The golden rule: A cornerstone in the ethical care of patients

How would you define the term "profession?" How does it differ from other occupations?

A profession has been defined as an occupation that 1) regulates itself through systematic required education or collegial discipline; 2) has a base in technical, specialized knowledge, and 3) has a service, rather than a profit orientation, enshrined in an ethical code.

How would you define the term "ethic?" The word ethic is derived from the Greek word "ethos", meaning character or custom. It implies conforming to moral standards, or conforming to the standards of conduct of a given profession. To be ethical, one must be in accord with some moral standard or code of conduct. The term moral is derived from the Latin word "moralis", which signifies manners. Morality deals with or makes a distinction between right or wrong conduct. It implies conforming to a standard of right behavior. Synonyms for moral include the term's virtue and ethic. Law is not a synonym for morality.

The original United States Veterinary Medical Association Code of Ethics was adopted in 1867. Now, broad-based and general principles of veterinary medical ethics have been adopted by the American Veterinary Medical Association. They encompass such topics as guidelines for professional behavior, advertising, fees, referrals, consultations, relationship with clients and various other aspects of the practice of veterinary medicine. Ethical principles governing the practice of veterinary medicine are often more stringent than legal controls. However, they do not cover all facets of veterinary medicine. The ultimate test of our ethics is the conduct they dictate or inspire. The ultimate challenge of our behavior is to choose the best course of conduct or action when existing rules and guidelines do not apply.

DVM Newsbreak

The American Veterinary Medical Association made the following statement about the "Principles of Veterinary Medical Ethics" (note the emphasis on the golden rule): "Exemplary professional conduct upholds the dignity of the veterinary profession. All veterinarians are expected to adhere to a progressive code of ethical conduct known as the Principles of Veterinary Medical Ethics. The basis of the principles is the golden rule. Veterinarians should accept this rule as a guide to their general conduct and abide by the principles. They should conduct their professional and personal affairs in an ethical manner."

The principle

Can you recite the golden rule from memory? Recall that the golden rule is a rule of ethical conduct from Matthew 7:12 and Luke 6:31, stating that we should do for others as we would have others do for us. A version of this principle is attributed to the Chinese philosopher Confucius (551-479 BC). He said, "What you do not want done to yourself, do not do to others." Compared with the Biblical version, this version is negative (do not do to others) rather than positive (do to others).

Practicing the positive version of the golden rule means that we must take the initiative in being altruistic (having unselfish concern for the welfare of others). Altruism (the opposite of egoism) demands that we consider the interest of others when we use our talents and possessions. Thus, the golden rule is of little value unless we recognize that the first move is ours. To practice the golden rule, we must strive to put ourselves in others' shoes, paws, hooves or claws. In keeping with this principle, I propose five applied rules to enhance the ethical care of patients. (This essay was adapted from a commentary published in JAVMA 217:1622 – 1624, 2000.)

Rule 1

Learn about the diseases of our patients as we want physicians to learn about us.

Consider the following corollaries of Rule No. 1.

• Corollary 1:

We must strive to continually maintain a level of contemporary professional competence that would allow us to provide the quality of medical care that we would desire if we were the patients in similar circumstances. To paraphrase the words of Dr. Donald G. Low, this will help us to practice 30 to 40 years of veterinary medicine in our professional lifetimes, rather than repeat one year 30 to 40 times. In context of the golden rule, we should ask ourselves, "If a member of my family or I was faced with a life-threatening illness, would I have confidence in a physician with study habits comparable to mine?"

• Corollary 2

There is a difference between knowledge and wisdom. Knowledge consists of our familiarity with facts. In contrast, wisdom consists of acquiring a combination of knowledge and understanding that enables us to successfully apply the facts. If we have knowledge but have not learned to properly apply it, we lack wisdom. In context of the practice of veterinary medicine, being wise implies continued effort to acquire sufficient depth of knowledge and breadth of understanding to provide us with the wisdom that will benefit our patients. By expending time, effort, and resources to learn and earn a living, we are applying the golden rule.

• Corollary 3

To put knowledge and wisdom into practice emphasizes the importance of practicality. But our commitment to practicality should not be misdirected. Practicality may be a virtue provided we do not hide behind it as an excuse for ignorance.

• Corollary 4

There is a difference between unanswered questions and unquestioned answers. Even if hundreds of experts unknowingly make incorrect statements, they are still incorrect statements. Repetition does not transform errors into facts.

• Corollary 5

The axiom "it is never too late to learn" is conceptually true. In practice, however, some things can be learned too late to be of optimum value. For example, if we learn about fatal adverse consequences associated with various diagnostic and therapeutic techniques after they occur in our patients, we have learned vital information too late to benefit those patients. This is sometimes called learning in the school of hard knocks (i.e. by experiencing difficulties first hand). Although experience is an effective teacher, she is often a tough one for the ignorant. Why? She gives the test first, and the lesson afterwards. Therefore, to minimize learning by the method of experiencing unwanted consequences of our mistakes, we must seek opportunities to learn in a timely fashion. Keeping in mind that "almost right" is still wrong, we must also be discriminating about what we learn, and how and where we learn it. Why? Because it takes just as much effort to learn useless facts as it does to learn useful ones. Those who become wise are most likely to learn lessons from the mistakes of others (i.e. they are teachable); those who choose to be ignorant often learn too late from their own. Whereas pride is often increased by ignorance and makes us prone to mistakes, humility will keep us from becoming overconfident and will help us to benefit from the experiences and counsel of others.

Rule II

Formulate diagnostic plans as if we were the patients:

Consider the following corollaries of Rule No. 2.

• Corollary 1

A well-defined problem is half solved. However, in defining patients' problems, we must use care not to consider the significance of observations as synonymous with the significance of interpretations. Why? Because, observations and interpretations represent distinctly separate facets of diagnosis. Although either observations or interpretations may be erroneous, in our experience misinterpretation of a correct observation is the most common pattern of error. If misinterpreted observations are accepted as facts, the result may be misdiagnosis leading to ineffective or even contraindicated therapy. This is indeed ironical since the patient may then be in a worse condition as a result of having visited us in our roles as doctors.

• Corollary 2

Belief or disbelief does not alter the truth. Clinical impressions are inherently unreliable, generally conforming to our preconceived biases. However, strong preconceptions are not a substitute for objective evidence. We must use caution not to ignore data because it does not coincide with our beliefs. Rather than interpreting facts in light of preconceived conclusions, we must train ourselves to allow reproducible observations (facts) to lead us to reasonable conclusions.

• Corollary 3

There is a difference between diagnostic possibilities and diagnostic probabilities. In general, collection and interpretation of relevant clinical data about a patient's illness allows us to reduce numerous diagnostic possibilities to a few or one diagnostic probability. However, diagnoses are often a matter of educated opinion rather than a matter of fact. It is one thing to make a diagnosis and another thing to substantiate it. Absence of clinical evidence of suspected diseases is not always synonymous with evidence of absence of these diseases. Likewise, detection of evidence that is consistent with a specific type of disease is not always pathognomonic for that specific disease. It follows that we as veterinarians should convey to our clients that our diagnoses (and prognoses) are based on probability, and therefore are not infallible.

• Corollary 4

Waiting to pursue the diagnosis of the underlying cause(s) of various diseases until the patient does not respond to symptomatic shotgun therapy is like saying, "Ready! Fire! Aim!" Not only does this approach to diagnosis often result in use of drugs that miss the therapeutic target, it often results in iatrogenic errors that can compromise the health of our patients further.

• Corollary 5

Not all diagnostic plans benefit patients in context of the balance of associated risks and benefits, and the resources that are required to implement them. Therefore, we should not confuse activity with accomplishment. Why do efficiently that which should not be done at all?

Rule III

Formulate prognoses as if we were the patients.

Consider the following corollaries of Rule No. 3:

• Corollary 1

Prognosis of diseases requires judgment in the absence of certainty. Therefore, when making prognoses, we must remember that almost right is still wrong.

• Corollary 2

For some patients, prognoses are life saving; for others they are a death sentence. Therefore, our decisions about the care of our patients should be based on the same conscientious, explicit and judicious use of current best evidence (so-called evidence-based medicine) that we would desire physicians to use in caring for us if we were in a similar situation. Putting evidence-based medicine into practice means integrating our individual clinical expertise with the best available external clinical evidence derived from systematic research.

The following scheme is recommended to score the strength and the quality of available external evidence (McGowan et al: Journal of Infectious Diseases, Vol. 165, pages 1-13, 1992). Grade "I" Evidence is defined as the highest quality evidence. It is derived from at least one properly randomized controlled clinical study. Grade "II" Evidence may be data obtained from:

1) at least one well-designed clinical study without randomization;

2) cohort or case-controlled analytic studies;

3) studies using acceptable laboratory models or simulations in the target species, preferably from more than one center;

4) multiple time series;

5) or dramatic results in uncontrolled studies. Grade "III" Evidence is defined as the weakest form of evidence, and may be derived from:

• opinions from respected authorities on the basis of clinical experience;

• descriptive studies;

• studies in other species;

• pathophysiological justification;

• reports of expert committees.

Rule IV

Treat others as we want to be treated.

Consider the following corollaries of Rule No. 4:

• Corollary 1

Hippocrates provided the following advice to his colleagues: "As to diseases, make a habit of two things — to help, or at least do no harm." When confronted with situations in which therapeutic options are associated with significant risk to the patient, we must use caution to avoid the mindset of "Just don't stand there — do something". Why? Because, although the psychological pressure imposed on veterinarians to do something is occasionally overwhelming, our desire to do something must be evaluated in light of the potential benefits and risks to the patient. There are times when it is in the patient's best interest to "don't just do something — stand there." We must not misplace emphasis on "what treatment to prescribe", when the fundamental question is "whether or not to prescribe".

• Corollary 2

Too often, justification for unproved therapy is the belief that some treatment is better than nothing at all. However, the prognosis of few diseases is so uniformly poor that any form of therapy is justified.

• Corollary 3

Just because two events occur in consecutive order does not prove a cause-and-effect relationship. Unrelated coincidences commonly are associated with the treatment and subsequent clinical course of diseases. Therefore, we must use appropriate caution in interpreting uncontrolled empirical observations. Just because a favorable outcome occurs in association with our treatment does not prove that our treatment was effective. Why? Diseases are often self-limiting. In fact, the severity of many disorders declines within a day or two. In this situation, any treatment may appear to be beneficial as long as it is not harmful.

• Corollary 4

We should conscientiously apply the same standard of care for our patients that we would use if we were implementing therapeutic plans for ourselves. When we offer to provide the type of care for our patients that we would select for ourselves, then at the very least, our clients know that our primary motive for doing so is based on the golden rule. Clients are more likely to have confidence in our recommendations and comply with them if they know that our actions are based on serving their best interests.

• Corollary 5

We should strive for a realistic view of our professional competency and technical skill. When uncertainty exists as to whether a particular drug, or medical or surgical procedure is in the best interests of our patients, we should contemplate the answers to the following questions:

1) Based on available information and my knowledge of my own skill and experience with this type of problem, would I consent to the proposed therapeutic plan of action if I were in this patient's situation?

2) What therapeutic goals are likely to be achieved?

3) If I follow the proposed plan of action, in all probability will the overall benefits justify the associated risks and costs?

• Corollary 6

Treating our patients as we would be treated also encompasses patient referrals. No veterinarian has perfect knowledge, understanding and wisdom about all healthcare problems. Will Rogers' statement applies: "We are all ignorant, only on different subjects." It is unethical to mislead a client by indicating our ability to manage a case, which is beyond our expertise or the capability of our hospital. Clients must be clearly advised about benefit/risk probabilities in such situations. When specialty care is reasonably available, ethics requires that the alternatives of specialty versus non-specialty care be discussed with clients. We must also strive to be aware of the client's ability to pay for veterinary services. Rather than recommending continued long-term care that is of questionable efficacy, it may be more ethical to refer a patient to a specialist with the goal of rapid diagnostic resolution and more effective management. In addition to improved patient care, overall costs may be less.

Rule V

Care about others, as we want them to care about us.

Consider the following corollaries of Rule No. 5.

• Corollary 1

If we genuinely care for each of our patients as we would want others to care for us, we would not let the intellectual challenge of studying diseases compromise our compassionate concern for them. There is a huge difference between taking care of diseases and taking care of patients, just as there is a difference between caring for our patients and caring about our patients.

• Corollary 2

If we apply the golden rule, we should be on guard to maintain our ethical balance so as not to tip the scales toward caring more about our profits than about our patients. We must use caution not to lose our balance to the extent that management of our fees becomes detrimental to the management of our patients. To this end, our actions should demonstrate that the humane aspects of veterinary medicine are just as important, if not more so, than financial considerations.

• Corollary 3

We are all members of a profession whose mission is to foster the well-being of others. Our mission is to serve, not to be served. Therefore the true importance of what we do should be measured in context of what it accomplishes in behalf of others, not just in light of what it does for us in terms of prestige or personal income.

Epilogue

At the beginning of this essay, I asked whether or not you could recite the golden rule. It is probable that most of us have committed the golden rule to memory. This being the case, the next question for us to contemplate on a daily basis is, "Do our actions reveal that we are committed to putting the golden rule into practice?"

Dr. Osborne, a diplomate of the American College of Veterinary Internal Medicine, is professor of medicine in the Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Minnesota.