HMGT 372 DISC 1

CHAPTER 1 An introduction to healthcare ethics

Laetus O.K. Lategan and Gert J. van Zyl

C o p y r i g h t 2 0 1 7 . U J P r e s s .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

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AN INTRODUCTION TO heALThCARe eThICS

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1. CONCePTUALISATION

The concept “ethics” finds its origin in the Greek èthos and/or êthos. These words refer to custom,

practice, attitude and motive and relate to universal principles for moral human behaviour and

the subsequent identification and application of norms or values derived from these principles.

Essentially ethics refers to people’s moral behaviour following on a particular value system.

Behaviour is informed by their deepest motivation, also known as ethos. The application of a

principle is commonly referred to as norms or values.

In view of these concepts can healthcare ethics be defined as the identified principles informing

the moral practices and behaviour of healthcare practitioners towards patients and the application

of the values and norms in the performance and execution of healthcare. Ethics influence both

healthcare practitioner and patient. In addition, ethics is also extended to healthcare management and

administration, and to the habitat supporting healthcare practitioner and patient. This view corresponds

with Glouberman and Mintzberg’s (2001) identification of the “four worlds” in healthcare: cure, care,

control and community. [See Chapter 2.2 for a description of these four worlds.]

The working definition of healthcare ethics in this book is the identification of principles and the

application of values and norms informing the practice of healthcare. The scope of this definition

will cover the four worlds associated with healthcare, namely cure, care, control and community.

2. ADDReSSING The MA JOR TheMeS IN heALThCARe eThICS

A central theme in this book (see Introduction and Chapter 2) is that healthcare ethics cannot be

limited in scope to apply only to the healthcare practitioner or only to the patient. In addition,

healthcare is not restricted to the conventional settings of hospital, clinic or hospice only.

A “site” that cannot be overlooked is the practice of healthcare within a community – as part of

basic healthcare or a context for research. Healthcare ethics deals with vulnerable people (healthcare

practitioners, patients, communities), situations and institutions (healthcare management and

administration). It is for this reason that Lategan (Chapter 2) and Vanlaere and Burggrave (Chapter 4)

deal with vulnerability and ethical relationships at length. Lategan’s arguments informed the three

positions taken in this book (the scope of healthcare ethics, the context for healthcare ethics

and the encompassing influence of vulnerability on healthcare ethic). In addition a cosmological

understanding of healthcare ethics is presented. In this presentation it is evident that ethics is always

defined within a particular context and that regardless of religion and/or cultural orientation, there are

universally accepted principles, values and norms that inform healthcare ethics.

It is therefore expected that (healthcare) ethics entertain the difference between right and wrong.

Van Zyl and Van Zyl (Chapter 3) argue that this differentiation is not that simple, and for the health

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HEALTHCARE ETHICS FOR HEALTHCARE PRACTITIONERS

professional, may be more complex than what is sometimes envisaged. Ethics is particularly

applicable to the professional practice of medicine in guiding decision making within the doctor-

patient relationship, and protecting self-directedness for the patient in an essentially unequal

power relationship. The maintenance of the reputation of the individual practitioner and the medical

profession as a whole are important. The links with freedom, ethics, morality and professionalism

are explained and some solutions are suggested. One of these solutions is the “patient charter”.

Ethics is the formal expression of values and norms that a profession or business or other societal

structure selects and prioritises to ensure a particular standard of moral decision making and to

protect their reputation. It is ethics that transforms the subjective nature of right and wrong to an

objective measure of moral behaviour.

Vanlaere and Burggraeve (Chapter 4) add a specific understanding to healthcare ethics. They

approach healthcare from a quality-of-care perspective. It is evident that today, more attention

is given to the quality of care than ever before. These authors link this interest to the greater

emphasis that is placed on service delivery because of safety requirements and to the impact that

good or poor healthcare delivery can have on healthcare systems. This raises the question as to

what quality is when it comes to healthcare. For them quality demands an increase in carefulness,

with its objective means and methods, and an increase in caring, with its subjective attitudes and

virtues. This has a direct impact on professionalism and responsibility. As a result healthcare must

be seen as a relationship and not a product. Hence an ethical framework has to inform healthcare

regardless of the context and situation.

This relationship is based on an ethical obligation for healthcare practitioners to provide culturally

competent, patient-centred care. MacKinnon and Comer (Chapter 5) claim that in order to do so,

healthcare practitioners need to be aware of patient and family culture, values, and faith-based

beliefs as they will impact end-of-life decisions, to mention but one scenario. Additionally, the

culture, values and faith beliefs of the healthcare practitioner will also affect end-of-life decision

making, and sometimes these two entities collide. In this chapter the authors provide some

guidelines to consider in working together to make culturally sensitive end-of-life decisions. It

is also evident that healthcare cannot be removed from a human rights point of view. Moore’s

contribution (Chapter 6) supports the notion that medical issues belong within a human rights

culture. It is this culture, with its universal principles, that contributes towards the care of patients

and the security of their well-being. To illustrate this point, Viljoen (Chapter 7) deals with euthanasia

in a South African context. She points out that although a case can be brought before court and

assisted life-end euthanasia can be granted, it still leaves the healthcare practitioner and patient in

a vulnerable position. This proves the point that although an act may be legal, it does not safeguard

the individual or enable the individual to be at ease with such an act.

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AN INTRODUCTION TO heALThCARe eThICS

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In healthcare the focus is very often on the healthcare practitioner and the patient only. A neglected

topic in healthcare ethics is how do we deal with communities? Lewitt, Campbell and Cross

(Chapter 8) address this issue by focusing on community-based participatory research (CBPR).

In CBPR community participants are actively engaged with, and influenced by, all aspects of the

research process, from design to dissemination. There is a commitment to practical change in

this strength-based approach, which builds trust, enhances community capacity and may lead

to solutions to complex health questions that were unforeseen by the academic researchers. As

healthcare research moves from working ‘on’ communities to working ‘with’ communities, a

concomitant shift in the ethical orientation of healthcare practitioners is required. CBPR requires an

awareness of power relationships between healthcare practitioners and the community members

or service users. In CBPR the whole community should be considered the subject of research and

ethical considerations should encompass respect for community as well as individual autonomy.

When working with children there is a fur ther need to work sensitively with power dynamics.

Kruger (Chapter 9) is right when he remarks that healthcare is not a new concept and several

modules are available to assist the healthcare worker with the decision making process. However

healthcare is a very dynamic field, causing the ethical decision making competency of healthcare

workers to become more and more important but also more challenging. The healthcare worker

should be aware of how changes within healthcare could influence the ethical decision making

process. Healthcare workers should be aware of the multifactorial approach that is needed within

the decision making process. It is recommended that an integrated approach be followed in which

the healthcare worker should consider following a systematic analysis of the ethical issue at

hand. The purpose of such an integrated approach is to ensure that the ethical decision making

process is conducted by means of a simplified step-by-step approach. Healthcare workers must

remember that they do function within a multidisciplinary team. However, the final ethical decision

is essentially an individual process and the healthcare worker will take responsibility for the entire

ethical decision making process no matter what approach is followed. The outcome of their ethical

decisions might have a much more far-reaching effect than expected.

Another neglected theme in healthcare ethics is spirituality. This should not be confused with

religion or faith. Swart (Chapter 10) unpacks this important theme and explains how spirituality

can assist with the healing of a patient but also how religion and faith can open existential issues

in healthcare that should be part of the holistic treatment of a patient. As healthcare practitioner,

patient, healthcare management and administration and habitat may not share the same spirituality,

religion and/or faith, all of those involved in healthcare should guard against making spirituality,

religion or faith the condition for treatment rather than a consideration in healthcare.

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HEALTHCARE ETHICS FOR HEALTHCARE PRACTITIONERS

3. AN OUTLINe OF heALThCARe eThICS

Based on the discussion of what healthcare ethics is, the following outline for healthcare ethics

can be presented:

■ Healthcare ethics is the identification of principles and the application of values and norms informing the practice of healthcare. It aims to transform a situation and to bring about a

change in attitude, behaviour and practice.

■ Healthcare ethics cannot be limited to the patient only but covers four worlds associated with healthcare, namely cure, care, control and community.

■ Vulnerability includes human experiences such as ethical decision making, physical suffering, psychological disorders, economic challenges and cultural orientation. It goes without saying

that every person is dependent upon other people’s understanding of his/her vulnerability and

therefore his/her care. In a medical context it is about caring for life, health, state of mind and

general well-being.

■ Quality healthcare is important due to safety associated with the healthcare value chain. The core of this value chain is not healthcare as a product but healthcare as a relationship.

■ Healthcare ethics is informed by family, culture and religious values. Although a healthcare practitioner may not share those same values, people’s values should be respected and

accommodated in the practice of care and decision making. The healthcare practitioner

deserves the same respect for his/her values as does the patient.

■ Healthcare ethics can never be removed from professional practice. Healthcare ethics should form part of healthcare education for professionals and healthcare ethics orientation for

patients and their habitat.

■ Part of extending our understanding of healthcare is to do research within communities. This often presupposes a power relationship between those who know and those from whom the

information is gathered. This situation opens the possibilities of power play and vulnerability.

In dealing with communities the primary objective should remain, namely the preservation of

the dignity of all involved in a project. This can be facilitated by shifting the emphasis from

research on to research with.

■ Legality can never be removed from healthcare. It does not, however, remove ethical responsibility from healthcare. The law dictates what can be done, while ethics informs how

it should be done.

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AN INTRODUCTION TO heALThCARe eThICS

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■ Ethical decision making cannot be avoided. Although informed decision making is the cornerstone of ethical behaviour, proper guidance is needed to make the ‘best interest’

decision to address the ethical challenges of a particular situation.

■ Spiritual needs and religious orientation should be integrated in healthcare but cannot form the basis for effective healthcare.

■ Healthcare practitioners, managers and administrators should be trained, mentored and coached in dealing with healthcare ethics. Patients and their habitat should be sensitised

regarding the ethical rights and responsibilities of healthcare practitioners, managers

and administrators.

ReFeReNCeS

Glouberman, S. & Mintzberg, H. 2001. Managing the care of health and the cure of disease. Part 1:

Differentiation. Health Care Management Review. Winter 56-69.

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