Download The Problem of Dual Loyalty - Healing Across the Divides

Dual Loyalty (DL)
of Healthcare Professionals
Zeev Wiener, MD.
International medical Codes
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“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
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Case Examples of DL Violation
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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
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Totalitarian regime
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Military/Police
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Area of violent conflict
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Position of worker at risk
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Treating minorities/stigmatized patients
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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
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Autonomy-Respect the decision-making ability
of autonomous person.
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Beneficence-The duty to maximize benefit to
the person or people in care.
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Non-Maleficence-The mandate to avoid
harm.
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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.
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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
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“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).
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Respect, protect, fulfill.
(See above, 2000)
Health Professionals
and Human Rights
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professionalism
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Society Expects
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Vulnerable profession
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HR language in professional ethical cods
Human Rights and Bioethics
BIOETHICS
Dyadic
Relations
Human Rights
Context
Justice (Access, discrimination)
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 Framework
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Human 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
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Monitoring
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Speaking out
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Advisory service
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Encouragement of best practices
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Proscription undesirable practices
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Victim redress
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Education and training
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Protection from reprisal
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Professional Accountability
Military Health Professional
Inherent Role Conflict
Soldier
Inflict harm to enemy
Health
Professional
Preserve life
Reduce suffering
Israeli-Palestinian Conflict
DL Obligations of Health Personal
Site
Role
Israeli State
Hospital
Civil/Military
Court
Triage
Treatment
quality
Emergency
triage
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Clinical
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Funding
Institutional
Management guidelines
Access to
healthcare
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Expert
witness
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Forensic
Occupied
Territories
Prison Holding
Palestinians
Triage
Treatment
quality
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Funding
Institutional
guidelines
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Medical
Investigation
Fitness to
interrogation
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SUPPORTING DL Conflict Resolution
Professional
Organization
NGO’S
& PUBLIC
Education
Institutional
Mechanisms
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.