THE MORAL AND TECHNICAL COMPETENCE OF THE OPHTHALMOLOGIST

American Academy of Ophthalmology

1991, revised 1999

The following Moral and Technial Competence material augments the AAO's Code of Ethics, which can be at http://www.aao.org/aao/member/ethics/code_ethics.cfm.

<http://www.aao.org/aao/member/ethics/moral_competence.cfm>

Information Statement

Introduction

The overall purpose of developing ophthalmologic competency is to improve the physician–patient relationship and the medical care that accompanies that relationship. Competent ophthalmologic practice requires both moral and technical capacities. Moral capacities are demonstrated by 1) appreciation of clinical ethical problems, 2) practicing as an agent of the patient, and 3) facilitating a caring relationship with the patient. Technical capacities are comprised of the knowledge and skills required to practice medicine, and especially ophthalmology, according to current standards of care.

Background

The American Academy of Ophthalmology is dedicated to providing ophthalmologists with information and education necessary for the optimal care of the public. The quality of such care is based on competence achieved through training and continuing education. The Academy's Code of Ethics, which serves as a standard of exemplary professional conduct, requires that an ophthalmologist be competent by virtue of specific training and experience (Rule 1). However, the Rules of the Code specify neither the components of competence nor the capacities of which it is comprised. Competence for medical (ophthalmologic) practice does not occur in the abstract. Physician competence exists for the purpose of advancing the best interests of the patient as a person—with sensitivity, and with respect for and understanding of their sovereignty needs and wants.

Bioethicists generally agree that "moral" and "ethical" values are equivalent; these words are used synonymously here. Moral (and ethical) capacities are those which preserve, protect and advance the best interests of the patient through the practice (a process) of applying knowledge, skills and attitudes which resolve the human conflicts and dilemmas of clinical and scientific endeavor on principled bases.

Ophthalmologic Competence

Ophthalmologic competence is comprised of both moral and technical capacities; both are necessary to establish ophthalmologic competence. Ophthalmologic competence is thus a continuing process of self-development; of acquiring and refining the knowledge, skills, values, and expectations to provide quality patient care.

This acquisition process, of necessity, must proceed along two paths:

1. An outer-directed process of study and instruction into the vocabulary, concepts, case studies, negotiation strategies, and so on, that concern moral and technical capacities, and
2. An inner-directed process of personal experience and insight that integrates personal and professional development and moral and technical capacities.

Moral Competence

Moral competence follows from understanding the purpose of medical care and calls upon the physician to practice moral discernment, moral agency, and caring in relationships.

Moral discernment is the ability to confront, discuss, and resolve the ethical considerations in a clinical encounter. In particular, it is the ability to:

• Use the vocabulary and concepts of ethical and moral reasoning to place a moral dilemma in perspective;
• Respect the cultural, social, personal beliefs, expectations, and values that the patient brings to the therapeutic setting;
• Respect the patient's chosen lifestyle and acknowledge the conditions and events that have helped to shape that lifestyle;
• Confront one's own beliefs, expectations, and values when faced with different perspectives; and
• Reflect on the causes and consequences of one's ethical decisions.

Moral Agency is the ability to act on behalf of the patient; to act with respect for social, religious, and cultural differences that may exist between physician and patient. It is the ability to:

• Consider the possible consequences of one's actions and to act to affect consequences that are in accord with one's values and those of the patient;
• Resolve differences on the basis of principle, rather than power;
• Provide medical care that is both professionally appropriate and socially responsible;
• Genuinely engage the patient as a fellow human being; and
• Keep the confidences of the patient.

A caring and healing relationship between physician and patient is the foundation of medical care. Such a relationship is characterized by ability to:

• Acknowledge the patient's right to self-determination in the process of participating in his or her own care;
• Avoid conflicts of interests in one's own personal, professional, and financial relationships with patients, colleagues, and other members of the health care community;
• Provide the patient complete, accurate, and timely information about treatment options in the best spirit of informed consent;
• Share one's weaknesses and limits as well as one's strengths and virtues; and
• Strive for the experience of compassion through progressively deeper understandings of others' behavior.

Technical Competence

Technical competence consists of the knowledge and skills necessary to diagnose and treat disease and disability according to the precepts of medical science and especially of ophthalmology, and to assist in the maintenance of health.

In particular, technical competence consists of the ability to:

• Apply principles of ophthalmic care;
• Differentiate normal and pathological anatomy and physiology of the eyes and visual system;
• Understand the relationships between ophthalmic and systemic health and disease;
• Perform skills intrinsic to medicine in general and to ophthalmology in particular;
• Provide necessary and sufficient medical care; • Develop, critique, and present appropriate therapeutic options;
• Provide timely, complete, and accurate documentation about patient care; and communicate appropriately with other members of the medical community and the health care system;
• Acknowledge one's limitations in skill and knowledge; and
• Make a commitment, through study, instruction, and experience, to keep one's medical skills and knowledge current.

We acknowledge the importance of these moral commitments and technical capacities to the education, practice and credentialing of ophthalmologists. Further, the curriculum of ophthalmology should specifically address each of these two competencies and the two paths to developing them and should be defined further for purposes of assessment and accountability.

Approved by: Ethics Committee, January 1991

Revised and Approved by: Secretariat for Ophthalmic Practice & Services, February 1999