Clinicians and patients' welfare: where does academic freedom fit in?

Short abstract

Academic freedom has accompanying responsibilities, and boundaries; but are there additional constraints specific to clinicians, such that research and teaching would conflict with caring for patients?

Suppose you are a surgeon who wants to do a randomised clinical trial comparing open with thoracoscopic spinal instrumentation and fusion. You prepare the trial and receive funding from a national funding agency—but the chief of surgery at your hospital deems that you fail to meet acceptable standards of competence and withdraws your privileges, effectively ending your research. Privileges in hospital can be limited or revoked for many reasons in addition to clinical proficiency: unacceptable standards of behaviour towards patients, failure to maintain adequate medical records, and substance abuse, for example. Inability to proceed with your trial means your academic freedom has been limited. Academic freedom for clinicians is contentious because the missions of universities and their faculty differ fundamentally from those of hospitals and their clinicians.^1-4 This article addresses a practical issue; are clinical faculty different from faculty in the rest of the university, and if so, what is the forum (hospital or university) for resolution of disputes about academic freedom? A clear policy (in addition to existing policies⁵—such as they are⁶) is needed for vindication of important competing values unique to clinicians, with an appropriate procedural framework that includes a dispute resolution mechanism. Academic freedom of clinicians must be protected, but in the rare circumstances when conflicts occur, the primacy of patient welfare must be established.

Academic freedom is a prerequisite for the relentless, objective, scholarly pursuit of knowledge and truth for the advancement of the human condition.⁷ Academic freedom is generally acknowledged to have its origin in the German university system of the 19th century.⁸ There is no universally accepted definition of academic freedom but most definitions include elements such as “full freedom in research and in publication of results,” “freedom in the classroom in discussing their subject,” and “freedom from institutional censorship or discipline.”⁹ Although, there are probably as many definitions as there are institutions, academic freedom is seen within universities as a fundamental right allowing faculty to comment on and study any topic in an unfettered way.^10-12

Responsibilities

An unappreciated aspect of academic freedom is that it also has certain inseparable accompanying responsibilities⁸,¹³ and, therefore, boundaries. For example, freedom from censorship is limited by special obligations that teachers “should at all times be accurate, should exercise appropriate restraint, should show respect for the opinions of others, and should make every effort to indicate they are not speaking for the institution.”⁹ Most universities have principles of confidentiality of privileged information and avoidance of discrimination or harassment.¹² Within these limitations, however, academic freedom is seen as the overriding principle governing scholarship. Relevant to your clinical trial, are there additional constraints on academic freedom specific to clinicians?

The primary mission of universities and the faculty who work there is to discover and disseminate knowledge by means of research and teaching.⁷ The primary mission of hospitals and the clinicians who work there is to care for patients. Academic centres—a combination of university, medical school, and hospital—attempt to integrate these roles, with the threefold mission of providing medical knowledge to prevent illness and suffering, educating practitioners, and serving as sites where optimal use of medical knowledge can be investigated and demonstrated.¹⁴ Thus, hospitals associated with universities and medical schools accept multiple roles that in addition to patient care include research and teaching. Although these roles should ideally complement, for clinicians these roles can conflict.

The responsibility of clinicians for patients' welfare was recognised by the American Association for the Advancement of Science's Committee on Scientific Freedom and Responsibility more than 25 years ago: “The prime responsibility of physicians or public health workers [is] to place the health of the people for whom they are responsible before all other considerations.”¹³ This principle has been recently reaffirmed by the Medical Professionalism Project, which placed the primacy of patients' welfare above the two other fundamental principles, patient autonomy and social justice.¹⁵ Although clinicians may have both clinical and university roles and though they do cherish academic freedom, patients' welfare must have primacy over academic freedom. Thus, for clinicians, when the two principles come into conflict, the principle of patients' welfare must take precedence over academic freedom, as in the example of the thwarted clinical trial.

Figure 1.

Disputes about employment, financial compensation, or access to resources related to patient care will inevitably become conflated with scientific disputes. Because moving from principles to practice will give rise to uncertainties, such disputes will need a forum for resolution. Although most university faculties have grievance procedures,⁹ judging clinical competence and commitment is a role which exceeds the expertise and responsibility of non-clinical university faculty members. Therefore, hospitals, in conjunction with universities, must develop special dispute resolution mechanisms to protect academic freedom, and these mechanisms must define who has jurisdiction over conflicts involving academic freedom, patient care, and remuneration These dispute resolution mechanisms should have the power to protect academic freedom and patients' welfare, and should make it possible to sort through the conflicts between the two. The elements of any dispute resolution mechanism must include graduated levels, due processes, and adjudication by peers both external to the dispute and with sufficient expertise to pass judgment on issues of clinical competence and commitment.²

Summary points

Many clinicians have both university and hospital roles; they must accept these dual roles and understand they will sometimes conflict

Dispute resolution mechanisms must be developed and adjudicated by clinical peers

For clinicians, academic freedom must be protected, but when university and hospital roles conflict, resolution must occur in an environment which acknowledges the primacy of patients' welfare