pp

Snapple_girl1

01CH_HealthCare_Bustillos.pdf

Home >Education homework help >pp

1The Evolution of Health Care Ethics: Overview, Theories, and Methods

Travel Pictures Ltd./SuperStock

Learning Objectives

After reading this chapter, you should be able to

1. Summarize major factors that contributed to the interest and importance of medical ethics in the mid-20th century.

2. Identify the major factors associated with the rise of bioethics committees, as well as with their primary functions.

3. Summarize ethical theory and how it attempts to explain and guide right action.

4. Discuss principlism, along with its strengths and weaknesses, as a prime method for addressing ethical problems.

5. Explain the process for ethical decision making.

Section 1.1The Rise of Contemporary Health Care Ethics

Introduction Ethics is a word that is frequently used, heard, and seen in the media. It generally refers to what people should do and how they ought to act. However, the meaning of the term is often unclear, and people do not always share a common understanding of what it means to be ethical or behave ethically. Additionally, what some may see as an ethical issue, others may not. Therefore, those going into the field of health care must learn the theories, principles, beliefs, and values that guide ethical decision making and problem-solving in the health care environment. While there are many concrete laws, rules, and regulations that must be fol- lowed to the letter in health care, the application of ethics in health care is more fluid in that each situation requires unique considerations and each outcome may be different as a result of those considerations.

As an academic study, ethics refers to a systematic analysis of the rightness and wrongness of actions, along with the theoretical basis and methods used in deciding which course of action to take. Ethics also encompasses a very practical application: It seeks to provide a guide to behaviors. How people behave toward one another is based on their personal morals as well as on societal ethics. There is some universal agreement about what is right and wrong; for example, murder and incest are almost always considered wrong. However, there is much variability in what an individual or particular society considers ethical behavior, depending on its laws and norms. This is in part due to the fact that different peoples regard different situations as posing an ethical dilemma, or a situation in which they are uncertain about the correct course of action. The goal of applied ethics is to identify and resolve such dilemmas.

Given that Western societies, particularly the United States, comprise many communities, cultures, and languages, it is not surprising that there is difficulty formulating concise and coherent language to describe a comprehensive set of ethical standards that can be applied to society at large. Similar challenges arise within organizations. These challenges are particu- larly pronounced in health care organizations, where communities, cultures, and languages intersect on a daily basis, sometimes under critical and urgent circumstances. Therefore, the major question we will explore in the chapters that follow is: Can health care professionals and organizational decision makers identify a core set of fundamental precepts and prin- ciples that should be considered regardless of location, religion, and law? We will consider which principles are to be prioritized, as well as how to address ethical questions systemati- cally. First, we will explore the ways in which health care and ethics have intersected through- out history.

1.1 The Rise of Contemporary Health Care Ethics Doing the right thing has long been a tenet of medical practitioners, with doctrines of ethi- cal practices such as the Hippocratic oath dating back to the 5th century BCE. Though other philosophers have commented on the oath and ethical duties over the centuries, and some have recently written contemporary versions, the original remains foundational to medical practice. Graduating physicians still swear to uphold the tenets of the oath, which include the promises to practice fidelity (faithfulness), observe patients’ confidentiality, and have respect for those under their care.

Section 1.1The Rise of Contemporary Health Care Ethics

Until the mid-20th century, health care was delivered without significant technology or capa- bility other than simple procedures and a great deal of compassion. For example, sterile tech- niques and anesthesia were unknown until the beginning of the 20th century, and antibiotics were not developed until World War II. In cases where effective treatments were not readily available (or not yet invented), paternalism, or the belief that the doctor knew best, was not significantly challenged, and, according to Cotler (2013), “kindness and caring were indeed the best medicine” (p. 4).

Beginning around the 1950s and 1960s, advents in both medicine and medical technology increased choices and costs, which complicated medical decisions. In the 1960s, the invention of dialysis, ventilators, and intensive care units vastly improved patient health; the advent of dialysis, for example, meant that patients could now be maintained on machines that essen- tially function as kidneys by mixing and monitoring the fluid that removes unwanted waste products from a patient’s blood. Such advancements in knowledge and technology were mak- ing it clear that age-old applications of medical ethics were no longer sufficient, and with that realization the field of bioethics was born. Drawn from the combination of the words biology and ethics, bioethics became the health care community’s answer to the question of how to study ethical issues arising from advances in biology and medicine.

Coinciding with a rise of technology were social justice movements calling for increased civil lib- erties and women’s rights. As part of these move- ments, individuals and interest groups also agi- tated for the right to make health care decisions (Cotler, 2013). On occasion, patients, their fami- lies, and their physicians disagreed about whether to continue treatment. In those cases it was not clear what to do, who should decide, and what basis to use for decisions. Given the plural- istic society of the United States and the fact that the nation lacks a common ethos, these decisions fell to the courts. New technology also required capital-intensive hospitals, specialization, and new financing mechanisms. Specialists who often did not have any relationship with the patient or the family replaced the old family doctor who had the luxury of knowing his or her patients. This affected the physician-patient relationship, and new forms of health care delivery developed.

In addition to court decisions that influence prac- tice, heightened public expectations sometimes result in malpractice suits. In turn, many physi- cians practice defensively. Practice is also regu- lated by third-party payers, including the state and federal governments and insurance compa- nies. Many health care organizations incorporate peer review for their physicians, and many hospitals are accredited through an independent, non-profit organization known as The Joint Commission.

Exactostock/SuperStock Advancements in medical technology, especially in life-support systems, have given rise to new ethical dilemmas for doctors, patients, and family members.

Section 1.1The Rise of Contemporary Health Care Ethics

Organizations and Physicians The relationships of individual physicians to health care organizations have become increas- ingly important and complex. These relationships vary by the particular characteristics of the organization, which may be integrated vertically, with facilities that offer either a lower or higher level of care (such as nursing homes or tertiary care hospitals), horizontally, with similar institutions at the same level of care, or both vertically and horizontally. Hospitals also differ in their characteristics and feature a wide array of options and potential arrangements: Health care organizations might be religious, private, governmental, for-profit, urban, or com- munity-based. According to Cotler (2013), the structural differences among organizations do not prevent ethical challenges; they simply change some of the contextual details of the cases. Individuals and organizations have somewhat different roles and functions, but they all share the principal aim of quality patient care. However, they also may compete for limited resources and power, which could create conflicts of interest. Thus, “duties and responsibili- ties of the board of directors, the CEO, and the administrative team and their relationships to individual physicians and medical groups all present potential ethical pitfalls” (Cotler, 2013, p. 14). The following are examples of structural differences that could potentially pose a con- flict of interest:

• Physicians may work independently of the organization in their own office, but they will usually also be a member of the medical staff, which has its own bylaws. They are thus constrained by rules with which they may not agree or which they may not respect.

• Administrators may have loyalty to their institution, but as part of a corporation, they are also required to comply with financial and managerial demands. Potential financial and clinical conflicts are part of their daily lives.

• The board of directors has differing power, authority, and functions, depending on whether the facility is independent or part of a corporation. Its philosophy of care may diverge from the corporation or from administration. In addition, the boundar- ies of the board’s authority may not be clear.

Human Subjects Research Another historical influence on the rise of bioethics was the realization, which began around World War II, that persons all over the world had been forced to become subjects in clini- cal research; in other cases, research subjects were mistreated or abused. Perhaps the best known example in the United States of grievous research misconduct was the Tuskegee syphilis study conducted by the U.S. Public Health Service from the late 1930s until the early 1970s. In that trial, individuals afflicted with the disease were not given antibiotics, despite availability and efficacy. Table 1.1 shows the number of participants who were not treated for syphilis for research purposes. Many research abuses have been reported worldwide, and in response, the international community has developed codes and regulations that foster ethi- cal practice.

Section 1.1The Rise of Contemporary Health Care Ethics

Table 1.1: Participants in the Tuskegee syphilis study Results of the Tuskegee syphilis study conducted from 1932 to 1972. In 1932 poor Black sharecroppers from Macon County, Alabama, were recruited to participate in the study so researchers could follow the progression of untreated syphilis over time. The men all believed they were receiving free health care and did not know they had the disease. The controversial study led to tight federal regulations that require informed consent to protect human research subjects.

Control participants

Syphilitic participants

Total

Classification at initial examination 200 411 611

Cases added in 1938–1939 – 14 14

Total—original classification 200 425 625

Controls infected during observation

–9 +9 –

Controls reclassified as syphilitic on basis of additional history

–1 +1 –

Controls reclassified as syphilitic on basis of treponemal tests

–8 +8 –

Total—final classification 182 443 625

Known dead—number 97 276 373

Known dead—percentage 53.3 62.3 59.7

Remainder; examined in 1968—number

36 53 89

Remainder; examined in 1968—percentage

42.4 31.7 35.3

Source: Department of Health, Education, and Welfare. Public Health Service. Health Services and Mental Health Administration. Center for Disease Control. Venereal Disease Branch. (1969). Tuskegee syphilis study administrative records, 1929–1972. Retrieved from https://catalog.archives.gov/id/281642

Indeed, ethics committees in many countries remain concerned with research rather than clinical or organizational issues. Clinical trials are heavily regulated to protect quality and human safety. According to Cotler (2013)

Major ethical issues, surrounding the protection of human subjects including informed consent, confidentiality, conflict of interest, and justice, are similar to the clinical concerns. There are essential differences between the clinic and the clinical trial. Patients’ rights to refuse recommended treatments are well established. In research, the primary ethical goals surround protection

Section 1.1The Rise of Contemporary Health Care Ethics

of human subjects . . . This is a soft paternalistic approach justified by a long and widespread international history of abuse of human subjects and by the complexity of proposed trials which require highly regulated review by insti- tutional review boards (IRBs). (p.13)

The true differences between clinical care and research, however, are in their goals. In clini- cal care, the goal is to heal and care for; in research, it is to discover and increase knowledge.

Possible research ethics issues include:

• how research subjects are selected • access to studies • use of placebos • international trials • compliance • relationships with outside vendors (Cotler, 2013, p. 14)

Another potential dilemma can occur when patients are asked to participate in clinical trials being run by their personal physician. While a patient must give consent to take part in a clini- cal trial, even if it is being conducted by their personal physician, both parties may be wary of the potential conflict when the researcher and the clinician are the same person. For instance, a patient may wonder if the physician is acting as the researcher or as the treating doctor who places the patient’s interests above all. Some ethical dilemmas are not easily resolved by regulation, and so require extra careful attention from both professionals and organizations.

Bioethics Committees According to Cotler (2013), bioethics committees (BECs) “have grown as a response to demands raised by exploding medical technology, diversity among the population, directives from the courts, and health-care systems attempting to address ethical conflicts in health- care organizations” (p. 6). Technology has increased choices and thus raised questions about what medical decisions to make, who should make them, and when they are appropriate. Ideally, BECs can prevent some of the many ethical dilemmas posed by these developments. Preventive ethics implies that the best resolution to a dilemma is to prevent it from arising in the first place.

Global diversity means that people of different cultures and beliefs bring an array of perspec- tives and values to the table when they make critical health care decisions. In some countries religion plays a strong enough role that it provides direction, and possibly resolution, to ethi- cal issues through consistent moral authority. Examples include the Catholic Church’s prohi- bition of elective abortions and the Islamic prohibition of male physicians touching female patients. Most countries lack a single authority, however, and many developed nations have various multicultural communities. Thus, particularly in diverse regions that lack a unified religion, language, or culture, there is confusion over how to universally address or resolve ethical dilemmas.

In an effort to prevent such confusion, most hospitals have established a mechanism for addressing bioethical problems such as who has the authority to give informed consent,

Section 1.2Theories and Methods of Contemporary Bioethics

whether to continue life support, and how to resolve disagreements between or among care- givers and families when patients can no longer represent themselves. Some larger institu- tions and university medical centers employ clinical ethicists. In the United States and other Western nations, most bioethics committees are part of the medical staff, although some are part of administrative departments. Though many other countries rely on ethics committees to also review proposed clinical trials and other institutional research, there is increasing interest in the Western model, which features a BEC that focuses on clinical concerns and an IRB that manages ethical concerns in research. The function of bioethics committees and institutional review boards will be discussed in greater detail in Chapter 3.

Prior to the mid-20th century, theology and philosophy provided the foundation for bioeth- ics scholarship. However, it was soon clear that the questions generated by new technology, which included life-sustaining equipment and complex organizational structures, required ethical study and explicit practice standards. Thus, in the United States, the 1960s and 1970s saw the birth of freestanding and university-affiliated entities devoted to the study and reflec- tion of bioethics. Early prominent examples are the Hastings Center, which is freestanding, and the Kennedy Institute of Ethics, which is affiliated with Georgetown University. Several professional organizations (now largely subsumed under the American Society for Bioeth- ics and Humanities) also developed within philosophy, law, and medicine. The field is still very new, and it continues to struggle with creating an identity, determining its own code and structural requirements, forming a unified theory and method, and determining whether such a multidisciplinary field should even have a unified theory or method.

1.2 Theories and Methods of Contemporary Bioethics Before turning to the specific ethical issues health care practitioners face, an introduction to ethical theory is helpful. The goal of this section is to discuss ways to think about the rightness or wrongness of actions that have been historically important. In particular, we will focus on principlism, an approach commonly used in health care, and how it is applied by practitioners to resolve bioethical problems.

Ethical Theory Traditionally, ethical theory has been the purview of philosophers, including Immanuel Kant, John Rawls, and John Stuart Mill. Today, ethics, or moral philosophy, is a major branch of aca- demic philosophy. Moral philosophers ask questions such as, “What features of an action or event make it right or good?” “What are the sources of our moral obligations?” and “Do out- comes matter when determining the rightness of an action? If so, are they all that matter or, at least, the most important factor?” Philosophers then attempt to systematize their answers to arrive at an explanation of the rightness or goodness of actions and events in general. These explanations are ethical theories. In essence, an ethical theory is a view about what makes actions or events right or good; an ethical theory gives general criteria for rightness and iden- tifies the right-making features of actions and events—in other words, that which we should take into account when judging whether an act is right or wrong. To see what philosophers mean by “right-making features,” consider the case study Rationing the Antidote.

Section 1.2Theories and Methods of Contemporary Bioethics

Principlism There are several methods for “doing ethics.” Whatever methods, or combination of methods, apply to the individual case or problem, it is helpful to remember that, basically, ethics is about respect for persons, truthfulness, and fidelity. Primarily in the 1970s and 1980s, courts and philosophers emphasized principlist ethics, which stresses the application of general principles, in a top-down fashion, to serve as the basis for rules or guides to action. These general principles include autonomy, nonmaleficence, beneficence, and justice. The princi- plist approach has mainly been associated with Tom Beauchamp and James Childress (2009), the authors of the canonical text on principlism, Principles of Biomedical Ethics. Figure 1.1 provides a diagram to help visualize the four principles.

Case Study: Rationing the Antidote

You are a hospital administrator. One afternoon, the director of your emergency department notifies you that six patients have been brought to your emergency room, all of whom are dying after ingesting a rare poison. Unfortunately, your facility does not have a large enough supply of the antidote on hand to save the lives of all six patients. There is also no way to acquire more antidote in time to save all the patients. The patients must be treated within one hour of ingestion of the poison for the antidote to be effective, and time is already run- ning out. The director informs you that one of the patients has ingested a much larger dose of the poison than the others. If the antidote on hand is divided five ways, there will be enough antidote to save the five who ingested a small dose. In order to save the patient who ingested the large dose, however, all the antidote on hand would have to be administered. How should the emergency department staff distribute the antidote?

The answer probably seems clear. Of course, the antidote should be divided among the five patients who require a smaller dose. Given that the hospital has a choice between saving one life or saving five lives, the hospital should save the greater number. This requires the assumption that there are no other factors that should influence the decision about whom to save. If, to give an extreme example, the five patients were violent criminals who escaped from prison and the one patient was the president of the United States, some might think the hospital should act differently. Or what if the patient who took the larger dose was a major donor to the hospital and the other five patients were just members of the com- munity? While many may feel that a person’s social standing or ability to financially invest in a certain institution should not be considered in a case like this, ethical dilemmas like these can come into play. The antidote case study is, of course, imaginative and unrealistic. However, it highlights an important moral intuition that many people share. In fact, in 1960 when dialysis units were first developed in Seattle, Washington, there were not enough for everyone who needed them. The question of how to distribute them was real, and a process for deciding had to be developed prior to selecting patients.

Section 1.2Theories and Methods of Contemporary Bioethics

Figure 1.1: Venn diagram of ethical principles in health care

A useful way to imagine the four ethical principles is as a Venn diagram, or a group of overlapping areas of concepts. These areas overlap because often the concerns and questions associated with the principles occupy more than one area. For example, “respecting a patient’s choices” falls under autonomy, but it can also fairly be described as observing the principle of nonmaleficence, since disrespecting a person is a form of harm. It might also be described as falling into the category of beneficence if respecting a patient’s wishes fosters autonomy or a sense of control that may itself be therapeutic or beneficial.

Dan Bustillos

Autonomy Court decisions in a variety of landmark cases have established autonomy as the dominant ethical principle. Literally meaning “self-determination,” autonomy grants patients the right to be left alone and not be touched without permission, and it forms the basis for our laws

Section 1.2Theories and Methods of Contemporary Bioethics

against battery. However, no one is entirely self-determining. Everyone has aspirations and dreams, and yet everyone encounters reality. In health care, for example, providing what the patient wants must be contrasted with what he or she gets; this is limited by the physician, who is responsible for clinical judgment and determining medical necessity.

According to Cotler (2013), the autonomy maxim “Do not do unto others that which they would not have you do, and keep your promises” has been such a misunderstood concept that Englehardt (1996) renamed it the principle of permission. Autonomy forms the rationale for informed consent. If one may not touch another without permission, informed consent provides a mechanism to obtain the permission by declaring risks, potential benefits, and alternatives. Note that the maxim includes the mandate to keep promises. Autonomy is par- ticularly confusing to providers and patients in that the principle grants the right to accept or reject recommended treatments, but decisions about appropriateness and effectiveness are the domain of the physician. Many cultures value community over individual choice, and autonomy may not be the most important value for such communities. It may not even be considered. In all cases practitioners need to discuss decisions with the patient to discern the relative value he or she places on autonomous choice. Does the patient want information? Does the patient want to be involved in decisions, or does he or she delegate to family? These are autonomous choices, and health care practitioners have a duty to assure they are stable and authentic.

As noted above, informed consent derives from the principle of autonomy, and it is discussed in detail in Chapter 2. However, note that informed consent requires a conversation between the physician and the patient or surrogate engaged in shared decision making. Informed con- sent requires that the patient be an active participant in the process, necessitating well-docu- mented notes in the medical records. It is much more than a signature on a form.

Though court decisions tend to favor patient autonomy, “the repeated lack of a clear mech- anism to resolve conflicts between and among the principles at the bedside demonstrates weakness in the principalist approach” (Cotler, 2013, p. 6). For example, consider a case in which, based on medical necessity and the physician’s clinical judgment, surgery is recom- mended for a particular patient. However, the patient refuses based on his or her own com- plex reasons, preferences, and values. This collision between the patient’s choices or refusals causes dilemmas at the bedside and in setting policy. Before life-sustaining technology, such dilemmas were precluded by old paternalistic methods in which the physician decided. Crit- ics ask how principles help resolve conflicts in a given case. Beauchamp and Childress address the question in their later editions by recommending specifying and balancing approaches in specific cases.

Nonmaleficence The ethical principle of nonmaleficence is based on the age-old medical precept “first, do no harm,” or the Latin primum non nocere. Nonmaleficence is the general duty to avoid causing harm to others, either directly or indirectly. It sometimes is necessary to risk harm in order to achieve a greater good or prevent a worse harm. For example, performing a difficult gastric surgery on a patient with heart or organ failure jeopardizes the weak organ, but it may be necessary to save the life. The decision about what to do is not primarily a medical one; there is a choice to make and values are at stake. Life-saving technology has sometimes made it

Section 1.2Theories and Methods of Contemporary Bioethics

difficult to know what is a harm and what is a benefit. For example, consider a dying patient who is on a ventilator. Is continu- ing aggressive support saving the life or prolonging the death? These questions require more information and much greater understanding of the case.

In clinical health care it is easy to think of the myriad ways in which a patient can be harmed through incompetence, error, or systems failure, or ways in which a phy- sician can inadvertently cause pain, dis- ability, or even death. Preventing harm to patients is the responsibility of the admin- istrator, in collaboration with the medical staff. In addition to the physical, psycho- logical, and economic ways that health care managers can affect patients or staff, those in leadership roles also have the ability to affect the culture of the organization in critical ways. The duty of nonmaleficence not only involves not causing harm, but also actively choosing the least harmful alternatives. Nonma- leficence requires that managers actively minimize or eliminate workplace hazards and risks that could harm employees and patients. It is prudential as well as practical for administrators to regularly review relevant policies, make rounds, meet with practitioners and employees, and attend meetings in which the topic is preventing or responding to error and other harms.

Beneficence Beneficence is the principle that guides health care professionals to do good. It provides the grounding for charitable duty to others. At the bedside, patients define their own good; this may present a conflict with a health care provider’s recommendations, which are based on the physician’s clinical judgment about the best medical good. Problems may occur when patients refuse recommended treatments. Conversely, they may occur when patients or their surrogates demand care that physicians deem inappropriate or nonbeneficial. Misunder- standings about patient and provider rights lead to many of the requests for bioethics con- sultation. In the case of refusal, autonomy usually trumps. However, it is critical to evaluate the patient’s capacity to make rational and authentic decisions. Capacity goes beyond being oriented to time, person, and place. It is the ability to understand the context, meaning, and implications of choices. If the patient is incapable of making his or her own decisions, it is necessary to evaluate whether the surrogate is acting in a way that is consistent with the patients’ directives and interests.

Health care professionals are not obligated to participate in acts about which they have a con- scientious objection. Organizations are also protected. For example, Catholic hospitals are not required to perform elective abortions or participate in assisted reproductive technologies that compromise their ethical and religious doctrine. The positive duty imposed by the prin- ciple of beneficence requires that health care managers do everything they can to reasonably care for and benefit patients, employees, and others for whom the organization is or may be

iStockphoto/Thinkstock Health care providers have an ethical obligation to bring no harm to their patients. However, sometimes harm must be risked in order to prevent a greater detriment.

Section 1.2Theories and Methods of Contemporary Bioethics

responsible. How this duty is put into practice depends upon the nature of the organization and its mission. For example, if a practitioner’s organization has an explicit mission to serve the health needs of a particular population or community, then those commitments should give shape and substance to the practitioner’s duty of beneficence.

Justice The justice principle can be broadly defined as “fairness.” It is exemplified by the Aristotelian ideal that people in similar situations ought to be treated similarly, and people in different situations should be treated differently. A distinction is sometimes made between distribu- tive justice, which refers to the allocation of resources, and procedural justice, the fair- ness and transparency of processes by which decisions are made. The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research, prepared by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1979), offers guidelines on ethical principles; it states that “[a]n injustice occurs when some benefit to which a person is entitled is denied without good reason or when some burden is imposed unduly” (p. 5). This may occur in the clinic or in research. For example, there is some evidence that persons who are poor and thus have less access to care and infor- mation about options may also have less access to clinical trials. They also have less access to the benefits of findings and to drugs that are approved as a result of such studies. Charges of injustice regarding access to research involving women have also been made (Mastroianni, 1998); women have proportionately been less often represented as research subjects. Data also indicate that persons belonging to some racial groups are treated differently when they appear at an emergency department (James et al., 2005; Selassie et al., 2003). Statistics have consistently shown differences in life expectancy by socioeconomic status (National Center for Health Statistics, 2012).

In 1971, the leading American political philosopher of the 20th century, John Rawls (1921– 2002), wrote A Theory of Justice, a highly influential book that advances the idea that the best principles of justice are those that we would all agree to if we were all impartially situated as equals. This he arrives at through his famous thought experiment “the veil of ignorance,” in which we are asked to imagine an “original position” from which no one was better situ- ated than anyone else (or at least that we’d be ignorant of any inequalities in such a utopian state-of-affairs).

A Rawlsian approach to distributive justice and health care ethics is one based on fairness. Therefore, even in cases where not everyone will have access to a certain good because it is scarce, there needs to be fair opportunity of access to the benefit. For Rawls, fair access was ensured by formal procedures that were themselves required to be fair. This leads us to the concept of procedural justice.

In order for the justice principle’s requirements to be met, any formal procedures or mecha- nisms by which people attempt to decide dilemmas must be fair and just, or equitable. Pro- cedural justice requires that policy makers craft regulations, laws, and formal procedures that are free from bias that would render them inaccessible to some, or that would unduly restrict the chances of fair treatment for others. For example, a policy that recognizes employees’ rights to opt out of procedures when they have a strong conscientious objection states that employees must provide documentation in writing to the supervisor at least two weeks prior

Section 1.2Theories and Methods of Contemporary Bioethics

to the event. But given the nature of acute care, in which the unexpected happens routinely, how can a nurse know in advance that something will be demanded of her that strongly vio- lates her conscience? When this issue came up in a local hospital, human resources had the policy rewritten to accommodate reality. Hospitals and nursing homes have to be clear about nurses’ rights and duties. For example, a policy might state that a nurse who has a strong moral objection to terminal extubations could be transferred to a unit where this procedure will not likely occur. Other policies might call for less supportive measures such as unpaid leave; such options could trigger a union dispute.

Justice is a fundamental principle for health care administrators and practitioners—particu- larly in their responsibilities to make resource allocation decisions—and among those who work toward eliminating health inequities. The justice principle impacts many other day-to- day decisions that health care managers make. Examples include policies regarding unioniza- tion, working conditions, and staffing patterns for employees; hiring and promoting staff; decisions about where and to whom the institution should be marketed; and determining whether promotion should be by merit, seniority, or favoritism. In addition, hospitals that undergo purchase or mergers often have to make choices about their mission and values.

Strengths and Weaknesses of Principlism Scholars continue to refine the principlist approach; with each new edition, Beauchamp and Childress refine the text to accommodate legitimate criticism. Some bioethicist academics turn to casuistry, a case-based method of resolving ethical issues. Most practitioners use a combined approach from different methods, depending somewhat on the particulars of the case. The several methods reflect the necessity of an interdisciplinary approach. According to Cotler (2013), “no single method has been successful in addressing the varied and com- plex dilemmas that arise in the clinic, the institution, or the community” (p. 7). Principles provide fundamental guidelines, but when they conflict with one another, there is a lack of clear instructions on how to prioritize. The courts have consistently favored autonomy, but that does not always seem correct in an acute health care setting. It is also not always clear whether a choice is consistent and authentic; in other words, will the decision be the same later today or tomorrow? Is it an accurate reflection of the person’s narrative and the other choices he or she has made?

Some argue that principlism fails to consider the complexities of real-world situations, or that it is too rigid in following prescribed formulas for making ethical decisions (Pellegrino & Thomasma, 1993). Other critics posit that principlism pays too little attention to the char- acter of the agent, opting instead to focus on actions that typify the principle in question; for example, asking if the decision was autonomous rather than also looking at precedent or important context (Bulger & Reiser, 1990). Does the way the four principles are selected, prioritized, and applied to ethical dilemmas depend on who gets to do the selecting, prioritiz- ing, and applying? Given that along with their great strengths, principles have weaknesses in application, leading proponents of principlism—especially Beauchamp and Childress—con- tinue to refine their text to include the necessity to specify and balance in individual cases. Whether in management, at the bedside, or in the community, it has become clear that princi- ples are important, but they are not to serve as a blind mantra. They work when they are aptly applied, usually along with other methods, and always in conjunction with good judgment.

Section 1.3Practical, Ethical Decision Making in Health Care Administration

1.3 Practical, Ethical Decision Making in Health Care Administration

The complicated nature of the work of modern health care administrators and leaders often means that they have to take into consideration a multitude of factors and facts when making a well-reasoned, ethical deci- sion. Typically we experience an ethical dilemma because one (or more) ethically relevant factor of the situation is pulling us to act one way while one (or more) ethically relevant factor is pulling us to act in a different or even opposing way. Ethically relevant factors (ERFs) are goods or values, rights, or any other factor to which we ought to be sensitive in determining the ethi- cally correct way to respond to the situation. Issues involving mergers with institutions at the same level of care or above or below the acuity level, changes in financing, relationships with the community, and profit status are only a few of the ethical challenges. Without an organization’s clearly defined moral identity, often made apparent through mission and vision statements, or without a well-articulated moral identity statement of his or her own, the modern health care leader may lack direction and base decisions on ill-defined or unde- veloped personal ethics. These types of decisions run the risk of being unfair, inconsistent over time, or easily swayed by factors that seem the most urgent, instead of those that are most important to the primary goals of the institution or practice.

The bulk of this textbook is devoted to helping cultivate in the student the characteristics of a moral leader capable of leading a moral organization. In this section we will consider the value of a flowchart method of resolving ethical dilemmas.

Introduction to the Sample Framework Flowcharts, or decision-tree diagrams, such as the one seen in Figure 1.2, help demonstrate some of the important factors and norms that should be a part of any thoughtful ethical deci- sion. However, it is also important to remember that these guides, when misused or relied on too strictly, can serve as a crutch for bureaucrats and can impede the kind of rigorous and nuanced analysis that usually needs to happen in modern health care ethics. Once you become confident in applying the rules and norms covered in this text, and become adept at identifying the most important stakeholders and factors that need to be addressed, then you can use the diagram as a reference. It can be stored in a file cabinet or on a computer so that it is accessible when you need to make sure nothing important has been overlooked. It can also be used as a reminder of important questions to raise in an ethics committee meeting.

Creatas/Thinkstock Administrators routinely face ethical dilemmas at the institutional level.

Section 1.3Practical, Ethical Decision Making in Health Care Administration

The Process You will progress through the diagram in a stepwise fashion, from top to bottom, answering questions about norms, limiting factors, ethically relevant factors, and stakeholders along the way. The chart and the following descriptions are meant only as guides. It is helpful to take copious notes on a different sheet of paper or on a note-taking application on your computer.

Norms At the start of the practical, ethical decision-making process, you should consider which ethi- cal principles, norms, or values are implicated. As discussed earlier in this chapter, the four principles that tend to predominate Western health care ethics are justice, beneficence, non- maleficence, and respect for autonomy. In practice, these four principles will often conflict. It then becomes important to make careful judgments about the relative importance and appli- cability of norms and values in a particular case after paying attention to the relative interests of stakeholders and ethically relevant factors. This should generate a list of possible candi- date decisions that are reasonably foreseen to achieve the desired goal.

Limiting Factors Once you have created your list of possible candidate decisions, you then need to temper those candidates with any limiting factors you have identified. In nearly every ethical dilemma there will be constraints that may make it more difficult to achieve the optimal ethical choice.

While these are really just different instances of ERFs, you may find it useful to relegate these constraints to the end of the decision-making process in order to more easily spot ways of mitigating these limiting factors while straying as little as possible from the optimal choice you would otherwise prefer. This is where you should assess and compensate for limiting resources such as funds, expertise, equipment, and time, or external constraints like hospital policy, state or federal laws, and public perception.

Stakeholders As part of the decision-making process, it is necessary to identify who has a stake in the deci- sion being made. You can do this by asking yourself “Who will be significantly affected by the decision made?” It will also be necessary to differentiate the stakeholders into primary, secondary, and even tertiary interests. These interests should also be distinguished by their importance, such as whether the interest being impacted is of core importance to this stake- holder or is a relatively minor interest.

Options, Review, and Feedback If all goes well, you should have a small set of alternative options at the end of the process from which to choose the final decision. However, it is also important to note that, in many cases, the final decisions of good ethical managers are not truly “final.” Ideally, they are tenta- tive and provisional rather than once-and-for-all solutions. If the decision fails to solve the

Practical, Ethical Decision Making in Health Care Administration

problem, or if the negative consequences of the decision turn out to be greater than expected, the expert health care manager should be amenable to refining or replacing the decision with a better one. Therefore, the review and feedback loop that goes from the bottom of the dia- gram back to the top is an essential part of the ongoing ethical decision-making process. You can practice using the flowchart, shown in Figure 1.2, in the St. Louis Apothecary case study in the end-of-chapter content.

Figure 1.2: Ethical decision-making flowchart

The process of ethical decision-making.

Chapter Highlights

Chapter Highlights • As disciplines concerned with doing the right thing, ethics and ethical behavior have

been of critical importance in health care in general, and medicine in particular, since the beginning of recorded history.

• The major factors associated with the rise in contemporary bioethics have been:

1. Changes to a. insurance. b. financing. c. costs. d. structure to accommodate inventions.

2. Developments in technology that a. increased the cost of care. b. offered life-supporting machines, including dialysis and ventilators. c. provided choices in treatments for physicians to offer and patients to accept

or reject. 3. Discovery of research misconduct, which led to regulation and the development

of ethical codes. 4. Cultural diversity under which there were differences in societal values and

understandings of the right thing to do. 5. Religious pluralism, which meant there was no consistent authority for deter-

mining right action. 6. Civil libertarian movements, which demanded that private individuals make

their own choices about what to accept and reject.

• Ethics committees have been mandated by the courts and accrediting agencies as a mechanism to address ethical dilemmas.

• Ethics committees are organized by medical staff or administration, but they need the support of both. Their functions are case consultation, education, and policy development and updating.

• Methods provide guidance for how to address problems. Principlism has served as the major method in bioethics; the four primary principles are autonomy, nonmalefi- cence, beneficence, and justice. Principles provide the foundation for rules. However, they require specifying and balancing, and the lack of ranking when principles com- pete has been a problem with the method.

• The chapter ended with a discussion of the importance of implementing a well- planned and reflexive procedure when organizing and making an ethical decision.

Case Study: St. Louis Apothecary

Using the ethical decision-making flowchart from Figure 1.2, consider the following dilemma and come up with a plan for responding to it.

The Problem

You are a human resources administrator for St. Louis Apothecary, a company that owns and runs 23 full-service pharmacies in Missouri and eastern Illinois. Your company prides

(continued on next page)

Chapter Highlights

Critical Thinking and Discussion Questions 1. The four principles of principlist ethics all outline general duties and responsibilities for ethi-

cal health care. Describe an example of when the four principles might generate competing, or even contradictory, duties for a health care manager.

2. Give an example of when a health care administrator might have to cause harm, despite the nonmaleficence principle.

3. Discuss, explain, and provide an example of informed consent in health care. 4. Give an example (either from personal experience or that you have read about) of a health

care administrator or professional acting in a way that had ethical implications. This can be an example of acting on a specific ethical problem or acting in a way that might result in ethi- cal problems. Critique the administrator’s actions or decisions (use this chapter’s flowchart if needed) and judge whether you believe the administrator acted or decided with appropriate regard for the four principles of health care ethics, and explain why you think so.

Key Terms

Case Study: St. Louis Apothecary (continued)

itself on providing exceptional customer experience and exceptional job satisfaction and has always offered among the highest pay and benefits in the field. One of the fringe benefits that has attracted excellent pharmaceutical staff is the tenure system at St. Louis Apothecary. A pharmacist who remains with the company for 5 years gains tenure and cannot be termi- nated unless it is for cause (basically, only for theft or revocation of license). This means that your pharmacies have had the best job retention and job satisfaction of any pharmacy in the region, a fact that has made your job of handling human resources easy—that is, until recently.

Although yours is a private company, it just so happens that a large percentage of your full- time pharmacists are Roman Catholic. Some of these pharmacists have decided to conscien- tiously object to filling prescriptions for any abortifacient or contraception drug or device. Until recently, this was not much of a problem, since there were usually other pharmacists at the location who would fill the prescription (Catholic or not). Recently, however, you have had to cut back your non-tenured pharmacists’ work hours because of the recession and declining profits. With the advent of new “morning-after” pills and a rise in other con- traception, the conscientious refusal by tenured pharmacists has become a dilemma at St. Louis Apothecary, since it has become increasingly difficult for customers to have these prescriptions filled at your pharmacies.

Usually, there is another pharmacy within a mile or two of a location if the only pharmacist on duty refuses to fill a prescription or sell contraception. But customers who have been turned away have begun complaining not only about the inconvenience but also the fact that some of the objecting pharmacists have become judgmental and rude. In addition, for several of your company’s rural locations, it is more than merely an inconvenience, since the St. Louis Apothecary store is sometimes the only option for dozens of miles around. For some customers, this imposes a real obstacle to health care. Sales are down now that quite a few customers have taken not only their birth control prescriptions but all of their business elsewhere. Your remaining customers have also started to show lower customer satisfac- tion on a recent questionnaire you instituted after becoming aware of the complaints.

Answer the Following Question

What would you do in your role as administrator for St. Louis Apothecary and why? Here are some helpful hints:

• Remember to justify any ethical decision made by appealing to what you have learned so far in this chapter as well as by using any other resources you care to incorporate. You may find it helpful to review the ethical decision-making flowchart (Figure 1.2) in this chapter and its accompanying video walk-through (available in your e-book) when organizing your decision.

• Who are the primary stakeholders in this case? Are there secondary stakeholders? How would you attempt to balance the relative interests of all of the stakeholders? Would the primary stakeholders’ interests always trump those of secondary stake- holders, or would an interest’s relative importance be the deciding factor? How would you decide the relative importance of rights versus privileges?

• Assume that you will face legal liability for breach of contract if you fire any tenured pharmacist for anything other than theft, revocation of license, or the elimination of his or her position (the last of which would only happen if you were to close a store permanently, since you cannot replace a licensed pharmacist with anything other than another licensed pharmacist).

Chapter Highlights

Critical Thinking and Discussion Questions 1. The four principles of principlist ethics all outline general duties and responsibilities for ethi-

cal health care. Describe an example of when the four principles might generate competing, or even contradictory, duties for a health care manager.

2. Give an example of when a health care administrator might have to cause harm, despite the nonmaleficence principle.

3. Discuss, explain, and provide an example of informed consent in health care. 4. Give an example (either from personal experience or that you have read about) of a health

Key Terms autonomy The concept that rational adult decision-makers have the ability, and should be given the opportunity, to make decisions for themselves. In the context of health care, it is the right to accept or reject recommended treatments, procedures, and clinical trials.

beneficence The ethical principle and requirement to benefit and care (do good) for others. It is especially relevant to health care because its goals are to care for and benefit patients or clients.

bioethics The study of ethical issues aris- ing from advances in biology and medicine. Drawn from the combination of the words biology and ethics.

bioethics committees (BECs) Bodies that deal with clinical and organizational ethical issues, including ethical conflicts in health care organizations.

casuistry A general case-based method of solving ethical problems, somewhat similar to the process of using legal precedent.

dilemma A situation in which one is either uncertain about the correct course of action or the right or optimal decision is not an available option.

distributive justice The just allocation of resources or goods in a society or group. It relies on a definition of justice as “fairness,” or what is deserved.

equitable The state of affairs that is fair or just. Achieving equity requires impartiality. It may not require that everyone be treated exactly equally; sometimes it requires that differently situated people be treated differently.

ethical theory A view about what makes actions or events right or good. An ethical theory gives general criteria for rightness and identifies the right-making features of actions and events—in other words, what sorts of things should be taken into account when judging whether an act is right or wrong.

ethically relevant factors (ERFs) Goods, values, rights, or any other factor to which we ought to be sensitive in determining the ethically correct way to respond to a given situation.

Case Study: St. Louis Apothecary (continued)

Answer the Following Question

What would you do in your role as administrator for St. Louis Apothecary and why? Here are some helpful hints:

Chapter Highlights

ethics The systematic study and the practi- cal application of the process for determin- ing right action, or what the individual or organization ought to do in a given situation.

fidelity The virtue of faithfulness. Keeping one’s word and making decisions that align with one’s professional integrity and eth- ics is a form of fidelity. It is also evidenced when a health care administrator makes difficult or unpopular decisions that are required by a duty.

nonmaleficence The ethical principle that requires people to avoid causing needless harm to others, or to minimize the harm- ful but necessary consequences of their actions. It has been termed the primary duty of physicians: “First, do no harm.”

paternalism In traditional health care, the belief that “the doctor knows best.”

preventive ethics The concept that the best resolution to an ethical dilemma is to prevent it from happening in the first place.

principlist ethics An approach to ethics that emphasizes the application of funda- mental principles, in a top-down fashion, to serve as the basis for rules or guides to action.

procedural justice The fairness and trans- parency of processes by which decisions are made.