"Is golf a good example for health care workers in terms of acting ethically?"

Johnson's explanation for not counting the two strokes was that he didn't realize the ball was in a bunker. Other golfers in previous tournaments have memorably demonstrated various forms of not knowing. When Paul Azinger accidentally moved a rock in a stream with his foot and Craig Stadler knelt on a towel to avoid muddying his trousers, they didn't know these actions would constitute unfair advantages. When Roberto De Vicenzo signed and submitted his scorecard, he had assumed that his partner had written down the correct score for a specific hole (the correct score was one shot more than what was on the card). Nick Price chose the incorrect option when dealing with an obstructed swing: he should have moved his golf ball rather than an advertisement board. Officials responded to these, again unintentional, rule violations by either levying costly penalty strokes or summarily disqualifying the player from the tournament.

Games depend immensely on their rules. Start changing a game's rules and it soon becomes a different game. Yet much of golf, certainly at the non-professional level, is played out of sight of other players, which creates moral hazard in terms of how easy it is to break a rule unnoticed. Accordingly, the integrity of golf -- that it is a game worthy of a general measure of respect -- depends a lot on the choices and actions of its players.

What about the integrity of health care? Health care work involves considerable leeway in terms of what one should do. This is because clients are unique in a myriad of ways, whether it's the personal meaning and significance of their particular health problem or their history of living with it and with interacting with the health system. Clinical judgment is the familiar catch phrase reflecting such leeway. Yet clinical judgment also includes knowing applicable "rules" and incorporating them into what one does. What might be ethics-related rules that frame all health care work?

This question reminds me of the orthopedic surgery resident (one of about 10 residents to whom I was giving an ethics in-service) whose frustration was clearly evident when he said bluntly, "You know those principles -- beneficence, non-maleficence, etcetera? They're fine if there's time, but there never is. Is it at all possible for you to tell me one thing you want me to always do?" I hesitated, not liking the idea of reducing health care to one "thing." But given the resident's emphasis on "at all possible," I suspected he felt ethics specialists were impractical, living in an idealized world of medicine far from the demands of daily clinical practice. Moreover, I worried that he had come to believe that these specialists, unlike medical specialists, never have to or choose not to "get off the fence" and provide clear advice. The body language of the other residents in the room conveyed their keen interest in my answer. I knew "the gauntlet had been thrown down." So I replied, "Have a good talk with your patient," believing this to be a foundational activity and responsibility that orthopedic surgical practices with long wait lists in big hospitals can short-circuit too often.

What other "rules" in health care might I add? Here are some that may not obviously come to mind, but that are foundational nonetheless: Never abandon your clients or patients. Live up to your College's or licensing board's expectations. See clients and family members as fully human and as persons. Contribute to others' good work (i.e., usually lots of health care workers and family members and friends contribute to someone's recovery). Recognize that all of health care is imbued with ethics-related values. Analogous to golf, start changing these "rules" and health care becomes something else.

There's an added crinkle to tournament golf that has ethical import and that is also relevant to health care workers. Television viewers who witness a rule being broken frequently contact the tournament, as the tournament is in progress, to let officials know about the violation when it has gone unnoticed or unreported. These calls are checked out and, if found to be correct (by re-playing the program's tapes), result in immediate penalty strokes or whatever response is stipulated by PGA rules. I can't think of any other sport that has and accepts such public monitoring.

This connects with health care workers' responsibilities when they notice a colleague whose practice falls below a College's standards or an organization's expectations. The case of golfer Bob Murphy fits here. A golf official told Murphy's golfing partner that taking a couple of practice swings was not permitted, which is what Murphy had just done. A few days later, the partner shared the information with Murphy. Murphy let the tournament official know what he had unknowingly done. He was disqualified. So was his golfing partner for not letting the officials know. In the case of health care, preserving its integrity and trustworthiness is a shared responsibility. And responding appropriately to colleagues' fallibility and limitations can reflect that we still see them, not just clients and families, but as fully human too.

________________________________________
 

Barbara Russell, bioethicist at the Centre for Addiction and Mental Health in Toronto, answers ethics questions that arise in the mental health and addiction fields. She is connected with the University of Toronto's Joint Centre for Bioethics and heads the neuroethics interest group of the Canadian Bioethics Society. She is also a contributing editor to the Journal of Ethics in Mental Health.

Do you have an ethics question for Barbara? Submit questions to be considered for this column to CrossCurrents editor Hema Zbogar at hema_zbogar@camh.net. Please omit personally identifiable health-related information in order to respect people's privacy and follow privacy legislation.