- Email: [email protected]
Advancing the Philosophy of Chiropractic: Advocating Virtue
Advancing the Philosophy of Chiropractic: Advocating Virtue Stuart Kinsinger, DCa ABSTRACT A practitioner using his or her patients as a means to furthering personal goals and objectives is at risk for violating professional standards and the principles of professionalism. How students’ ethics and principles are developed carries into practice, thus we should advocate for the inclusion of the virtues of care as a critical aspect of chiropractic practice in educational programs. This paper discusses the influence of moral relativism on professional students. (J Chiropr Humanit 2004;11:24-28) INTRODUCTION framework of the expectation of professional behaviors, with these predicated on the fiduciary relationship between practitioner and patient, the combined societal influences of the media and various educational milieus have placed the realization of affluence, entitlement, permissiveness and personal excess as the ultimate calling and reward for the novice professional.2 This is in sharp contrast with the principles of professionalism. From an inherent perspective, with respect to our current social values and mores, there can be no assumption that this current generation of practitioners has acquired a basic working knowledge of the standards of behaviors and codes of conduct required of the professional.
As chiropractic moves into its second century, multiple forces act on the profession both from within and without. While groups or individual stakeholders may either suffer or benefit from the changes effected by these forces, the profession’s obligation to nurture a specialized body of knowledge and to use this knowledge always and without exception for good, remains immutable. All professions serve the public under this broad twofold mandate.1 Modern Western society places enormous conflicts on individual practitioners. The influence of moral relativism over the past forty years has greatly affected the current generation of practitioners including students learning this specialized knowledge. Rather than society itself providing a solid
Jurisdictional regulatory boards and governing bodies set out standards of practice protocols, as mandated by each jurisdiction’s legislators. These proclamations set out the standards of care, which practitioners must support and adhere to. By mandating the legal duty of the health care practitioner, regulators serve the public good. Codes of conduct and standards of behaviors state the minimum
a
Chair, Department of Chiropractic Principles and Practice Submit requests for reprints to: Dr. Stuart Kinsinger, Canadian Memorial Chiropractic College, 6100 Leslie St, Toronto, Ontario, Canada M2H 3J1 E-mail: [email protected] Paper submitted September 10, 2004; in revised form September 22, 2004 Journal of Chiropractic Humanities 2004 © NUHS
24
Virtue
Kinsinger
“… it is part of the principles of professionalism to continually strive to work above the proscribed mandated minimum.”
therapeutic conservatism and vitalism in the care of the patient. These tenets have been well established and significantly advanced by the profession. Inherent in these tenets was then, and still is today, an ethical framework encompassing the philosophical concepts. The primary benefit of the ethical tenets is to provide for a safe healing encounter between the provider and client, upholding the goals of the fiduciary relationship. As essential as the philosophical tenets were historically, in carving out a unique place for the emerging distinctiveness of the profession, so today, in this current culture, a renewed professing of not just the ethics but professing the virtues of care would further distinguish and significantly enhance the profession’s philosophy of care.
acceptable standards required by professional members, delineating the line not to be transgressed. While optimal or ideal behaviors and standards are not codified by law, it is part of the principles of professionalism to continually strive to work above the proscribed mandated minimum. The influence of moral relativism has affected the behavior of professional students.3,4 Educators in all disciplines deal with the effects of the influence of changing values on individuals. Of great concern is the necessity to teach the ethics of clinical care and the principles of professionalism. If this obligation is not met, a greater concern is that this younger generation of professionals may not appropriately advocate for serving the needs of the client; but rather consider the needs of the professional as being equally important. A practitioner using his or her patients as a means to furthering personal goals and objectives is at risk for violating professional standards and the principles of professionalism.
Ethics of Care There are specific ethical concepts that regulate appropriate behaviors in the professional encounter. By demonstrating an understanding of how the ethics of care apply to the clinical setting, both the professional and the client are served well by honoring the healing encounter, serving the needs of the patient and strengthening his or her bond of trust with the caregiver.6,7 Autonomy - Autonomy provides that a client is free to make decisions that affect their needs: free from deceit, duress, constraint or coercion, and they are to be an informed participant in making those decisions. Autonomy provides a respect for personal freedom for both client and professional; respect that ennobles and professionalizes the encounter.
PHILOSOPHY OF CHIROPRACTIC Coulter has described the historical concepts of chiropractic that initially defined the young growing profession, and the emergence of a developing philosophy of care.5 This was at a time of intense struggle with fierce opposition primarily from the medical establishment. Chiropractic distinguished itself as a primary contact healing arts method by advocating for an alternative type of care, and advancing the specific philosophical tenets of critical rationalism, holism, humanism, naturalism, Journal of Chiropractic Humanities 2004 ©NUHS
In health care, inherent to the principle of autonomy is the concept of informed consent. Patients have the right to be properly
25
Virtue
Kinsinger
communication of information, and binds the professional and client in an association of truth. This obligation, based on the respect owed to the client, is closely linked with the virtue of fidelity (to fulfill an agreement and keep a promise) and never intends to deceive. This ethical tenet particularly guards trust.
informed of their condition (veracity also being complicit here with autonomy), and the benefits and risks of the procedures that will be used to assess and treat them, in order to facilitate their decision, and their care. Beneficence – Beneficence describes the principle of doing good; as much good as possible to benefit another person. It is a very strong concept of a positive action to remove or prevent the client’s problem and strives to promote the ‘good, better and the best’. Beneficence is not served by partially withholding goods or services in order to prolong or extend the services provided for increased financial gain.
Confidentiality – Confidentiality further guards the professional’s trustworthiness. While clients surrender some privacy by granting to their professional personal and privileged information, they do not surrender control over how that information is used. Confidentiality binds the provider not to divulge that privileged information to another party, unless permission has been given by the client. The trust bond becomes severely weakened if the client fears unauthorized disclosure, thus impairing the ability of the professional to fully serve the client.
Nonmaleficence – Stated bluntly, nonmaleficence means one should not do harm or inflict evil on another. In health care, nonmaleficence is embodied in the principle of Primum Non Nocere and found in the Hippocratic Oath as “physician do no harm.” Some patient’s problems have solutions that may not be worth the treatment risk. Autonomy, veracity, beneficence and nonmaleficence all apply to this type of decision making.
Paternalism – Paternalism is the principle empowering the professional to act on behalf of the client when the client is not able to choose or act for him or herself, much like how a parent makes choices for their child. Linked with both autonomy and veracity, paternalism gives authority to the professional in helping the client to make a decision, always acting within the confines of a fiduciary relationship; that being, placing the needs of the client above their own needs, and the needs of others.
Justice - Justice addresses the concepts of fairness and entitlement. Fairness is difficult to measure objectively but encompasses the distribution of goods and services; who receives benefits and to what degree. Most importantly, all clients are to be treated on a fair and equal basis irrespective of ethnicity, social status or any other type of social or personal uniqueness.
Clinical ethics and their application are now taught as a vital part of curricular content to health care students in all disciplines. All health care institution’s libraries, including the Complementary and Alternative Medicine (CAM) disciplines and the established disciplines of nursing, medicine and physical therapy sport a growing section of titles featuring the role of ethics in clinical practice. Many of these are biomedical in nature, dealing with issues not usually applicable to
Justice is not served by using one’s authority to engage the client on the basis of financial benefit over the prudent management of the client’s condition or problem. Veracity - Veracity refers comprehensive, accurate and
Journal of Chiropractic Humanities 2004 ©NUHS
to the objective
26
Virtue
Kinsinger
Compassion – Compassion is a trait that combines an active regard for another’s welfare by modeling an awareness and a response of sympathy and tenderness for a client’s misfortune or suffering. Closely allied with compassion is respect, this being the essence of humanism, a central concept of professionalism. Individuals have immutable rights and therefore are worthy of respect for their individuality. Compassion and respect are virtues, which follow from the ethical tenets of both autonomy and justice.
the CAM disciplines, including issues of birth, life, dying and allocation of resources. The chiropractic profession has an opportunity to confront the unhelpful aspects of moral relativism in society by advocating for and professing the virtues of care as the setting in which the ethics of care are set. It is this professing that refines, enhances and advances the dynamic of the philosophy of chiropractic. Virtue - The classic source for referencing information about virtue is Aristotle’s Nicomachean Ethics. Modern understanding of morals and ethics takes its inspiration from the Aristotelian understanding of character, motives and quantifying virtue. Aristotle maintained that we acquire virtues like we do other skills, such as learning to play the cello, water ski or perform spinal adjustments.8
Excellence – Excellence entails conscientious effort: an effort to exceed the ordinary expectations of the patient; an effort to continually pursue being a life-long learner; and in an effort to give back to the profession either as a volunteer in regulatory matters, by financial support of professional programs or community charities, and in mentoring students and young professionals.
A virtue is defined as a trait of character that is socially valuable, so that our personal character consists of a set of traits or virtues, which affect our thinking, our words, and our actions. Professionalism encourages the caregiver to consider that the foundational ethical tenets, the set, be embodied in an appropriate setting, codified as virtues, or character traits.9
Fortitude – Fortitude is one of Aristotle’s cardinal virtues. This virtue deals with a firm courage and perseverance of discomfort, misfortune, and even suffering when pursuing a professional task. In health care, history is rich with examples of caregivers and researchers who placed themselves in situations of risk when dealing with unknown threats and diseases.
Accountability – Professionals are accountable on many levels: client, peers, governing bodies, and society at large. An important part of this accountability is accepting one’s duty to serve, sometimes with personal inconvenience, and sometimes with risks when advocating for the best possible service; for example to a patient in a hardship situation. Accountability and duty also help form the concept of volunteerism in the community where the chiropractor lives and works. Professionals number significantly in service clubs and in other community organizations, large and small.
Journal of Chiropractic Humanities 2004 ©NUHS
Integrity – Integrity is the consistent regard for the highest standards of both professional and personal behavior; being a ‘whole’ person, and not given to a dual character contrasting one’s personal behaviors and professional duties. It speaks of consistency in being fair, straightforward, speaking the truth, and in being faithful to finish the job. Prudence – Prudence, another cardinal virtue, refers to acting thoughtfully and discretely. A prudent person is mindful of the task at hand, taking care to always think about the
27
Virtue
Kinsinger
“… there is substantial support for enhancing and advancing the principles and philosophy of chiropractic.”
provider is strengthened, honoring the healing encounter between two individuals. From the public’s perspective, the principles of professionalism are well served, maintained at a high level, and continually being raised to an even higher standard. There is no higher calling, nor greater reward than to be found trustworthy. Application of the virtues does that, and provides a powerful enhancement to the traditional philosophy of chiropractic.
implications to the client and those close to the client in discharging professional duties. It is linked with the virtue of compassion and the ethical tenets of veracity and confidentiality, and embodies temperance, the ability to demonstrate self-control.
REFERENCES Fidelity - Fidelity is a strong concept referring to loyalty and trust, going beyond just being true to one’s word. The professional favors the patient’s interests over all others.
1. Bayles MD. The professions. In: Callahan JC, editor. Ethical issues in professional life. Oxford U Press; 1988. p. 26-30. 2. Ruggiero VR. Thinking critically about ethical issues, 5th ed. Mayfield Publishing; 2001. p. 23-8. 3. Schneider A. Insubordination and intimidation signal the end of decorum in many classrooms. Chronicle of Higher Education; 1998 Mar 27; Sect A:12–4. 4. Astin AW. The changing American college student: thirty year trends, 1966 – 1996. Review of Higher Education 1998;21(2):115–35. 5. Coulter ID. Chiropractic: a philosophy for alternative health care. Butterworth Heinemann; 1999. p. 37 – 55. 6. Purtilo R. Ethical dimensions in the health professions. 2nd ed. Philadelphia: WB Saunders; 1997. p. 18–35. 7. Beauchamp TL, Childress JF. Principles of biomedical ethics, 5th ed. Oxford: Oxford University Press; 2001. p. 26–39. 8. Hinman LM. Ethics: a pluralistic approach to moral theory. 3rd ed. Belmont, CA: Wadsworth Publishers; 2002. p. 82-3. 9. Povar GJ, Blumen H, Daniel J, Daub S, Evans L, Holm RP et al. Ethics in practice: managed care and the changing health care environment. Ann Intern Med 2004;141:131-6. 10. Lynch DC, Surdyk PM, Eiser AR. Assessing professionalism: a review of the literature. Med Teach 2004;26:366–73.
While the law cannot force one to practice virtuously, these virtues combine to make up the setting in which the ethics of care, the set of professionalism, are applied.10 CONLCUSION By advocating for the inclusion of the virtues of care as a critical aspect of chiropractic practice being integral in the patient encounter, there is substantial support for enhancing and advancing the principles and philosophy of chiropractic. In no way does this detract from the traditional concepts of the philosophy of chiropractic, nor from the pursuit of greater understanding of the newer aspects of our philosophy, such as quantum and complexity theories. From the practitioner’s perspective, this upholds the professional’s calling to adhere to a higher standard than non-professionals. From the patient’s perspective, the trust bond with the
Journal of Chiropractic Humanities 2004 ©NUHS
28
Virtue
Kinsinger
As chiropractic moves into its second century, multiple forces act on the profession both from within and without. While groups or individual stakeholders may either suffer or benefit from the changes effected by these forces, the profession’s obligation to nurture a specialized body of knowledge and to use this knowledge always and without exception for good, remains immutable. All professions serve the public under this broad twofold mandate.1 Modern Western society places enormous conflicts on individual practitioners. The influence of moral relativism over the past forty years has greatly affected the current generation of practitioners including students learning this specialized knowledge. Rather than society itself providing a solid
Jurisdictional regulatory boards and governing bodies set out standards of practice protocols, as mandated by each jurisdiction’s legislators. These proclamations set out the standards of care, which practitioners must support and adhere to. By mandating the legal duty of the health care practitioner, regulators serve the public good. Codes of conduct and standards of behaviors state the minimum
a
Chair, Department of Chiropractic Principles and Practice Submit requests for reprints to: Dr. Stuart Kinsinger, Canadian Memorial Chiropractic College, 6100 Leslie St, Toronto, Ontario, Canada M2H 3J1 E-mail: [email protected] Paper submitted September 10, 2004; in revised form September 22, 2004 Journal of Chiropractic Humanities 2004 © NUHS
24
Virtue
Kinsinger
“… it is part of the principles of professionalism to continually strive to work above the proscribed mandated minimum.”
therapeutic conservatism and vitalism in the care of the patient. These tenets have been well established and significantly advanced by the profession. Inherent in these tenets was then, and still is today, an ethical framework encompassing the philosophical concepts. The primary benefit of the ethical tenets is to provide for a safe healing encounter between the provider and client, upholding the goals of the fiduciary relationship. As essential as the philosophical tenets were historically, in carving out a unique place for the emerging distinctiveness of the profession, so today, in this current culture, a renewed professing of not just the ethics but professing the virtues of care would further distinguish and significantly enhance the profession’s philosophy of care.
acceptable standards required by professional members, delineating the line not to be transgressed. While optimal or ideal behaviors and standards are not codified by law, it is part of the principles of professionalism to continually strive to work above the proscribed mandated minimum. The influence of moral relativism has affected the behavior of professional students.3,4 Educators in all disciplines deal with the effects of the influence of changing values on individuals. Of great concern is the necessity to teach the ethics of clinical care and the principles of professionalism. If this obligation is not met, a greater concern is that this younger generation of professionals may not appropriately advocate for serving the needs of the client; but rather consider the needs of the professional as being equally important. A practitioner using his or her patients as a means to furthering personal goals and objectives is at risk for violating professional standards and the principles of professionalism.
Ethics of Care There are specific ethical concepts that regulate appropriate behaviors in the professional encounter. By demonstrating an understanding of how the ethics of care apply to the clinical setting, both the professional and the client are served well by honoring the healing encounter, serving the needs of the patient and strengthening his or her bond of trust with the caregiver.6,7 Autonomy - Autonomy provides that a client is free to make decisions that affect their needs: free from deceit, duress, constraint or coercion, and they are to be an informed participant in making those decisions. Autonomy provides a respect for personal freedom for both client and professional; respect that ennobles and professionalizes the encounter.
PHILOSOPHY OF CHIROPRACTIC Coulter has described the historical concepts of chiropractic that initially defined the young growing profession, and the emergence of a developing philosophy of care.5 This was at a time of intense struggle with fierce opposition primarily from the medical establishment. Chiropractic distinguished itself as a primary contact healing arts method by advocating for an alternative type of care, and advancing the specific philosophical tenets of critical rationalism, holism, humanism, naturalism, Journal of Chiropractic Humanities 2004 ©NUHS
In health care, inherent to the principle of autonomy is the concept of informed consent. Patients have the right to be properly
25
Virtue
Kinsinger
communication of information, and binds the professional and client in an association of truth. This obligation, based on the respect owed to the client, is closely linked with the virtue of fidelity (to fulfill an agreement and keep a promise) and never intends to deceive. This ethical tenet particularly guards trust.
informed of their condition (veracity also being complicit here with autonomy), and the benefits and risks of the procedures that will be used to assess and treat them, in order to facilitate their decision, and their care. Beneficence – Beneficence describes the principle of doing good; as much good as possible to benefit another person. It is a very strong concept of a positive action to remove or prevent the client’s problem and strives to promote the ‘good, better and the best’. Beneficence is not served by partially withholding goods or services in order to prolong or extend the services provided for increased financial gain.
Confidentiality – Confidentiality further guards the professional’s trustworthiness. While clients surrender some privacy by granting to their professional personal and privileged information, they do not surrender control over how that information is used. Confidentiality binds the provider not to divulge that privileged information to another party, unless permission has been given by the client. The trust bond becomes severely weakened if the client fears unauthorized disclosure, thus impairing the ability of the professional to fully serve the client.
Nonmaleficence – Stated bluntly, nonmaleficence means one should not do harm or inflict evil on another. In health care, nonmaleficence is embodied in the principle of Primum Non Nocere and found in the Hippocratic Oath as “physician do no harm.” Some patient’s problems have solutions that may not be worth the treatment risk. Autonomy, veracity, beneficence and nonmaleficence all apply to this type of decision making.
Paternalism – Paternalism is the principle empowering the professional to act on behalf of the client when the client is not able to choose or act for him or herself, much like how a parent makes choices for their child. Linked with both autonomy and veracity, paternalism gives authority to the professional in helping the client to make a decision, always acting within the confines of a fiduciary relationship; that being, placing the needs of the client above their own needs, and the needs of others.
Justice - Justice addresses the concepts of fairness and entitlement. Fairness is difficult to measure objectively but encompasses the distribution of goods and services; who receives benefits and to what degree. Most importantly, all clients are to be treated on a fair and equal basis irrespective of ethnicity, social status or any other type of social or personal uniqueness.
Clinical ethics and their application are now taught as a vital part of curricular content to health care students in all disciplines. All health care institution’s libraries, including the Complementary and Alternative Medicine (CAM) disciplines and the established disciplines of nursing, medicine and physical therapy sport a growing section of titles featuring the role of ethics in clinical practice. Many of these are biomedical in nature, dealing with issues not usually applicable to
Justice is not served by using one’s authority to engage the client on the basis of financial benefit over the prudent management of the client’s condition or problem. Veracity - Veracity refers comprehensive, accurate and
Journal of Chiropractic Humanities 2004 ©NUHS
to the objective
26
Virtue
Kinsinger
Compassion – Compassion is a trait that combines an active regard for another’s welfare by modeling an awareness and a response of sympathy and tenderness for a client’s misfortune or suffering. Closely allied with compassion is respect, this being the essence of humanism, a central concept of professionalism. Individuals have immutable rights and therefore are worthy of respect for their individuality. Compassion and respect are virtues, which follow from the ethical tenets of both autonomy and justice.
the CAM disciplines, including issues of birth, life, dying and allocation of resources. The chiropractic profession has an opportunity to confront the unhelpful aspects of moral relativism in society by advocating for and professing the virtues of care as the setting in which the ethics of care are set. It is this professing that refines, enhances and advances the dynamic of the philosophy of chiropractic. Virtue - The classic source for referencing information about virtue is Aristotle’s Nicomachean Ethics. Modern understanding of morals and ethics takes its inspiration from the Aristotelian understanding of character, motives and quantifying virtue. Aristotle maintained that we acquire virtues like we do other skills, such as learning to play the cello, water ski or perform spinal adjustments.8
Excellence – Excellence entails conscientious effort: an effort to exceed the ordinary expectations of the patient; an effort to continually pursue being a life-long learner; and in an effort to give back to the profession either as a volunteer in regulatory matters, by financial support of professional programs or community charities, and in mentoring students and young professionals.
A virtue is defined as a trait of character that is socially valuable, so that our personal character consists of a set of traits or virtues, which affect our thinking, our words, and our actions. Professionalism encourages the caregiver to consider that the foundational ethical tenets, the set, be embodied in an appropriate setting, codified as virtues, or character traits.9
Fortitude – Fortitude is one of Aristotle’s cardinal virtues. This virtue deals with a firm courage and perseverance of discomfort, misfortune, and even suffering when pursuing a professional task. In health care, history is rich with examples of caregivers and researchers who placed themselves in situations of risk when dealing with unknown threats and diseases.
Accountability – Professionals are accountable on many levels: client, peers, governing bodies, and society at large. An important part of this accountability is accepting one’s duty to serve, sometimes with personal inconvenience, and sometimes with risks when advocating for the best possible service; for example to a patient in a hardship situation. Accountability and duty also help form the concept of volunteerism in the community where the chiropractor lives and works. Professionals number significantly in service clubs and in other community organizations, large and small.
Journal of Chiropractic Humanities 2004 ©NUHS
Integrity – Integrity is the consistent regard for the highest standards of both professional and personal behavior; being a ‘whole’ person, and not given to a dual character contrasting one’s personal behaviors and professional duties. It speaks of consistency in being fair, straightforward, speaking the truth, and in being faithful to finish the job. Prudence – Prudence, another cardinal virtue, refers to acting thoughtfully and discretely. A prudent person is mindful of the task at hand, taking care to always think about the
27
Virtue
Kinsinger
“… there is substantial support for enhancing and advancing the principles and philosophy of chiropractic.”
provider is strengthened, honoring the healing encounter between two individuals. From the public’s perspective, the principles of professionalism are well served, maintained at a high level, and continually being raised to an even higher standard. There is no higher calling, nor greater reward than to be found trustworthy. Application of the virtues does that, and provides a powerful enhancement to the traditional philosophy of chiropractic.
implications to the client and those close to the client in discharging professional duties. It is linked with the virtue of compassion and the ethical tenets of veracity and confidentiality, and embodies temperance, the ability to demonstrate self-control.
REFERENCES Fidelity - Fidelity is a strong concept referring to loyalty and trust, going beyond just being true to one’s word. The professional favors the patient’s interests over all others.
1. Bayles MD. The professions. In: Callahan JC, editor. Ethical issues in professional life. Oxford U Press; 1988. p. 26-30. 2. Ruggiero VR. Thinking critically about ethical issues, 5th ed. Mayfield Publishing; 2001. p. 23-8. 3. Schneider A. Insubordination and intimidation signal the end of decorum in many classrooms. Chronicle of Higher Education; 1998 Mar 27; Sect A:12–4. 4. Astin AW. The changing American college student: thirty year trends, 1966 – 1996. Review of Higher Education 1998;21(2):115–35. 5. Coulter ID. Chiropractic: a philosophy for alternative health care. Butterworth Heinemann; 1999. p. 37 – 55. 6. Purtilo R. Ethical dimensions in the health professions. 2nd ed. Philadelphia: WB Saunders; 1997. p. 18–35. 7. Beauchamp TL, Childress JF. Principles of biomedical ethics, 5th ed. Oxford: Oxford University Press; 2001. p. 26–39. 8. Hinman LM. Ethics: a pluralistic approach to moral theory. 3rd ed. Belmont, CA: Wadsworth Publishers; 2002. p. 82-3. 9. Povar GJ, Blumen H, Daniel J, Daub S, Evans L, Holm RP et al. Ethics in practice: managed care and the changing health care environment. Ann Intern Med 2004;141:131-6. 10. Lynch DC, Surdyk PM, Eiser AR. Assessing professionalism: a review of the literature. Med Teach 2004;26:366–73.
While the law cannot force one to practice virtuously, these virtues combine to make up the setting in which the ethics of care, the set of professionalism, are applied.10 CONLCUSION By advocating for the inclusion of the virtues of care as a critical aspect of chiropractic practice being integral in the patient encounter, there is substantial support for enhancing and advancing the principles and philosophy of chiropractic. In no way does this detract from the traditional concepts of the philosophy of chiropractic, nor from the pursuit of greater understanding of the newer aspects of our philosophy, such as quantum and complexity theories. From the practitioner’s perspective, this upholds the professional’s calling to adhere to a higher standard than non-professionals. From the patient’s perspective, the trust bond with the
Journal of Chiropractic Humanities 2004 ©NUHS
28
Virtue
Kinsinger