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BY: MARILYN MARTONE, PhD

Dr. Martone is assistant professor, moral theology, St. John's University, Jamaica, NY.

New Temptations Reveal the Limitations of Professional Healthcare Codes

Ethical codes contain the rules that govern the conduct of members of a profession. For those members, a code "embodies the collective conscience of [the] profession and is testimony to the group's recognition of its moral dimension."¹ By providing general performance standards, ethical codes protect the professional's patient or client, society at large, and the profession itself.

Since the promulgation of Hammurabi's Code in 1727 BC, societies have had codes of ethics governing healthcare professionals. Today, however, three social forces are making such codes problematic.

The Market Although the market has long been a concern in professional life, it usually was a side issue. Now, however, the market dictates to the professions, including those in healthcare. Physicians are increasingly caught between loyalty to their patients, on one hand, and the demands of insurance companies, on the other, as health maintenance organizations (HMOs) define "appropriate" forms of care.

But if healthcare professionals' survival is determined by the bottom line, what does this do to the integrity of those professions? Can efficiency be measured only in monetary terms? What would happen to society's weakest and most vulnerable members if access to healthcare should depend entirely on one's ability to pay for it?

The Information Revolution Technology has put vast amounts of information at the fingertips of anyone with access to a computer — and raised new ethical dilemmas, too. Can healthcare professionals maintain their patients' confidentiality in the computer age? Will they? The growth of both market influences and a growing hunger for information is creating a volatile situation, one in which some professionals will be tempted to sell data they used to take care to protect.

Genetic Discoveries Lawyers have already seen the impact of DNA on the legal system. How, as more and more people have their DNA identified, will this information be used in healthcare? Will pharmaceutical companies, for instance, use genetic testing to screen prospective employees on their tolerance to various chemicals? Will insurance companies use it to deny coverage to prospective customers?

Limitations of Professional Codes
These changes force us to ask whether professional ethics codes still provide their old protections for professionals, patients, and society at large. Although modern codes cover a broader field of ethical concern than that covered by law, they are nevertheless limited because they address only work-related issues. Unlike older codes, which also addressed personal behavior, modern codes are cautious in this regard. Some codes do include broader guidelines (e.g., "the nurse in private life adheres to standards of private ethics which reflect upon [the] profession"; "a physician shall recognize a responsibility to participate in activities contributing to an improved community"²). But most contemporary ethics codes concern only the professional's work.

What such codes do, at best, is keep certain behavior in check in certain situations for certain periods of time. They may restrain a chronic liar's lying as long as the liar is on the job (although that is unlikely — a private liar will not be a professional truth teller). But ethics codes cannot change a professional's character. In fact, codes are not concerned with character.³ That is their limitation.

The power in ethics codes derives from their external control of a professional's behavior, not from that person's internal motivation. As a result, ethics codes tend to be minimalist, individualist, and oriented toward maintenance of the status quo. They offer little incentive for growth. Unconcerned with a professional's integration and development, codes seek to maintain the appearance of conformity. Yet the most alarming thing about contemporary society is precisely what many see as a widespread breakdown of personal integrity and character.

Integrity is a "state of being whole or undiminished."⁴ It is what Aristotle called a "kind of virtuous activity" — performing noble actions, for example, or working for a society in which people are free to develop to their full potential.⁵ Modern philosophers are more likely to define integrity as a person's desire to do his or her best as he or she understands it, even under adverse conditions.⁶

Both definitions, the classical and the modern, emphasize internal intention rather than external control. It is only when a person has reached a certain degree of integrity that he or she is able to be self-governing and can transcend the limited guidelines that others have put in place. People of integrity do not worry about fitting their actions to situations; they simply act in a way that will build, rather than diminish, character. Such acts cannot be designated as either public or private, because all acts affect one's character.

Beyond Codes of Ethics
Why should professionals be concerned about developing character, rather than simply controlling behavior? Character is important because expertise is never sufficient in itself. During the O. J. Simpson trial, two groups of laboratory technicians came to different conclusions after examining the same piece of DNA evidence. Although we like to believe that professional people deal in facts, that is only partly true, because facts have to be interpreted. One's character, because it directs one's intentions and choices, influences what one does with facts. It informs decisions about (for example) which facts to publish, which technologies to develop, and when and how to share facts.

In the new age of money, information, and genetic engineering, healthcare professionals will need to be men and women who can resist temptation: people of integrity. Codes of ethics are valuable tools for educating and reminding professionals about appropriate behavior. But they are neither replacements for nor guarantors of ethical behavior. Healthcare professionals must work on developing character. They can probably do this best by strongly emphasizing moral questions, perhaps illustrated by stories of actual moral struggles undergone by role models, in professional education. When character is strengthened, everyone — patient, professional, and society at large — is truly served.

NOTES

1. Mark S. Frankel, "Professional Codes: Why, How, and with What Impact?" Journal of Business Ethics, February 1989, p. 110.
2. International Council of Nurses' International Code of Nursing Ethics, in Joan Callahan, ed., Ethical Issues in Professional Life, Oxford University Press, New York City, 1988, p. 453; American Medical Association's Principles of Medical Ethics, in Callahan, p. 451.
3. James Keenan, "There Are No Private Lives," Josephinum Journal of Theology, vol. 3, no. 2, 1996, pp. 76-84.
4. Donald Zauderer, "Integrity: An Essential Executive Quality," in John Richardson, ed., Business Ethics, Dushkin Publishing, Guilford, CT, 1996, p. 24.
5. Aristotle, The Nichomachean Ethics, Penguin Books, London, 1975, p. 81.
6. Zauderer.

Copyright © 1999 by the Catholic Health Association of the United States
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