Trust, Covenant, Service Orientation

CONSCIENCE, TRUST,
AND
SERVICE ORIENTATION
CONSCIENCE
• “WITH KNOWLEDGE”
• A person’s moral sense of right and wrong, viewed as
acting as a guide to one’s behavior
• Metaphysical guide that acts in a judicial way to direct
person’s actions
• Closely related to person’s beliefs or convictions about
actions that are deemed morally right or wrong
Oxford University Press, “Conscience,” Oxford Dictionaries, 2013, http://oxforddictionaries.com/definition/english/conscience?q=conscience

CONSCIENCE
• Two main components (Medical Ethicists)
1. Person’s conscience is rooted in the fundamental
responsibility to consider all situations within a
framework of ethical obligation
2. This responsibility leads to judgements and
reasoning about the types of actions and
behaviors which characterize a moral right
P. Fuss, “Conscience part I,” in Conscience, J. Donnelly and L. Lyons, Eds., pp. 35–50, Alba House, New York, NY, USA, 1973.
CONSCIENCE
• Rather than a mystical intuition based on emotions,
feelings, or preferences
• REPRESENTS THE DECISION- MAKING
CAPACITY OF THE HUMAN MIND FOUNDED
ON A DESIRE TO LIVE AN UPSTANDING AND
HONOURABLE LIFE WHICH PROMOTES
GOOD FOR ONESELF AND OTHERS
Sulmasy, D. P. (2008). What is conscience and why is respect for it so important? Theoretical Medicine and Bioethics, 29(3), 135–149. doi:10.1007/s11017-008-9072-2
Retrospective and Prospective
JUDICIAL CONSCIENCE
• Things that we have done or have failed to do
• RETROSPECTIVE CONSCIENCE
• GUILT- main emotion associated
LEGISLATIVE CONSCIENCE
• Things that we anticipate doing or not doing
• JUDGEMENTS OF PROSPECTIVE
MORAL ACTS
Meta-judgement
that arises in
ORIGIN: ACT
particular moral
OF WILL
deliberations
Assent to the
truth that one
should act
morally Judgement that a
proposed act
would violate
Rooted in a
one’s
fundamental
fundamental
commitment to
moral
MORALITY
commitments
Acts are JUDGEMENTS.
Judgements that what one
Arises from a
has done or one is
fundamental commitment
contemplating doing are
or intention to be
in violation of this
MORAL.
fundamental commitment
It is a commitment to
to be moral.
uphold one’s deepest, self-
Most fundamental of all
identifying moral beliefs.
moral duties- the duty to
Arises from the meta-
unite one’s powers or
moral commitment to
reason, emotion and will
morality
into an integrated moral
whole- based upon one’s
most fundamental moral
principles and identity.
ERRONEOUS CONSCIENCE
• Adolf Eichman
• Major organizers of the holocaust
• Implementation of the genocide Final Solution to
the Jewish Question
• Acted conscientiously
• His conscience was troubled by the few exceptions
he made for those Jews that he allowed, solely
because of personal connections with him and his
family, to avoid the concentration camps, he
honestly felt they justly deserve
• CONSCIENCE IS NOT AN INFALLABLE MORAL GUIDE
• Moral error is possible through ignorance of important facts, or of the proper
moral rules, or of one’s most fundamental self- identifying moral commitments
• Occur through faulty reasoning, emotional imbalance, or poor judgement
• May be cognitive
• May be ignorant of the facts, moral premise may be in error, employed faulty
moral reasoning or because of strong emotions have clouded one’s ability to
decide
• Obligation to FORM ONE’S CONSCIENCE CORRECTLY
• Adoption of moral principles and with respect to accurate knowledge of the
particulars necessary to decide a case correctly
CONSCIENCE and
MORAL COMPLICITY
• First judgement: INTENT OF THE ONE WHO IS DOING WRONG
• FORMAL COOPERATION
CONSCIENCE and
MORAL COMPLICITY
How necessary is one’s cooperation to the carrying out of the act?
How proximate is one to the act, in space and time and in causal chain?
Is one under any degree of duress to perform the act?
How likely is one’s cooperation to become habitual?
CONSCIENCE and
MORAL COMPLICITY
Is the a significant potential for scandal?
Does one have a special role that would be violated by this action?
Does one have a proportionately important reason for the cooperation?
CONSCIENCE and
HEALTHCARE
STRESS OF CONSCIENCE
• Healthcare providers are unable to FREEDOM OF
fully address the needs or CONSCIENCE
challenges of those receiving care • Healthcare providers is asked
• Elevated stress of conscience is a or expected to participate in a
contributor to burnout, job specific action he or she deems
dissatisfaction, and the provision of to be ethically wrong
suboptimal patient care
Genuis SJ, Lipp C. Ethical diversity and the role of conscience in clinical medicine. Int J Family Med. 2013;2013:587541. doi: 10.1155/2013/587541. Epub 2013 Dec
12. PMID: 24455248; PMCID: PMC3876678.
Do not necessarily provide consistency of
care between clinicians; interpretations
may differ and subsequent course of action
may vary in accordance with diverse
opinions about integrity, best interests, and
human rights.
12. PMID: 24455248; PMCID: PMC3876678.
CONSCIENCE and
HEALTHCARE
Contend that the issues of ethical collision should be openly acknowledged and respectfully discussed between
professionals and patients.
Make an introspective assessment and perspicacious understanding of the ethical values guiding one’s decisions.
1. Which values guiding their conscience are deeply held standards

2. Which represent habitual patterns from socialization
3. Which are mere personal preferences
12. PMID: 24455248; PMCID: PMC3876678.
CONSCIENCE and
HEALTHCARE
Patiently and humbly seek to be empathetic and to understand patient objectives and beliefs in a non-
judgemental manner.
Understand and appreciate the ethical standards embraced by professional associations
12. PMID: 24455248; PMCID: PMC3876678.
CONSCIENCE and
HEALTHCARE
MORAL RESIDUE- That which each of us Failure to act in accordance with deeply- held
carries with us from those times in our lives when beliefs in times of “moral distress”
in the face of moral distress we have seriously MORAL TRAUMA/ MORAL INJURY
compromised ourselves or allowed ourselves to be
compromised.
Anger, resentment, guilt, frustration, sorrow, and
powerlessness
CONSCIENCE VIOLATION
12. PMID: 24455248; PMCID: PMC3876678.
12. PMID: 24455248; PMCID: PMC3876678.
POINT OF
DISCUSSION
1: ELECTIVE ABORTION FOR FETUSES WITH FATAL
CONGENITAL ANOMALIES
2. USE OF ELECTIVELY ABORTED FETUSES IN FORMULATION

OF VACCINES
3. GENDER TRANSITION (CHEMICAL/ HORMAL AND/ OR

PHYSICAL) OR ADOLESCENTS
4. MEDICAL EUTHANASIA IN PATIENTS WITH CHRONIC

DEBILITATING DISEASES
BREAK
TRUST
• Essential attribute in ALL human social
interactions
• Basic level of trust is important in any
transaction between human beings.
TRUST
• Optimistic acceptance of vulnerability
• PATIENT BELIEVES THAT THE DOCTOR
WILL DO WHAT IS BEST FOR THE
PATIENTS
• Forward looking COVENANT between the
doctor and the patient
PHYSICIAN
PATIENTS • Knowledge about the
• Exposes his/ her illness illness, management and the
body
VULNERABILITY
POWER DIFFERENTIAL
EXPLOITATION
Appropriate Correct
diagnosis treatment
TRUST = EXPECTATIONS
Genuine
Non-
interest in
exploitation
patient welfare
Transparent
disclosure of all
information
DIMENSIONS AND DETERMINANTS OF
TRUST IN HEALTHCARE
Gopichandran V, Chetlapalli SK. Dimensions and determinants of trust in health care in resource poor settings--a qualitative exploration. PLoS One. 2013 Jul
16;8(7):e69170. doi: 10.1371/journal.pone.0069170. PMID: 23874904; PMCID: PMC3712948.
TRUST IN HEALTHCARE
Perceived competence of Doctor/ Health Facility
‘‘My entire family gets treatment for any of their problems here (in the
primary health center). I refer all my friends and family to come to this
PHC for treatment. That is because they give good treatment. I came
here for my knee pain and the doctor saw me very well and treated
me well. My pain went off within a week. The drugs work very well
and we become alright soon.’’
RESOURCE RICH SETTING RESOURCE POOR SETTING
(Western Standards)
1. PERFORMING LAB TESTS
1. AVOIDING MEDICAL ERRORS 2. MAKING CORRECT DIAGNOSIS
2. PROVIDING BEST POSSIBLE OUTCOME OF 3. GIVING APPROPRIATE MEDICINES IN
HEALTH CARE TERMS OF ABILITY TO ACHIEVE
POSITIVE TREATMENT OUTCOME
COMPETENCE OF THE PHYSICIAN OR THE COMPETENCE JUDGEMENT IS DERIVED

HEALTH FACILITY FROM SHARED COMMUNITY OPTIONS
TRUST IN HEALTHCARE
Assurance of treatment
‘‘the PHC is like our home. Sometimes we like to eat outside in hotels.
But finally we have to come back to our home for home-food. Like that
we can go to any private hospital we want and spend any money we
want. But if we want something that we can always depend on then
we have to come to the Primary Health Center. Whatever happens we
can always go there and some kind of treatment will be given. They
will not turn us away for want of money’’
• In poor resource setting
• Eating out = LUXURY, reserved for special occasions
• Home cooked meals = daily source of sustenance
• In a cultural context
• Home food = guaranteed availability and SURETY
YOU NEED YOU NEED
PLEASE STICHES, IT’S STICHES.
HELP, I’M IN $$$ DO YOU PLEASE WAIT
SO MUCH HAVE IF THAT’S THE CASE HERE WHILE
, WE PREPARE
PAIN! MONEY? WE’LL CLEAN THE
WOUND, PUT A YOU ARE
WE DO NOT VERY
DRESSING AND
HAVE THAT WELCOME!
YOU’LL BE
MUCH. DISCHARGE
PLEASE
HELP, I’M IN
SO MUCH
PAIN!
THANK YOU
SO MUCH!
TRUST IN HEALTHCARE
Willingness to accept drawbacks in the doctor
‘‘If the doctor is good it doesn’t matter even if he is rude to us. Even if
he scolds us we know very well that he is doing it for our own good.
Therefore it is most important for the doctor to be knowledgeable and
good.’’
Willingness to accept drawbacks in the doctor
‘‘If the doctor is good it doesn’t matter even if he is rude to us. Even if
he scolds us we know very well that he is doing it for our own good.
Therefore it is most important for the doctor to be knowledgeable and
good.’’
• Reflection of the level of trust instilled by competence
judgements and a level of treatment assurance.
RESOURCE POOR SETTING

RESOURCE RICH SETTING
Behavioral issues such as rudeness are accepted as a
There is a choice of doctors tradeoff for competence or other trust dimensions
1/3 of the patients have dissatisfying clinical
encounters Willingness to spend money on a treatment is an
important dimension of trust
TRUST IN HEALTHCARE
Loyalty
Whatever illness it may be, they would come to a particular doctor/
facility
They would not take treatment from a higher center without first
consulting the particular doctor
• Strongly influenced by positive experiences, comfort with the
doctor/ facility, perceived competence
• Relates to willingness of the patient to accept drawbacks
TRUST IN HEALTHCARE
Respect
‘‘the doctor is a very learned man. He has studied for many years to
learn this noble art of curing people. I respect the fact that he is more
educated and knows a lot of things about disease and treatment’’
• Patients perceived the differential in the level of knowledge
between them and the doctor
• Respected the doctor for their knowledge
TRUST IN HEALTHCARE
TRUST IN HEALTHCARE
Comfort
‘‘The only important thing in a doctor is that he should be able to talk
to you in your own language and help you out to solve your problem.
If you can’t even talk to the doctor properly in your own language,
how can you get cured? For people like us who have language
barriers, if we have a doctor from our own language we are very
happy. If we see a doctor who talks our language we can be sure he
will treat us well’’
• Shared language, comfort communication
• Language, ethnicity and cultural competence
• Comfort in the familiarity

• Knowledge of the place
• Friends/ relatives working/ vouching for the center/ health
facility
TRUST IN HEALTHCARE
Personal involvement of the doctor/ health care provider
‘‘My husband and I live alone in the village. My sons and daughters all
live in [away]. They come here only for festivals. So we are always
looking for somebody to care for us and somebody to talk to us. That
young doctor took extra interest and cared for me like my own son.
Now I will go and tell my husband and everybody else to come and see
this doctor.’’
• Expect community health providers/ doctor to be involved at a
personal level with them
• “Good doctor”- person from own family, like own brother/

sister, person who cares
• The greater the personal involvement of the doctor, the
greater the level of trust
RESOURCE RICH SETTING RESOURCE POOR SETTING
Issue of personal involvement is seen in the lens of Personal involvement was considerable favorable
boundary crossing/ boundary violations Gift giving is favorable
TRUST IN HEALTHCARE
Doctor/ health care provider’s behavior and approach
‘‘More than half of the healing takes place because of the kind words
of the doctor. Only the remaining is because of the treatment. When
we come to a new hospital we are clueless. At that time the doctor
should be kind and talk to us patiently. The reason why we prefer
private doctors to PHC is because the private doctor talks to us
patiently. He spends time with us and checks us up thoroughly. He
talks to us and explains everything. That is very important…’’
• Kindness and compassion
• Putting themselves in the patient’s shoes and understanding
them
• Listening to the patient
• Addressing all doubts and questions
• Explaining the treatment
• Touching the patient
TRUST IN HEALTHCARE
Economic factors
‘‘But nowadays doctors in the private hospitals are asking for a lot of
money. When they ask for a lot of money the main problem is that
patients cannot believe if the doctor is doing things for the patient’s
good or for the doctor’s own benefit’’
• In low resource setting, no discussion of health care trust can be
complete without consideration of the cost factor.
• Expenses are usually out of pocket
• General mistrust in doctors who charge a lot- left with no choice
• High trust and distrust coexistence
TRUST IN HEALTHCARE
Health awareness
‘‘Nowadays patients are very much empowered. They ask the doctors
questions. Last week one day I had to leave early because of some
important meeting. The patients asked why the doctor is not there and
raised a big issue. Because of that I had to arrange for another doctor
to come and run the clinic when I was not there. Nowadays we cannot
take the patients for granted. They have become very smart and they
ask us questions’’ <doctor perspective>
• “Google culture”
• Patients are more aware about health, demand treatment and
asks a lot of questions
• Patients are empowered by easily accessed knowledge and
information
• May ask a lot of questions/ clarifications
BREAK
SERVICE ORIENTATION
• “disposition to be helpful, thoughtful, considerate, and
cooperative… [it is] a set of attitude, behaviors that affect
the quality of the interaction between hospital employees
and patients”
• More than just likeability, it is a manifestation of “fussy
kindliness”- characteristic of employees who “are stable,
dependable, charming and self confident”
O’Connor, S. J., Trinh, H. Q., & Shewchuk, R. M. (n.d.). Determinants of service orientation among medical students. Advances in Health Care Management, 217–249.
doi:10.1016/s1474-8231(00)01010-7
SERVICE ORIENTATION
• Ability to recognize and meet patient needs
• Focus on anticipating, recognizing and meeting people’s

needs no matter if they are patient’s or not.
doi:10.1016/s1474-8231(00)01010-7
SERVICE ORIENTATION
• Service quality expectations
1. Tangibles
2. Reliability
3. Responsiveness
4. Empathy
5. Assurance
doi:10.1016/s1474-8231(00)01010-7
Thank you.

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CONSCIENCE, TRUST,

Oxford University Press, “Conscience,” Oxford Dictionaries, 2013, http://oxforddictionaries.com/definition/english/conscience?q=conscience

Is one under any degree of duress to perform the act?

How likely is one’s cooperation to become habitual?

Does one have a proportionately important reason for the cooperation?

1. Which values guiding their conscience are deeply held standards

Understand and appreciate the ethical standards embraced by professional associations

2. USE OF ELECTIVELY ABORTED FETUSES IN FORMULATION

3. GENDER TRANSITION (CHEMICAL/ HORMAL AND/ OR

4. MEDICAL EUTHANASIA IN PATIENTS WITH CHRONIC

COMPETENCE OF THE PHYSICIAN OR THE COMPETENCE JUDGEMENT IS DERIVED

RESOURCE POOR SETTING

• Comfort in the familiarity

• “Good doctor”- person from own family, like own brother/

• Focus on anticipating, recognizing and meeting people’s

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