포격 속의 프로페셔널리즘: 갈등, 전쟁, 그리고 전염병

포격 속의 프로페셔널리즘: 갈등, 전쟁, 그리고 전염병

Professionalism under fire: Conflict, war and epidemics

MICHELLE MCLEAN1, VIKRAM JHA2 & JOHN SANDARS3

군복을 입고있든 아니든, 정권의 탄압이 있든 없든, 관리의료기관의 수문장 역할이든 아니든, 의사는 환자의 마지막 보루이다. 이 역할을 저버리는 것은 의학의 본분 - 지식을 사람을 돕고, 낫게 하고, 돌보는 것 - 을 저버리는 것이다.

Whether in a military uniform or not, whether a bureaucrat in an oppressive regime, whether a gatekeeper in a managed care organization, the doctor is the patient’s last safeguard. To abandon that role is to defect from what medicine is about: the use of knowledge to help, heal, cure, and care for persons. (Pellegrino & Thomasma 2000, p. 270)

의학에서 프로페셔널리즘은 다음과 같이 정의되어 왔으며 그리고 이는 의학과 사회 사이에 맺어진 사회적 계약이다.

In medicine, professionalism has been defined as ‘‘a set of values, behaviors, and relationships that underpin the trust that the public has in doctors’’ (Royal College of Physicians 2005) and is the basis of a social contract between medicine and society (Cruess & Cruess 2014). 

오늘의 의학전문직업성을 규정한 것은 Swick의 professional competencies를 기반으로 하고 있다. Sox에 따르면 '전문직업성'이라는 단어는 현대 의사에게 특별한 의미를 지닌다. 이 단어는 존경하는 모든 동료에 대한, 그리고 고군분투하는 자신에 대한 것을 모두에 대한 것이다.

Today’s medical profession- alism codes such as the 2001 American Medical Association Principles of Medical Ethics and the 2002 Professional Charter have been framed around Swick’s (2000) professional competencies (Table 1). For Sox (2007), ‘‘the word profes- sionalism has a particular meaning to contemporary phys- icians. It connotes everything that we admire in our colleagues and strive for in ourselves’’ (p. 1532).

Conflict and war

홀로코스트의 잔혹성은 아마도 인간에 대한 범죄의 가장 극명한 사례일 것이다. 뉘른베르그 코드와 같이 이런 일이 다시는 일어나서는 안된다는 전 세계적인 합의가 있었지만, 다시 일어나고 말았다. IMAP TF 보고서와 US SSCI에서는 부시행정부가 테러와의 전쟁을 치르는 동안 CIA에 의해 자행된 고문과 비인간적 행위를 인정했다. IMAP 보고서에서는 구체적으로 기술했다. 

The atrocities of the Holocaust are probably the most explicit examples of crimes against humanity (Pellegrino & Thomasma 2000; Geiderman 2002a,b; Chelouche 2005, 2008). Despite universal acceptance (e.g. Geneva Conventions, Nuremburg Code) that such abuse and dehumanization should never be allowed to happen again, it has. Both the Institute on Medicine as a Profession (IMAP) Task Force Report (2013) and the United States (US) Senate Select Committee on Intelligence (2014) have made public the torture and inhumane treatment of detainees at the hands of the US Military and the Central Intelligence Agency (CIA) during the Bush regime’s War on Terror which began after the events of 9/11. The 2013 IMAP report specifically described how military medical personnel were involved in monitoring oxygen saturation during water- boarding, watched for edema in detainees forced to stand in stress positions, shared information from prisoners’ health records with interrogators and force-fed prisoners (Okie 2005; Clark 2006; Miles 2007, 2013; IMAP 2013; Kimball & Soldz 2014), as well as failing to document evidence of torture in many instances (Iacopino & Xenakis 2011).

911사건은 새로운 종류의 전쟁을 이끌어낸 계기가 되었다. 군의사가 개입하기 시작한 것이다.

The events of the 11 September 2001 led to ‘‘a new kind of war’’ (War on Terror), one in which the ‘‘long-accepted norm barring military clinicians from being involved in coercive interrogations of prisoners and in administering non-thera- peutic drugs to soldiers’’ (Miles 2013, p. 117) was set aside. So began a period of obtaining information at any cost, a time in which military medical personnel participated in activities which ‘‘represent a dramatic departure from the conventional medical ethics, which are anchored in the ‘‘do no harm’’ principle’’ (Kimball & Soldz 2014, p. 1) and which violated widely accepted ethical standards set out in the United Nations Principles of Medical Ethics, the Geneva Conventions and the Declarations of Tokyo and Malta (Clark 2006; Miles 2007; IMAP 2013).

Clark의 질문은 주목할 만 하다. "잘 훈련받은 의료인이 이러한 행위에 동참하는 것, 더 나아가 여기에 대해 조용히 있는 것은 우리의 의학교육 시스템이 문제가 있음을 보여주는 것일까? 이 부적절한 프로페셔널리즘적 행위와 주변 맥락을 함께 살펴본다면, 이 행위 중 일부는 미국 정부가 WoT 를 치르는 동안에 자행된 것임을 눈여겨봐야한다."

In the light of this discussion, Clark’s (2006) question becomes pertinent: Is there something fundamentally wrong with our medical education system that allows well-trained medical personnel to become actively involved in abuses, or, even worse, remain silent? To place these reported ‘‘lapses’’ in professionalism into context, it is important to note some of the actions taken by the US government and military during the War on Terror (IMAP 2013):

따라서, WoT동안 많은 군 의사와 심리학자들은 법적 구속력이 있는 지침에 따라 행동했고, 이것을 따르지 않는 것이 위법이 될 상황이었다.

Thus, during the War on Terror, many military physicians and psychologists acted under legally binding instructions, with disobedience carrying the threat of misconduct and possible dismissal (Physicians for Human Rights 2014).

감염질환과 유행병

Infectious disease and epidemics

역사적으로 유행병에 대한 의사들의 반응은 여러 갈래였다. 흑사병 시기에 그 환자들을 보는 것은 개인적 선택이었지만, 1847년 이후 여러 규정이 등장하였다. 1912년에는 그러한 환자를 돌보는 것이 대중의 일반적인 기대였고, 이것으로 인해서 1920년과 1940년 사이에는 많은 의사들이 결핵에 걸리거나 사망하기도 했다. 그러나 1950년대가 되어서는 유행병이 크게 줄어들면서 1977년에는 전염병과 관련된 조항이 삭제되었다.

Historically, physicians’ responses during epidemics have been mixed. For example, during the plague outbreaks of Europe, some stayed with their patients, often succumbing to the disease. Others fled, abandoning their patients (Huber & Wynia 2004). At that time, treating such patients was viewed largely a matter of personal choice, a charitable act or a religious obligation until the founding of 

• the American Medical Association (AMA) in 1847 when explicit professional ethical standards around treating infected patients were formalized. The 1847 Code specifically stated ‘‘when pestilence prevails, it is [physicians’] duty to face the danger, and to continue their labors for the alleviation of suffering, even at the jeopardy of their own lives’’. 
• This was strengthened in 1912 (Principles of Medical Ethics) with ‘‘When an epidemic prevails, a physician must continue his labors for the alleviation of suffering people, without regard for risk of his own health or financial return’’ (Baker et al. 1999). At that time, it became a public expectation that physicians treat the sick which probably accounted for many physicians contracting and even succumbing to tuber- culosis between 1920 and 1940. 
• By the 1950s, however, the risk of epidemics had fallen dramatically and, in 1977, the principle of care relating to epidemics was removed from the Principles of Medical Ethics (Huber & Wynia 2004).

1980년대에 HIV가 등장하면서 전염병에 대한 경험이 없던 두 세대의 의사는 감염된 환자를 보는 것을 거부하기에 이르렀다. 이는 30년이 지난 시점에서 그러한 상황에서 의사의 역할에 대한 논의를 촉발시켰고 AMA는 다음과 같이 기술했다. HIV환자에 대한 문제는 의사의 사회적 의무보다 '차별을 금지하는 것' 혹은 '장애'에 대한 것에 더 초점이 맞춰졌다. 

With the emergence of HIV in the 1980s and with two generations of doctors having had no experience of outbreaks or epidemics, some medical practitioners refused to treat infected patients. This fuelled the first discussions in about 30 years about physicians’ duty of care in such instances. Eventually, the AMA stated that ‘‘A physician may not ethically refuse to treat a patient whose condition is within the physician’s current realm of competence solely because the patient is [HIV] seropositive’’ (Huber & Wynia 2004, p. W8). The issue of duty to HIV patients thus related to non- discrimination (Huber & Wynia 2004) or ‘‘disability’’ (Reid 2005) rather than the profession endorsing a broad social duty to treat during epidemics.

최근의 Ebola, 조류독감, 사스 등의 사태는 의료 전문직업성을 더 살펴볼 수 있는 계기였다. 어떤 사람은 이타적으로, 어떤 사람은 보다 자신의 안전을 중심으로 행동했다. 그리고 이것을 바라보는 관점도 자신에 대한 보호라는 견해부터 책무를 이행하지 않았다는 것까지 다양했다.

Recent outbreaks of Ebola, avian flu and SARS (severe acute respiratory syndrome) have provided opportunities to further explore medical professionalism in the context of emerging health threats. While altruism led to many individ- uals risking their lives to serve affected patients, the behavior of others could be deemed to be more self-serving: Compensation requests, failure to report for work and refusal to put oneself at risk (Straus et al. 2004; Reid 2005; Shiao et al. 2007; Seale et al. 2009; Kinsman 2012; Silva 2014; Yakubu et al. 2014). Perceptions of these actions have ranged from self- preservation to abandonment of duty (Reid 2005; Kinsman 2012).

행동에 대한 이해

Towards an understanding of behavior

어떤 행동의 근간을 이해하는 것은 왜 의사들이 그렇게 다양하게 행동하는지를 이해하는데 도움이 될 것이다.

Understanding what underpins behavior may help to explain why health care professionals chose to behave differently when faced with moral challenges.

모든 행동은 개인적, 사회적, 환경적 복잡한 관계의 영향을 받는다. 따라서 의료 전문직업성에 대한 개인주의적 관점은 의사들이 전문직으로서 어떻게 행동하는지를 완전히 설명해주지 못하며, 이는 특히 전문직으로서의 가치와 신념이 도전받는 상황에서 더욱 그러하다. 다음과 같은 다양한 관점이 있다.

Any behavior is therefore a complex relationship involving the individual and social influences, including environmental factors (e.g. threat, peer pressure, law). An individualistic perspective of medical professionalismtherefore does not fully explain how physicians develop and act as professionals, especially when their fundamental professional values and beliefs are challenged (Martimianakis et al. 2009).

• For Ginsburg and colleagues (2000), context is important in influencing individual factors in this model. In terms of military medical personnel, dual loyalty, the need to balance the medical needs of patients in the face of a duty to an employer, has been used to explain why physicians have been seen to act ‘‘unprofessionally’’ in challenging circum- stances (Sidel & Levy 2003; Clark 2006; Snow 2007; Miles 2013; Kimball & Soldz 2014; Solberg 2014).

• As Powell (2005) has pointed out, the ethos of an organization or a cause can be internalized, prompting actions which the individual would not normally perform. Such acts might include medical personal being aware of (and not reporting) or participating in physical or psychological abuse or torture.

• Gross’ (2006) provocative debate on nationalism vs. morality in challenging circumstances such as conflict considers the rights of the individual (the prisoner) and ‘‘the greater good’’ (national security). 
• In his view, a physician’s duty, like any citizen, is to consider the humanitarian issues involved and question national directives. 
• He argues, however, that there may be times, in the interest of national security, that a physician is required to certify that a detainee is medically fit to undergo interrogation because the benefit to the nation outweighs the needs of the individual. 
• TBP에 따르자면 이런 상황에서는 주관적인 규범이 더 강력한 동기가 된다.
  In terms of the TPB, the subjective norm (i.e. social pressure to respond) would thus be a powerful motivator to comply.

전염병이나 공공보건에 관한 이슈에 대해서 이해할 때 어떤 연구자들은 어떻게 개개인이 반응하며, 무엇이 그러한 행동의 기저에 있는가에 대한 통찰을 제시했다. 

In terms of understanding responses to epidemics and public health issues, several authors have provided useful insight into how individuals respond and what might underpin their actions (Straus et al. 2004; Reid 2005; Qureshi et al. 2005; Seale et al. 2009; Connor 2013, 2014; Silva 2014). Of particular relevance in this context are Reid’s (2005) debate on risk and the duty to care and Connor’s (2014) TPB modeling on the intention of health care workers to respond. 

• Reid에 따르면 사회는 적절한 보건의료 시설을 갖추고 예방적 규정을 마련하는 것과 같이 동등한 책임을 갖는다.
  Reid’s (2005) discussion, sparked by the SARS epidemic revolves around the risk health care workers faced and the unrealistic social expectation to treat, irrespective of their personal well-being. For Reid (2005), unrealistically, ‘‘the social contract forming the professions leaves us with no one but the licensed healthcare professionals to turn to in an emergency’’ (p. 353) and ‘‘posing the issue of duty of care solely in terms of an obligation to others in conflict with self-interest fails to capture the real moral dilemmas faced by healthcare workers in an infectious epidemic’’ (p. 358). In Reid’s (2005) opinion, it should be incumbent upon society to equally share in the responsibility during such episodes by, for example, ensuring appropriate health care infrastructure and by having appropriate precautionary regulations.

• 공공적 응급상황에 대응하는 것은 perceived behavioral control > subjective norm > outcomes belief 순서로 영향을 받는다.
  Connor (2013, 2014) found that the intention to respond to public health emergencies is influenced directly and foremost by perceived behavioral control, followed by the subjective norm, and, to a lesser extent, by outcomes beliefs. The decision to respond to a disaster is thus a complex balance between 
• personal (e.g. knowledge, skills, duty to patients vs. loved ones), 
• contextual and environmental (e.g. natural disaster vs. biological or chemical) and 
• social (e.g. response role) factors (Connor 2013, p. 5). 

• 확실한 가이드라인 없이는 의료인력은 도덕적 딜레마에 빠지게 된다. 여러 상황이 종합되면 '양심'의 값이 비싸진다.
  Yakubu and colleagues’ (2014) article on the ethical obligations during the recent Nigerian Ebola outbreak identifies just this in the face of no clear guidelines: ‘‘In the absence of clear guidelines, healthcare workers face a moral dilemma. Their conscience urges themto treat all patients, but convergence of...
• failed health system factors, 
• the danger to life, 
• emotional considerations like danger posed to family and friends, and 
• the absence of commensurate compensation for engaging in high risk service can make following one’s conscience costly’’ (p. 1).

교육에 대한 함의 

Addressing the challenges: Implications for medical and health professions education (and beyond)

Bryan은 기초-전문직업성과, 상위-전문직업성을 구분하였다.

Bryan (2003) explains some health care professionals risking their own lives for the greater good in terms of two types of professionalism, which he calls basic and higher professionalism. 

• 모든 의료인은 기초-전문직업성 All health care professionals should demonstrate basic professionalism. 
• 소명과 같은 상위-전문직업성 Higher professionalism, however, becomes important in challenging situations. Higher professionalismis a calling, often with little or no prospect of reimbursement, is virtue-based and usually involves substantial personal risk. 
• 에볼라에 대응한 의사와 같은 사례
  Time Magazine’s recent Person of the Year issue, which recognizes the heroic work of some of those involved in dealing with the recent Ebola outbreak in Liberia, exemplifies this higher professionalism: ‘‘Doctors who wouldn’t quit even as their colleagues fell ill and died; nurses comforting patients while standing in slurries of mud, vomit and feces’’ (http:// time.com/time-person-of-the-year-ebola-fighters/). 
• 학생을 선발할 때 이러한 상위-전문직업성을 보유한 개인들이 비록 최상위 성적이 아니더라도 입학할 수 있게 해야 함.
  As many individuals with such a calling will apply to study medicine and other health professions, the challenge is to ensure that our admission criteria include such individuals, even if they are not the highest academic achievers (Box 1).

이러한 상황에 직면한 모든 의사가 근본적 도덕 원칙에 반하여 행동하는 것은 아니다. 사회학적 관점이 유용한 통찰을 제공한다.

Not all doctors faced with challenging situations will, however, act against their fundamental moral principles (Perl 1948; Leyton & Locke 1998). A sociological perspective provides a useful insight, highlighting the dynamic relationship between individual agency (freedom to choose from a range of valued options and outcomes) and the social structures within which the individual is working and living (Archer 1995). 

• The development and maintenance of individual agency is complex but depends on a clear moral purpose and a well-developed professional identity (Korsgaard 2009). We believe that medical and health professions education has a responsibility to assist individuals to develop a strong moral purpose, with well-constructed personal and professional identities and to explore how these may be challenged. 
• This can be done by selective prompts for discussion (Lifton 2000;Hsin & Mercer 2004) and by fostering a constant reflective approach to practice thereby creating an increased awareness of the influence of social structures on one’s behavior(Archer 2003). 

학생의 성찰 능력을 키워줘야 한다. 그러한 상황이라면 자신의 신념에 의해, 그리고 행동의 결과에 기반하여 어떻게 행동했을지 생각해봐야 한다.

By developing students’ reflective skills, medical and health professions education can assist students (and later, as professionals) maintain their moral purpose in difficult situations. Students (and health professionals) need to reflect on how they might behave during challenging times, based on their own beliefs about their behavior, as well as the outcomes of the behavior (i.e. their behavioral beliefs). 

TPB를 활용한 시나리오 제공

Using the TPB,students can be provided with scenarios in which personal risk needs to be evaluated, taking into consideration the possible variables, opinions e.g. and 

• outcomes (e.g. personal benefit or loss),
• involvement of colleagues (i.e. normative beliefs), 
• incentives (e.g. financial or social gains) and 
• barriers (e.g. unsafe working conditions). 

We also need to make our graduates aware of the need to continue to develop the skills required to deal with challenging situations. This is particularly important for those joining the armed forces or who volunteer during civilian crises. Although ethical guidelines have emerged from the experiences of medical personnel during the War on Terror (e.g. 2012 British Medical Association toolkit for ethical decision-making for doctors in the armed forces), understanding how humans behave in a range of challenging contexts and examining how one might respond if confronted with similar scenarios, will contribute to developing the skill of reflection as an tool to regulate our graduates’ actions when under pressure and to ensure the maintenance of a True North on their moral compass. 

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Med Teach. 2015 Sep;37(9):831-6. doi: 10.3109/0142159X.2015.1044951. Epub 2015 Jun 1.

Professionalism under fire: Conflict, war and epidemics.

Mclean M1, Jha V2, Sandars J3.

Author information

• 1a Bond University , Australia .
• 2b University of Liverpool , UK .
• 3c University of Sheffield , UK.

Abstract

Today's medical students (tomorrow's doctors) will be entering a world of conflict, war and regular outbreaks of infectious diseases. Despite numerous international declarations and treaties protecting human rights, the last few decades has been fraught with reports of "lapses" in medicalprofessionalism involving torture and force-feeding of detainees (e.g. captured during the War on Terror) and health care professionals refusing to treat infected patients (e.g. HIV and Ebola). This paper provides some historical background to the changing status of a physician's duty to treat and how medical practitioners came to be involved in the inhumane treatment of detainees during the War on Terror, culminating in reports of "lapses" inprofessionalism. The Theory of Planned Behavior, which takes into account the individual, the environment and the social context, is used to explain the factors that might influence an individual's behavior in challenging situations. The paper concludes with some recommendations for medical and health professions education. The recommendations include selecting students who, as a minimum, can provide evidence of "basic"professionalism, engaging them in exploring the history of the medical profession, exposing them to contexts of uncertainty and moral dilemmas and challenging them to reflect on their responses.

PMID:

 

26030379

 

[PubMed - in process]