Dual Loyalty (DL) of Healthcare Professionals

Zeev Wiener, MD.

International medical Codes

“The health of my patient shall be my first consideration” (WMA Declaration of Geneva 1949).

“A physician shall owe his patients complete loyalty and all the resources of his science” (WMA International Code of Medical Ethics 1983)

The Problem of DL

Simultaneous obligations,

expressed or implied,

to a patient and to a third party.

Clinical Definition

Clinical role conflict between professional duties to a patient and obligations, expressed or implied, real or perceived, to the interest of a third party such as an employer, an insurer or the state that can violate patient’s rights.

Conflict-obligation-pressure-risk

Difficult Settings

Prisons Refugee and immigrants

camps Workplace Forensic evaluation Military

Case Examples of DL Violation

Using medical skills to inflict unnecessary damage or pain on behalf of society or state.

Subordinating independent medical treatment or judgment to state policy or interest.

Limiting or denying medical treatment or information related to individual or subgroup.

Disclosing patient’s medical confidentiality to state and powerful non-state authorities.

Using medical skills to develop CBW. Remaining silent in the face of health care abuse.

Social Context in Which DL Occurs

Environment where the health system itself violates HR because it fails to meet basic health needs, can lead health professionals to become complicit in HR violation.

Risk Factors for DL Conflict

Totalitarian regime

Military/Police

Area of violent conflict

Position of worker at risk

Treating minorities/stigmatized patients

Discrimination (personal or istitutional)

Bioethics

Discipline that enables clinicians to

analyze their actions in morally

complex clinical situations and to

identify rational arguments to

substantiate their moral choices.

Principles of Bioethics Autonomy-Respect the decision-making

ability of autonomous person.

Beneficence-The duty to maximize benefit to the person or people in care.

Non-Maleficence-The mandate to avoid harm.

Justice-Fairness in deciding competing claims

Beauchamp and Childress, Principles of Biomedical Ethics,2001.

Dual Loyalty and Human Rights

When the health professional acts on duty, to support the interest of the state or other entity instead of those of the individual in a manner that violates the human rights of the individual.

Repressive government, closed institutions

(prisons, military, psychiatric facilities), health policy.

Discrimination against: gender, ethnic, religious, refugees, immigrants.

Human Rights Definition

Rights of individuals in society that take the form of legitimate, valid, justified claims upon his or her society to various “goods” and “benefits” deemed essential for dignity and well being.

Henkin, The age of rights,1990

The Right for Health

Human Rights Codes “All human beings are born free and

equal in dignity and rights”. (UDHR,1948, art.1)

“Every human being is entitled to the enjoyment of the highest attainable standard of health conductive to living a life of dignity”. (The International Covenant on Economic, Social and Cultural Rights 1966, art 12).

Respect, protect, fulfill. (See above, 2000)

Health Professionals and Human Rights

professionalism

Society Expects

Vulnerable profession

HR language in professional ethical

cods

Human Rights and Bioethics

BIOETHICS

Human Rights

Dyadic

Relations

Context

(Access, discrimination)Justice

Principle of Solving the DL Conflict

Mediating the clinical

circumstances in a way that

preserves the primacy of keeping

faith with patients while conceding

the legitimacy of third party’s

other expectations of medicine.

Resolving DL Conflicts Within Bioethics-Hr

FrameworkHuman Rights

Human rights analysis enables the health professional to resolve DL conflicts by reference to agreed- upon universally applicable set of moral principles.

Human rights principles are not subject to balancing against other interests and none may be derogated or suspended.

Bioethics

Autonomy

Beneficence

Non-Maleficence

Justice

Institutional Mechanisms Monitoring Speaking out Advisory service Encouragement of best practices Proscription undesirable practices Victim redress Education and training Protection from reprisal Professional Accountability

Military Health Professional Inherent Role

Conflict

Health Professiona

l

Soldier

Preserve life

Reduce sufferingInflict harm to enemy

Israeli-Palestinian ConflictDL Obligations of Health Personal

SiteRole

Israeli State Hospital

Civil/Military Court

Occupied Territories

Prison Holding

Palestinians

Clinical

TriageTreatment quality

Emergency triage

TriageTreatment quality

Management

FundingInstitutional guidelines

Access to healthcare

FundingInstitutional guidelines

Forensic

Expert witness

Medical InvestigationFitness to interrogation

SUPPORTING DL Conflict Resolution

ProfessionalOrganization

Education

InstitutionalMechanisms

NGO’S &PUBLIC

DL Guidelines

A Project of the International Dual Loyalty Group.

A Collaborative Initiative of Physicians for Human Rights and the School of Public Health and Primary Health Care, University of Cape Town, Health Science Faculty,2002.