Please complete the following REVIEW QUESTIONS

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CHAPTER 16

Healthcare Ethics

Learning Objectives (1 of 2)

Describe the concepts of ethics and morality.

Describe how an understanding of ethical theories, principles, and virtues is helpful in resolving ethical dilemmas.

Explain the relationship between spirituality and religion.

Learning Objectives (2 of 2)

Discuss situational ethics and how one’s moral character can change as circumstances change.

Explain how one’s reasoning skills influence the decision-making process.

Discuss the purpose of an ethics committee and its consultative role in the delivery of patient care.

Any Good I Can Do

I expect to pass through the world but once. Any good therefore that I can do, or any kindness I can show to any creature, let me do it now. Let me not defer it, for I shall not pass this way again.

—Stephen Grellet, French-American Religious Leader (1773–1855)

Words Are “Tools of Thought”

The following are true of the study of any new subject:

New vocabulary and an understanding of abstract theories and principles of ethics will be necessary.

Such knowledge will arm the decision maker with the information necessary to help make difficult care decisions.

Ethics

Ethics is the branch of philosophy that deals with values relating to human conduct with respect to rightness and wrongness of actions and goodness and badness of motives and ends.

It involves the study of morality, virtues, and values, and how they affect one’s character.

It involves how individuals decide to live within accepted boundaries and how we live in harmony with one another and nature.

Scope of Ethics

Micro-ethics: Individual’s view of right and wrong

Macro-ethics: Global view of right and wrong

Ethics from Various Perspectives

Ethics is used in different but related ways.

Philosophical ethics involves inquiry about ways of life and rules of conduct.

Ethics may also be a general pattern or way of life (e.g., religious ethics).

Ethics may refer to moral codes.

Why Study Ethics?

To recognize healthcare dilemmas

To provide tools for constructive deliberation and conflict resolution

To make sound judgments

To better understand the goodness and badness of motives and ends

Morality

Aim above Morality.

Be not simply good;

be good for something.

—Henry David Thoreau

What Is Morality?

Morality is a code of conduct.

It implies the quality of being in accord with standards of right and good conduct.

It describes a class of rules held by society to govern the conduct of its individual members.

Morals

Ideas about what is right and wrong

Guides to behavior that rational persons put forward for governing their behavior

Moral Judgments (1 of 3)

Judgments concerned with what an individual or group believes to be right or proper behavior in a given situation

Involve assessment of another person’s moral character based on how he or she conforms to moral convictions established by the individual and/or group

Moral Judgments (2 of 3)

Lack of conformity typically results in:

Moral censure

Condemnation

Possible derision of the violator’s character

What is considered right varies from nation to nation, culture to culture, religion to religion, and person to person.

Moral Judgments (3 of 3)

There is no “universal morality.”

Whatever guide to behavior an individual regards as overriding and wants to be universally adopted is considered that individual’s morality.

Codes of Ethics

Codes of ethics provide for:

Standards: As guides to human conduct

Principles: Describe responsibilities

Rules of expected conduct: No allowance for individual judgment

Morality Legislated

Law differs from morality.

Law has explicit rules, penalties, and officials who interpret laws and apply penalties.

Laws are created to set boundaries for societal behavior.

Laws are enforced to ensure expected behavior happens.

Ethical Theories

Attempt to introduce order into the way people think about life and action

Are the foundation of ethical analysis and provide guidance in the decision-making process

Present varying viewpoints that assist caregivers in making difficult decisions that impact the lives of others

Ethics, too, are nothing but reverence for life. This is what gives me the fundamental principle of morality, namely, that good consists in maintaining, promoting, and enhancing life, and that destroying, injuring, and limiting life are evil.

—Albert Schweitzer

Normative Ethics (1 of 2)

Attempt to determine what moral standards should be followed so that human behavior and conduct may be morally right

General normative ethics is the study of major moral precepts of what things are right.

Applied ethics is the application of normative theories to practical moral problems.

Normative Ethics (2 of 2)

Descriptive ethics, also known as comparative ethics, deals with what people believe to be right and wrong.

Meta-ethics seeks to understand ethical terms and theories and their application.

Consequential Ethics (1 of 2)

Morally right action involves:

Maximum balance of good over evil

The greatest good for the greatest number

Rightness or wrongness of an action is based on the consequences or effects of the action.

Consequential Ethics (2 of 2)

Questions to be asked

What will be the effects of each course of action?

Will the effects be positive or negative?

Who will benefit?

What will do the least harm?

Utilitarian Ethics

Form of consequentialism

Philosophy that advocates the greatest good for the greatest number

Nonconsequential Ethics

The rightness or wrongness of an action is based on properties intrinsic to the action, not on its consequences.

Situational Ethics (1 of 3)

Refers to a particular view of ethics in which absolute standards are considered less important than the requirements of a particular situation

The importance of a particular value may vary as one’s situation changes.

Situational Ethics (2 of 3)

Moral character can be compromised when someone is faced with difficult choices.

Good people behave differently in different situations.

Situational Ethics (3 of 3)

Good people sometimes do bad things.

One’s moral character can sometimes change as circumstances change (thus, the term situational ethics).

Situational Ethics: The Creation of Ignorance

How common is the creation of ignorance?

It’s pretty common. I mean in terms of sowing doubt, certainly global warming denialists who for years have managed to say, “well the case is not proven. We need more research.” And what’s interesting is that a lot of the people working on that were also the people working on Big Tobacco.

—Interview with Robert Proctor, professor, Stanford University, Discover, 2008

Situational Ethics: Discussion

Why do people who do bad things in one job repeat their pattern of doing bad in another? What is their motive?

Why do people watch bad things happen and then deny they are happening? Explain.

What is often referred to as being the “root of all evil?” How does it apply in this case?

Situational Ethics: Sustaining Life

A decision not to use extraordinary means to sustain the life of an unknown 84-year-old may result in a different decision if the 84-year-old is one’s mother.

Situational Ethics: Ethical Decision Making

Ethical decision making is the process of deciding what the right thing to do is in the event of a moral dilemma.

Situational Ethics Case: High in the Andes (1 of 2)

Those who survived the plane crash high in the Andes Mountains were faced with some difficult survival decisions.

Their need to survive illustrates to what (see text for details).

lengths one may go in certain situations in order to survive

Situational Ethics Case: High in the Andes (2 of 2)

How might you change as circumstances change?

Describe how your consultative advice might change based on the patient’s needs, beliefs, and family influences.

Deontological Ethics

Focuses on

Duty to others

Rights of others

Forms

Religious ethics based on religious beliefs

Secular ethics based on codes developed by societies that have relied on customs

Ethical Relativism (1 of 2)

The theory that holds that morality is relative to the norms of one’s culture; that is, whether an action is right or wrong depends on the moral norms of the society in which it is practiced.

Ethical Relativism (2 of 2)

What is morally correct behavior in one society may be morally wrong and another.

An action can be considered right or wrong depending on the accepted norms of the society in which it is practiced.

Example: Slavery may be considered an acceptable practice in one society and an unacceptable practice in another.

Virtue-Based Ethics

Focuses on the inherent character of a person rather than on the specific actions that he or she performs

A virtue is normally defined as some sort of moral excellence or beneficial quality.

Virtues are those characteristics that differentiate good people from bad people.

A morally virtuous person is one who does the good and right thing by habit.

Principles of Healthcare Ethics

Autonomy

Right of a person to make one’s own decisions.

Patient has the right to accept or refuse care even if it is beneficial to saving his or her life.

May be inapplicable in certain cases:

Disability

Mental status

Maturity

Incapacity to make decisions

Beneficence and Justice

Beneficence

Principle of doing good

Paternalism

Medical paternalism

Nonmaleficence

Avoid causing harm

Tuskegee Syphilis Experiment

National Research Act of 1974

Justice

Obligation to be fair in the distribution of benefits and risks

Distributive justice

Requires that all individuals be treated equally

Injustice for the Insured

Even if you’re insured, getting ill could bankrupt you. Hospitals are garnishing wages, putting liens on homes, and having patients who can’t pay arrested. It’s enough to make you sick.

—Sara Austin, SELF, October 2004, p. 247

Justice and Age (1 of 2)

Should an 89-year-old patient get a heart transplant because he or she is higher on the waiting list to receive a heart transplant than a 10-year-old girl?

Justice and Age (2 of 2)

Should a pregnant 39-year-old single parent get a heart transplant before a 10-year-old boy because she is higher on the transplant waiting list?

Justice: Who Gets Treated First During a Disaster?

Room 1: Severely injured patients not expected to live

Room 2: Severely injured patients most likely to live if treated

Room 3: Injured patients who will live but will suffer varying degrees of disability if not treated promptly

Justice: Emergency Care

Two patients are in critical condition. Who gets treated first?

First patient who walks through the door

Younger patient

Patient most likely to survive

Patient who can pay for services

Patient with most serious condition

Justice: Scarce Resources

What happens when resources are scarce and only one of two patients can be treated?

What should be the determining factors?

Age

Position in life

Patient wishes

Values

Moral value is the relative worth placed on some virtuous behavior.

What has value to one person may not have value to another.

A value is a standard of conduct.

Values are used for judging goodness or badness of some action.

Values give purpose to each life; they describe one’s moral character.

Intrinsic and Instrumental Values

Intrinsic value

Something that has value in and of itself

Instrumental value

Something that helps to give value to something else

Money is valuable for what it can buy.

Values Can Change

People make value judgments and choices among alternatives.

Values one so dearly proclaims may change as needs change.

If one’s basic needs for food, water, clothing, and housing have not been met, one’s values may change in such a way that a friendship, for example, might be sacrificed if one’s basic needs can be better met as a result of the sacrifice.

The motivating power of a person’s actions is a necessity for survival.

Differing Values

If mom’s estate is being squandered at the end of life, a financially well-off family member may want to hold on to mom despite the financial drain on her estate.

Another family member financially struggling to survive may more readily see the futility of expensive medical care and find it easier to let go.

Courage

Courage is the greatest of all virtues, because if you haven’t courage, you may not have an opportunity to use any of the others.

—Samuel Johnson

Virtues and Values: What is Courage?

Courage is the mental or moral strength to persevere and withstand danger.

Courage is the ladder on which all the other virtues mount.

Courage involves balancing fear, self-confidence, and values.

Without courage, we are unable to take the risks necessary to achieve the things most valued.

Virtues and Values: The Courageous Person

A courageous person has good judgment and a clear sense of his or her strengths, correctly evaluates danger, and perseveres until a decision is made and the right goal that is being sought has been achieved.

Virtues and Values (1 of 4)

Wisdom

Temperance

Commitment

Detachment

Virtues and Values (2 of 4)

Compassion

Conscientiousness

Discernment

Fairness

Virtues and Values (3 of 4)

Fidelity

Freedom

Honesty, trustworthiness, truth-telling

Integrity

Virtues and Values (4 of 4)

Kindness

Respect

Hopefulness

Tolerance

Forgiveness

Religious Ethics

Religion provides a moral code for appropriate behavior.

The prospect of divine justice helps us tolerate the injustices in life.

There is a need to better understand cultural diversity and the importance of religion in the healing process.

Spirituality

Spirituality in the religious sense implies that there is purpose and meaning to life.

Spirituality generally refers to faith in a higher being.

Religious Beliefs (1 of 2)

Judaism

Monotheistic religion

Hinduism

Buddhism

Falun Gong

Zen

Taoism

Religious Beliefs (2 of 2)

Christianity

Based on Jesus Christ as Savior

Jehovah’s Witnesses

Anointing of the sick for healing

Islam

Religious Beliefs and Duty Conflict

Belief that it is a sin to accept a blood transfusion

Right to refuse

Necessity to work within the law and judicial system when states’ rights and the rights of a minor are involved

Secular Ethics

Based on codes developed by societies that have relied on customs to formulate their codes

Code of Hammurabi

Professional Ethics (1 of 2)

Standards or codes of conduct established by the membership of a specific profession.

Healthcare professionals are governed by ethical codes.

Codes of ethics are created in response to actual or anticipated ethical conflicts.

Professional Ethics (2 of 2)

Documentation falsified

Psychologist’s sexual misconduct

Attorney–minister misconduct

Ethics Committee: Objectives

Provide support and guidance.

Analyze ethical dilemmas.

Advise and educate healthcare providers, patients, and families.

Assist patient and family in coming to consensus with options that best meet patient’s goal for care.

Ethics Committee: Functions

Policy and procedure development

Educational role

Consultation and conflict resolution

Requests for consultations

Expanding role of the ethics committee

Internal role: Organizational and patient care issues

External role: Political advocacy

Reasoning and Decision Making (1 of 4)

Reason guides our attempt to understand the world about us. Both reason and compassion guide our efforts to apply that knowledge ethically, to understand other people, and have ethical relationships with other people.

—Molleen Matsummura

Reasoning and Decision Making (2 of 2)

Reasoning is the process of forming conclusions, judgments, or inferences based on one’s interpretation of facts or premises that help support a conclusion.

Reasoning and Decision Making (3 of 4)

Partial reasoning

Involves bias for or against a person based on one’s relationship with that person

Circular reasoning

Describes a person who’s already made up his or her mind on a particular issue and sees no need for deliberation

Reasoning and Decision Making (4 of 4)

Ethical decision making is the process of deciding what the right thing to do is in the event of a moral dilemma.

Patients have an obligation to make medical preferences known to their treating physician.

Any glimmer of uncertainty as to a patient’s desires in an emergency situation should be resolved in favor of preserving life.

Ethical Dilemmas

Ethical dilemmas arise when ethical principles, values, rights, duties, and loyalties conflict.

A caregiver must not only examine what he or she considers the right thing to do, but what are the alternatives, and what are the patient’s known wishes.

Moral Compass Gone Astray (1 of 3)

The world is a dangerous place. Not because of the people who are evil; but because of the people who don’t do anything about it.

—Albert Einstein

Moral Compass Gone Astray (2 of 3)

Hartford Police Chief questions the city’s “moral compass” a week after bystanders and drivers maneuvered around the motionless body of the 78-year-old victim of a hit-and-run crash.

Moral Compass Gone Astray (3 of 3)

The continuing trend of awareness of declining value systems, coupled with increased governmental regulations, mandates that caregivers understand ethics and the law and the relationships.

Moral Compass Gone Astray: Discussion

What moral principles might the sheriff have been referring to when he questioned the city’s lack of a moral compass? Explain.

Discuss your thoughts as to why society in general is losing its moral compass.

Practical Suggestions (1 of 2)

Be a good listener.

Listen with the intent to learn, not to find fault or argue.

Listen to contribute and resolve ethical dilemmas.

Practical Suggestions (2 of 2)

Believe in good values.

Become virtuous by practicing good values until they become habits.

Summary Thoughts

Be careful of your thoughts, for your thoughts inspire your words.

Be careful of your words, for your words precede your actions.

Be careful of your actions, for your actions become your habits.

Be careful of your habits, for your habits build your character.

Be careful of your character, for your character decides your destiny.

What Can You Control?

Although you cannot control the amount of time you have in this life, you can control your behavior by adopting the virtues and values that will define who you are and what you will become and how you will be remembered or forgotten.

Helpful Hints (1 of 2)

Be aware of how everyday life is full of ethical decisions and that numerous ethical issues can arise when caring for patients.

Help guide others to make choices.

Ask your patient how you might help him or her.

Be aware of why you think the way you do. Do not impose your beliefs on others.

Helpful Hints (2 of 2)

Ask yourself whether you agree with the things you do. If the answer is no, ask yourself how you should change.

When you are not sure what to do, the wise thing to do is to talk it over with someone whose opinion you trust.

Do not sacrifice happiness for devotion to others.

Do not lie to avoid hurting someone’s feelings.

Review Questions (1 of 2)

Describe how ethical theories differ and how ethical principles are helpful to caregivers and the ethics committee in resolving ethical dilemmas.

Describe how spirituality and religion help to shape one’s healthcare choices.

Review Questions (2 of 2)

Describe the term situational ethics and how decisions can change as circumstances change.

Describe the consultative role of the ethics committee when addressing ethical dilemmas.

Please complete the following REVIEW QUESTIONS

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