Ethical requirements for the professional culture of a doctor and moral dilemmas of medical specialists

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Professional culture plays a pivotal role in a specialist's professional life today. It helps individuals select the right career, understand the skills, knowledge, and competencies required for their profession, distinguish one specialization from another, and provide clarity on the expectations placed on workers in each field. It can also be a crucial factor for career success, achieving professional goals, and self-identification within society.

Professional culture is an integrative concept that reflects the level of mastery attained in one's work. It denotes a creative and constructive attitude toward labour, the ability to make decisions and assess them from two perspectives: technical and socio-cultural. This culture can be formed through the constructive combination of professional and social competencies, incorporating the continual improvement of skills and knowledge as well as an understanding of the social and cultural spheres in which the professional activity takes place [1].

This term describes the high quality of professional activity among physicians, enabling them to work effectively with colleagues and patients, while also adapting to changes within the profession. Professional oaths and ethical codes are key elements of professional culture that help establish the inviolable principles of the profession. For medical workers, professional oaths are of utmost importance, they represent commitments that must be upheld, promising to follow certain principles and standards. These oaths maintain high standards of professional behaviour and foster trust between patients, society, and medical specialists.

Ethical codes are written documents outlining principles and rules for behaviour within a specific professional group. They help structure professional behaviour, ensure mutual respect among colleagues, and protect the interests of patients and society [2]. Both elements of professional culture, professional oaths and ethical codes, play a crucial role in establishing the unshakable principles of the profession, allowing specialists to perform their duties at a high level and earn the trust of their patients.

The Role of Medical Deontology and Professional Responsibility

Modern physicians face ethical choices on a daily basis. Their moral qualities directly impact the health and lives of many people. The medical profession demands self-denial, humility, and purity of heart from doctors. Duty serves as a means of promoting the happiness of people and humanity. Actions worthy of duty must be moral, while those contrary to duty are immoral. Even a moral act may be motivated not only by a desire to fulfil duty but also by the need to meet expectations. Undoubtedly, a physician’s professional culture is shaped by moral actions performed for the sake of duty and in accordance with the standards of deontology.

Medical deontology (from the Greek “deon”, meaning duty) encompasses the norms and rules of conduct for healthcare workers who strive to maximise treatment outcomes and minimise the negative effects of ineffective medical care. Deontology is an essential component of medical ethics and moral principles in healthcare. The term “deontology” was introduced by I. Bentham in the 19th century. While ethics and deontology in medicine are closely related, they are not synonymous concepts. Deontology constitutes a set of norms for healthcare workers regarding proper interaction with patients, and these norms are based on medical ethics.

The foundations of ethical rules for healthcare professionals are enshrined in Articles 4, 5, 6, 7, 11, 13, 71, 73, 74 of the Federal Law of November 21, 2011, N 323-FZ (as amended on December 28, 2013, with amendments of June 4, 2014) “On the Fundamentals of Health Protection of Citizens in the Russian Federation”. This law not only outlines the responsibilities of doctors but also mandates adherence to ethical norms in the provision of medical care. Article 71, in particular, stipulates the text of the physician’s oath, which is legally binding and must be followed by all medical professionals [3].

Shifts in Medical Professionalism

There are several key features in the evolution of the medical profession today:

1. Changing Doctor-Patient Interaction Models: Previously, patients had little say in the choice of medications or treatment plans. Now, they can select their treatment options and even their doctor, marking a shift from a paternalistic model to one of collaboration.
2. Complexity of Healthcare as a Social Institution: Medicine is a complex social institution that involves a wide range of interactions within the healthcare system. Modern deontology aims to preserve the principles and traditions that facilitate effective collaboration.
3. Expanded Responsibility of Doctors: In the past, physicians were accountable primarily to individual patients. Today, they bear responsibility not only to individual patients but also to society as a whole.

A doctor has long been a symbol of purity, nobility, intelligence, and professional competence. The white coat embodies the ideals of professional ethics and intellectual integrity, serving as a symbol of hope, help, and care for others' health.

Ethical Principles in Modern Medicine

The most important principle in modern healthcare is “Primum non nocere” or “First, do no harm”. Although seemingly simple, the healthcare system is complex, and those working in this high-stakes field face difficult choices daily. B.G. Yudin outlined four types of harm from a physician’s perspective: harm caused by inaction, unqualified actions, negligence or malice, and necessary actions given the circumstances [4, p. 122].

High ethical standards are mandatory for all healthcare professionals, whether doctors, nurses, or administrators. Ethical issues in healthcare, a domain of applied ethics, concern the moral principles that medical personnel must apply when making decisions. Ethical and moral values in medicine often vary depending on the country and culture. Tom L. Beauchamp and James F. Childress developed a standardised approach to ethical issues in healthcare that remains relevant across borders and cultures. Their guidelines help healthcare workers resolve or avoid ethical dilemmas by examining the core moral principles of medicine (Identification of ethical problems in healthcare and their management. URL: https://www.sermo.com/resources/ethical-issues-in-healthcare). Their system of ethical standards comprises four key principles: non-maleficence, beneficence, respect for patient autonomy, and justice.

It is easy to see why these four principles have had such a profound influence on medical ethics. The values embedded in these principles clearly resonate with modern moral standards, and their practical application in ethical decision-making is immediately evident. As a theoretical foundation, these four principles remain as relevant today as when they were first published over 30 years ago, although their application has changed significantly over time.

The System of Medical Ethics: Core Principles and Contemporary Challenges

Today, medical ethics is a comprehensive system of principles, norms, and requirements that regulate the behavior of doctors, nurses, other healthcare professionals, and organizations involved in patient care. This system is built on several foundational principles:

1. The Principle of Safety and Well-being: Physicians are responsible for protecting the rights and interests of patients, ensuring the safety and welfare of their lives.
2. The Principle of Non-maleficence: Physicians must refrain from causing harm to patients, even with their consent.
3. The Principle of Informed Consent: Doctors are required to inform patients of all potential consequences of treatment, including risks and possible failures.
4. The Principle of Consent: Whenever possible, physicians must obtain the patient’s consent before proceeding with treatment.
5. The Principle of Justice: Physicians must ensure equality and fairness in patient care, regardless of a patient's social status, gender, age, religion, or other factors.
6. The Principle of Confidentiality: Physicians are obligated to maintain the confidentiality of patient information, unless doing so would harm the patient or others.
7. The Principle of Impartiality: Doctors must remain objective, avoiding decisions based on personal beliefs, interests, or moral principles. For example, healthcare professionals may display empathy toward impoverished or disabled patients, but feel less compassion toward well-educated individuals with substance abuse issues.

Physicians are responsible for their actions and decisions, and they must respect the dignity and rights of patients while ensuring the most comfortable treatment conditions. One of the key ethical requirements for doctors today is maintaining professional boundaries with patients. Developing overly close or personal relationships with patients can lead to conflicts of interest and lower the quality of medical care. It is crucial to maintain a professional approach and distance to preserve objectivity in medical decision-making.

Respect for Cultural Diversity in Healthcare

In today’s multicultural world, respect for the cultural specifics of patients is more relevant than ever. Physicians often work in multinational and multi-religious environments, and they must take into account the ethnic and cultural traditions of their patients. Doctors must be prepared to interact with individuals from various cultural and religious backgrounds, demonstrating respect for their beliefs and customs [5]. This is particularly important in the context of medical decisions that may involve moral or ethical considerations.

Physicians must be aware of differences in perceptions of health and illness, as well as how cultural and religious values can influence a patient's choice of treatment. For example, some patients may prefer alternative treatment methods or adhere to specific dietary restrictions based on their religious beliefs. In his 1963 study, Irving Zola found that the treatment of medically unexplained symptoms in three clinics at Massachusetts General Hospital varied depending on the patient’s ethnicity, the specialisation of the physician, and the spatial organisation of the clinic [6]. Zola focused on the organisational factors that influenced complex interactions between patients and physicians, as well as ethnic differences (Italians and Irish) in how lower-class patients presented their symptoms.

The Emotional Resilience of Healthcare Professionals

The fast-paced and demanding work schedules of medical professionals raise questions about emotional resilience and stress management. Working in healthcare often involves high levels of stress and emotional burnout. Physicians are faced with situations that require difficult decisions, communication with critically ill patients, and interactions with grieving relatives. It is essential that doctors possess emotional resilience, know how to manage stress, and find methods of self-care, such as regular physical activity, meditation, or hobbies. Not only does this help physician maintain their mental health, but it also enables them to be more responsive and attentive to the needs of their patients.

The Importance of Communication and Emotional Engagement in Patient Care

Medical ethics play a vital role in ensuring the quality of healthcare, protecting patients' rights, and improving relationships between doctors and patients. The emotional connection between healthcare workers, patients, and their families is based on principles of partnership, mutual understanding, and respect for individual identity. Emotionally charged communication between doctor and patient creates space for a deeper understanding of the patient’s personal characteristics. This, in turn, fosters active patient participation in the therapeutic process and brings a sense of satisfaction to both the physician and the patient, even if treatment outcomes are not ideal.

When it comes to personal relationships between doctors and patients, this becomes a sensitive issue in the realm of medical ethics. Like any other individual, a doctor is not immune to temptation. During the course of interaction, complex emotions may arise, including sexual attraction. The care, trust, and attention required during treatment can become heightened in critical moments when emotional intensity is at its peak. In such cases, a healthcare professional's professional restraint may weaken, sometimes leading to the development of intimate relationships. Intimate relationships between a doctor and a patient are condemned because they jeopardise the effectiveness of treatment. The American Medical Association’s Ethics and Judicial Affairs Committee asserts that if a healthcare provider becomes aware of such a relationship among colleagues, they are obligated to report it to the local medical association, licensing board, or other regulatory authorities. The Belarusian Medical Code of Ethics similarly states that, “A physician has no right to engage in intimate relationships with a patient”. A doctor must distinguish between sympathy for a patient and sexual attraction. If such feelings arise, the doctor should consult colleagues or specialists to prevent negative consequences for the treatment, or, if necessary, transfer the patient to another physician [7].

Ethical Dilemmas in Healthcare Decision-making

Ethical questions frequently arise during patient care, requiring discussion and careful consideration. Waiting lists, access to medical resources, and decisions regarding the best course of treatment all pose ethical dilemmas. It is essential to recognise that what is ethical is not always synonymous with what is legal. For instance, something might be unethical but entirely lawful.

An example of this is the situation in emergency departments, which are often overburdened. Legally, there is no requirement for a medical facility or hospital administration to expedite its work. However, ethically, it may be advisable to raise the issue with the hospital leadership to explore ways to assist more patients more efficiently.

It stands to reason that medical professionals and hospital administration should work together to find optimal solutions for patient care. This might involve reorganising processes, allocating additional resources, or modifying operational protocols to improve efficiency and quality of service.

Ethical Challenges in Organ Donation and Resource Allocation

Other examples of ethical dilemmas in healthcare relate to prioritising patient treatment. Who should receive immediate attention, and who should wait? Is it ethical, in organ donation cases, to prioritise giving a liver to an elderly patient suffering from alcoholism over a younger patient who would also benefit from the organ?

Moral dilemmas in the field of transplantation are particularly relevant, as they affect both donors and recipients. Transplantology is an ethically charged area of medicine, and it raises many questions regarding the priority and justification for the use of limited healthcare resources for organ and tissue transplantation.

Social justice plays a critical role in this issue, as redistributing resources in favour of transplantology could mean that other vital areas of healthcare – such as chronic disease management, prevention, and diagnostics – might lose priority. Additionally, transplantology serves a limited pool of potential recipients, which can raise questions about equitable access to medical care.

The global practice of organ harvesting from healthy donors is indeed based on the principle of autonomous voluntary consent, a key bioethical principle. In practice, transplantology typically requires the donor and recipient to be genetically related to prevent ideas of compensation, whether material or financial, that could arise if the donor were not related to the recipient. Most countries prohibit the sale and purchase of donor organs, and humanity continues to seek ways to prevent the illegal harvesting of organs [8].

Ethical Considerations in Healthcare: Navigating Complex Decisions

Ethical considerations in healthcare are intricate, and sometimes even the right decision may not seem the most ethical. Healthcare professionals frequently face ethical dilemmas, especially in life-threatening situations. These dilemmas often require balancing legal obligations with moral imperatives. However, the resolution of ethical dilemmas in medicine is not always black and white, as in the case of lawful versus unlawful actions. Today, modern medical professionals must contend with several key ethical challenges.

One such challenge is the patient’s right to refuse resuscitation, often expressed through a Do Not Resuscitate (DNR) order. End-of-life care decisions are among the most critical and contentious ethical dilemmas in healthcare. In the United States, a DNR is a medical order that can be given either in writing or verbally, depending on local laws. It indicates that, in the event of a cardiac arrest, the patient should not undergo cardiopulmonary resuscitation (CPR).

Each U.S. State has its own laws and regulations that healthcare professionals must follow. For instance, in some regions, DNR orders are only valid within the hospital setting and may not be recognized in other circumstances. If a healthcare professional is aware of a DNR order but initiates resuscitation anyway, the patient’s family may have grounds for legal action against the provider.

However, one of the ethical questions in healthcare is: What happens when a patient clearly refuses resuscitation?

In 2017, a resident of Florida had “Do Not Resuscitate” tattooed on his chest, which raised questions about the seriousness of the tattoo. Although the patient could not speak or breathe, the intensive care unit respected the tattoo and chose not to initiate artificial respiration (URL: https://postnauka.org/video/65552). This case highlights the complexities of honouring patient wishes, even when the form of expression (in this case, a tattoo) is unconventional.

In Russia, healthcare professionals follow Article 20 of the Federal Law on Health Protection, which outlines the process for obtaining informed voluntary consent to medical intervention or refusal of such intervention. If a patient is conscious, they have the right to refuse medical care. This decision can be made in advance during the patient’s first visit to a healthcare facility. Furthermore, patients can refuse specific medical interventions. For example, a patient may consent to taking aspirin but decline a blood transfusion. They may also inform the physician that they do not require medical assistance under certain conditions and should be released, provided they are conscious and capable of making such a decision (URL: https://www.cnews.ru/news/top/2022-11-28_rossijskie_mediki_vse_chashche).

Patient Privacy and Confidentiality: A Major Ethical and Legal Concern

One of the most significant legal and ethical issues in healthcare is patient privacy. Confidentiality in the doctor-patient relationship is of paramount importance in medical practice. In Russia, it is reported that up to 90% of personal data from clinics and hospitals is exposed due to either hacking or negligence by medical personnel. A 2022 InfoWatch report analysed data breaches in healthcare from January to October of that year.

The report found that the proportion of intentional data leaks increased from 58.3% in 2021 to 87.5% in 2022, meaning that more than four out of five data breaches were deliberate. Moreover, the total volume of leaked data from Russian patients in 2022 decreased by 33% compared to 2021. There were eight incidents in which medical organisations’ databases were made publicly accessible, resulting in a 775-fold increase in stolen information, totalling 31 million records.

Igor Bederov, head of the Internet Investigation Company, noted that Russia has not yet introduced turnover-based fines, which is a drawback for private organisations. He compared this situation to that of the American company EyeMed, which was fined $600,000 for leaking data on two million clients, while the Russian company “Gemotest” was fined only 60,000 rubles for leaking information on 30 million patients [9]. This disparity highlights the need for significant legal reforms in Russia’s personal data protection laws.

Moral Challenges and Dilemmas Faced by Physicians

The moral challenges and dilemmas that physicians encounter are complex and multifaceted, touching upon not only medical ethics but also the personal and professional qualities of doctors. To overcome these moral challenges, physicians need to develop key personal and professional traits, including communication skills, empathy, ethics, and self-awareness [10].

The moral requirements of a physician’s professional culture form the foundation of their work and influence the quality of medical care. These requirements not only help doctors achieve high professional standards but also enable them to build trust with their patients, which is a crucial aspect of successful treatment. By showing compassion and respect for their patients, adhering to ethical standards, and continuously improving their skills, doctors make significant contributions to the overall health and well-being of society.

Ethical Decision-Making in Medical Practice

Moral dilemmas represent a key aspect of medical ethics, arising frequently in professional practice and often placing physicians in difficult positions. A lack of skills or experience in addressing these dilemmas can lead to unethical behaviour. The ability to think ethically is critical to providing quality medical care. Professional principles, accountability, and knowledge are all essential components of moral reasoning in the medical field.

For instance, physicians often face dilemmas regarding how to allocate limited medical resources, such as prioritising who should receive life-saving treatment first. These decisions require careful ethical consideration, weighing the urgency of each patient’s condition, societal values, and available resources.

Another recurring ethical challenge in medical practice is the handling of sensitive issues, such as end-of-life decisions, organ donation, and the appropriate use of medical interventions. These situations often require doctors to navigate not only clinical complexities but also profound moral questions about human life, dignity, and autonomy. For instance, determining whether to perform a medical intervention that aligns with a patient’s wishes or to respect their refusal of treatment can be emotionally and ethically charged, particularly when there are conflicting views between the patient’s family and the medical team.

Conclusion

The ethical demands placed on physicians from the foundations of professional medical culture directly influence both the quality of care and patient trust. In today's modern multicultural world with rapid technological and medical advancements, the ability to navigate complex ethical issues, while maintaining compassion and respect for patients’ cultural and personal values, is essential for modern healthcare professionals.

As medical technology and patient autonomy continue to evolve, so too will the ethical dilemmas faced by physicians. The core of a physician’s professional responsibility lies the coherence to high ethical standards, patient confidentially, informed and fair treatment decision-making, and continuous improvement in both technical skills and ethical reasoning. These principles will not only guide doctors in making difficult decisions but also ensure that the trust placed in them by society continues to endure.

 

Additional information

Author contribution. All authors made a substantial contribution to the conception of the work, acquisition, analysis, interpretation of data for the work, drafting and revising the work, final approval of the version to be published and agree to be accountable for all aspects of the work.

Funding source. This study was not supported by any external sources of funding.

Competing interests. The authors declare that they have no competing interests.

 

Дополнительная информация

Вклад авторов. Все авторы подтверждают соответствие своего авторства международным критериям ICMJE (все авторы внесли существенный вклад в разработку концепции, проведение исследования и подготовку статьи, прочли и одобрили финальную версию перед публикацией).

Источник финансирования. Авторы заявляют об отсутствии внешнего финансирования при проведении исследования.

Конфликт интересов. Авторы декларируют отсутствие явных и потенциальных конфликтов интересов, связанных с публикацией настоящей статьи.

About the authors

Elena A. Tkachenko

Volgograd State Medical University

Author for correspondence.
Email: elena-cherednichenko@mail.ru
ORCID iD: 0000-0002-3745-7835

Postgraduate student of the Department of History and Cultural Studies

Russian Federation, Volgograd

Sodder S. Sebastian

Volgograd State Medical University

Email: svelton.ru@gmail.com

Graduate student

Russian Federation, Volgograd

References

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