Ethics and Professionalism
A Guide for the Physician Assistant
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Ethics and
Professionalism
A Guide for the Physician
Assistant
Barry A. Cassidy, PhD, PA-C
Senior Vice-President Professional Services
NEXTCARE Urgent Care
Mesa, Arizona
Former Executive Director
Arizona Medical Board and Arizona Regulatory
Board of Physician Assistants
Former Professor, Associate Dean and Director
Physician Assistant Program
Midwestern University
Glendale, Arizona
J. Dennis Blessing, PhD, PA-C
Associate Dean for South Texas Programs
School of Allied Health Sciences
Professor and Chair
Department of Physician Assistant Studies
The University of Texas Health Science Center at
San Antonio
San Antonio, Texas
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F.A. Davis Company
1915 Arch Street

aspects. 3. Medical ethics. I. Cassidy, Barry A. II. Blessing, J. Dennis.
[DNLM: 1. Physician Assistants—ethics. 2. Clinical Competence. 3. Decision Making. 4. Ethics, Clinical.
W 21.5 E84 2008]
R697.P45E84 2008
174.2—dc22 2007002960
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Dedication
My efforts for this book are dedicated to the memory of Eugene A. Stead, Jr., MD, founding father
of the PA concept; and James R. Pluth, MD, retired thoracic and cardiovascular surgeon. Both men
were mentors, friends, and ethical role models for me. I also dedicate this book to my wife Barbie
Cassidy, who keeps me grounded and helps me live an ethical life with love.
—BAC
My efforts for this book are dedicated to Richard R. Rahr, EdD, PA-C, colleague, mentor, friend. A
role model and example of ethical behavior for us all.
—JDB
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Preface
This book was conceived more than 5 years ago. Its production was a labor of love and a program
of persistence. In our roles as educators of physician assistant students, we recognized that a text-
book discussing ethics and professionalism focused specifically for PA students would be helpful to
both them and their educators.

J. Dennis Blessing, PhD, PA-C
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ix
Contributors
Barry A. Cassidy, PhD, PA-C
Senior Vice-President Professional Services
NEXTCARE Urgent Care
Mesa, Arizona
Former Executive Director
Arizona Medical Board and Arizona Regulatory Board of
Physician Assistants
Former Professor, Associate Dean and Director
Physician Assistant Program
Midwestern University
Glendale, Arizona
Randy D. Danielsen, PhD, PA-C
Arizona School of Health Sciences
Associate Professor and Chair
Physician Assistant Studies
Mesa, Arizona
Ann Davis, MS, PA-C
Director of State Government Affairs
American Academy of Physician Assistants
Alexandria, Virginia
Moira Fordyce, MD, MB, ChB, FRCP Edin, AGSF
Laguna Niguel, California
Danny L. Franke, PhD
Alderson-Broaddus College
Philippi, West Virginia

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xi
Reviewers
Gilbert A. Boissonneault,
PhD, PA-C
Professor
Division of Physician Assistant
Studies
University of Kentucky
Lexington, Kentucky
Courtney Cribbs
Graduate
Physician Assistant Program
University of Findlay
Findlay, Ohio
Katherine M. Erdman,
MPAS, PA-C
Assistant Director and Instructor
Physician Assistant Program
Baylor College of Medicine
Houston, Texas
Carl Fasser, BA, PA-C
Director and Associate Professor
Physician Assistant Program
Baylor College of Medicine
Houston, Texas
James Hammond, MA, PA-C
Director
Physician Assistant Program

Mary Ann Laxen, MAB, PA-C
Director and Associate Professor
Physician Assistant Program
University of North Dakota
Grand Forks, North Dakota
Anthony A. Miller, MEd, PA-C
Director
Division of Physician Assistant
Studies
Shenandoah University
Winchester, Virginia
Rena N. Mitchell, MS, CHES,
RPA-C
Acting Chairperson and Clinical
Assistant Professor
Physician Assistant Program
SUNY Downstate Medical Center
Brooklyn, New York
John M. Schroeder, JD, PA-C
Director
Physician Assistant Program
Idaho State University
Pocatello, Idaho
Victoria Scott, MHS, PA-C
Director and Senior Physician
Assistant
Breast Wellness Clinic
Duke University Medical Center
Durham, North Carolina
Robert J. Spears, MPAS, PA-C

more time than we ever imagined. We are sure that our stops, starts, turnabouts, and changes of
minds on this book would have driven other people crazy. Fortunately, they stayed sane (even when
we were not), and we are eternally grateful for that.
We also want to acknowledge our colleagues who inspire us to make such efforts and those who
support us while we do. Of course, we can never forget our families and friends. They are the ones
who keeps us grounded, which we often need.
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Contents
1. Ethics and the Physician
Assistant Student 1
James E. Meyer, MD
2. Ethical Decision Making and
Ethical Principles 19
Therese Jones, PhD
3. The Ethics of Everyday
Practice 35
Michael Potts, PhD
Special Section:
Clinical Ethical Case Discussions 61
F.J. Gianola, PA-C
Case 1. Compelled Birth Control
in a Minor 63
Case 2. Somatizing Patient 70
Case 3. Addiction and
Autonomy
76
Case 4. Informed Consent, Culture,
Sex, and Language 83

Assistant Student
James E. Meyer,
MD
CHAPTER OUTLINE
Ethical Violations and Their Significance: Case Studies
In Search of Common Meaning: Ethical Integrity Versus Professionalism
Versus Civility
Is Ethics (Ethical Integrity) the Same as Professionalism?
Civility as the Behavioral Expression of Ethical Integrity and Professionalism
Ethics and the Traditional Curriculum
PA Training Versus Physician Training: Impact on Ethical Development
Today’s PA Students
Selection and Evaluation
Experience and Expectations
Moral Values
Unethical Behavior as “Incivilities”
Preventing and Responding to Incivilities
Emotional Intelligence as an Important Prerequisite for Civility
Student Disagreements With Preceptors/Attending Physicians
Application of Principles of Ethical Professionalism to Case Studies
Summary
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Case 1.1
During the third week of class of a new group
of physician assistant (PA) students, one of the
students makes a derogatory comment to this
instructor. The instructor is offended and retali-
ates with a demeaning verbal put-down. Several
other students hear the exchange and report
the faculty member’s behavior to the program

her as a medical student rather than as a PA stu-
dent. At first, the student was reluctant to object,
for fear of upsetting her preceptor, but she is
now feeling more uncomfortable about being
introduced this way. She calls to ask for advice.
Case 1.6
The office manager from a family practice site
discovers that a PA student has been taking sam-
ples of antibiotics and Viagra from the sample
closet. The office manager is trying to decide
whether to dismiss the student from the rotation
and wants to discuss the situation with the PA
program.
CASE STUDIES
Ethical Violations and Their Significance
A
ll of the preceding scenarios are, with minor
variations, real events that this author has heard
about in the past few years while working with PA
students. Unethical behavior of PA students is some-
thing that all PA programs must confront sooner or
later. Breaches of ethical behavior occur during both
the didactic year and the clinical year. Although most
PA students, like most students enrolled in other pro-
fessional fields, demonstrate good moral character,
there are always a few students who exhibit inappro-
priate, unethical, uncivil, or unprofessional behavior.
Similar types of behaviors are seen in most clinical
training programs, whether the trainees are medical
students or students in pharmacy, nursing. or other

Traditional forms of academic evaluation were much
2
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less likely to be predictive of future disciplinary
action. The authors make a plea for the development
of better tools to evaluate personal attributes of stu-
dent applicants and better training in professionalism,
with testing for competency.
d’Oronzio describes his work with physicians who
have had their licenses suspended for inappropriate
behavior related to “transgressions of professional
ethics.”
3
He observes that the most common types of
professional misbehavior fit into one of the following
three general categories: (1) boundary violations, (2)
misrepresentation, and (3) financial infractions. Each
of the examples given at the beginning of this chapter
could fit into one of these three categories.
Students in PA training programs are less likely
to get into difficulty with unethical financial behav-
ior than with boundary violations or misrepresenta-
tion. Financial fraud is more likely to develop after
graduation, in a practice setting. Because of the
dependent nature of the PA’s practice, the supervising
physician may be more likely to be the culprit in
financially unethical practices. However, stealing
samples from a preceptor’s office would fit into a
student category. Up-coding for services rendered,
submitting false claims, and similar financial indis-

dent and clinical preceptor are also similar. All
trainees are in a dependent relationship with their pre-
ceptor or attending physician.
The terminology used in discussions of ethics
and professionalism can be confusing. In spite of
the extensive literature on the subject (or because of
it?), there is still no common understanding of how
best to define professionalism.
6
Doukas remarks that
“the concept of professionalism has been bandied
about in whatever context the user intends. The cur-
rent discussion of professionalism is like the fable of
six men assessing an elephant: you believe what you
perceive.”
7
Numerous professional groups have
recently produced or revised their statements on pro-
fessionalism. The American Board of Internal
Medicine’s (ABIM) Project Professionalism outlines
“the six elements of professionalism” (altruism,
accountability, excellence, duty, honor and integrity,
and respect for others) and the challenges to those
elements (abuse of power, arrogance, greed, misrep-
resentation, impairment, lack of conscientiousness,
and conflict of interest)
8
(Box 1-1 and 1-2). Robins et
al suggest using these elements as the basis for teach-
ing ethics to medical students.

the Same as Professionalism?
Dr. Peter Singer, Professor of Medicine and Director
of the University of Toronto Joint Centre for Bio-
ethics, in his article “Strengthening the Role of Ethics
in Medical Education” states that professionalism and
the role of ethics in medical education are so similar
that there is no real benefit in distinguishing between
the two. He believes that the most important issue for
the professional is to create a “shared medical experi-
ence with the patient.”
13
Dr. Singer believes that a
“Flexner-like commission” needs to be created to
strengthen the role of ethics in medical education,
much like what Abraham Flexner did nearly 100 years
ago to standardize and improve the quality of general
medical education.
Wear and Kuczewski, in their discussion of the
professionalism movement, seem to differ with Dr.
Singer by stating that “Perhaps the greatest poten-
tial danger is that we educators will simply rename
what has been called ‘medical ethics’ as ‘profession-
alism’ in the curriculum and consider ourselves
done.”
14
The authors take issue with the “seemingly
immutable…group of attitudes, values, and behaviors
subsumed under the label of ‘professionalism.”’They
note that the typical features of professionalism have
been developed “by and for male physicians who

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Chapter 1 Ethics and the Physician Assistant Student 5
and professionalism does not necessarily guarantee
ethical behavior.
So how are the two different? Dudzinski relates a
story from the book My Own Country [by Verghese,
1994] in which an AIDS patient went to see a new
doctor: “The doctor said to the patient, ‘I don’t
approve of your lifestyle and what it represents. It is
ungodly in my view. But that doesn’t mean I won’t
continue to take good care of you….’ To which the
patient replied, ‘Oh yes it does!’ Whether uttered
aloud or kept secret, the values, attitudes, and expe-
riences physicians bring with them deeply impact
their practice. I fear that professionalism divorced
from medical ethics would advise this physician to
keep quiet. But when ethics takes precedence, he
might realize that it is disrespectful to reduce a per-
son to his sexual orientation and disease. He might
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learn to be more compassionate with his patients,
neighbors, and colleagues. Then, and only then, does
professionalism have integrity.”

the healthcare system.”
16
They contend that profes-
sionalism operates differently, depending on the pro-
fessional group to which one belongs. “For nurses
and social workers, for example [could PAs be
added?] the power and privileges of professionalism
are far more tenuous than for physicians.” Shirley
and Padgett may be referring to the “social prestige”
of physicians, one of the structural attributes of
professionalism alluded to by Hammer.
17
Nurses
and PAs may view physicians as taking advantage
of their prestige in a way that borders on abuse of
power and arrogance, characteristics that the ABIM
lists as challenges to the elements of professional-
ism (see Box 1-2).
Anyone who has worked in the medical field
knows clinicians who are viewed as “professionals”
in the popular sense of the term but who do not
behave with civility and ethical integrity, demonstrat-
ing the six elements of professionalism (see Box 1-1).
Coulehan and Williams cite the following examples
that seem to illustrate this: “He’s an extremely good
doctor, but he sure is nasty with patients.” “Her bed-
side manner is terrible, but she’s the best gastroen-
terologist in…the city.”
18
Their comments suggest

4
Should the physicians mentioned above be
described as “uncivil” but “good professionals,” or
does their incivility provide proof that they are not
truly “good” professionals? Should clinicians be
referred to simply as good “technicians” rather than
“professionals” if they do not exhibit the full range of
desirable character traits listed in the proposed “Six
Elements of Professionalism”? Or should those who
are exhibiting unprofessional behavior be called pro-
fessionals?
Berger has edited an excellent text for pharmacy
students and faculty titled Promoting Civility in
Pharmacy Education. The text is a very practical
6
Ethics and Professionalism
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approach to dealing with some of the typical behav-
ioral problems exhibited by students and faculty in
any professional training program. The authors state
that civility is the foundation for professionalism, and
they illustrate this with a diagram of a triangle, with
civility at the base and professional behavior at the
peak, representing a specialized and more refined
type of behavior, but behavior that has civility as its
foundation
17
(Fig. 1.1).

• Respect
• Proper conduct
• Diplomacy
19,20
Civility is, therefore, viewed as the behavioral
expression of, and foundation for, professionalism;
the minimum behavioral standard.
It can be argued that moral or ethical princi-
ples are the basis for appropriate thoughts and behav-
ior. It is reasonable to propose a modified diagram,
with ethics or “ethical integrity” at the base, civil-
ity at the midpoint, with professionalism at the top
(Fig. 1.2).
Civility is the behavioral expression of underly-
ing ethical integrity. Professionalism is the more spe-
cialized development of ethical and civil behavior,
above and beyond what is expected from the non-
professional. Professionalism’s structural and atti-
tudinal features also further define its specialized
nature and will vary depending on the specific profes-
sional field represented. A medical professional will
be expected to demonstrate behavioral characteristics,
attitudes, and structural attributes (body of knowledge
and skills, licensure, etc) that are different from
those of a “professional” engineer, hockey player, or
lawyer.
Chapter 1 Ethics and the Physician Assistant Student 7
Professional
Behavior
Civility

Traditional Curriculum
Current medical training programs seem to have a
pretty good grasp of what it takes to teach students
the foundational principles of the basic sciences and
clinical sciences, which some have simply called
“bioscience.” “Medical education has traditionally
placed the highest value on scientific (rationalistic)
knowledge, which may have little to do with the crit-
ical thinking about oneself, the medical profession,
and society, all of which are basic to professional
development.”
21
So what does all this scientific
knowledge “have to do with educating doctors [and
PAs] to be compassionate, communicative, and
socially responsible?” Wear and Castellani worry that
the overwhelming immersion in bioscience may
cause students to believe that the principles of science
are also the key to relationships with patients and col-
leagues,
21
when in fact this is not the case.
Robert Coles, MD, of Harvard Medical School
writes that “Medical education barrages students with
information, fosters sometimes ruthless competition,
and perpetuates rote memorization and an obsession
with test scores—all of which stifle moral reflec-
tion.”
22
He wonders how we can teach students to

And
Singer states that “Moral reasoning is a precondition
for ethical behaviour in medicine.”
13
Where in the
medical curriculum is moral reasoning taught? Do we
assume that students have this capability fully devel-
oped when they matriculate?
Glick encourages teachers of ethics in medical
training programs to “help create an academic envi-
ronment in which well motivated students have rein-
forcement of their inherent good qualities.”
25
This
must be done actively, and with awareness of the
potential consequences of leaving this teaching to
chance. Is the current academic environment in PA
programs one that promotes the reinforcement and
further development of “character”—of ethical
behavior? Can we, in our pluralistic society, promote
key ethical values in a medical culture that is increas-
ingly controlled by financial and time constraints
determined by nonclinicians and by excessive work
(and study) demands?
Some reports on the physician training process are
rather disturbing. There are numerous articles about
the negative impact that medical training has on the
moral and emotional development of medical stu-
dents and residents. Coulehan and Williams, in their
article “Vanquishing Virtue: The Impact of Medical

sionalism and medical ethics, the truth of the matter is
that trainees are exposed to environmental influences
that have been shown to damage or erode the moral
values and commitment to the ideals of medicine that
they originally held.
18,28,29
These influences are not
discussed openly; rather, they are experienced in the
day-to-day activities of the developing clinician.
Feudtner et al studied 665 third- and fourth-year med-
ical students in six Pennsylvania medical schools;
62% believed that at least some of their ethical prin-
ciples had been eroded or lost as a direct result of their
medical training.
30
Dr. Coles reminds us that during
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