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Is professional integrity a futile argument?

by Dominic Wilkinson

In an earlier post this week I argued that there are only two substantive reasons for doctors not to provide treatment that they judge futile – either on the basis of a judgement that treatment would harm the patient (a form of paternalism), or on the basis that providing treatment would harm others (on the basis of distributive justice). I rejected the idea that professional integrity provided an additional reason to withhold or withdraw treatment.

In reply Risa Denenberg comments

“I find it problematic to state that it is unclear what is meant by violating the doctor's integrity. (Not to mention the rest of the medical team–nurses, respiratory therapists, etc.– who are affected by the medical decision.) It sounds as if the ethical position here is that it doesn't matter if the procedure the patient wants harms the providers who have to deliver it. We don't ask physicians who oppose abortion to perform them, out of consideration of their values. It is certainly repugnant and damaging to many in the medical field to perform resuscitation and deliver complex and prolonged ICU care to patients in the last minutes, hours, and days of their lives. It can have the effect of desensitizing medical providers to our own feelings and limiting our ability to be fully present to patients, family, and colleagues. It has the potential to violate and damage us indeed.”

In the previous post, what I meant to argue was not that professional integrity does not provide a reason to deny patients 'futile' treatment, rather that it provides only a derivative or secondary reason. I fully agree with Risa that those who work in palliative care, and in intensive care often find it disturbing and challenging when they are required to provide care that they believe is futile. (This is a major cause of moral distress amongst nursing staff and junior medical staff). But the underlying reason that the providers' integrity is at stake must be either of the reasons outlined above.

If neither of these is the case, then the question is why the professional feels their integrity to be at stake? Imagine for example, patient P. Earlier in his life P clearly and competently expresses his belief that they would like mechanical ventilation to be provided if he were in a permanent vegetative state, he would count it as a benefit to be kept alive in such a state, and that it would be an affront to his dignity to allow him to die when he could be supported in this condition. Moreover, P has set aside a large amount of money in a bank account that will pay for treatment, and would not be used for any other purpose.

If P does end up in a persistent vegetative state there is not good reason to think that providing ventilation to this patient would deny treatment from any other patient. Set aside, for the sake of the argument, any uncertainty about the diagnosis, or about the possible conscious experience of patients who appear to be in a vegetative state. We have good reason to think that P would suffer no pain from treatment. It does not appear that providing mechanical ventilation would harm P.

But now, P’s caregivers might complain that they still feel that treatment would be an assault to their professional integrity. They might claim, for example, that they did not spend years developing their specialist medical or nursing skills in order to be able to keep patients alive in a state in which they have no prospect of conscious experience. They might claim that they personally still feel violated or distressed by providing treatment to P. Peter Wicks, in a reply to the previous post, suggested that the emotional distress of medical or nursing staff would count in a utilitarian analysis of whether it was right to provide futile treatment. However, there are three problems with this justification for refusing to provide futile treatment on this basis.

The first is that it matters whether the sentiments of medical and nursing staff are justified. How much weight we give to these sentiments depends on the reasons that they have for holding them. Imagine, for example, that a professional felt their professional integrity threatened because they happened to be a racist doctor in apartheid South Africa, and they had not trained to keep coloured patients alive etc. In this circumstance we should give the professional’s integrity claim no weight whatsoever. In a more realistic example, some nursing and medical staff find it personally threatening to provide treatment for infants with a severe chromosomal disorder, Trisomy 18, because they believe that the condition is incompatible with long term survival, and that death is inevitable within a short period. However, there is reason to think that these factual beliefs are mistaken, and consequently, the integrity threat should be given much less weight or no weight at all in our deliberation about antenatal or postnatal management. So we still need to assess whether there is a good reason for professionals feeling that their integrity is at stake. That reason, if it is a good one, may justify withholding treatment, or if it is a weak one may not, but professional integrity disappears from the equation.

Secondly, if professional integrity is included in a utilitarian calculus, then the moral distress of medical professionals might be included in the arguments against providing or continuing treatment. But if we are going to include professionals’ emotional distress if treatment is continued, then we must also include family members’ emotional distress if treatment is discontinued. In futility disputes there is often distress on both sides of the dispute, and it is going to be very hard to say which is the greater. In practice then, professional integrity understood as professional distress, is unlikely to provide a strong reason for withholding treatment.

Thirdly, the integrity claim, as spelled out for example as “I did not develop these skills in order to keep alive a patient permanently lacking consciousness”, often contains concealed value judgements about the value of life in a certain state, or about the value of small chances of success. The reason that the professional does not want to provide treatment is because they personally would not choose to live in such a state, they personally do not think that it is a benefit to be alive like this, perhaps that it would be a harm to them because it would be inconsistent with their notion of ‘dignity’. But, to return to the previous post, the question then is why the professional’s values or preferences should be given priority over those of the patient. As I argued in that previous post, it is not that paternalism is never justified. The patient might have a completely irrational basis for wanting to be kept alive in a persistent vegetative state. But it is much harder to justify overruling the patient’s values – particularly where, as in P’s case, there is good reason to think that they are not suffering.

Professional integrity does have a meaning. We should pay attention to the strong feelings of medical, nursing and paramedical staff about treatment. Those feelings are often going to be justified on the basis of concerns about harm to the patient, or potential harms to other patients if treatment is provided. But once we have looked to those reasons, then professional integrity gives us no extra reason to stop treatment. That would be a form of double counting. (‘We shouldn’t provide treatment because it will harm the patient, but in addition because staff believe that it would harm the patient’). And where those reasons are inadequate in themselves to justify stopping treatment (as in the case of P), then we should look to other ways of dealing with the emotional distress of staff. As Risa suggests, one way may be for staff to opt out of caring for a particular patient. (In the case of Samuel Golubchuk, several medical staff in intensive care resigned from the hospital.) Though we should note that in the abortion setting this response by medical staff is only appropriate where doctors are able to refer the patient to another professional willing to provide treatment. But the other response to the professional integrity concern would be to counsel and support professionals who are providing care. That may involve correcting factually mistaken beliefs about the chance of success of treatment. Or it may involve sensitive exploration of the personal values of professionals and the way in which they conflict with the values of the patient.


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3 Comment on this post

  1. Many thanks Dominic for addressing so extensively my suggestion in relation to the previous post.

    In my original suggestion I tried to draw attention to the distinction between “professional integrity” as such, which I am inclined to agree does not really add anything to the other arguments you addressed in your previous post, and the issue of emotional distress. While you have correctly referred to my suggestion as referring to the latter, most of the issues you raise as “problems” seem still to refer to the issue of professional integrity. But even where the emotional distress is caused by a values conflict, I think there is more to it than professional integrity. A further consideration is that emotional distress can be caused by values conflict, but it can also be caused much more directly. (If I am scared of spiders, for example, that is a natural instinct and not the result of my values, although it may well have an influence on my values.)

    I do agree that there are various ways in which one can deal with this emotional distress – which is in any case a general occupational hazard for health providers – which would not necessarily involve anyone withholding treatment. The question though is whether emotional distress (as opposed to professional integrity) provides a valid argument, in addition to the others you have addressed, for withholding treatment. From a utilitarian perspective I think it must, even if it is not a strong argument and would easily be outweighed by other considerations, at least if we assume that the alternatives you mention would come at a (net) cost. One could argue that this is not the case since they would also bring ancillary benefits, but then we have the option of implementing these suggestions in a general sense (correcting mistaken beliefs, sensitive exploration of values conflicts) while still withholding the futile treatment.

    All in all, though, I’m inclined to agree with you that the strongest argument is the resources one, and since this does not arise in the case you raise here (where the treatment is privately funded) the justfication for withholding treatment appears weak.

  2. So, we don’t really know what “professional integrity” is, because we are side-tracked by such ideas as what the person trained for, what the person feels about some kinds of conduct, etc. On the other hand, there are ideological limits imposed by the traditions of a profession, some of which are harmful. For example, it was the ideology of physicians and surgeons to prevent death at all costs, without regard to the quality of life of the patient (who, then, was mainly an object). Attacking that ideology, I think, does not attack the integrity of the person functioning as a physician or surgeon

    I take a teleological view of what might be called “professional integrity” because I trained for and practiced law and later taught law, including the rules that govern lawyer conduct. The integrity of a professional is that of the person as professional, which is a role different from person as a parent, a politician or a participant in some other activity not involving professional conduct. Moreover, I take “professional” to be a place holder for particular roles involving service to others in an occupational (as opposed to familial, etc.) context.. The social system provides definition by assuming a certain kind of function for each professional. So, a person’s integrity is affected by what the person does in a particular role. An example outside the professional context is the parent. It violates the parents’s integrity as parent to compel her to favor children other than her own; it does not violate her integrity, however, if she is serving as a caregiver of disabled children and her child is not disabled. There is no real clash of roles here, I think.

    A physician functions as a healer and fixer of physical problems, preferably in that physician’s specialty; similarly for surgeons and psychiatrists. This is a general kind of end, which admits of no exceptions other than those involving the ability of the professional to perform the particular activity competently. This means that a racist physician who refuses to treat a human who is not of the favored group is unprofessional. Of course, that physician’s distaste could be so powerful that it prevents him or her from acting competently. Similarly with abortions. Deeply held beliefs may prevent competent service. But, none of this has to do with integrity unless the physician or surgeon is compelled to act where that person cannot function competently.

    What about emergency situations, where the only available surgeon is faced with the case of a pregnancy which threatens to kill the mother before the surgeon can beg off the case? The surgeon is against abortion in all cases, on religious grounds. It is part of his religious faith that the child must always be favored over the mother in such cases. If he refuses to abort the fetus (to him, the child) then the mother dies. Again, his integrity is not affected; he is allowed to refuse because acting to save the mother’s life is a mortal sin. On the other hand, his professional integrity are involved if he is the only surgeon on duty by his own volition, and not having told the hospital management that he would always refuse to perform an abortion.,

  3. Dennis, Dominic, I think I agree with all of the above as far as professional integrity is concerned. But there remains the question, for me, as to whether emotional distress (as opposed to professional integrity) on the part of the care-givers could ever be a grounds, separate from a “paternalistic” assessment of the patient’s interests or the resources issue, for refusing treatment. It seems to me that it can, if one takes a utilitarian approach to ethics based on the maximisation of overall well-being.

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