Gifts can undermine integrity?

Gifts can compromise AAOS’s Principles in Medical Ethics of Professionalism in Orthopedics by undermining the physician’s integrity and challenging his or her honesty regarding the use of the knowledge or equipment being highlighted at a company-sponsored “educational” course. Gifts also can produce a conflict of interest in deciding the most appropriate care to be provided to the patient.

At the center of the ethical concern is that the orthopedic profession exists for the primary purpose of caring for the patient and thus the patient’s well-being is central to all orthopedic ethical decisions.

The AAOS opinion on gifts and the orthopedic surgeon’s relationship with industry states: “Generally, the Academy believes it is acceptable for industry to provide financial and other support to orthopedic surgeons if such support has significant educational value and has the purpose of improving patient care. All dealings between orthopedic surgeons and industry should benefit the patient and be able to withstand public scrutiny.”
Gifts should benefit patients

The academy’s guidelines emphasize that any gift or other financial support accepted by an orthopedic surgeon should include a benefit for his or her patient. Under no circumstances should an orthopedic surgeon accept gifts with conditions attached.

image For instance, it would be unethical to attend an educational meeting in which there was an understood or implied requirement that products highlighted at the course must be utilized by the attendees. Social functions may also take on the appearance of a gift if there is no educational value attached to the event — such as a sporting event, evening at the theatre, golf outing or gourmet dinner. The absolute ethical “no-no” is acceptance of monetary gifts.

In review, there are basically two times when gifts from industry are ethically permissible. One is for subsidies to underwrite the cost of educational events. CME credits must be awarded at these events, and the purpose of the event must be to improve practitioner knowledge, thus improving patient care. Furthermore, support for the educational opportunity must be acknowledged, and the content of the educational experience and the desired attendees should be determined by the sponsoring organization and not by the industry providing the subsidy.

The other occasion when a gift from industry is appropriate is in relationship to expenses and honoraria for faculty. Providing an educational experience to an industry-sponsored conference is ethically sound as long as the sponsoring organization controls the content and attendance.

The orthopedic surgeon must remember that the welfare of the patient is paramount in any ethical dilemma. Surgeons should diligently avoid industry incentives intended to influence treatment choices or use of devices or diagnostic approaches that are contrary to the best interests of the patient.

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When is it ethical to accept a gift?

AAOS guidelines make clear that support from industry must have educational value and improve patient care.

by David Apple, MD

 The dictionary defines a gift as something that is bestowed voluntarily and without compensation. Gifts are often given in appreciation, as thanks, or in response to a favor. Many gifts are given freely and with no strings attached; however, with some gifts there may be an expectation for something in return.

Accepting such gifts frequently or carelessly can lead to abuse and an ethical dilemma for physicians. Test your “Ethics IQ” on accepting gifts by answering the following true/false questions:

   1. When attending a drug company dinner and educational presentation, you can accept a Mont Blanc pen as a favor.       True or False?

   2. An equipment company sponsoring a course offers to pay your fellow’s expenses to the course. You cannot accept the offer.       True or False?

   3. You are invited to lunch and a tennis game to discuss a new NSAID. You can accept the invitation.
      True or False?

   4. You are invited to be an all-expenses-paid lecturer at a company-sponsored course. You will also receive an honorarium. You can accept the invitation.       True or False?

   5. A company representative volunteers to bring lunch for your staff if the physicians attend. You can accept the offer.       True or False?
The correct answers
1. False: Attending a drug company dinner with an educational presentation is within ethical guidelines, but accepting a Mont Blanc pen, which has a value of around $100, would be unacceptable.

   2. False: A company can provide money for an educational course that can be designated for resident and fellow attendance, but the entity developing the course content also must maintain the authority to determine those who may attend utilizing funds provided by the company.

   3. False: A reasonably priced lunch with a discussion of a new NSAID would be acceptable, but adding a recreational event would make this ethically unacceptable.

   4. True: An invitation to be a lecturer with all expenses paid for a company-sponsored course that also provides an honorarium is acceptable under the guidelines of the academy’s statement on ethics as well as AdvaMed’s Code of Ethics, the ethical consortium for industry.

   5. True: It is acceptable for a company representative to bring lunch for the office staff if the physicians attend as long as the lunch is of reasonable value and the educational content will benefit the patient care.

Bribery

April 9, 2007

In a recent article in the Financial Times, columnist and legal counsel Patti Walmeir says that: “for decades bribery has just been just another cost of doing business” and that “more companies are now finding that what previously seemed like harmless acts of foreign palm-greasing can cost millions.”

The French company, Total, the world largest oil company is under investigation both in France and in the U.S. for bribing foreign officials and individuals.

The same is true for the German company Siemens, one of the world’s largest electrical and telecommunication company. (Ranked 22 on Fortune Global 500 companies)

What is bribery?

Most likely we were all offered bribes in the earliest part of our lives by…..our parents!

Some say that bribery is a parent’s best tool. Offering child a treat in exchange for induced good behavior does qualify as a bribe.

A bribe is a gift given with the intention to change the behavior of the person in a way that is not consistent with his or her responsibilities.

There is a difference between bribery and extortion. A bribe is offered to obtain a favor but an extortion is a demand made under threat.

Rabbi Asher Meir thinks that there is a difference, (at least a moral difference) between a bribe given to expedite an action that the person would take anyway and one which he or she would not.  It is one thing to bribe a building inspector to expedite the delivery of a permit if the building is in conformity with the building code. It is quite another matter to bribe a building inspector to grant a permit when the building is not in comformity with the code.

Others have a more absolute view.   

The U.S. Government has a clear, comprehensive definition! More than 30 years ago, in 1997, Congress passed the Foreign Corrupt Practice Act (FCPA) that covers every U.S. company or any company that does business in the U.S.

Bribery violates justice and fairness. It also damages trust. As John Jay Hooker said:

“But there will be no justice, there will be no government of the people, by the people, and for the people, as long as the government and its officials permit bribery in any form. “

Who Counts?

Developed by Manuel Velasquez, Claire Andre, Thomas Shanks, S.J., and Michael J. Meyer

For over eight years the three monkeys immobilized in harnesses have sat staring helplessly from their cages. Their paralyzed limbs dangling at their sides have been useless appendages since researchers eight years ago cut their nerves in experiments. According to the director of the National Institutes of Health, they now "give evidence of frequent, unrelievable pain." Experimenters plan next to surgically remove the tops of the monkey's skulls, insert electrodes to take brain measurements, and finally kill them, all as part of a research project on spinal cord injuries financed by the National Institutes of Health.

Clearly, the experimenters would never have done to humans what they did to these monkeys. Their moral principles and ours dictate that inflicting such massive insults is a shockingly abhorrent injustice. But, like some of us, the experimenters apply their principles to humans and not to animals: animals don't count. In fact, one of the most fundamental dividing lines in morality is the one we draw between those who count in our moral considerations and those that don't, or, as ethicists sometimes put it, between those who do and those who don't have moral standing.

What is moral standing? An individual has moral standing for us if we believe that it makes a difference, morally, how that individual is treated, apart from the effects it has on others. That is, an individual has moral standing for us if, when making moral decisions, we feel we ought to take that individual's welfare into account for the individual's own sake and not merely for our benefit or someone else's benefit.

Take, for example, a doctor who attends to the physical welfare of her patients and believes that it would be morally wrong to mistreat them. Suppose that she believes this not because of any benefits she will derive from taking good care of them nor because she is afraid of being sued, but only because she has a genuine concern for her patients' well-being. Her patients have moral standing for her. On the other hand, take a farmer who looks after the welfare of his cows and who also believes that it would be morally wrong to mistreat them. But suppose he believes this only because mistreating them would decrease their milk production and their milk is an essential source of nourishment and income for his family. Although this farmer considers his cows' welfare, he does so only for the sake of his family and not for the sake of the cows themselves. For the farmer, the cows have no moral standing.

The oldest and most prevalent view of who has moral standing is the belief that only human beings have moral standing; only human beings ultimately count in matters of morality. This anthropocentric or "human centered" conviction is usually linked to the idea that only creatures with the capacity to reason (perhaps as expressed through language) have absolute value and consequently they are the only creatures whose well-being ought to be taken into account for their own sakes.

The ancient Greek philosopher Aristotle, for example, viewed nature as a hierarchy, believing that less rational creatures are made for the benefit of those that are more rational. He wrote "Plants exist for the sake of animals, and brute beasts for the sake of man." In a similar vein, the seventeenth century philosopher Immanuel Kant wrote that "So far as animals are concerned, we have no direct moral duties; animals are not self-conscious and are there merely as a means to an end. That end is man." For these thinkers, therefore, only human beings have moral standing, so the welfare of other creatures matters only if they are useful to humans.

The conviction that only human beings ultimately count in morality doesn't imply that we have no moral obligations whatsoever toward nonhumans. Even anthropocentric views hold that it is immoral to destroy plants or animals needlessly since by doing so we are destroying resources that may provide significant benefits to ourselves or to future human generations. Some anthropocentric positions also hold that all cruelty toward animals is immoral because, as the philosopher and theologian Thomas Aquinas put it, "through being cruel to animals one becomes cruel to human beings." Non-humans count, however, only to the extent that the welfare of human beings is affected.

Although every anthropocentric ethic holds that, morally speaking, only humans can matter, there is wide disagreement about exactly which humans matter. Some anthropocentric views hold that any human creature that has at least the potential to be rational has moral standing. According to this view, a fetus has moral standing. Others hold that only those humans who are already rational count morally. From this perspective a fetus doesn't count. Other anthropocentric views claim that both present and future generations of humans count, while still others argue that only currently existing humans count.

In the eighteenth century the view that only humans count was challenged by several philosophers, including the utilitarians Jeremy Bentham and John Stuart Mill. According to these philosophers our only moral duty is to maximize pleasure which they claimed is the only fundamental good, and to minimize pain, the only fundamental evil. In making moral decisions, therefore, we have to take into account all creatures, rational or not, that have the capacity to experience pleasure or pain. As Bentham wrote, "The question is not, Can they reason nor Can they talk, but, Can they suffer?"

This early view, which extended moral standing to animals, set the stage for the "animal rights" movement. Following in the footsteps of Bentham and Mill, utilitarians in the 1970s began vigorously defending the view that it is as immoral to inflict pain and suffering on animals as on human beings. For humans to fail to recognize the moral standing of animals, they argued, is discrimination on the basis of species and is as wrong as discrimination on the basis of race or sex.

Some defenders of animal rights, however, argue that the welfare of animals matters morally not only for utilitarian reasons, i.e., minimizing pain, but also because animals have moral rights that should not be violated. They claim that the rights of animals are based on the idea that animals have interests, and moral rights exist to protect the interests of any creatures, not merely those of human beings. Others have held that animals have a life of their own deserving of respect. Advocates of animal rights have concluded that in addition to freedom from pain, animals have a right also to protection of their interests or to respectful consideration of their independent lives.

During this century an even broader view of what has moral standing has emerged, one which holds that all living things have moral standing. The most well-known proponent of this view is Albert Schweitzer who claimed that all life merits reverence. More recent philosophers have based their stand on the view mentioned above that anything with interests has moral rights. They point out that all living entities, including plants, have interests, exhibiting certain needs and propensities toward growth and self-preservation. All living entities, therefore, have rights to the protection of their interests and we have an obligation to take their interests into account in our moral deliberations.

Perhaps the broadest view about what counts morally is the view that entire natural systems count. This "ecocentric" view was first put forward by the naturalist Aldo Leopold who argued in favor of a "land ethic" that gives all of nature moral standing. He wrote: "The land ethic... enlarges the boundaries of the community to include soils, waters, plants, and animals, or collectively, the land." For Leopold and many others, whole ecological systems, such as lakes, forests, or entire continents, have an "integrity" or a "welfare" of their own that should not be harmed or damaged.

Which of these views on moral standing is correct? The answer we give to this question will depend on the moral importance we attach to rationality, the capacity to experience pain and pleasure, to the interests of all living things, and to the integrity and "welfare" of our ecological systems. A great deal hinges on our answer. If we believe that only humans count, we will not voice strong objections to painful animal experiments that benefit humankind. But if we believe that all sentient creatures have equal moral standing, then we will demand that the welfare of these animals be taken into account, and perhaps lobby for legislation to protect animals from painful experiments or industrial uses. And if we believe that all natural things count, then we may oppose as immoral any activities that threaten to harm our forests and wilderness, such as logging or real estate.

Of course, deciding "who counts" doesn't tell us whose welfare or interests should be given more or less consideration when competing interests are at stake. But it does make us more aware of our boundaries of moral concern, and the criterion we use to establish those boundaries.

This article appeared originally in Issues in Ethics V4 N1 (Spring 1991)

Ethical Relativism

Developed by Manuel Velasquez, Claire Andre, Thomas Shanks, S.J., and Michael J. Meyer

Cultures differ widely in their moral practices. As anthropologist Ruth Benedict illustrates in Patterns of Culture, diversity is evident even on those matters of morality where we would expect to agree:

We might suppose that in the matter of taking life all peoples would agree on condemnation. On the contrary, in the matter of homicide, it may be held that one kills by custom his two children, or that a husband has a right of life and death over his wife or that it is the duty of the child to kill his parents before they are old. It may be the case that those are killed who steal fowl, or who cut their upper teeth first, or who are born on Wednesday. Among some peoples, a person suffers torment at having caused an accidental death, among others, it is a matter of no consequence. Suicide may also be a light matter, the recourse of anyone who has suffered some slight rebuff, an act that constantly occurs in a tribe. It may be the highest and noblest act a wise man can perform. The very tale of it, on the other hand, may be a matter for incredulous mirth, and the act itself, impossible to conceive as human possibility. Or it may be a crime punishable by law, or regarded as a sin against the gods. (pp.45-46)

Other anthropologists point to a range of practices considered morally acceptable in some societies but condemned in others, including infanticide, genocide, polygamy, racism, sexism, and torture. Such differences may lead us to question whether there are any universal moral principles or whether morality is merely a matter of "cultural taste." Differences in moral practices across cultures raise an important issue in ethics -- the concept of "ethical relativism."

Ethical relativism is the theory that holds that morality is relative to the norms of one's culture. That is, whether an action is right or wrong depends on the moral norms of the society in which it is practiced. The same action may be morally right in one society but be morally wrong in another. For the ethical relativist, there are no universal moral standards -- standards that can be universally applied to all peoples at all times. The only moral standards against which a society's practices can be judged are its own. If ethical relativism is correct, there can be no common framework for resolving moral disputes or for reaching agreement on ethical matters among members of different societies.

Most ethicists reject the theory of ethical relativism. Some claim that while the moral practices of societies may differ, the fundamental moral principles underlying these practices do not. For example, in some societies, killing one's parents after they reached a certain age was common practice, stemming from the belief that people were better off in the afterlife if they entered it while still physically active and vigorous. While such a practice would be condemned in our society, we would agree with these societies on the underlying moral principle -- the duty to care for parents. Societies, then, may differ in their application of fundamental moral principles but agree on the principles.

Also, it is argued, it may be the case that some moral beliefs are culturally relative whereas others are not. Certain practices, such as customs regarding dress and decency, may depend on local custom whereas other practices, such as slavery, torture, or political repression, may be governed by universal moral standards and judged wrong despite the many other differences that exist among cultures. Simply because some practices are relative does not mean that all practices are relative.

Other philosophers criticize ethical relativism because of its implications for individual moral beliefs. These philosophers assert that if the rightness or wrongness of an action depends on a society's norms, then it follows that one must obey the norms of one's society and to diverge from those norms is to act immorally. This means that if I am a member of a society that believes that racial or sexist practices are morally permissible, then I must accept those practices as morally right. But such a view promotes social conformity and leaves no room for moral reform or improvement in a society. Furthermore, members of the same society may hold different views on practices. In the United States, for example, a variety of moral opinions exists on matters ranging from animal experimentation to abortion. What constitutes right action when social consensus is lacking?

Perhaps the strongest argument against ethical relativism comes from those who assert that universal moral standards can exist even if some moral practices and beliefs vary among cultures. In other words, we can acknowledge cultural differences in moral practices and beliefs and still hold that some of these practices and beliefs are morally wrong. The practice of slavery in pre-Civil war U.S. society or the practice of apartheid in South Africa is wrong despite the beliefs of those societies. The treatment of the Jews in Nazi society is morally reprehensible regardless of the moral beliefs of Nazi society.

For these philosophers, ethics is an inquiry into right and wrong through a critical examination of the reasons underlying practices and beliefs. As a theory for justifying moral practices and beliefs, ethical relativism fails to recognize that some societies have better reasons for holding their views than others.

But even if the theory of ethical relativism is rejected, it must be acknowledged that the concept raises important issues. Ethical relativism reminds us that different societies have different moral beliefs and that our beliefs are deeply influenced by culture. It also encourages us to explore the reasons underlying beliefs that differ from our own, while challenging us to examine our reasons for the beliefs and values we hold.

This article appeared originally in Issues in Ethics V5 N2 (Summer 1992)