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Abstract

Professional integrity has emerged in the last 20 years as a response to various claims and requests from patients and society, in the wake of the patient rights movement, scientiﬁc progress, and societal pressure. It signiﬁes medical collective standards and principles of action which are irreducible to personal conscience and which serve as a tool for doctors to forge their collective identity. The concept of professional integrity has been used to reafﬁrm doctors’ opposition to assisted death, “futile” care, enhancement techniques, some forms of genetic screening and research practices, and participation in objectionable acts like capital punishment and female circumcision. Upholders of professional integrity might be accused of being paternalistic and conservative, as well as of presenting a purely defensive view of the ethical core of medicine. However, discussing novel issues in terms of professional integrity encourages a collective self-reﬂection on the purpose and values that should constitute doctors’ own professional identity and goals. Also, the content of professional integrity can, and does, evolve through time and can be complemented by personal virtues like altruism, justice, empathy, and compassion. Finally, it can be understood as a basic “capacity” for thinking difﬁcult professional challenges anew.

Introduction

As science and technology advance, and as novel treatments and approaches are developed, new needs emerge, and doctors have to respond to requests which seemingly challenge medicine’s core values: medically assisted death, “futile” care, enhancement practices, genetic screening, and unconventional forms of ART. More importantly, since the 1980s a major ethical shift toward respect for patients’ autonomy and away from doctors’ paternalism has created special requests from patients, which challenge the identity of medicine and its power to deﬁne what is proper treatment of disease. The notion of professional integrity has emerged in this context and been used as an ethical guideline in order to deﬁne what is good medicine over and above different forms of societal pressure. Integrity is a complex concept which comprises the three dimensions of coherence, identity, and purity. Professional integrity differs from personal integrity that is related to conscience and conscientious objection; it signiﬁes the importance for doctors to identify with the deﬁning values of medicine and refer to them in their practice. Four areas of concern for professional integrity will be described: the relationship between medicine and assisted death, the administration of so-called “futile” care, the use of technological advances for purposes which go well beyond treatment in the traditional sense of the word, and ﬁnally the uses of medicine for political purposes or culturally objectionable practices. Several critiques of the appeal to professional integrity can be – and have been – put forward: paternalism, conservatism, and a general stance more prone to cultivate a nostalgic view of medicine and negatively centered upon the protection of the profession rather than positively reaching out to patients and embracing novel forms and contexts of action. However, several positive lessons can be drawn from a critical discussion of professional integrity. First of all, focusing on the notion allows healthcare professionals to think medical practices, needs, and objectives anew. Secondly, what appears to be crucial is not integrity as such but rather the purpose and the ethical core values of medicine. These evolve through time and need to be readjusted to ﬁt a new ethical, scientiﬁc, and cultural environment. Thirdly and more importantly, integrity, with its emphasis on purity and the absence of corruption, has to be complemented by positive virtues and ideals, like altruism, empathy, courage, and justice.

Professional Integrity: The History Of A Concept

The practice of medicine requires more than competency, efﬁcacy, and professional engagement: a normative ethical component as well as a human and personal involvement have always been part of the deﬁnition of medicine since the Hippocratic Oath. As the history and practice of medicine unfolded, and as the scientiﬁc basis for medical interventions evolved, the medical profession has taken on different social conﬁgurations and codes of ethics. Thus in a generic sense, the issue of professional integrity is as old as medicine, and it is just the name of a question. More precisely, however, starting from the 1990s, ethicists and practitioners have increasingly felt the need to redeﬁne the purpose and core commitments of medicine both in the professional and in the ethical sense. This effort took two distinct roads: professionalism and professional integrity.

The purpose of professionalism (Physician’s Charter) is to stress and reafﬁrm the humanistic values of medicine, its commitment to patient’s autonomy and welfare, and doctors’ own personal integrity in the face of external corrupting forces like conﬂict of interests, commercialization, and globalization. However, another more insidious threat, internal so to speak to the practice of medicine, prompted an examination of the ethical core of professionalism itself. This discussion is carried out under the label of “professional integrity.” Professional integrity can be seen as a way of analyzing the ethical underpinnings of professionalism and of spelling it out in a way that is consistent with practice: “The context for professionalism is the moral life of the physician, and medical ethics provides the conceptual framework for examining the moral life. How can we require physicians to act with integrity if we do not teach and model professional integrity as a dimension of moral integrity?” (Dudzinski 2004, p. 27).

Indeed, the very ethical values highlighted in the “Physician’s Charter” needed some clariﬁcation, both in the face of a debate within the global medical community itself and with respect to the afﬁrmation of patient’s autonomy: to what extent can a patient ask for a speciﬁc treatment, rather than simply refusing it? What if this treatment is considered as “futile” by medical standards? And can society ask a doctor to deliver certain controversial services that go beyond the traditional deﬁnition of medical treatment (enhancement techniques, assisted reproductive technologies, assisted dying, etc.)? The content and extension of professional integrity are meant to ﬁnd an ethically acceptable solution to some of the consequences of the patients’ rights movement and to the emergence of controversial medical practices that stretch the deﬁnition of the role of medicine beyond its traditional boundaries. Therefore, behind a seemingly self-understanding appeal to professional integrity lies a full range of more controversial issues, concerning the basic contract between patients, society, and medicine.

The Definition Of Professional Integrity

In the common sense of the term, a person of integrity refers to a person possessing a “supervirtue,” so to speak, which encompasses a whole range of different personal qualities: accountability, coherence, good character, ﬁdelity, honesty, etc.. However, upon a closer analysis, the term can be understood to refer to a more speciﬁc personal feature, one that allows a person to hold on to his/her own values and to perform actions which live up to high quality standards. Indeed, the precise meaning of the term can be gathered from the Latin etymology of the word “integer” which means “whole”: “Etymologically, integrity is oneness (..). We use the term for someone who lives up to his own standards. And that is because we think that living up to them is what makes him one, and so what makes him a person at all” (Audi & Murphy 2006, p. 8). However, although wholeness is the core of integrity, three dimensions illustrate the complexity of the notion. First of all, wholeness signiﬁes an integrated self, a self in which one’s desires, evaluations, and commitments are blended together into a coherent whole. Secondly, and more speciﬁcally, integrity means ﬁdelity, not to any project, but to those projects that are constitutive of one’s core identity. Thirdly, integrity deﬁnes the limits beyond which a person will not cooperate with those forces of evil that will undermine those essential values. In this respect the term signiﬁes a sense of purity related to one’s agency.

When applied to medicine, physicians and nurses, integrity can refer either to personal or to professional values. Personal integrity is related to the notion of conscience: when a doctor or a nurse cannot for personal reasons realize a medical procedure (like abortion, withdrawal of care, or certain reproductive practices), he can appeal to his/ her own personal integrity in order to refuse to perform the action and refer the patient to a colleague. Thus, personal integrity underlies the practice known as “conscientious objection.” Professional integrity on the contrary is invoked when a doctor is faced with patients’ or societal requests which challenge, not his/her own conscience but what has been called “the internal morality of medicine” (Miller and Brody 2001). Whereas personal integrity is mostly invoked to justify exceptions to widely accepted medical practices, professional integrity is meant to exclude from legitimate medical action practices which lie at the limits of the legitimate borders of medicine (Callahan 1996). Professional integrity thus constitutes a defensive ethical strategy against what are perceived as inherent threats to the core of the medical profession, rather than to one’s own personal deeply held beliefs: “Integrity is the lynchpin of resisting any practice outside the professional standard” (Doukas 2009, p. 20). A comprehensive and useful deﬁnition of professional integrity can be found in an article devoted to doctors’ moral impossibility to participate in female mutilation and capital punishment: “Professional integrity constitutes the value system of the professional group and deﬁnes the boundaries of acceptable practice. The concept of professional integrity provides the rationale for consistent ethical behavior over time and in the face of diverse situations (..). Professional integrity, unlike personal integrity, is determined not only by individual conscience, but also by the duties and obligations that accompany membership in a speciﬁc profession (..) that describe professional expectations common to all members” (Sikora and Fleischman 1999, p. 402). Underlying the appeal to professional integrity is the general claim that doctors are not just “skilled technicians” but have higher obligations not only toward patients’ autonomy and welfare but also toward the values underlying their own engagement and their covenant with society (ibid.).

The Ethical Debate About Professional Integrity: Balancing Patients’ Rights, Scientific Change, And Societal Pressure With The Internal Morality Of Medicine

The Role Of “Professional Integrity”

Appeals to professional integrity function as a timely reminder of the fact that medicine as an applied science has a special status and needs to reafﬁrm its nature against disruptive forces: “Professional integrity sets boundaries that are constitutive of the identity of physicians (..). Any physician who violates professional integrity risks damage – perhaps irreversible damage – to his or her identity as a physician and therefore to the moral authority that ﬂows from professional integrity” (McCullough 1995, p. 3). Thus, the justiﬁcation for appeals to professional integrity is ﬁrst and foremost a defensive one against four contemporary threats to medicine immemorial goals: its intrinsic connection with saving lives, the doctor’s duty and unique ability to beneﬁt the patient, the distinction between treatment and enhancement, and the purity of medical practice in the face of cultural or political pressure. Indeed, these four goals can be threatened by patients, proxies’, and societal requests to participate in active dying, so-called “futile” practices, enhancement techniques, and doubtful uses of medical knowledge (as in circumcision, capital punishment, and the trade of human organs to name only a few). Thus, professional integrity serves to set appropriate limits to potentially inappropriate uses of medical tools, techniques, and power. Insofar as medical integrity is most often cited as a rallying cry and a call for unity rather than as the description of a precise set of objectives, its meaning and role vary according to the four contexts that have been highlighted.

The ﬁrst context concerns the intrinsic relationship between medicine and the purpose of saving life. Starting from the 1990s, massive therapeutic and technological changes have obliged medicine to balance its main role of saving and preserving patients’ lives from fatal and crippling diseases, against another duty, that of allowing, and even participating in, the dying process. As new powers have brought about new responsibilities, medicine has been caught, so to speak, in its own trap: by attempting – and to a certain extent succeeding – to vanquish death and prolonge life, it has been forced to bring it about, be it only passively, by purposively withdrawing or withholding care and providing double effect medications. A few dramatic cases of previously unforeseen situations at the limits of medicine – most notably persistent vegetative states – received extensive media coverage and started a movement toward patients’ rights, including a right to refuse life-saving treatment. Slowly, it became ethically acceptable for doctors to step back so to speak from the traditional goal of saving life at all costs. Acceptable withdrawing of treatment concerned ﬁrst cases of “extraordinary” treatment, then cases when treatment was merely considered as “futile,” and later even situations when treatment was indeed medically appropriate and useful, but a patient refused it for whatever reason it saw ﬁt. The right to refuse treatment has become commonplace at least in the western world and is legally enforced in many parts of the world. Thus, it became acceptable to doctors, and compatible with their professional integrity, to let patients die in certain speciﬁc circumstances. However, in the wake of these developments, a new question came to the fore: if medicine accepts making death the foreseeable outcome of medical so-called passive actions, what about actively terminating the patient’s life in order to alleviate intractable suffering? In the face of it, alleviating suffering is part of the traditional medical role. Couldn’t, or shouldn’t, this worthwhile goal prevail over the equally traditional interdiction of bringing about death, either by assisted suicide or by active euthanasia? It is precisely in the name of medical integrity that a majority of physicians still refuse to support the legalization of assisted dying worldwide. Indeed, even though some confess to having ceded to a patient’s request in some circumstances, and consider that in that particular case it was ethically justiﬁed for them to help a patient die, ofﬁcially accepting assisted dying as a medical goal among others remains highly controversial (Pellegrino 2006). It is worth noting that from the point of view of professional integrity, the case of assisted suicide is signiﬁcantly different from that of active euthanasia, despite the fact that both actions consist in a doctor’s helping a patient die: in the former, the doctor only assists the patient in committing an autonomously chosen act; in the latter, on the other hand, he/she directly brings about the patient’s death by administering the lethal injection himself. Indeed, assisted suicide is considered as a lesser threat to medical integrity than a lethal injection.

In the wake of the generalization of respect for patient’s autonomy as one of the main pillars of medical ethics, a second subtle problem has arisen in medical practice. Indeed, if a patient has an absolute right to refuse any treatment, what about requests for a treatment that doctors consider as medically inappropriate? Some argue, however, that autonomy grounds negative rights of refusing treatment but not positive rights of requesting treatment (Halevy 2008). The dilemma goes by the name of “requests for futile treatment”; such requests may originate either with the patient or with proxies and family members. Professional integrity is invoked to justify doctors’ refusal to go along with such requests: “Clinicians respect patient autonomy, but nonetheless constrain the range of choices over which patients may exercise autonomy” (Lantos et al. 2011, p. 497). Medical integrity functions as one such constraint: “This is especially true when the patient asks the clinician to provide unusual care, as opposed to the patient refusing treatment” (Lantos et al. 2011, p. 498). A doctor can appeal to his/her own professional integrity for reasons of just distribution of medical scarce resources, but he/she can also do so in order to exercise the medical duty par excellence: a “beneﬁcence based obligation to do what is best for the patient” (ibid.). Beneﬁcence in this context does not simply consist in a generic call for altruism and compassion but has to be rigorously determined by appealing to evidence-based medicine and professional levels of competence: “Physician integrity is the virtue which should be used to best discern what can best beneﬁt the patient within established standards of care and EBM” (Doukas 2009, p. 20).

A third dimension of professional integrity concerns its intrinsic relation to the treatment of disease as opposed to its potential contribution to personal fulﬁllment by all possible technical means. Despite an enlarged deﬁnition of health as including a psychological dimension, some doctors appeal to professional integrity in order to restrict legitimate medical action to the treatment of disease and to exclude all sorts of enhancing techniques (neurological, reproductive, and psychological) from the proper domain of medical action. In this perspective, enhancement is seen as an unwelcome consequence of medical progress, as far as both diagnostic and treatment are concerned. Indeed, there may be legitimate doubts as to whether fast scientiﬁc and technological advances in both genetics and pharmacology contribute to good and fair patient care, or whether, on the contrary, the entire profession is held hostage to an increasingly technical and blind approach, threatening not only patients’ well-being as such but also a sense of justice. Indeed, enhancement techniques as well as cosmetic practices more generally, violate the integrity of medicine on two counts: they lie outside the goal of medicine which is to treat disease, and they violate beneﬁcence insofar as they have potential patients run risks which are not compensated by clear beneﬁts (Miller & Brody 2005). But these techniques do not only potentially undermine patients’ wellbeing, but, on some interpretations, they can also be seen as violating patients’ own autonomy. This is the reason why, according to some, medically unnecessary genetic and diagnostic tests have to be resisted all the more so when they are directly sold to consumers outside any medical information and supervision process: “There needs to be an oversight mechanism of all asymptomatic screening, tailored screening, and diagnostic testing requests by the medical community. (..) Physicians must be able to refuse patient requests (such as DCTA-based screening) based on professional integrity” (Doukas 2009, p. 20). Indeed, “DCTA is a loss of choice through choice” (Doukas 2009). More radically still, enhancing techniques can be – and are – sometimes viewed as the illegitimate use of medical skills and knowledge. It is not only beneﬁcence and autonomy which are threatened but also medicine’s original covenant with society. Doctors, writes Rebecca Dresser, should consider the practice of preconception sex selection – a form of reproductive enhancement – as unacceptable because it violates professional integrity: “Clinicians assume some responsibility to use their skill and resources to meet the legitimate health needs of the society (..). They ought to consider the long-term effects that performing such a service could have on public respect for and trust of the medical profession” (Dresser 2001, p. 12). Indeed, doctors are not “workers in a service industry that caters to consumer preferences :” (Dresser 2001).

A fourth area of concern, globalization, encourages a reﬂection on healthcare professionals’ role. When confronted with the realities of global epidemics, wars, markets of human organs, capital punishment, and female circumcision, the need to reassert physicians’ integrity appears to be of the utmost importance. Also, stressing professional integrity is meant to reafﬁrm doctors’ common culture and philosophy, irrespective of race, religion, nationality, and politics. Medicine’s adaptation to cultural pluralism only goes so far, and basic human rights need to be part of a common universal framework which regulates acceptable medical practices worldwide: “Respect for cultural diversity, whether within a multicultural society or across national borders, must give way when cultural practices violate the human rights of any segment of the population” (Macklin 2014, p. 166). Much like the principles of biomedical ethics, professional integrity goes beyond local perspectives (Jewish, Muslim, Asian, etc.) and serves as a reminder for doctors not to accept compromising medical core values in the name of local practices. Cases in point are female circumcision and capital punishment. Doctors might be tempted to provide assistance in these practices in the name of safety and beneficence. However, these practices violate medical integrity for two reasons: ﬁrst of all, people subjected to it are not sick. They are rendered potentially sick because of the intentional actions of some authority. Secondly, in this case seemingly acting to limit unnecessary suffering for the person undergoing the procedure contributes instead to reinforce the legitimacy of these authorities and to condone procedures that are intrinsically objectionable (Sikora & Fleischman 1999). Therefore, in this context medical integrity plays a crucial role, not as a tool for tending to patients’ welfare and well-being but rather in the name of an original covenant with society, which has an interest in protecting the purity of medical action from the intrusion of corrupting forces. The same reasoning applies to the domain of clinical research. The corrupting power of money is increasingly viewed not only as unprofessional practice but also as a threat to medical integrity itself. Thus, investigators have to be wary of using monetary rewards in a way might amount to a form of exploitation: “Enrolling desperate ill patients does not compromise the integrity of the biomedical enterprise in the same way as employing relatively healthy volunteers by means of monetary rewards” (Kuczewski 2001, p. 50). This is the reason why the reproductive technology industry is also increasingly scrutinized in order to limit excessive rewards from gamete sales and surrogacy. Here, generic appeals to professionalism are not enough but have to be complemented by a strong notion of professional integrity which allows medicine to resist the lure of technique and money: “The whole point of looking at medical practice in terms of professional integrity is based on the argument that medical ethics can never be reduced to the ethics of marketplace encounters” (Miller and Brody 2005, p. 16).

The Critiques Of Professional Integrity: Purity And Medical Ethics

Reasonable and useful as it might sound, professional integrity can be subject to several criticisms.

First and foremost, one can argue that integrity is invoked in order to reinstate a form of paternalism and limit the extent to which patient’s autonomy can orient medical action. Indeed, unlike paternalism, integrity has an aura of ethical and scientiﬁc legitimacy: integrity is an ethical notion which can easily be put on the same footing as other ethical principles, and thus counteract appeal to respect for patient’s autonomy, beneﬁcence, and justice. Also, doctors’ own judgment is increasingly replaced by recommendations established on the basis of evidence-based medicine. However, in cases of value conﬂict between patients and doctors, as in requests for “futile” care, professional integrity may be judged to have a lower status than patients’ and proxies’ values. This is all the more true that futility cannot be entirely deﬁned in medical terms alone but necessarily includes a judgment about when a life is worth living. As a critic of professional integrity in this context writes: “How can the physician claim value primacy, particularly if the consequences for him of her amount to little more than psychological distress when the patient will face death as a result” (Biegler 2003, p. 361).

A second widespread critique which can be leveled against professional integrity is conservatism. Some argue that emphasis on professional integrity will tend to reafﬁrm the boundaries and prerogatives of doctors and reinforce corporatist tendencies as well as sheer prestige in the face of societal changes. Healthcare professionals should rather embrace novelty and be ready to serve society in new ways. Indeed, according to some, there is a nostalgic side to professional integrity which ties medicine to a fundamental distinction between treatment and enhancement practices. Besides the fact that these ideals may be “based on a past that never was,” some argue that striving for “moral purity” is both inaccessible and dangerous (Erde 2008, p. 20). Medicine has always contributed to the pursuit of happiness and human welfare, and enhancement techniques are only the latest tools for improving the fate of mankind and reenacting the fundamental utopia of delivering human kind from all sorts of evil.

A third important criticism of professional integrity concerns its role in the shaping of good medical practice. It can be argued that with its focus on purity, integrity is a defensive and so to speak negative concept. Although it stresses competency and procedural appropriateness, it does so at the expense of a larger call for humanism and personal positive virtues. Humanizing healthcare has long been perceived as a worthwhile goal. However, some argue, humanism in medicine is a complex ideal, which thrives on personal virtues, whereas professional integrity is a conventional and socially constructed local phenomenon. Values like empathy, compassion, respect, humility, courage, patience, and loyalty, to name only a few, have to be promoted together with integrity. Indeed, in some circumstances, doctors’ personal virtues can legitimately be in opposition to their professional identity. One may think, for example, of courageous medical interventions that violate professional standards of risk/beneﬁt analysis. This example shows that there may well be a “struggle between lay humanistic and professional values,” a tension which many doctors perceive as “real, deep, and systematic” (Goldberg 2008, p. 720). Indeed medical students describe their enculturation into medical practice as slowly abandoning the loftier humanistic values that might have motivated them to join the professional in the ﬁrst place. Goldberg concludes his article on the “white coat ceremony,” a widespread ritual that serves as a reminder of the profession’s unifying values: “We do not need to teach students how to put on their white coats, but how to take them off” (Goldberg 2008, p. 720). Some go as far as saying that medicine cannot be reduced to professional standards and qualities but depends on a special sense of calling which may on certain occasions – as for example in the case of world epidemics – verge on heroism.

Some Positive Suggestions

Critiques of the notion of professional integrity are useful because they point to a positive way of using the concept in order to improve the practice of medicine. This is so because discussions around the notion of integrity can promote self-reﬂection both within the medical profession and in the academia. It can be argued that one of the main advantages of introducing the concept is precisely to encourage discussion about what it means to be a doctor today, and to push practitioners to elaborate a common philosophy in order to deal with new challenges. It may well be that even though the precise content of professional integrity will never be positively identiﬁed in a consensual way, the very fact of focusing on its importance will be conducive to changing certain medical practices, most notably with respect to patients’ end of life. In this respect, it can be argued that, quite like other concepts, professional integrity has a per formative role.

The second necessary element that has emerged in the discussion on professional integrity is that contrary to what the Hippocratic Oath would have us believe, the ethical content of medical practice evolves with time and societal changes. Professional standards must not be conceived as a one size ﬁts all list of norms which, by trying to make it “pure,” would isolate medicine from the society in which it is embedded. Indeed, assisted suicide may well become a more acceptable medical procedure in the future at least in some contexts (Miller and Brody 1995). Also, it is now admitted that the justiﬁcation for certain types of medical research in developing countries has to take into account local standards of care.

Nostalgic views of medicine as a timeless enterprise would only isolate it from its own basis and purpose, and ultimately make it obsolete and counterproductive. What is needed therefore in order to ensure that professional integrity plays a constructive role is to focus positively on the content of medical integrity— what has been called the “internal morality of medicine”—in an evolutionary perspective, rather than using a formal notion of integrity as a defensive strategy (Miller and Brody 2001).

But a third point appears as crucial: professional integrity is ethically unacceptable if it is only focused on a scientiﬁc medical deﬁnition of patients’ well-being. In order for medicine to fulﬁll its purpose as a special applied science, doctors’ notion of integrity has to include a positive personal commitment to patients even to the detriment of one’s own interests – be they material or ethical (Pellegrino 2002). In other words the larger context of medical decisions, be it societal, psychological, or simply personal, has to be taken into account in order to ensure that decisions improve patients’ welfare well beyond their medical well-being. This is what it means for medicine to respect patients as persons. This attitude will allow for the possibility that practices seemingly opposed to professional integrity like assisted suicide, futile care, and enhancement might on certain occasions be considered as ethically acceptable at the individual level. Also, the same practices might one day become mainstream since medical integrity is bound to change following a collective reﬂection on its core values as wel as in reaction to societal changes. At another level, however, integrity may continue to play its negative defensive role and protect medicine against political, ideological, and ﬁnancial pressures, opposing capital punishment, political corruption, and practices denying basic human rights.

Conclusion

In conclusion, the best way of accounting for all the facets and roles of professional integrity is to consider it as a second order concept, rather than to emphasize its role in identifying and maintaining the purity of medical action. Professional integrity has been usefully viewed as a “situationally related competence”: “a competence or capacity for reﬂection and discernment in the midst of the conﬂicting demands between professional and personal values, roles and ethical systems” (Edgar & Pattison 2011, p. 95). In other words, doctors constantly face challenges to their own sense of what it means to practice medicine well and to uphold certain self-deﬁning ethical values. Rather than considering rules and good practices as ready-made recipes, doctors should acquire and cultivate the capacity to think all these issues anew. As they are bent on solving daily dilemmas, doctors will thus indirectly reformulate the internal morality of medicine and to redeﬁne professional integrity in ways that are more adjusted to challenging new ethical and social environments.

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