchical order within the groups of work (whether they are called Departments, Services, Sections or Units, whether they are located in Hospitals, Clinics or Outpatient Departments), must always be respected, but it can never constitute an instrument of domination or exaltation staff. The person in charge of group shall ensure that there is an atmosphere of ethical demands and tolerance for the diversity of professional opinions, and shall accept abstention from acting when any of its components opposes a reasoned objection of science or conscience. The Code adds to this that the Colleges will not authorize the constitution of groups in which the exploitation of any of its members by others could occur.
The fact of hierarchical organization is recognized: whenever two or more physicians come together to cooperate in the care of the sick, to schedule or perform clinical research or to educate students or graduates, one of them must assume ultimate responsibility for group to the patient, the sponsoring institution research or the academic authority. It is necessary, at the same time, that the power to coordinate the contribution of each one to the common task be assigned and recognized. In this sense, hierarchical organization responds to a basic functional need: it is a legitimate way of creating order and efficiency in a group of people who have to work together.
It happens, on the other hand, that ours is a very demanding time for those who govern. It has become customary to criticize, and criticize very harshly, those in power. Today it is not enough to be in charge. In spite of the almost unlimited possibilities of manipulating public opinion, those invested with hierarchy must not only take care of their image; they have to win the adhesion of the governed day by day by means of skill, honesty and example. The person in charge of the health care group must have, in addition to the technical ability to make decisions, moral and scientific authority, and also, and above all, the ability to work and respect for subordinates. Authority must be conceived more as a service than as an occasion for domination or exaltation. It should never be a award granted to mere seniority in the ranks, nor a perk of political servility.
It is very difficult to govern a group without written rules. Their lack makes the task of governing more tiring, while increasing the risk of falling into arbitrariness and creating disorientation and displeasure among the governed. In general, people want to know where they stand. Each person must know what his ordinary duties are and also who can give him orders and on what matters. The indeterminacy of the responsibilities of those in charge is particularly harmful.
In addition to a minimum of permanent codification (rules of governance, description of the functions of each position and of each work space), it is advisable for good governance that all those who have the right and obligation to participate in the making of certain decisions be called upon, so that with their voice and, if necessary, with their vote, they can help to make the best decisions. Participation favors the acceptance of decisions and loyalty among all those who make up the group and makes it possible to create an atmosphere of respect and tolerance. There will always be conflicts, but it is easier to resolve them without violence in an environment where everyone feels responsible.
The Code imposes on those who assume management the duty to respect the convictions of their collaborators, to agree to refrain from acting when someone objects on the grounds of science or conscience and to provide the means to ensure that such conduct does not undermine the equitable distribution of the burden of work among all. This deontological rule will be of increasing relevance and interest.
Among the most significant phenomena of contemporary society are the recognition of ethical pluralism as a reality to be lived with and the acute sensitivity to individual human rights. Both phenomena are embodied, among other things, in the need to respect the convictions of others and in the condemnation of coercion.
Respect for ideological diversity must be present in the hierarchical relationships between colleagues. Whoever directs the distribution of work must accept and respect the objection to certain actions that some or all members of group may invoke because of their scientific or conscientious convictions. It is true that such objections, by breaking established routines, may cause inconveniences of a certain amount. But these inconveniences are not a negative magnitude: they are the price to be paid for the moral progress of society. There are those who do not see it this way, and tend to consider conscientious objection as an irregular, annoying, even uncivil status . They suspect that conscientious objection is sometimes invoked as an alibi to avoid unpleasant work and that objection always creates friction within group. It is morally odious to invoke scientific or conscientious objection as a ploy to get out of unattractive jobs. The moral integrity of the objector requires him to accept a burden from work that fairly compensates for what he has failed to do by virtue of his abstention. And he who has the government of group, while respecting the objection, must provide, without arbitrariness for or against, that this compensation is made in justice.
At times, a civil, ecumenical and peaceful Ethics has been invoked as the minimum common ethical dividing line for the coexistence of all in today's pluralistic society, to which one should not object. They claim that this civil ethics should be compulsorily accepted by all, which is nothing less than a tyrannical pretension and the death of ethical pluralism. It is much more congruent with the respect for freedom and infinitely more humane to respect the convictions of each one, than to authoritatively force everyone to violate their conscience, putting them in the alternative of abjuring their beliefs or abandoning a work to which they have given their existence.
There is an interesting aspect of respect for the autonomy of those who form the group. Whoever directs the hierarchically organized group is manager to supervise not only the internal actions of the members of group, but also those that, as such, the members of group carry out externally. This may involve, for example, communications to congresses or articles for scientific publications, prepared with the material and experience of group. Logically, this supervisory task should involve loyal criticism, appropriate advice and recommendations, and respect for differences of opinion. In case of disagreement at subject scientific or professional, the person in charge of group may require the authors to include an exclusion of liability clause in their work . Under this clause, the published article states that the ideas expressed by the authors do not represent the collective opinion of group.
In conclusion, I believe that it is appropriate to make some considerations on the relationship between physicians and pharmacists, since certain conflictive situations can arise. To avoid them, physicians and pharmacists should have a very precise and clear idea of what their reciprocal rights and duties are, in order to respect and fulfill them, remembering that both professions share as their prevailing purpose the best service to the patient.
Physicians should refrain from recommending that their patients go to a particular pharmacy in preference to others, nor should they make directly or indirectly derogatory comments about the quality and price of the services provided by a particular pharmacist. On the contrary, he/she will be strictly impartial towards all pharmacists working in his/her environment. If he/she suspects that a product (specific or magistral formula) served by a pharmacist is not in good condition or does not correspond to the one he/she has prescribed, he/she will deal with the matter directly with the pharmacist manager, never through the patient.
Pharmacists act as drug experts, especially in the field of side effects and drug-drug interactions. They are also legally authorized to substitute, if necessary, identical or equivalent drugs prescribed by the physician. However, in all cases of generic substitution and, in particular, in cases of therapeutic substitution, they must act with prudence, contact the physician at contact to consult him/her or inform him/her of the appropriate points and act together with him/her at agreement .
And just as the physician must respect the pharmacist's interventions, the pharmacist will refrain from criticizing the content of prescriptions to his customers or undermining his reputation with patients. The pharmacist may advise his customers informally on the treatment of obviously minor ailments and dispense medicines that are advertised, i.e. that do not require a prescription. But he can never replace the physician in his diagnostic and therapeutic role, nor, except in emergencies, perform minor interventions or cures that could have the appearance of unfair skill .