Prototypes of Ethical Problems

Prototypes of Ethical Problems

Objectives

The reader should be able to:

• Recognize an ethical question and distinguish it from a strictly clinical or legal one.

• Identify three component parts of any ethical problem.

• Describe what an agent is and, more importantly, what it is to be a moral agent.

• Name two prototypical ethical problems.

• Distinguish between two varieties of moral distress.

• Compare the fundamental difference between moral distress and an ethical dilemma.

• Describe the role of emotions in moral distress and ethical dilemmas.

• Describe a type of ethical dilemma that challenges a professional’s desire (and duty) to treat everyone fairly and equitably.

• Discuss the role of locus of authority considerations in ethical problem solving.

• Identify four criteria to assist in deciding who should assume authority for a specific ethical decision to achieve a caring response.

• Describe how shared agency functions in ethical problem solving.

NEW TERMS AND IDEAS YOU WILL ENCOUNTER IN THIS CHAPTER

legal question

disability benefits

ethical question

prototype

clinical question

agent

moral agent

locus of authority

shared agency

moral distress

moral residue

ethical dilemma

Topics in this chapter introduced in earlier chapters

Topic

Introduced in chapter

Ethical problem

Integrity

Interprofessional care team

Professional responsibility

A caring response

Accountability

Social determinants of care

Justice

Introduction

You have come a long way already and are prepared to take the next steps toward becoming skilled in the art of ethical decision making. The first part of this chapter guides you through an inquiry regarding how to know when you are faced with an ethical question instead of (or in addition to) a clinical or legal question. A further question is raised: How do you know whether the situation that raised the question is a problem that requires your involvement? This chapter helps you prepare to answer that question too. You will learn the basic components of an ethical problem and be introduced to two prototypes of ethical problems. We start with the story of Bill Boyd and Kate Lindy.

 The Story of Bill Boyd and Kate Lindy

Bill Boyd is a 25-year-old soldier who lives in a large city. Bill served in the U.S. Army for more than 6 years and was deployed to both Iraq and Afghanistan for multiple military missions in the past 4 years. During his final deployment, Bill suffered a blast injury in which he sustained significant shoulder and neck trauma and a mild traumatic brain injury (TBI) and posttraumatic stress. He was treated in an inpatient military hospital and transitioned back to his hometown, where he moved into his childhood home with his mother.

Kate Lindy is the outpatient psychologist who has been treating Bill for pain and posttraumatic stress. Bill is in a structured civilian reentry program. This competitive program is administered by a government subcontractor; its goal is to help injured veterans find meaningful careers or employment on return from the front lines. Bill reports that he is struggling with the transition to civilian life. He originally was prompt in keeping his appointments but recently has missed almost all of his sessions. Twice Bill has arrived for his appointment more than 30 minutes late and smelling of alcohol. Kate informed Bill that she could not treat him in this condition and that if he continued to arrive in this state, she would need to discontinue therapy. Bill responded to Kate and said “You have no idea what all of this is like. And don’t even go there on the alcohol; like you have never had a drink on a bad day.”

Kate is concerned about Bill. She calls his home and gets no answer. She then calls the case manager listed on his intake form. Kate tells the case manager about Bill’s regularly missed appointments (three in the last 4 weeks). She also tells the case manager that Bill has been charged for the missed visits because he has not called to cancel, which is the billing policy of the institution where Kate is employed.

The manager responds that Bill does not qualify for transitional career/employment services unless he is compliant with all outpatient care. She adds that in her experience patients like Bill have a hard time adjusting to the fact that they are no longer eligible for active duty.

The case manager says she will talk to Bill about the unacceptability of his failing to let the therapist know when he decides not to keep his appointment. In fact, if Bill keeps that up, the case manager continues, he will be kicked out of the civilian reentry program because the government cannot be expected to pay for his lack of responsibility. Kate responds that maybe Bill was unclear about the policy. The manager replies, “It doesn’t matter. He’s an army man; he knows better than that.”

A week goes by. At the scheduled time for Bill’s appointment, he again does not appear. Kate has been uneasy about the conversation with the manager, and when the time comes for her to fill out the billing slip for another missed appointment, she feels positively terrible.

 Reflection

Do you share Kate’s feelings that something is not right? If yes, what do you think the problem is? Jot down a few thoughts here and refer back to them as the chapter progresses.

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Recognizing an Ethical Question

Health professionals face all types of questions in clinical practice. Some are ethical questions, but others are not. Many times, what may appear to be an ethical question is in fact something else, such as a miscommunication or a question about a clinical fact or a legal issue. Often, complex clinical situations include clinical, legal, and ethical questions; part of your challenge is to distinguish them and sort them out for their relevance to the patient and the delivery of care.

The following exercise is designed to walk you through one example of an issue that includes clinical, legal, and ethical dimensions, with a description of why the last is an ethical question.

Is this an ethical question? Answer Yes or No:

Can a person status post TBI drive?

If you answered “no,” you are correct. This is a clinical question because clinical tests and procedures can help answer it. Patients who pass various cognitive assessments and an on-road driving evaluation have the clinical ability to drive, and those who fail do not. Refer back to the story at the beginning of this chapter. In the narrative about Bill Boyd, Kate Lindy, and the case manager, what additional clinical information can help you better evaluate the situation?

Now consider the following question:

Must patients with TBI comply with medical advice in this type of situation if they want to continue to drive?

Is this a clinical, legal, or ethical question? If you said “a legal question,” you are on the right track. A tip-off is the word “must.” As you learned in Chapter 1, the laws of the state and other laws are designed to monitor public well-being and enforce practices that protect the public good. Almost all states include procedures to help ensure road safety. Relevant information about people who are dangerous behind the wheel is found in part through clinical examinations. Clinical and legal systems are interdependent in that and other situations, so the decision to ignore clinical recommendations is not always up to an individual patient.

Now, go to the specific legal implications of Bill Boyd’s situation. When the physician referred Bill for therapy, she assessed that the patient’s discomfort was from a combat-related injury. The time may come when Bill wants to apply for disability benefits for his condition. Veterans disability benefits are legally enforced governmental programs in the United States to help protect members of the military from financial duress when injured during service duty. And so, a related legal question relevant to this situation is: Do patients have the right to benefits provided by the government if for any reason they miss prescribed treatment and the professional reports this?

Eligibility usually requires that a patient comply with treatments that are prescribed; the fact that Bill missed multiple treatments may compromise his case. The case manager may choose to fight Bill’s claim for disability benefits now that Kate has contacted the manager with this information.

Finally, consider this question, which is an ethical question. As you read it, think about why it is an ethical question.

Should people with TBIs who refuse to take a recommended onroad driving assessment be allowed to continue driving? If so, under what circumstances?

The word “should” is the tip-off here. It points to something in society all have agreed to support and each individual has a responsibility to help do so. Kate’s reflection on whether she should have talked with Bill’s case manager and her ambivalence about having to charge for treatments that she did not administer are examples of ethical questions about the wrongdoing or rightness of her actions that she was pondering.

 Summary

Ethical questions can be distinguished from strictly clinical or legal questions, although all of these questions often arise in health professional and patient situations. An ethical question places the focus on one’s role as a moral agent and those aspects of the situation that involve moral values, duties, and quality-of-life concerns in an effort to arrive at a caring response.

For your continued learning, we now introduce several prototypes of ethical problems, into which many different everyday ethical questions will fit.

Prototypes of Ethical Problems: Common Features

What is a prototype? Prototypes are a society’s attempt to name a basic category of something. Prototypes can be objects, concepts, ideas, or situations.1 Prototypes of ethical problems are recognizable as a group by three features they have in common. Each of the prototypes in this chapter appears different from the others; in fact, each has a different role to play when ethical questions have arisen. That said, the first step into this venture is to become familiar with the same basic structural features found in all the prototypes of ethical problems:

A: A moral agent (or agents)

C: A course of action

O: An outcome

Each feature is discussed in turn.

The Moral Agent: A

Which of the following best describes your idea of a health professional as an agent?

A. A person with more than one basic loyalty; a deeply divided loyalty (e.g., a double agent).

B. A person who has the moral or legal capacity to make decisions and be held responsible for them (e.g., a signee on a contract).

C. A person who plans schedules or events (e.g., a booking agent).

If you answered “B,” you are most clearly focused on the meaning of agency in the health professions roles you will assume. In ethics or law, an agent is anyone responsible for the course of action chosen and the outcome of that action in a specific situation. Obviously, being an agent requires that a person be able to understand the situation and be free to act voluntarily. Acting as an agent also implies intention: The person wants something specific to happen as a result of that action. A moral agent is a person who “acts for him or herself, or in the place of another by the authority of that person, and does so by conforming to a standard of right behavior.”2

 Reflection

This book emphasizes your role as a moral agent in the health profession setting because as a professional, you must answer for your own actions and attitudes. If you have observed a situation in which someone in your chosen field has had to act courageously, then you have observed a moral agent at work. Briefly describe what you observed and why you feel the responsibility fell to that person to be on the front line of the decision.

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A moral agent intends the morally right course of action. The idea of responsibility that you learned about in Chapter 2 is in fact the description of what an agent does; when faced with an ethical challenge in the health professions, the actor assumes the role of a moral agent. Professional responsibility is exercised through moral agency, and professional accountability and responsiveness to the patient through ethical action. Kate and the case manager are both agents whose actions influence the outcome of Kate’s efforts and affect Bill’s health. As a health professional, Kate clearly is in the role of a moral agent.

Agents and Emotion

Moral agency is grounded in a relational context. The moral agent must have not only cognitive ability but also emotional capacity to demonstrate an attitude of respect for the other.3 Both reason and emotion operate as part of your internal processor where you can go and search to find the appropriate tools to exercise your professional responsibility. Much is said about ethical reasoning and problem solving in this book. Through the years, considerable debate about the significance of emotion in an agent’s activity has taken place. Strict rationalists view emotion as too subjective and unpredictable to serve as a reliable guide. However, a burgeoning body of current professional and lay literature lends new knowledge about the role of emotion in decision making more generally to support the essential role of emotion in ethical decision making. Such well-regarded bodies as the Harvard Decision Science Laboratory conduct research on the mechanisms through which emotion and social factors influence judgment and decision making. From their work and the work of others, we find convincing arguments for assigning emotion at least two functions in ethics.

First, emotion is an “alert” system that warns you that you may be veering off the road of a caring response. When you encounter a morally perplexing situation, you, who will be accountable, feel discomfort, anxiety, anger, or some other disturbing emotion. Nancy Sherman, a contemporary philosopher who is working on the place of emotion in morality, proposes that emotions are “modes of sensitivity that record what is morally salient and… communicate those concerns to self and others.”4 Sometimes, an emotional response stirs a person out of lethargy and moves him or her into thinking and action on someone else’s behalf.5,6 In other words, your emotions help grab your attention and motivate you to “do something.” We saw this in the process Kate was going through as she faced the reality of Bill’s missed appointments.

Second, according to current research, emotion kicks in again at the point of decision making to complete the human picture of what is happening.7 Even if you have been logical in your assessment of the ethical problem, emotion puts the last strokes on the canvas and brings the decision into focus as one example of how humans actually conduct their lives all around. In the end, emotion, attention, and behavior interact with each other for real-time decision making.8 Effective moral agents work to integrate emotional responsiveness with critical thinking, so that rather than disregarding emotion, they develop the right emotion, suited to the situation.

 Summary

An agent has responsibility for an action. A moral agent has a responsibility to act in a way that protects moral values and other aspects of morality. An ethical problem requires attention to both reasoning and emotion in the process of decision making. Emotion alerts, focuses attention, motivates, and increases one’s knowledge about complex situations.

The Course of Action: C

The course of action includes the agent’s analysis, the judgment process of discerning the best likely resolution to the problem, and the decision to act in accordance with that judgment. The next two chapters explain how this process works within the context of ethical problem solving with ethical theories and approaches, so more detail about that is not necessary now. Kate Lindy used the information she had to analyze the situation. One attempt at resolution was to call the case manager looking for Bill. Kate’s emotional response afterward reflected a concern for her patient’s well-being, even though she was irritated when she made the call; her discomfort suggests she was unsure she had exercised the correct moral judgment in what she said to the case manager. As we know, Kate also felt a sense of responsibility to bill for the scheduled treatments Bill did not receive, although she did not like this policy in her workplace. This back-and-forth reflection about what she was feeling and doing kept the course of action alive to the possibilities of what should happen.

The Outcome: O

The outcome is the result of having taken a particular course of action. Of course, the goal is that a caring response is achieved in what actually happens as a result of the whole process. We need to have more information about what actually happened as a result of Kate’s conversation and what she thought about it to know whether she considered it a good outcome for her patient Bill Boyd.

Some ethical approaches that you will learn to use in the next chapter place much more weight on the outcome; others place moral priority on the course of action. In everyday descriptions of ethics, this tension is sometimes referred to as the “ends” one achieves and the “means” used. The important point is that real-life professional situations require your full participation in all three features of an ethical problem. The decision of which of the features takes precedence in a particular ethical problem depends in part on the approach or theory you adopt.

 Summary

The two prototypes of ethical problems share three features in common: a moral agent (or agents), a course of action, and an outcome.

Considerations in Moral Agency

Locus of Authority

The role of the moral agent is not always easy. At times, one may have the emotional and cognitive capacity to act as a moral agent; however, constraints in the practice environment limit one’s authority to respond. A locus of authority conflict arises from an ethical question of who should have the authority to make an important ethical decision. In other words, who is the rightful moral agent (A) to carry out the course of action (C) and be held responsible for the outcome (O)? Locus of authority problems most often arise when ambiguities exist about who is in charge (Figure 3-1). Schematically, the situation looks like this:

FIGURE 3-1 Locus of authority problem.

Note that two people assume themselves to be appropriate moral agents (A1 and A2) and proceed along parallel (or even conflicting) courses of action (C1 and C2). As each analyzes the situation, they may come to different conclusions about how to achieve the best outcome (O1 versus O2) for a patient.

This consideration of agency highlights that it does matter who has decision-making authority and say-so. In these situations, structural and team empowerment, which is discussed subsequently in this book, are vital to the nourishment of a moral culture.

 Reflection

In the story of Kate Lindy and Bill Boyd, who do you think should make the decisions about whether to charge for missed treatments?

The health professional who is providing the service?

The supervisor of the unit?

The institutional administrator?

The government or some other, larger societal regulating body?

The patient?

Give a brief explanation for your thinking that supports your position.

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Sometimes, no ambiguity or conflict exists, but reflection on the issue reveals that the wrong person has the authority. In that case, the situation creates moral distress. The challenge of determining the appropriate locus of authority is the topic of thoughtful reflection by ethicists and other individuals. In the context of the health professions, there are at least four ways of thinking about authority in healthcare decisions.

1. Professional expertise. You are in a professional role along with other people in different professional roles. This is the essence of interprofessional teamwork that characterizes so much of quality healthcare today. The role differences mean that you bring different spheres of expertise to the situation. In some areas of the patient’s care, each professional is an authority on a part of the whole picture. That alone should be a vote for the person who has the most relevant knowledge about the patient’s condition and other factors that influence the situation.

2. Traditional arrangements. Traditionally, in the healthcare system, the physician has been the authoritative voice in healthcare decisions. The physician is considered to be in authority because of his or her office or position rather than (or in addition to) an authority because of special expertise. From this perspective, the medical director of the unit unquestionably is the one to make a decision about what to do, although he or she may choose to invite advice and counsel from other individuals.

3. Institutional arrangements and mechanisms. Sometimes, the decision about the authoritative voice comes from special institutional arrangements. For example, some tasks may be delegated to committees. In these instances, the committees or designated individuals assume specific task-related roles. This is really a variation of the first two roles, with the designated individuals in authority because of their expertise and the positions they hold. For example, the authority for making a decision regarding billing for missed treatments may be referred to a committee designed to deal with humane treatment of patients in unusual situations rather than billing solely as a financial issue.

4. The authority of experience. A voice of authority may emerge because of the insight that comes from experience. Situations always exist in which we seek the advice of people who have been in similarly perplexing situations and defer to their judgment. Kate Lindy may wish to seek advice for the next step from a supervisor, senior member of the professional staff, or other person judged to have the benefit of experience. This is seldom institutionalized as a formal mechanism for dealing with locus of authority challenges and is a variation of the professional expertise approach, which assumes that expertise often is refined with experience in a wide range of situations.

None of these sources should be taken for granted as the appropriate authority for all situations. The ethical gold standard remains what will result in a caring response for the patient.

Shared Agency

Given that care is increasingly provided by interprofessional teams, another consideration in moral agency is shared agency. As you recall from Chapter 1, the interprofessional care team is a group of care providers (including licensed health professionals, assistive staff, and ancillary support staff) who work together to deliver quality, evidence-based, and client-centered care. These teams share day-to-day concerns as they arise and work together to navigate practice while upholding professional responsibilities, values, and duties. When faced with the moral dimensions of professional practice, sharing concerns among the team members can create an atmosphere that nurtures ethical reflection. One question that often arises is: Who is the moral agent? Because the goal is to achieve a caring response, the care team may give consideration to shared agency. Shared agency is not to be taken lightly because it requires high levels of engagement from all team members. It entails a commitment to group discussion, collaborative decision making, and mutual trust in the disposition to act on the intentions of the team over the individual, taking into account the previous discussion that at different times various members of the team may emerge as the appropriate authority when the actual decision making is imminent. A prerequisite for shared agency is that each team member is heard (including those with dissenting views), respected, and participatory in decision making and agrees to uphold mutual responsibilities when implementing a plan.9

 Summary

Considerations of locus of authority and shared agency are important features to attend to in a shared moral community. The goal in both considerations is to achieve an outcome consistent with a caring response.

Two Prototypes of Ethical Problems

Now that you have acquainted yourself with the common features of all prototypes, you are ready to learn more about the prototypes themselves: moral distress and ethical dilemmas.

Moral Distress: Confronting Barriers to Moral Agency

Moral distress focuses on the agents (A) themselves when a situation blocks them from doing what is right. Moral distress as a term came into the ethics literature primarily through nursing ethics and has become more generalized because of its usefulness in understanding ethical problems that all health professionals experience. Moral distress reflects that you, the moral agent, experience appropriate emotional or cognitive discomfort, or both, because of a barrier from being the kind of professional you know you should be or from doing what you conclude is right. Your emotional response and feelings play a major role in the recognition that you have moved from striding confidently along in your moral life to experiencing that something is wrong. You can see that your response to the situation comes from an awareness that your integrity is threatened because a threat to integrity arises when you cannot be the person you know you should be in your professional role or cannot do what you know for certain is right. Health professionals find that these emotional signals give rise to physical expressions that warn something is wrong: a knot in the pit of their stomach, a catch in the otherwise confident stride, or an awakening in the early hours of the morning with the haunting feeling that something is awry. Again, we are reminded that emotions and feelings are critical data of the moral life, trying to say, “Stop! Wait! Don’t! Think twice!”

Moral agents in the health professions encounter two types of barriers that create moral distress: type A and type B.

Type A: You Cannot Do What You Know Is Right

A common problem today is the barrier to adequate care of individual patients created by the mechanisms for the delivery and financing of healthcare, although other sources also exist. Recent studies have found that high percentages of moral distress occur over resource allocation and reimbursement constraints, goal setting, maintaining confidentiality, limiting autonomy, withdrawing and withholding care, prenatal testing, and balancing institutional needs versus what is best for the client.3,10–12 For example, a hospital policy may be to refuse admission of patients who do not have insurance to fully cover the cost of their treatment or to discharge patients who the interprofessional care team judges to be unsuited for the rigors of transition to the home environment. Here, the morally right course of action (C) that would lead to the desired outcome (O) is blocked by policies and practices, resulting in moral distress. Type A barrier is illustrated in Figure 3-2. The moral distress comes precisely because of the repercussions the professionals believe they may have to endure. Institutional and traditional role barriers keep them from exercising their moral agency for the good of patients.

FIGURE 3-2 Moral distress: type A.

This does not mean that you will never take into account the larger social context in which you are practicing. As you learned in Chapter 2, social determinants of a caring response sometimes do alter the course of action you would otherwise take. For instance, health professionals must always attend to the larger public health considerations in the case of a patient with a serious highly infectious disease. The patient may experience forced quarantine or be placed in isolation. The health professional’s emotional discomfort in such a situation that requires acting for the good of many other individuals is not an example of moral distress. The patient still can be the recipient of the best care possible. Only when you are quite sure you cannot be faithful to the basic well-being of the patient is there legitimate reason for moral distress.

Another powerful barrier to doing what is right is suggested in the previous paragraph but all too often fails to be included in discussions of moral distress. Moral distress often occurs because of internal barriers such as the fear of repercussion of one kind or another—real or imagined—that looms in the professional’s awareness, blocking action. Wanting to do the right thing and not having the knowledge, skill, or inner strength to do it while under the weight of anxieties and fears often results in heightened moral distress rather than leading to freedom through action (Figure 3-3). This process, faced time after time, can result in moral residue, an accumulation of compromises that takes a heavy toll on one’s integrity.13

FIGURE 3-3 Internal barriers. (From Purtilo R, Haddad A: Respect: the difference it makes. In: Health professional and patient interaction, ed 7, Philadelphia, 2002, Saunders, p 12.)

To face those uncomfortable feelings and emotions and remain motivated to do the right thing requires that each and every one of us receive support from others to step up, speak out, or stand firm as the occasion calls for it. In some other parts of this book, you will be introduced to team and institutional supports that can help you navigate out from under the burden of these internal barriers.

Type B: You Know Something Is Wrong But Are Not Sure What

Often the barrier may not be policies and practices or internal anxieties and fear but instead may be that the situation is new or extremely complex. Your only certainty is an acknowledgment that something is wrong; the rest is a big question mark. You may question how to arrive at the morally correct course of action (C) or how to work toward a specific outcome (O) that is consistent with your professional goal of achieving a caring response in this instance. Type B barrier is illustrated in Figure 3-4. The ethical challenge is to remove the barrier of doubt or uncertainty as much as possible, sometimes through probing deeper into the facts of the situation. When there is high uncertainty, doubt requires that the moral agent must seek advice and critically problem solve through the situation to better understand how to address its complexity. As you can readily see, emotions often play a major role in this type of situation too.

FIGURE 3-4 Moral distress: type B.

 Reflection

Think about Kate Lindy’s moral distress. We asked you to think about why you might feel uneasy too if you were in her situation. What subtype of moral distress is she facing? Explain your answer in a few words here.

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We assume that Kate’s discomfort partially stems from wanting to do what is best for Bill Boyd but being unsure what that is because she likely has not been faced with this set of issues before. She wants to show a caring response that befits a health professional, but she is not sure how to do that under the circumstances. Understandably, she also wants to honor the rules and policies of her workplace but is distressed about charging for Bill’s missed treatments given that his lack of adherence is likely associated with his clinical condition. Her moral distress is more of type B, as we read her situation.

 Summary

Moral distress occurs when the moral agent knows what the morally appropriate course of action is but meets external barriers, internal resistance, or a high level of uncertainty.

As she analyzes the situation, Kate thinks about whether her distress also is related to the fact that she is facing an ethical dilemma. So, join her now in that reflection, as we turn to the second type of prototypical ethical problem: the ethical dilemma.

Ethical Dilemma: Two Courses Diverging

Many people call all ethical problems ethical dilemmas. More correctly, an ethical dilemma is a common type of situation that involves two (or more) morally correct courses of action that cannot both be followed; that is, to take course C1 precludes you from taking course C2. As a result, you (the agent, the responsible one) necessarily are doing something right and also wrong (by not doing the other thing that is also right). You are between a rock and a hard place, between the devil and the deep blue sea (Figure 3-5).14

FIGURE 3-5 Ethical dilemma.

Ethical dilemmas involve both ethical conflict and conduct. Suppose that Kate Lindy has just read the previous paragraph and realizes that she had an ethical dilemma but did not recognize it at the time. She was aware of her moral distress and that further analysis was needed. Here is why she now knows she had a dilemma.

On the one hand, Kate is an agent (A) who has a professional duty to look after her patient Bill Boyd and to take the course of action (C1) that demonstrates her attempt to give Bill the best treatment possible. The desired outcome (O1) is psychological well-being and relief of the patient’s pain. On the other hand, Kate is an agent (A) who has a duty to abide by the policies of her place of employment. The course of action (C2) that expresses that duty is to charge for all treatments that are given or are not officially canceled. The desired outcome (O2) is the financial solvency of the psychotherapy practice. Both outcomes are ethically appropriate, taken alone. However, Kate Lindy probably caused some negative repercussions for Bill in her course of action that included sharing potentially damaging information with Bill’s case manager. The case manager did not sound pleased, either by Bill’s absenteeism from scheduled treatments or the fact that Bill was being charged for the missed treatments. In charging for the treatments, Kate maintained fidelity to her workplace at the price of protecting Bill Boyd from exposure that may cause him additional problems.

Of course, Kate might have thought that charging for missed appointments is wrong under any circumstance, a position that is periodically examined in the health profession literature.15

In subsequent chapters, you will have ample opportunity to work with several types of dilemmas because they are the most commonly confronted type of ethical problem.

Ethical dilemma in the story of Bill Boyd and Kate Lindy.

Justice Seeking as an Ethical Dilemma

A special ethical dilemma arises in regard to attempts to allocate societal benefits and burdens fairly and equitably. Recall that the one social determinant of healthcare often rests on the availability of a valued resource. As in all ethical problems, the agent (A) makes a judgment to take a course of action (C) that results in an outcome (O). The situation is this: Competition exists for cherished but scarce resources, such as a medication, health professionals’ time, money to pay for healthcare, or an organ or other types of lifesaving or quality-of-life–enhancing procedures. The agent’s (A) morally right course of action (C) is to give everyone a full measure of the resource to the extent their needs warrant it. In so doing, the outcome (O) is that the patient’s legitimate claims are honored and the professional can rest assured in having provided a patient-centered outcome. The scarce supply, however, requires that the agent take difficult, even tragic, courses of action, with the outcome that some claimants get the cherished goods and others do not, or they get less than an clinically optimal share.16 In short, it is morally right to give your own patients everything they need to benefit from your interventions. It is also morally right to spread resources around to the benefit of others. The question of how to treat each person fairly, and to treat groups equitably, becomes a challenge that involves a dilemma of justice, a problem that physical therapists in an important study of the meaning of caring in their professional practice found increasingly difficult in a healthcare system that values cost control and a high margin of profit.17 This dilemma is by no means limited to one profession; in fact, it is a common theme in health professions literature today. You will study this and how you can optimize your efforts in the face of contemporary justice dilemmas more extensively in later chapters of this book.

 Reflection

Describe an example in your chosen field of how you might become involved in a dilemma that requires you to make tough decisions because of scarce resources. One way to approach this is to think of the setting in which you are likely to work and the special, sometimes expensive, procedures that may be available to a range of patients. Another is to imagine conditions under which your worksite is short staffed and you must make difficult choices about where to cut corners.

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 Summary

An ethical dilemma occurs when a moral agent is faced with two or more conflicting courses of action but only one can be chosen as the agent attempts to bring about an outcome consistent with a caring response. A special case of a dilemma involves justice issues when a needed resource or service is in limited supply.

Summary

This completes the introduction to your role as a moral agent, the components of any ethical problem, and the two prototypes of ethical problems that will help you to be ready to act ethically. The prototypes of moral distress and ethical dilemmas, along with locus of authority and shared agency considerations, will guide you as you analyze and decide which course of action is the most likely to achieve an intended outcome consistent with honoring your professional responsibility.

Questions for Thought and Discussion

1. Jane is a health professions student who is pregnant and does not want to treat a patient admitted to the inpatient medicine service from a local prison for management of end-stage renal disease. Her clinical supervisor thinks her reluctance is because of her pregnant condition and assures her that she is safe because the prisoner is nonviolent and has a one-on-one guard assigned to his room. Jane still hesitates and says, “I know it’s irrational, but I’m afraid I will not be effective.” She pauses and then adds, “To be honest, I also feel it is God’s will when bad people get sick.”

Is Jane’s reason sufficiently compelling to warrant her being excused from assignment to this patient? Why or why not? What type of ethical problem faces her clinical supervisor? Describe how you have arrived at this conclusion with use of the three features of any ethical problem.

2. Loretta is a physical therapist specialized in diabetic foot care. She sees Mary monthly. Mary is quite down when she hobbles into the clinic today, with her ankles bandaged and blood oozing through the gauze. She tells Loretta, “I’m sure my feet are much worse this month. I haven’t been so good about my sugar, and it didn’t help that my husband hit my ankles with his cane twice last week. I think he is upset about my taxi fare to get here. I should stop coming.” She begins to cry.

What are the clinical, legal, and ethical questions that face Loretta in this case? What should she do?

3. Describe an ethical dilemma that you or someone you know has faced. This dilemma does not have to be a problem that arose within the healthcare context. What did you have to take into consideration as you moved toward a decision about which of the two or more courses of action available to you should be taken? Did your decision result in a good outcome?

References

1 Lakoff G. Women, fire and dangerous things: what categories reveal about the mind. Chicago: University of Chicago Press; 1987 p 12.

2 Taylor C.R. Right relationships: foundation for health care ethics. In: Pinch W.J.E., Haddad A.M., eds. Nursing and health care ethics: a legacy and a vision. Silver Spring, MD: American Nurses Association; 2008:163–164.

3 Lutzen K., Ewalds-Kvist B. Moral distress and its interconnection with moral sensitivity and moral resilience: viewed from the philosophy of Viktor E. Frankl. Bioethical Inquiry. 2013;10:317–324.

4 Sherman N. Emotions. In: Post S., ed. ed 3 New York: Thomson Gale; 740–748. Encyclopedia of bioethics. 2004;vol 2.

5 Purtilo R. Moral courage: unsung resource for health professional as friend and healer. In: Thomasm D., Kissell J., eds. The health professional as friend and healer. Washington, DC: Georgetown University Press; 2000:106–112.

6 Molewijk B., Kleinlugtenbelt D., Widdershoven G. The role of emotions in moral case deliberation: theory, practice and methodology. Bioethics. 2011;25(7):383–393.

7 Bechara A. The role of emotion in decision-making: evidence from neurological patients with orbitofrontal damage. Brain Cognition. 2004;55:30–40.

8 Xing C. Effects of anger and sadness on attentional patterns in decision making: an eye-tracking study. Psychological Reports: Employment Psychology Marketing. 2014;114(1):50–67.

9 Bratman M. Shared agency: a planning theory of acting together. Oxford: Oxford University Press; 2014.

10 Doherty R.F., Dellinger A., Gately M., et al. Ethical issues in occupational therapy: a survey of practitioners. In: Poster presented at the American Occupational Therapy Association 2012 Annual Conference, Indianapolis; 2012.

11 Slater D.Y., Brandt L.C. Combating moral distress. In: Slater D.Y., ed. Reference guide to the occupational therapy code of ethics and ethics standards. ed 2010 Bethesda, MD: AOTA Press; 2011:107–113.

12 Kinsella E.A., Park A.J., Appiagyei J., et al. Through the eyes of students: ethical tensions in occupational therapy practice. Can J Occupational Ther. 2008;75:176–183.

13 Hardingham L.B. Integrity and moral residue: nurses as participants in a moral community. Nurs Philos. 2004;5(2):127–134.

14 Beauchamp T.L., Childress J.F. Professional-patient relationships. Principles of biomedical ethics. ed 7 New York: Oxford University Press; 2012 pp 288–331.

15 Fay A. Ethical implications of charging for missed sessions. Psychol Rep. 1995;77:1251–1259.

16 Freeman J.M., McDonnell K. Making moral decisions: a process approach. Tough decisions: cases in medical ethics. ed 2 New York: Oxford University Press; 2001 pp 241–246.

17 Greenfield B.H. The meaning of caring in five experienced physical therapists. Physiother Theory Pract. 2006;22(4):175–187.

Ethics Theories and Approaches

Conceptual Tools for Ethical Decision Making

Objectives

The reader should be able to:

• Distinguish between an ethical theory and an ethical approach.

• Understand the process of clinical reasoning in the health professional.

• Distinguish the different modes of clinical reasoning.

• Describe ethical reasoning as a distinct mode of clinical reasoning.

• Describe the usefulness of the basic ethics theories and approaches as tools in analyzing ethical problems and attempting to resolve problems by arriving at the most caring response.

• Name five types of ethical theories and approaches that help illuminate what a caring response entails.

• Describe a narrative and what it means to take a narrative approach to an ethical issue or problem.

• Assess the contribution of psychologist Carol Gilligan and others who stress relationships.

• Relate the basic features of an ethic of care to a caring response, introduced in Chapter 2.

• Describe the role of moral character or virtue in the realization of a good life and its significance for health professionals faced with the goal of arriving at a caring response.

• Describe ways the various story or case approaches help one understand what a caring response involves.

• Describe the function of a principle (norm, element) in ethical analysis and conduct.

• Identify six principles often encountered in professional ethics that can help guide one in trying to arrive at a caring response to a professional situation.

• Discuss the meaning of autonomy in Kant’s and Mill’s theories and the relevance of each to ethical conduct.

• List five reasonable expectations a patient or client has because of the health professional’s responsibility to act with fidelity.

• Describe the principle of veracity as it applies in the professional context.

• Describe the basic difference between deontologic and utilitarian ethical theories of conduct and the role of each in the health professional’s goal of acting in accordance with what a caring response requires.

NEW TERMS AND IDEAS YOU WILL ENCOUNTER IN THIS CHAPTER

clinical reasoning

ethical reasoning

theories and approaches

story or case approaches

narrative approaches

ethics of care approach

virtue theory

character trait

moral character

principles

principle-based approach

nonmaleficence

beneficence

autonomy

self-determination

paternalism

fidelity

veracity

justice

deontology

deontologic theories

teleology

absolute duties

prima facie duties

conditional duties

teleologic theories

utilitarianism

rule utilitarians

Topics in this chapter introduced in earlier chapters

Topic

Introduced in chapter

Moral duty and character

Codes of ethics

Interprofessional care team

A caring response

Patient-centered care

Professional responsibility

Right(s)

Prototypes of ethical problems

Moral agency

Moral distress

Ethical dilemma

Introduction

In this chapter, you are introduced to a conceptual “toolbox” of ethical theories and approaches you can use to accomplish your professional goal of arriving at a caring response in the wide variety of challenges you may encounter. An ethical theory is researched and well developed and provides us with an assumption about the very nature of right and wrong. Most theories are historically based and have evolved for current usage according to a society’s or group’s development and a need for interpreting or addressing current moral challenges. In contrast, an approach does not propose to be a complete system or model but an aid to existing theories. For instance, the principle-based approach introduced in this chapter is more recent and has roots in ancient Western ethical theories. Both ethical theories and approaches provide you with a framework for diagnosing, communicating, and problem solving ethical questions you encounter in your clinical practice.1

If you are like us, you probably took a look at how many pages you have ahead of you for your assignment and quickly concluded that this is a very long siege of reading! The idea behind this chapter is to provide you with a “mini book” of ethical theory. Depending on your course of study, your professor may add to these pages with another more theoretic text or may split the chapter into smaller parts. We encourage you to work your way through the chapter carefully so that the rest of your study of this book is easier and your preparation in ethics more complete.

In Chapter 1, we suggested three general ways that ethical tools have usefulness in your everyday life: (1) to analyze moral issues, (2) to help resolve moral conflicts, and (3) to move toward action when faced with a problem. In Chapter 2, you learned about the caring response as the goal of professional ethical practice. In Chapter 3, you had an opportunity to learn the basic varieties (i.e., prototypes) of ethical problems you will encounter in your professional career. In this chapter, you will gain more knowledge and tools that will enable you to move skillfully from the identification of a problem, through its analysis, and, hopefully, to its resolution through action that achieves your goal of a caring response. Chapter 5 provides a simple six-step process you can follow as you apply everything discussed in this and the previous chapters. We set the stage for your thinking with the story of Elizabeth Kim, Max Diaz, Melinda Diaz, and Michael Leary.

 The Story of Elizabeth Kim, Max Diaz, Melinda Diaz, and Michael Leary

Elizabeth Kim is a speech and language pathologist who works in a large urban school system. She is responsible for performing many student evaluations and interventions each day and takes her job seriously. Elizabeth services the Richards Elementary School and two other schools in the Lakeview district. Students and parents who meet Elizabeth quickly learn that she is a bright spot in the otherwise anxiety-producing ordeal of navigating services for children with learning disabilities. Elizabeth prides herself on being thorough and always explains everything to both the students and the parents in language they can understand.

Two weeks ago, Elizabeth had an experience that upset her, and she is not sure what to do about it. A young student, Max Diaz, had met Elizabeth for his speech and language pathology evaluation at Richards Elementary School. Max has an expressive language disorder, and Elizabeth felt strongly that he would benefit from an augmentative communication device. She has used these devices in the past and has seen great success with them. Elizabeth had her quarterly supervision meeting with Michael Leary, the school principal, that afternoon. She talked about Max in the meeting because she was intrigued by his case. She told Principal Leary her evaluation results and that she would be recommending the augmentative device. Principal Leary told Elizabeth, “Please do not put that recommendation in your written report. Max’s mother has not been overly involved in advocating for his needs. If we can hold off on meeting with her for Max’s education plan until the end of the school year, I won’t have to buy the device until the next academic year. Those devices are really expensive, and I don’t know if we have the money right now. Besides, who knows if it will really even work for him, given English is his second language.” Elizabeth left the meeting feeling uncomfortable.

The speech and language pathology evaluation report was completed and submitted to the administration. Elizabeth did include the recommendation for the augmentative device in the report because she knew that it was in Max’s best interest. She was eager to train Max in how to use this type of device. All that was needed now was administrative and parental approval. As soon as the individualized education plan (IEP) could be scheduled, they could move forward. A copy was sent to Principal Leary, Max’s homeroom teacher, and his mother, and one was placed in his academic record in the administrative office.

Several weeks later, Elizabeth asked Principal Leary when Max’s IEP would take place. She wanted to get his mother’s and the team’s approval to move forward with various interventions, including the augmentative device. He told her that Melinda, Max’s mom, had been slow to respond to the school’s request for a meeting and said, “We offered her a date, but she could not make it. Since then, we have not been able to coordinate with a Spanish interpreter. I may just try to schedule her without one. Actually, the longer it is put off, the better, as we won’t have to bear the cost of the device you recommended on this year’s school budget.”

Elizabeth knew that the longer the meeting took to arrange, the longer Max would go without service; she wanted to say, “Aren’t you going to follow up and encourage her to get in soon?” but she did not. She knew Principal Leary would have to schedule the meeting and was also afraid he may be insulted by such a question.

Today, 3 months after the evaluation was completed, Elizabeth is walking another student to the after-school program when she sees Max with his mom, Melinda Diaz, in the corridor. Melinda says, “Oh, you must be the speech therapist. Thanks for the papers you sent to me about Max. It’s too bad that you and the teacher couldn’t meet a couple months ago. I was looking forward to talking with you all. I can’t read English that well, so I had a hard time understanding the papers.”

“Oh. Did Principal Leary talk with you about setting another meeting time sooner rather than later?” Elizabeth asks, feeling tense.

“No, he didn’t. He just keeps saying, ‘Don’t worry.’”

“Well,” Elizabeth says. “You have the right to set another meeting time sooner rather than later and to have an interpreter there if you want to.”

Melinda immediately looks concerned. Elizabeth wants to say something to reassure her, but the words fail her. The school bell rings, and Elizabeth says a hurried good-bye. She feels a gnawing in the pit of her stomach, but she cannot immediately figure out what, if anything, she should do next.

That Elizabeth Kim is distressed is not surprising because something definitely is wrong. In fact, we might wonder about a health professional who felt no emotion at all about this situation: a young child with a learning disorder who is not performing to his potential, and communication between his mother and the school staff that appears to have broken down. Maybe Elizabeth has said too much—or too little—to help this family and school, both of whom have had some difficult discussions to confront. She is not sure how far she should go in advocating for her client and taking on the system.

 Reflection

What is the caring, morally responsible action in this type of situation?

__________________________________________________________________________

We return to this story throughout the chapter, so keep your response in mind.

Ethical Reasoning: A Guide for Ethical Reflection

Clinical Reasoning

As a health professional, you must learn to blend your knowledge, skills, and attitudes in response to varying clinical situations that require your professional judgment.2 As you have read in the previous chapters, health professionals must learn to be responsible for their actions on others, both clients and the public. So, before we highlight theoretical parts of ethical study that take you deeper into addressing situations, we must discuss clinical reasoning. You may be familiar with the terms critical thinking or practical reasoning. These terms are similar to clinical or professional reasoning.

Clinical reasoning is the complex thought process that health professionals use during therapeutic interactions. Schell defines this process well by stating that clinical reasoning is used by practitioners to “plan, direct, perform and reflect on [client] care.”3 Health professionals use clinical reasoning to analyze and synthesize the information they gather when caring for (or preparing to care for) a patient. Clinical reasoning informs decisions and guides actions in the context of professional ethics and community expectations.4

You have likely already been trained to develop your clinical reasoning. During your educational process, has a professor, clinical instructor, or supervisor ever asked you “why” when you gave an answer to a clinical question? If so, they are trying to understand your reasoning. They want to ensure that you not only know the answer to the question but that you have thought about and analyzed the situation from a broad perspective. The process of clinical reasoning is important because it guides your decision making in the care of the patient. The more complex the clinical case, the more demands placed on your reasoning.

Modes of Reasoning

Health professionals use different modes of reasoning in response to particular features of a clinical case (Table 4-1).5–7 Many modes of clinical reasoning are used simultaneously to solve a clinical problem. For a caring response to be actualized, health professionals must use clinical reasoning to ensure that their decisions have meaning for the client. At various points in your clinical practice, you should stop and ask yourself, “Why am I doing what I am doing?” This helps you reflect on your clinical reasoning. Your reasoning is one of the strongest foundations you can have as a professional. It must continue to grow throughout your career to meet the demands and challenges of our ever-changing patient population and service delivery environment.

Table 4-1

Forms of Clinical Reasoning

Forms of clinical reasoning

Description

Scientific reasoning

A framework for understanding the impact of illness or disease on the patient. Involves the use of scientific methods, such as hypothesis testing, cue and pattern identification, and evidence as related to a diagnosis. Scientific reasoning includes both diagnostic and procedural reasoning. The focus is generally on the diagnosis, procedures, and interventions for a specific condition. Data are systematically gathered, and knowledge is compared.

Narrative reasoning

A framework for understanding the patient’s “life story” or illness experience. This type of reasoning helps clinicians make sense of the patient’s past, present, and future. Includes an appreciation of how the patient’s life story is influenced by culture, condition, and experiences.

Pragmatic reasoning

A framework for consideration of the practical issues that impact care. Such issues include treatment environments, equipment, availability of resources (including training of individual providers), and other realities associated with service delivery.

Interactive reasoning

A mode of reasoning that is used to help clinicians better interact with and understand their patient as a person. Highlights the interpersonal nature of the therapeutic relationship (e.g., the use of empathy, nonverbal communication, therapeutic use of self).

Conditional reasoning

A blending of reasoning that involves the moment-to-moment treatment revision based on the patient’s current and future context. Used to anticipate outcomes over short or long periods of time.

Ethical reasoning

A mode of reasoning used to recognize, analyze, and clarify ethical problems that arise. Helps clinicians make decisions regarding the right thing to do in a particular case. The moral basis for professional behaviors and actions. The focus is not on what could be done for the patient, rather on what should be done.

Modified from Schell BAB, Schell JW: Clinical and professional reasoning in occupational therapy, Philadelphia, 2008, Wolters Kluwer/Lippincott Williams and Wilkins; Mattingly C, Fleming M: Clinical reasoning: forms of inquiry in therapeutic practice, Philadelphia, 1994, F.A. Davis; and Leicht SB, Dickerson A: Clinical reasoning, looking back. Occupational Therapy Healthcare 14(3/4):105–130, 2001.

Ethical Reasoning

Ethical reasoning is a mode of reasoning used to recognize, analyze, and clarify ethical problems. It is an essential component of clinical reasoning. You use ethical reasoning when you ask yourself, “What is the morally correct action to take for this client?” Ethical reasoning helps guide the provision of professional care with an emphasis primarily on conduct. When you recognize the morally significant features of a clinical scenario, you are using your ethical reasoning. Ethical reasoning requires that you be able to gather relevant information and correctly apply your ethical knowledge and skills in the process of ethical reflection. This requires great attention to the details of each case. Ethical reasoning not only is concerned with recognizing, gathering, and applying ethical knowledge but also emphasizes the process one goes through when reasoning about the situation. We successfully engage ethical reasoning when we not only recognize that x is good and y is bad but when we also articulate reasons for why x is good and y is bad.8 Some theories and approaches to ethics today use the modes of reasoning outlined in Table 4-1 (e.g., narrative or interactive reasoning) that complement strictly ethical reasoning. Even the theories that focus mostly on character traits, narratives, or relationships must be reflected on. More is said about this as the chapter unfolds.

 Summary

Clinical reasoning requires that you be able to gather relevant information and correctly apply your knowledge and skills in a way that meets your desired goal of a caring response. Ethical reasoning is a component of reasoning focused on the ethical dimensions of the situation.

The Caring Response: Using Theories and Approaches to Guide You

You have already learned that the goal of ethical deliberation is to answer the question: “What does it mean to provide a caring response in this situation?” You also have learned that although you will be faced with legitimate competing loyalties as a health professional, your primary loyalty must always be patient centered. All these insights beg for further description about how to actually arrive at the ethically appropriate caring response in a particular situation.

Several ethics theories and approaches are relevant to your work of putting together this caring response. Your ethics work differs from an academic philosopher’s because you must not only apply clear thinking to ethical problems, which a philosopher must do (as you learned in Chapter 3), but also decide on purposive action. You will not use all the theories or approaches covered in this chapter for any one situation. You need to select the correct tool for building anything; the same is true for the tools we are describing.

The first two types, story-driven or case-driven approaches and virtue theories, emphasize the importance of the kind of person you should strive to be (i.e., your attitudes and dispositions) so that you are well positioned to enact a caring response. Taken together, the several varieties share the common themes of attending to the details of stories for their moral content, awareness of one’s emotions in relation to what is happening in the story, and development of character traits that allow one to be prepared to act in a caring manner. Collectively, they also stress the moral relevance of relationships, both between individuals and within the institutional structures of society.

The last three approaches and theories, principle-based approaches, deontologic theories, and teleologic theories, are geared to forms of ethical conduct itself. Principle-based approaches have been developed to help people understand general action guides for ethical behavior, some of which are related to duties or rights, others related to consequences. The deontologic and teleologic theories can be broken down into more digestible pieces with a look at their roots: the root word deonto means duty; the root word telos means end. Already you can see a distinction developing. Deontologic theories delineate duties (actually duties, rights, or other forms of action), whereas teleologic ones rely on an assessment of the ends or consequences to determine right or wrong. You have heard the expression, “Do the ends justify the means?” Deontologists would say “no”; teleologists would say “yes.” As noted previously, some principles guide you toward duty, others toward the “telos” or consequences. Are you ready to delve into these five theories or approaches in more detail?

Story or Case Approaches

In professional ethics, the story is the inevitable beginning point of ethical reflection because you encounter ethical problems in everyday life with everyday patients (or others). In story or case approaches, the assumption is that morally relevant information is embedded in the story.

In professional ethics, you also are equipped with foundation stones of ethical codes, a tradition, and societal expectations of how you will respond to legitimate requests for your professional services. Therefore, although the appropriate starting place for ethical analysis is the story, there are standards, principles, and other moral guides against which your opinion must be tested when you are deciding on a caring response. The answer is not simply, “You hold your view and I hold mine, and they are on equal footing, morally speaking.” Therefore, professional ethics also is foundationalist based by nature.

Narrative Approaches

Narrative is the technical term applied to the story’s characters, events, and ordering of events (e.g., the plot), although in healthcare ethics and legal circles you more often see the term “case.” Narrative approaches are based on the observation that humans pass on information, impute and explore meaning in theirs and others’ lives, commemorate and celebrate, denounce, clarify, get affirmation, and, overall, become a part of a community through the hearing and telling of stories. Stories help us make sense of experiences. Interprofessional care teams increasingly use narrative approaches in practice to better communicate with each other about the patient and to focus on the patient as the center of care.9 Narrative ethicists conclude that good moral judgment must rely on the analysis and understanding of narratives. Kathryn Hunter, a contemporary leader in narrative approaches to ethics within healthcare, reiterates this point and notes that through narratives:

[W]e spin and untangle explanatory accounts of the way the world works and how we and our fellow human beings act in every conceivable circumstance. Memories of the past and ideas of the future are expressed in narrative accounts of how the world was and how it will, or should, become.10

Her emphasis on “should” underscores the narrative ethicists’ position that future moral choices of individuals and communities are shaped through understanding and taking seriously the information and lessons embedded in stories.

Elizabeth Kim’s situation is revealed to you as a narrative. The fragmented narrative she herself has received is probably disturbing to her. She lacks certain information about the student’s mother, the principal, and their exchanges that she needs to be confident of the moral challenges in the situation. Thus, not only is she without all the facts and details, but she may feel she lacks pertinent information to make a valid ethical judgment about the real significance and meaning of the events unfolding before her. From the standpoint of ethical problems, Elizabeth is in a situation of moral distress.

Narrative approaches also highlight that in complex situations, not just one but several accounts exist. Suppose this story simply was titled “The Story of Principal Leary.” What different concerns might Principal Leary express regarding his role, his relationships with the student Max, Max’s mother (and all students and parents), and Elizabeth, or anything else? It may be a different story than the one told by Elizabeth. Or suppose this story was titled “The Story of Melinda Diaz.” Surely this mom’s account would include details about her personal life and experiences, her response to her son’s learning disability, and her hopes, dreams, and fears. These details would alter inexorably what Elizabeth’s story taken alone conveys. Elizabeth finds herself in the middle of a story to which she does not know the ending and wonders what to do. By listening to the many differing perspectives, she can begin to link values to action.11 Ideally, the incorporation of differing perspectives leads to higher-order reflection and allows all involved to consider points of view different from their own.12 This diligent effort to consider as many voices as possible before interpreting the situation for moral significance is key to narrative analysis.

 Summary

Narrative ethics requires attention to the details of the story and that all voices be considered before the situation is assessed for its moral significance.

Approaches That Emphasize Relationships

Some ethical approaches rely on a narrative search for the central moral themes of human relationships revealed in the story. You can immediately see the importance of this insight for health professionals because almost all their work involves relationships. In this approach, ethical issues or problems are embedded in the relationships, not just in the individual’s situation. Patient-centered understanding of clinical situations is an example of such a relationship. A patient-centered approach in your professional orientation means that you always take the patient (and the patient’s network of support) deeply into account regarding your ethical decisions. Not surprisingly, this approach has been promoted and refined by psychologists, particularly those who work in the area of moral development.

Carol Gilligan became an important leader in this area in the 1980s; her work was drawn from a widely accepted model of children’s moral development advanced by Harvard psychologist Lawrence Kohlberg. Kohlberg hypothesized that children go through stages of moral development similar to cognitive development and that children become more independent and autonomous as they mature as moral beings. His work became a dominant, if not the dominant, moral development theory in the early 1980s.13 At that time, Gilligan, who was working as Kohlberg’s graduate student, noted that his work depended on studies of boys and young men. She repeated some of the work with girls and young women and discovered that her subjects conceptualized ethical issues and problems differently than did their male counterparts. Girls had a high sensitivity to how various actions would affect their important relationships (i.e., with parents, friends, teachers, or other authority figures); Gilligan concluded that girls’ “awareness of the connection between people gives rise to a recognition of responsibility for another.”14 Moral maturity was not characterized by an increasing independence from everyone else but rather by decisions that would result in deeper and more effective connections and relationships to significant others and the larger community.14

Gilligan’s work has become one vital basis for ethicists to emphasize how relationships figure into morality. Many have worked to refine our understanding of the ways relationships are central within various social settings, including professional relationships. Moreover, further examination has shown that although girls and women may be socialized to think in terms of sustaining relationships, the significance of Gilligan’s findings is by no means gender specific. All health professionals enter into a relationship with the patient, and through these relational networks, moral agents have responsibilities toward particular patients with whom they are connected and who in turn are affected by the moral agent’s action.15

Institutional and other social arrangements of a society influence individual action and relationships too. Ethical reflection requires recognition of the powerful influence of each player’s and some groups’ socially assigned “place” in society and how relationships are affected by the assumptions regarding social status.

If you noted the difference in power between Elizabeth Kim and Melinda Diaz or between Elizabeth Kim and Principal Leary because of their relative power and status within the delivery of care, you were correctly paying attention to social or institutional influences on relationships as relevant considerations in ethical analysis.

In summary, in story-driven approaches, the first major task is to be attentive to the details of the situation. How is this accomplished? You must be not only humble in the face of rich diversity but also respectful of deep differences and, to the extent possible, show respect for those differences in your relationships with others. You also must take seriously the larger social and institutional forces that influence relationships, a topic covered in more detail in Chapter 6.

Ethics of Care Approach

So far you have been introduced to ethical approaches you can use to:

• discover the areas of moral relevance by paying attention to the details of a narrative;

• highlight the moral significance of relationships in the situation;

• remember to be attentive to deep differences among persons or groups; and

• appreciate the power of institutional and other social arrangements to influence a situation.

In this subsection, you have an opportunity to examine some ethical approaches that take the idea of care itself as their central feature. Many varieties of a “care ethic” exist at this time, but generally speaking, in an ethics of care approach, the major question is “What is required of a health professional to be best able to express, ‘I care’?” As you noted in Chapter 2, taken in its richness, care is the language adopted in the health professions ethical literature to emphasize the imperative that professionals must keep a focus on the well-being of the whole person. Within this context, we have emphasized the goal of professional ethics as being a caring response. Bishop and Scudder describe the core of an ethic of care as residing in the health professional’s “caring presence” as follows:

Caring presence does not mean an emotive, sentimental, or maudlin expression of feeling toward patients. It is a personal presence that assures others of another’s concern for their well-being. This way-of-being fosters trust, mutual concern, and positive attitudes that promote good health. When caring presence pervades a health care setting, the whole atmosphere of that setting is transformed so that not only is sound therapy fostered, but patients appreciate, take pride in, and feel part of the health care endeavor.16

At least two aspects of a care ethic approach are implied. First, the approach is dependent on real contact with the patient as a person; that is, it is deeply relational. Second, the approach fosters trust. Baier17 places trust as one of the central notions for an ethics approach that derives from a perspective of care. That, in turn, suggests that you as the health professional must bring trustworthiness to the relationship, a notion that is discussed in greater detail subsequently in this chapter.

In an ethics of care approach, the caring relationship serves as a frame to evaluate ethical issues. Good care is a process that involves the caregiver’s attentiveness, competence, and responsiveness. An emphasis on connectedness, dependency, and vulnerability as essential features provides a focus on humans as relational beings, who need interpersonal relationships to flourish.18,19

 Summary

Good care is a process that involves the caregiver’s attentiveness, competence, and responsiveness. In an ethics of care approach, the caring relationship serves as a frame to evaluate ethical issues.

Story and Ethics of Care Approaches and a Caring Response

Story or case approaches combine to illuminate several facets of the overall picture of care. For instance, the vigilance directed to the details of the story and its narrator, the emphasis on relationships that shape the story, and a deep respect for the differences that exist among peoples and cultures all are important tools in understanding what it means “to care.” We encourage you to embrace opportunities to refine your own interpretation of what a full theory of an ethics of care involves in your relationships with patients. Not only are these approaches tied to the development of one’s professional identity, but they have become increasingly important in fostering the kinds of self-reflection and interpersonal communication essential to interprofessional practice.

We turn now to virtue theory. The appropriateness of giving your attention to this theory is expressed by a health professional who, in thinking about her profession, said, “caring behavior involves the integration of virtue and expert activity of… [professional] practice.”20 In other words, “being” and “doing” are both involved and deeply related. An understanding of virtue theory provides an important link between the motivation to find a caring response and the ethical acts or behaviors that follow from the character traits we cultivate.

Virtue Theory

Many varieties of virtue theory have been developed over the ages. We provide you with some basic threads that have created the general tapestry of varieties called virtue ethics. In a look back on the early Western development of those theories, Aristotle can be credited with providing us with a basic framework for this thinking.21 Within the Judeo-Christian theologic tradition that has deeply influenced Western ethics, the virtue dimensions of Thomas Aquinas’s theories have had a profound impact on the shaping of virtue theory.22 Within the health professions and early medical ethics writings, the idea of virtue also was dominant. For example, authors of the Hippocratic School wrote approximately 70 essays on healthcare in addition to the Oath, several of which discussed character traits. For example, The Decorum enjoins that a physician “should be modest, sober, patient, prompt, and conduct himself [sic] with propriety in professional and personal life.”23 In short, the professional caregiver will have the moral fiber necessary to carry out the duties outlined in the Oath.

Maimonides was a highly respected and renowned Jewish philosopher of the 13th century who wrote extensively about the relationship of medical issues to Jewish law. The prayer of Maimonides is based directly on the belief that the development of certain character traits enables the caregiver to exhibit appropriate moral behavior. In making this promise, the physician calls on God for help to have the right motives worthy of this high calling:

May neither avarice nor miserliness nor thirst for glory nor for great reputation engage my mind, or the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to my patients. May I never see in a patient anything but a fellow creature of pain.24

Maimonides believed that important character traits of the health professional are sympathy for the patient’s plight, humility, and a devoted commitment to helping others.

From those early influences, many versions of virtue theory have evolved so that the tapestry of thought today is splendid indeed. The easiest way into the understanding of virtue theory is through the basic idea of character traits and moral character.

Character Traits and Moral Character

A character trait is a disposition or a readiness to act in certain ways. Some character traits are moral character traits because they are supportive of high ethical standards. Persons who habitually act in a manner that can be praised by others because their conduct upholds high ethical standards are said to be persons of high moral character. To some extent, our society is measured by the type of people in it, and professionals are judged on this basis more than on any other criterion. Your oaths, codes, and standards of practice declare it. Your state licensing laws require it of you.

Certain character traits enable you to be the kind of person you want to be as a caregiver.25 For example, honesty manifests itself in your trying to refrain from deceiving others for your own comfort or protection. Courage may be needed to speak out against injustice or other wrongdoing. Courage combined with honesty is needed for health professionals to admit that they mistakenly took the wrong treatment approach. Compassion can help motivate you to refrain from thoughtlessly harming vulnerable people.

Recall the health professionals involved in Max Diaz’s case. Honesty taken alone would dispose you to encourage Elizabeth Kim to tell his mother about the intentional delay in her son’s IEP. Honesty and courage taken together would dispose you to telling her but also to take every step to ensure that she actually receives the correct information. This may involve some risk-taking conduct if Elizabeth believes an intentional misappropriation is going on. In other words, the two virtues together will drive her to take measures that ensure Principal Leary is held accountable. These two character traits combined with compassion would motivate her to make sure the information is transmitted in a way that shows respect for everyone involved. Taken together, the habitual practice of exercising these traits would create a high moral character that prompts her to do everything possible to diminish harm and foster a morally healthy work environment, not only in this situation but also in others she encounters.

 Reflection

Patients are very different in their responses to personality types of health professionals. But more fundamentally, they almost all have strong feelings about the kind of person you as a health professional are. Character traits of respect, compassion, and honesty are high on the list of character traits that most patients want to be able to count on. What other character traits do you feel are necessary for health professionals?

__________________________________________________________________________

Probably the most widely esteemed traits are those that convey an attitude of respect for individuals who come to you as patients. The underlying ideal is that individuals should be treated as ends, not as means to some other end.

Individual, interprofessional, and institutional virtues are important within the health professions. In this respect, one can speak of the moral character of an individual health professional, a team of healthcare providers, or the moral character of healthcare institutions. In addition to the elaboration of specific virtues that should be cultivated, you need to know several other points about the cultivation of virtue.

First, experience is extremely important. Only through experience can we ultimately learn exactly what contributes to a morally good life (the goal of exercising virtue in the first place).

Second, because the cultivation of virtue depends on experience, we cannot simply think ourselves into being virtuous or knowing what virtue consists of. We must add feelings. Emotions must be attended to; as you learned in Chapter 3, they are the motivators toward certain kinds of actions and not others.

Third, in the process of experiencing and feeling what is happening in the situation, we ourselves become transformed. When we follow the inclination of virtue, we are working at becoming more virtuous. We grow into virtue by acting in accordance with what virtue counsels us to do.

Fourth, a community of persons is vital for discerning virtue in a situation. In this regard, the health professions are one community in which such discernment takes place.26 We ask that you keep these four points on cultivation of virtue in mind as we explore them further in Chapter 6.

Character Traits and a Caring Response

Several positive character traits may be called into play at one time or another to prepare you attitudinally for the action you will have to take to achieve a caring response. Understandably, the development of habits that allow you to move easily into a caring response will serve you well. The ability to live a life of moral excellence requires exercise, but we believe Aristotle was correct in saying that high moral character is the key component to a good life overall. Morality is about the pursuit of good; along the way, we all struggle with the balance. We must understand our duties as moral agents and uphold these duties for the right reasons. In addition, because healthcare is increasingly delivered by interprofessional care teams, we have a shared moral obligation to work together to improve care. Acting with honesty and integrity demonstrates commitment to these virtues. Good character traits help us build good moral character and foster a stronger moral culture for the many uncertain tasks we face.

 Summary

The early crafters of the idea that professionals must exert high moral character through the cultivation of virtues make good common sense when viewed through the lens of the professional’s moral task of achieving an outcome consistent with a caring response.

We have come a considerable distance already in this chapter. Although the professional ethic takes the story and your attitudes to what you learn from it as the fundamental starting point, the ethical challenge does not end there. You must now link virtue with conduct. The caring response requires that you become a certain type of person (i.e., of high moral character) for a purpose—that is, to do what is right. Therefore, because professional ethics require action, dispositions, and character traits, we turn now to ethical theories and approaches collectively termed action theories. They include principle-based approaches, deontology, and teleology.

Principle-Based Approach

When you move to purposive action, it is helpful to be able to say, “Toward what end?” Moral agent Elizabeth Kim will ask, “What guidelines can I use to help know if my course of action is in the (morally) right direction to achieve the right outcome?” This concern, and the recognition that guidelines are needed, led to the development of methods that emphasize ethical principles and therefore are termed a principle-based approach. In most professional ethics literature (and modern social ethics writings), these methods are called principles, but we also think of them as elements because they do for ethical theory what the basic chemical elements do for chemistry theory: They provide a way to see something concretely that is quite abstract. As you know, a chemical element can be combined with other elements. Sometimes, they combine to form a new compound that looks and acts differently than each of the units taken individually. Sometimes, they clash. Often, two or more elements have different relative weights so that one is heavier than the other. Key principles are shown in Table 4-2 for your future reference.

Table 4-2

Ethical Principles

Principle

When applicable

Nonmaleficence (refraining from potentially harming myself or another)

I am in a position to harm someone else.

Beneficence (bringing about good)

I am in a position to benefit someone else.

Fidelity

I have made a promise, explicit or implicit, to someone else.

Autonomy

I have an opportunity to exercise my self-determination, say-so.

Veracity

I am in a position to tell the truth or deceive someone.

Justice

I am in a position to distribute benefits and burdens among individuals or groups in society who have legitimate claims on the benefits.

Paternalism

I am in a position to decide for someone else.

There is more to the story than Table 4-2 indicates because “I” may be a person, a group, or even an institution. Principles can help you know how an individual, group, or institution stands in relationship to others, morally speaking. These principles, or shared moral beliefs, guide action and serve to act as standards for moral behavior.27 The British philosopher David Hume28 justified this position in his belief that we incur obligations to act in certain ways because we have received positive responses to our own needs to be treated humanely: “I have benefitted from society, and therefore ought to promote its interests.” Some philosophers argue that principles help to identify what we should do in special relationships regardless of whether we have received benefits from the other person (or from society). Some such relationships, Hume says, are between parent and child, spouses, faculty and student, or citizen and society. The health professions are another source of special relationship: with patients.

Several principles are extremely important in the healthcare context. For example, the principle of nonmaleficence, or “above all, do no harm,” was an explicit theme in the ancient Hippocratic Oath and ever since has been viewed as an overriding moral principle that guides health professionals’ conduct toward patients. Because of the importance of these principles, you have this opportunity to examine several in more detail.

Nonmaleficence and Beneficence

Primum non nocere (“First, do no harm”) is thought to be at the nexus of traditional healthcare ethics and often is attributed to the authors of the Hippocratic Oath. It is at the very heart of what is meant by a caring response! The principle of nonmaleficence is used today to talk about this type of action. The general meaning of the term can be found by breaking it into its prefix, non, and the root, maleficence (“mal, bad, or evil”). The difference in power between professional and patient alone helps to support the instinctive wisdom of this strong call to refrain from abuse. Furthermore, Western societies in general usually attribute greater significance to a harmful act done out of deliberate intent than out of neglect or ignorance. It is difficult to believe that a society could survive if people went around trying to harm each other, and the laws of our land take seriously the necessity of stemming the potential for harm to go unchecked. The early purveyors of professional ethics left nothing to chance and warned health professionals that there was no room whatsoever for acting in ways designed to bring about harm.

In professional ethics, not harming and acting to benefit another (beneficence) are treated as separate duties. Sometimes, philosophers treat them as different levels of the same principle or element. When duties are thought of in this latter fashion, at least four types fall along the continuum of the same principle:

• Do no harm.

• Prevent harm.

• Remove harm when it is being inflicted.

• Bring about positive good.

Professional ethics limits beneficence to the last three on the list.

Because these two principles are so pervasive in the everyday decision making by health professionals, you are well advised to think about their relevance in every new situation you encounter.

 Reflection

Consider the principles of nonmaleficence and beneficence in relation to the story in this chapter. Elizabeth is worried about the direction of Max Diaz’s care. She believes his learning and academic progress are being delayed, which is causing harm to his overall success at school. Is Elizabeth following the principle of nonmaleficence by her actions so far? The principle of beneficence?

__________________________________________________________________________

What evidence do you have that she is or is not?

__________________________________________________________________________

In your opinion, what would she have to do to be beneficent in this case, given the level of her authority and her knowledge, skills, and compassion?

__________________________________________________________________________

What members of the interprofessional education team are likely to coconstruct this narrative and serve as resources to Elizabeth?

__________________________________________________________________________

Autonomy

The principle of autonomy is the capacity to have the say-so about your own well-being, “the capacity to act on your decisions freely and independently.”29 Some call this the principle of self-determination. Obviously, the principle applies to you whether you are acting in your professional role (professional autonomy) or as a citizen (social autonomy) or have become a patient (patient autonomy). Professional autonomy points out that a health professional must be free of encumbrances to act in the best judgment on behalf of patients. Much of the discussion that follows focuses on the important arena of patient autonomy.

A patient’s basic healthcare needs have not changed significantly over the decades, but the idea of what fully constitutes a caring response has changed. Today, so many clinical interventions are possible that the type and number of interventions alone may lead to suffering. A few years ago, the health professional who did everything clinically possible for a patient was seen as beneficent. Today, that same professional could find that the process leads to moral regret; the patient or patient’s family may charge that harm has resulted because the interventions have gone beyond what the patient wanted or could tolerate.

In light of this situation, the past several decades have seen the emergence of the patient as a more active participant and negotiator of healthcare decisions. The patient’s autonomy—say-so or self-governance—has come to be accepted as a legitimate moral claim to be placed in the balance with the health professional’s independent judgment about what is beneficent. Again, we are reminded that the emphasis today on patient-centered care is dependent on shared decision making in the relationship. Some suggest that in the United States and many other Western countries, autonomy has too much emphasis and creates a monopoly on our moral attention.

The principle of autonomy (or self-determination) and its role in morality have been developed from the views of diverse and colorful figures in philosophy. Two who have been especially influential are the deontologist, Immanuel Kant, and one of the crafters of a consequence-oriented theory, John Stuart Mill (they are discussed subsequently in this chapter). Both of their interpretations of the principle of autonomy have been adopted in health professions usage. Kant30 emphasized the role of being in control of one’s own choices in accord with a moral standard that could be willed valid for everyone. Therefore, his main contribution was his discussion of self-legislation, the reasons for actions. Conversely, Mill31 focused his thought more on the context of the freedom of action, with the argument that an individual’s actions legitimately can be restricted only when they promise to harm someone else. Up to that point, he contends, each person should be permitted to act according to his or her own convictions. Therefore, his main contribution was to highlight the social and political context in which the exercise of autonomy can thrive.31 The two interpretations together point to our assumption today that a patient’s input can be rational and that the context of decision making must be conducive to the patient’s exercise of real and informed wishes. Anything less fails to meet the criterion of a caring response (Figure 4-1).

FIGURE 4-1 This statement was written on a pad of paper by a 27-year-old hospitalized woman with metastatic ovarian-breast cancer. She could not communicate verbally because she had a tracheostomy and therefore could not speak. The physician had explained that he wanted to reimplement chemotherapy for a tumor that had appeared in her remaining ovary. She had already undergone an oophorectomy and hysterectomy and had received radiotherapy and chemotherapy for the previous tumors before their removal.

Gilligan, whose studies were introduced previously in this chapter, is among those who criticize a focus on autonomy because it requires that a person be treated as an isolated unit standing alone, over and against all other people, whereas, as you recall, she is among those who emphasize the importance of relationships for the moral life.32 Hers is a serious criticism. She is correct in her observation that we understand ourselves as moral beings largely within the context of our relationships. Be that as it may, we also live in a society that is highly individualistic in its behavior and laws. The principle of autonomy provides direction in those situations in which individuals are in a position to make a claim on others to respect their selfhood.

Conditions and Considerations in Autonomy

For true autonomy, two conditions are necessary. The individual must have liberty (freedom from controlling influences) and agency (capacity for intentional action). These conditions for autonomy are discussed subsequently in this text as they relate to specific ethical dimensions of practice. For example, much discussion currently is ongoing about autonomy in regard to decisions about the timing and type of death one will have, a topic you will encounter again in Chapter 13. Underlying the idea of a right to die is the more fundamental belief in the right to autonomy or self-determination. But the principle of autonomy has much broader applications than end-of-life situations.

Although autonomy is highly valued in American society in general, this value varies across individuals, communities, and cultures. Given our global and growing national diversity, communal or familial decision making is a consideration that often presents in clinical scenarios. Race, gender, age, ethnicity, socioeconomic status, occupation and place of residence, religion, and sexual orientation are among the most frequently cited cultural characteristics. Because culture itself has a broad impact on health and health-related issues, these differences must be appreciated to achieve a caring response. Regardless of the patient’s cultural background and beliefs, the act of approaching each patient with respect itself upholds the moral principle of autonomy, even though their decision making may be influenced by specific values that may lead to communal or other forms of decision making that vary from the self-determination we associate with patient autonomy.33

Paternalism

At times, the patient’s deep preferences conflict with the health professional’s judgment of what is best for the patient on the basis of the professional’s values, which are not necessarily those of the patient. In other words, the conflict is between the patient’s choice and the professional’s (or interprofessional care team’s) judgment of what is best for the patient. In this situation, the principle of paternalism or parentalism may come into play. Paternalistic or parentalistic decisions are those in which a health professional acts as a parent, with all of the negative and positive connotations. Paternalism is in play when relevant information regarding an individual’s medical condition is withheld, defended by the claim that the person interfered with is better off or protected from harm.34 Paternalism limits patient autonomy; when evoked, the health professional makes a decision for the client instead of with the client. Considerations of paternalism also arise with respect to the implementation of public health policies and laws (e.g., mandatory seat belt use).

 Reflection

The principle of autonomy (or self-determination) is a helpful principle, but like all of the principles, it is not absolute in the delicate complexity of real-life situations. Liberty and agency are both essential to autonomy. Many patients experience restrictions to these conditions when their health and functioning are compromised. An elderly patient with advanced Alzheimer’s disease who lacks decision-making capacity is one such example. Can you think of others?

__________________________________________________________________________

You will revisit the principle of autonomy several times later in this book. Watch for it.

Fidelity

The principle of fidelity comes from the Latin root fides, which means faithfulness. Fidelity is about being faithful to one’s commitments. Being faithful to the patient entails meeting the patient’s reasonable expectations. Patients come with all kinds of expectations. What can be counted as a reasonable expectation?

First is a reasonable expectation that basic respect will be shown to anyone, anywhere. Sometimes, health professionals have been criticized for failing to show basic respect, such as respecting the modesty of a patient.

Second, the patient has reason to expect that you will be competent in what you do.

Third is the patient’s reasonable expectation that you will adhere to statements you have subscribed to as a member of a profession. The most public of these statements is your code of ethics.

Fourth, the patient has a good basis for believing you will follow the policies and statements adopted by your place of employment and the laws that are designed to protect patient well-being.

Finally, the patient has good reason to expect that you will honor what the two of you have agreed to, such as the promises involved in any informed consent form the patient has signed, verbal agreements, and serious conversations.

Can you think of others? A caring response cannot be affected if you fail to meet the reasonable expectations of your patients and others.

Veracity

The ethical principle of veracity binds you to honesty. Veracity means that you will tell the truth. This principle is more specific than, say, beneficence or fidelity. For this reason, some call it a second-level principle that directs you to engage in a specific type of behavior, which in turn can support your intent to be beneficent or to maintain your fidelity in relationships with patients and others. Kant gave veracity a central role, with the position that veracity is an absolute to which no exception can be made. The lie, he argues in one place, always is wrong because the practice of lying is something that weakens the entire human fabric.35 Most others weigh veracity heavily regarding its potential for benefiting others but do not make it the absolute or governing duty above all others.

In our story, Elizabeth Kim understandably seemed disappointed about the possibility that Melinda, Max’s mom, was not being told the truth about Max’s status and the IEP process. The situation was made more complex by the different professional roles of the principal and the speech and language pathologist.

Justice

Patients do not always get all the treatment and attention they deserve or need because of a lack of resources, and anyone who worries about that is worrying about the principle of justice in the situation. Discrimination against some individuals or groups may appear to shortchange them, and anyone who worries about that is worrying about the justice of the situation. A lack of due process regarding who receives priority in situations of conflict may cause concern, and anyone who worries about that also is worrying about the justice of the situation. In general, the concern is that all similarly situated individuals receive their fair share of benefits and assume their fair share of burdens. The caring response is achieved when individuals or groups are treated fairly and equitably.

Justice can be thought of as an arbiter. It serves to ensure a proper distribution of burdens and benefits when there are competing claims, not all of which always can be met fully. As you recall, a dilemma of justice is one variety of an ethical dilemma problem. The principle is called on with problems regarding what is rightfully due a person, institution, or society. Three types of justice have particular importance in professional ethics situations: distributive, compensatory, and procedural. The complex issues of justice are discussed more fully in Chapters 14 and 15.

Principles and a Caring Response

As you can see, the ethical principles you will encounter most often in your professional roles are very general, but they do serve as guidelines to move you in the direction of action. In their particularity, they are instrumental in helping you further delineate the conditions that must be met if you are to show a caring response toward the patient. For instance, you know that you must honor the patient’s reasonable expectations, you must do it truthfully, and so on. In short, the principles themselves force you to consider who the patient is as an individual different from all others.

 Summary

Principles provide general moral guidelines in the search for a course of action that will result in an outcome consistent with a caring response.

You may have noticed that some principles are oriented more toward a conduct or duty-driven ethic. They include fidelity, autonomy, veracity, and justice. Others, namely beneficence and nonmaleficence, require you to weigh the most favorable (or least damaging) consequences in a situation. Both deontologists and teleologists express the need for individual or group actions to be guided according to principles. However, you have not yet had the opportunity to look more closely at these two major theories that have been highly influential in traditional professional ethics approaches. We turn to them now.

Deontologic and Teleologic Theories

Taking Duties Seriously: Deontology

Elizabeth Kim faces a perplexing situation regarding balancing loyalty and honesty. One approach is to identify whether she has a duty that can help her decide what to do. In her search for a duty (or duties), she is appealing to deontology and deontologic theories.

One place where duties are codified is in codes of professional ethics. For example, currently you can find statements such as “respect a patient’s dignity” or “honor the patient’s [or client’s] right to consent to a potential treatment.” When you look more closely, the statements imply fundamental ideas about humans—namely, that we stand in relation to each other in a number of morally significant ways. In this regard, deontologists agree with Gilligan and others discussed in this chapter who emphasize the centrality of relationship and the importance of paying attention to the details of a patient’s (or another’s) story. Deontologists hold that the basic concepts that individuals and societies recognize and agree on give rise to a shared sense of duty or right. These could be arrived at through reasoning about such things or, others might argue, we intuit them. Although a narrative approach correctly helps to focus attention on particular details of a story, the deontologist goes further to say that a concept of duty informs (or is at least available to) all individuals.

Deontologic theories hold that you are acting rightly when you act according to duties and rights. In other words, duties and rights are the correct measuring rods for evaluating a course of action and its outcome. Many versions of deontology exist. The person most often identified with deontologic approaches is Immanuel Kant, whose philosophies were introduced in the discussion of the principle of autonomy. His basic premises still figure strongly in arguments within healthcare ethics today. He held that every person has an inherent dignity and on that basis alone is entitled to respect. Respect is shown by never using people to achieve other goals or consequences that do not benefit them. He thought that duties help to determine how respect toward others can best be expressed. It follows that the morally correct thing is always to be guided by moral duties. He concluded that some actions are intrinsically immoral, no matter how positive and beneficial one might judge the consequences to be, and that other actions are intrinsically moral, no matter how negative the consequences might be. In short, he said that one cannot judge the moral rightness or wrongness of an act on the basis of its consequences alone.35 Whatever Elizabeth’s conclusion about what Melinda Diaz or Principal Leary should do, Kant would arrive at his decision by a process of determining what their duty should be, not simply whether a better consequence overall would be achieved by one type of act or another. Professional responsibility would be guided by accountability more than responsiveness in the range of consequences.

 Reflection

Do you think that this appeal to duties is the correct moral tool to use in the situation in which Elizabeth Kim and Principal Leary find themselves?

Yes____ No____

What important moral considerations are taken into account in this approach?

_____________________________________________________________________________

What could be overlooked if they appealed to their sense of duty alone?

_____________________________________________________________________________

As you can begin to see, there are some challenges to applying the deontologic approach in its “pure” form. For instance, the idea that we ought to do the right thing, informed by duty, is general. How to show respect for individuals still needs further interpretation in any situation. What do we do when duties or rights themselves come into conflict? Deontologic theories require that a method of weighing be available to determine what to do when conflicts arise, and critics charge that there is no obvious way to weigh them (Figure 4-2). Such a process is not self-evident. Thus, the appeal to principles discussed in the previous section is one attempt to provide further detail and interpretation to the general idea of duty and order, or to give varying weight to conflicting duties and rights.

FIGURE 4-2 Weighing duties.

Absolute, Prima Facie, and Conditional Duties

We have seen that from a deontologic viewpoint, principles can assist in interpreting one’s duty. Principles that carry the weight of duties may be absolute, prima facie, or conditional. Absolute duties are binding under all circumstances. They can never give way to another compelling duty or right. Prima facie duties or rights allow you to make choices among conflicting principles. For instance, the prima facie duty of veracity is actually binding if it conflicts with no other duties, or rights, that carry more weight in a given situation. But it is not an element that is absolute either because other elements may be more compelling. In the discussion of the primacy of “do no harm” over “beneficence” in the clinical ethics context, we suggested that each is being treated as a prima facie principle, and the mandate not to harm is more compelling than the mandate to bring about some positive good. A conditional duty is a commitment that comes into being only after certain conditions are met. For example, the Americans with Disabilities Act outlines certain duties and rights that apply solely to individuals who have disabilities.36

However binding a principle or element is deemed to be, it has the role of providing a marker to guide the conduct of individuals and groups wanting to live a good moral life.

Paying Attention to Outcomes: Teleology

Partially because of some of the criticisms of deontology, teleology and teleologic theories emerged and placed the focus on the ends brought about and the consequences of actions. The most important teleologic theory for our consideration of healthcare ethics is utilitarianism. This word takes its root from the idea of utility or usefulness.

Utilitarianism

In utilitarianism, an act is right if it helps to bring about the best balance of benefits over burdens—in other words, the best “utility” or consequences overall. The original approach was developed first by two English philosophers, Jeremy Bentham (1748-1832)37 and John Stuart Mill (1806-1873).38 Note that they are roughly contemporaries of Kant. In fact, they were vigorous opponents of Kant’s position.

From a utilitarian point of view, as a moral agent, you must consider what several different courses of action could accomplish, the goal being to fit the action to the outcome that brings about the most good or least harm overall, all things considered. In the case of Elizabeth Kim, you might say, “The goal is to treat Max Diaz in such a way that everyone else will be able to have the same type of care he gets” or “The goal is to be able to live with my own conscience.” If both of these goals can be attained by taking one single course of action, it should be taken. If this is not possible, the course of action you believe will bring about the best consequences or “outcomes” overall should take priority.

One important task of this approach is to distinguish alternate paths of action and then predict as accurately as possible the consequences of each path. Rule utilitarians are sometimes thought of as a hybrid of deontologic and utilitarian approaches. Pure utilitarians weigh the consequences solely in the specific details of each situation. A rule utilitarian holds that you will always bring about more good consequences by following certain “rules” or duties. What the rules should be then becomes the task for these theorists.

Duties, Consequences, and a Caring Response

The deontologic and teleologic normative theories have been helpful tools for health professionals because they set a general framework for thinking about specific moral issues and problems in healthcare settings with a focus on the action that needs to take place. Probably as you were reading you were thinking, “Well, both the idea of courses of action consistent with duties and rights and the idea of consequences or outcomes are important in my attempt to arrive at a caring response.” In fact, most of us do draw on both to make practical everyday moral decisions. Only occasionally does it make a big difference in what you judge to be right if you follow solely a deontologic line of reasoning or appeal to consequences only. Fortunately, most of the time, you can take action that is in line with your sense of duty, honor others’ rights, and consider the outcomes you are bringing about without any conflict among the three. But it is in the occasional moment during which the means and the ends seem to be competing that it may become necessary to plant your feet firmly in one theory or the other and be able to justify why. See Table 4-3 for a brief summary of deontology and teleology.

Table 4-3

Theories of Deontology versus Teleology

Deontology

Teleology

Duty-driven

Goal-driven

Means count

Ends count

Kant (deontologist)

Bentham, Mill (utilitarians)

Summary

This chapter introduced you to ethical theories and approaches, the conceptual tools that help you the most when faced with ethical problems in your role as a health professional. The ability to absorb a narrative for its moral content and the development of moral character help you to be ready for the hard times when no answers seem to be forthcoming or when you are confronted with something that is not easy to face. You also have learned the most important principles, or norms of ethics, that you need to understand the ethical aspects of your life as a professional. Duties and rights are tools for recognizing and working to resolve problems that arise in your everyday practice. They must be balanced with values so that a caring response can be achieved. Although traditionally much of the language of healthcare ethics has been that of what is owed the patient (i.e., the language of duties), the importance of character traits and attitudes and, more recently, the ideas of patient (and professional and society) rights have enriched the understanding of professional ethics with its goal of ascertaining a caring response. With these basic frameworks at your disposal, you are well positioned to engage in the six-step process of ethical analysis and decision making introduced in the next chapter.

Questions for Thought and Discussion

1. This is an opportunity for the class to create a narrative of a patient, Esther Korn. This group exercise is about a healthcare situation that came to the attention of the hospital ethics committee. (If you have forgotten what an ethics committee is, go back to Chapter 1.) The whole class can participate in the discussion as members of the ethics committee, and five people can assume various important roles.

The ethics committee has been asked to give advice on whether Esther Korn should be sent back home or to a nursing home.

Esther Korn, a 72-year-old woman, has been admitted to the hospital with a diagnosis of dehydration and serious bruises from a fall sustained in her home. She was found by a neighbor, Anna Knight, who says she stops by Esther’s home daily because Ms. Korn has lived alone with her eight cats since being discharged from a state hospital with a diagnosis of paranoid schizophrenia, which is believed to be under control with medications. From the degree of dehydration, the health professionals believe that Ms. Korn was very dehydrated before she fell and that she had been lying on the floor for at least a day. The emergency medical technicians who brought her to the hospital described her home as “filthy, full of dirty dishes and clothes strung all over, with cat droppings everywhere.”

Now, 5 days later, Ms. Korn seems confused about where she is, but she does know her own name. She says over and over, “Let me out of here! I want to go home!” Her sister, whom she has not seen “for several years” (according to Anna Knight), does not return the nurses’ calls or voice messages. The nurses are not in complete agreement, but most of the staff believe that Esther would be better off placed in a supervised setting for her own safety. Anna Knight and the local priest, who visits her regularly, also have strong opinions about where Esther should live.

Five people will be “storytellers” to provide some missing parts to her story: one will be Esther, and the other four will be significant others in her life. Together the class can create a fictional story that fills in information about who she is and what may, in fact, be in her best interest in this difficult question facing the ethics committee.

Person A: Write a few paragraphs about Esther from her neighbor Anna’s perspective and what Anna thinks should be done.

Person B: Write about her from the Episcopal priest’s perspective and what she would recommend.

Person C: Write about her from the perspective of her long-lost sister and what she would recommend.

Person D: Write a report from the point of view of the primary nurse and what he thinks.

Person E: Speaking as Esther, give some background as to what kind of person she believes herself to be, what is important to her, and so on.

When each of the five storytellers has completed this part of the exercise, read the notes aloud to the ethics committee (i.e., rest of the group). After everyone has heard the “bigger picture,” answer the following questions:

• What should be done?

• What ethical approaches or theories influence your thinking the most?

• Which values do you think are the most prominent in this discussion?

• Did anything that was said in these stories change your mind about your initial thoughts regarding what should be done? If so, explain.

• Discuss what the health professionals must do to show caring in their relationship with Esther Korn.

2. Elva, a 370-lb, 62-year-old woman, is in a nursing home after complications of diabetes and several small strokes. Although she has been overweight all her life, she now is at a weight where it is unsafe to transfer her without a bariatric lift. Elva, however, refuses to be moved with it, claiming, “I’m not a piece of meat.”

She can be transferred to a chair with the assistance of four or five staff members. The administration, however, is worried that the staff could be injured physically while moving her. Her daughter insists that it is a violation of Elva’s dignity and an unnecessary compromise of her autonomy to submit her to “the indignity of the mechanical lift.”

You are the supervisor of the unit. What ethical principles presented in this chapter can help you to assess what to do in this situation? What should you do?

3. Walter is a resident in the same nursing home with Elva. He is a 78-year-old widower who has been taking antidepressants since the sudden death of his wife 5 years ago. He, too, is visited often by his daughter. The staff of the nursing home inadvertently threw out his dentures with the sheets while making his bed. He had a habit of leaving them on the bed, and although the staff usually noticed them, a new employee failed to do so.

Since then, Walter has adamantly refused to have his teeth replaced. The nursing home administration is more than willing to fit him with a new set of dentures and to pay all costs. His daughter is very much in agreement with the administration that he should have his teeth replaced. They are all aware that his nutrition is suffering, as is his ability to be understood when he tries to talk.

Should Walter be allowed to continue without his dentures? What principles and other considerations of ethics should you, as a nursing home administrator, bring to bear on your decision on how to proceed in this situation? What should you do? Use your understanding of the different ethical theories and principles to add to the depth of your ethical thought and proposed action.

References

1 Doherty R.F. Ethical practice. In: Schell B.A.B., Gillen G., Scaffa M.E., eds. Willard and Spackman’s occupational therapy. ed 12 Philadelphia: Wolters Kluwer/Lippincott, Williams, & Wilkins; 2014:413–424.

2 Sullivan W.M., Rosin M.S., Shulman L.S. A new agenda for higher education: shaping the life of the mind for practice. New York: Wiley; 2009.

3 Schell B.A.B. Professional reasoning in practice. In: Schell B.A.B., Gillen G., Scaffa M.E., eds. Willard and Spackman’s occupational therapy. ed 12 Philadelphia: Wolters Kluwer/Lippincott, Williams, & Wilkins; 2014:382–397.

4 Higgs J., Jones M. Clinical decision making in multiple problem spaces. In: Higgs J., Jones M., Loftus S., et al., eds. Clinical reasoning in the health professions. ed 3 St. Louis: Elsevier/Butterworth-Heinemann; 2008:3–18.

5 Schell B.A.B., Schell J.W. Clinical and professional reasoning in occupational therapy. Philadelphia: Wolters Kluwer/Lippincott Williams and Wilkins; 2008.

6 Mattingly C., Fleming M. Clinical reasoning: forms of inquiry in therapeutic practice. Philadelphia: F.A. Davis; 1994.

7 Leicht S.B., Dickerson A. Clinical reasoning, looking back. Occupational Ther Healthcare. 2001;14(3/4):105–130.

8 Devettere R.J. Practical decision making in health care ethics. ed 3 Washington, DC: Georgetown University Press; 2009.

9 Clark P.G. Narrative in interprofessional education and practice: implications for professional identity, provider-patient communication and teamwork. J Interprofessional Care. 2014;28(1):34–39.

10 Hunter K. Narrative. In: Post S.G., ed. Encyclopedia of bioethics. ed 3 New York: Macmillan; 2004:1875.

11 Brody H., Clark M. Narrative ethics: a narrative. Hastings Center Report. 2014;44(1):S7–S11.

12 Hunter K. Narrative. In: Post S.G., ed. Encyclopedia of bioethics. ed 3 New York: Macmillan; 2004:1875–1876.

13 Kohlberg L. The philosophy of moral development: moral stages and the idea of justice. San Francisco: Harper and Row; 1981.

14 Gilligan C. A different voice: psychological theory and women’s development. Cambridge, MA: Harvard University Press; 1982.

15 Nortvedt P., Hem M.H., Skirbekk H. The ethics of care: role obligations and moderate partiality in healthcare. Nurs Ethics. 2011;18(2):192–200.

16 Bishop A., Scudder Jr. J. Caring presence. In: Nursing ethics: holistic caring practice. ed 2 Sudbury, MA: Jones and Bartlett Publishers; 2001:41–65.

17 Baier A. The need for more than justice. In: Held V., ed. Justice and care. Boulder, CO: Westview Press; 1995:47–58.

18 Nortvedt P., Hem M.H., Skirbekk H. The ethics of care: role obligations and moderate partiality in healthcare. Nurs Ethics. 2011;18(2):192–200.

19 deVries M., Leget C.J.W. Ethical dilemmas in elderly cancer patients: a perspective from the ethics of care. Clin Geriatric Medicine. 2012;28:93–104.

20 Bradshaw A. The virtue of nursing: the covenant of care. J Med Ethics. 1999;25:477–481.

21 Aristotle. Nichomachean ethics. In: Barnes J., ed. Princeton, NJ: Princeton University Press; 1729. The complete works of Aristotle. 1984;vol 2.

22 Aquinas T. Summa theologica. In: Pegis A.G., ed. Basic writings of St. Thomas Aquinas. New York: Random House; 1945.

23 Hippocrates. Decorum. In: Jones W.H.S., ed. Hippocrates II. Cambridge, MA: Harvard University Press; 1923:267–302 Loeb Classical Library.

24 Maimonides. Prayers of Moses Maimonides (H. Friedenwald, Trans.). Bull Johns Hopkins Hosp. 1927;28:260–261.

25 Loewy E.H. Developing habits and knowing what habits to develop: a look at the role of virtue in ethics. Cambridge Q Healthcare Ethics. 1997;6(3):347–355.

26 Marton M. Personal communication. In: National Endowment for the Humanities Seminar on “Justice, equality and the challenge of disability.” Bronxville, NY; June 24, 2002.

27 Doherty R.F., Peterson E. Responsible participation in a profession: fostering professionalism and leading for moral action. In: Braveman B., ed. An evidence-based approach to leading & managing occupational therapy services. Philadelphia, FA: Davis; 2016:356 ed 2.

28 Hume D. On suicide. In: Gorowitz S., Macklin R., Jameton A., eds. Moral problems in medicine. Englewood Cliffs, NJ: Prentice Hall; 1976:356.

29 Beauchamp T., Childress J.F. Principles of biomedical ethics. ed 7 New York: Oxford University Press; 2012.

30 Kant I. Lectures on ethics. (L. Infield, translator) New York: Harper and Row; 1963 pp 147–154.

31 Mill J.S. On liberty. In: Burtt E.A., ed. The English philosophers from Bacon to Mill. New York: Random House; 1939:1042–1060.

32 Gilligan C. Psychological theory and women’s development. Cambridge, MA: Harvard University Press; 1982.

33 Purtilo R.D., Haddad A.M., Doherty R.F. Respect in a diverse society. In: Health professional and patient interaction. ed 8 Saunders: St. Louis; 2014:34–53.

34 Dworkin G. Paternalism. In: Zalta E.N., ed. The Stanford encyclopedia of philosophy. 2014. Available at http://plato.stanford.edu/archives/sum2014/entries/paternalism/.

35 Kant I. Critique of practical reason and other writings in moral philosophy. In: Beck L.W., ed. Chicago: University of Chicago Press; 1949:346–350.

36 Americans with Disabilities Act, H.R. Rep. No. 485 (II), 101st Congress, 2nd Sess. at 22 12, 1990.

37 Bentham J. An enquiry concerning human understanding. In: Burtt E.A., ed. The English philosophers from Bacon to Mill. New York: Random House; 1939:792–856.

38 Mill J.S. Utilitarianism. In: Burtt E.A., ed. The English philosophers from Bacon to Mill. New York: Random House; 1939:895–1041.

A Six-Step Process of Ethical Decision Making

Objectives

The reader should be able to:

• Identify six steps in the analysis of ethical problems encountered in everyday professional life and how each plays a part in arriving at a caring response.

• Describe the central role of narrative and virtue theories in gathering relevant information to achieve a caring response.

• Understand how the application of evidence based practice supports the ethical decision making process.

• List four areas of inquiry that will be useful when gathering relevant information to make sure you have the story straight.

• Describe the role of conduct-related ethical theories and approaches in arriving at a caring response.

• Describe why imagination is an essential aspect of seeking out the practical alternatives in an ethically challenging situation.

• Discuss how courage assists you in the ethical decision making procees.

• Identify two benefits of taking time to reflect on and evaluate a chosen moral action.

NEW TERMS AND IDEAS YOU WILL ENCOUNTER IN THIS CHAPTER

six-step process of ethical decision making

chemical restraints

evidence-based practice

time-limited trial

rounds

Topics in this chapter introduced in earlier chapters

Topic

Introduced in chapter

Ethics

A caring response

2, 3, 4

Moral agency

Moral distress

Ethical dilemma

Ethical reasoning

The importance of story or narrative

Paternalism

Deontology

Utilitarianism

Character traits

Introduction

You have come a long way in your search for resolution of ethical problems consistent with a caring response. Distinguishing prototypes of ethical problems and understanding ethical theories and approaches provides you with a necessary foundation to support your ethical reasoning. In this chapter, you have an opportunity to apply the conceptual tools you have learned using a problem-solving method to analyze and move toward resolution of ethical problems. The story of Michael Halloran and Amrou Croteau is a good starting point for this discussion.

 The Story of Michael Halloran and Amrou Croteau

Amrou Croteau, a physical therapist, has just begun working in a municipal group home. The facility has a reputation for maintaining high standards of care. When Amrou interviewed for the position, she made a thorough tour of the home and talked with several employees and residents. Everything seemed “in order,” and she took the job.

Amrou is now ending her second week of work. She goes to the group home office to read the medical record of a resident who may be transferred to another facility because of his apparently worsening mental status. She learns that Mr. Michael Halloran is a 46-year-old man with cerebal palsy, insulin-dependent diabetes mellitus, renal hypertension, and a history of depression. Mr. Halloran has been a resident at the home for almost 2 weeks. He was admitted because of his inability to safely care for himself after a recent hospitalization for a fall and renal insufficiency. According to the record, he is “confused” most of the time and has required heavy sedation to “keep him from becoming violent.” Mr. Halloran is almost blind as a result of diabetic retinopathy. No neurologist’s report is found in the record.

Amrou decides to introduce herself to Mr. Halloran before she goes to lunch. When she finds Mr. Halloran’s room, she is surprised to see a frail-looking middle-aged man, slumped over in a wheelchair and struggling to read the sports section of the newspaper. Amrou introduces herself and tells Mr. Halloran that she is the physical therapist on staff and that she will be coming back to treat him in the afternoon.

Mr. Halloran squints in an effort to see Amrou. Abruptly he raises up on one elbow and says, “Maybe you’ll listen to me. I’m scared! They keep giving me shots and pills that make me crazy here! Can you get them to stop?”

Just at that moment, a nurse comes into the room with a syringe on a tray. “Hi, Mr. Halloran,” she says in a firm, loud voice. “Lift your johnny, please. It’s time for your shot!”

Mr. Halloran protests that the shots are making him “crazy as a hoot owl.” But the nurse has exposed his loose-skinned thigh and is deftly injecting the solution before Mr. Halloran succeeds in resisting. He tries to take a swipe at her, but she backs off quickly. She pats his bony hip and says, “There now, you’re okay, Mike,” and leaves immediately. Mr. Halloran leans back in the wheelchair and sighs. He looks toward Amrou and says, “See what I mean! I may have a disability, but I am not stupid. I know these places dope people like me so we stay quiet.” Amrou struggles with what to say to Mr. Halloran; he seems to be in genuine anguish. She reaches out to pat his hand, but he pulls it away, motioning her away with his paper.

Amrou is upset and confused. She has a gnawing feeling in her stomach that something is wrong in the way Mr. Halloran is being treated. At lunch, she shares her concern with Brenda Rendazzo, the nursing supervisor for the residence. Brenda is highly respected by residents and staff alike. Amrou tells Brenda it seems that Mr. Halloran is not being treated with the dignity that the residents deserve. She doubts that Mr. Halloran is “violent” but cannot put her finger on why she felt so much anger at the nurse who efficiently and without undue harshness gave him the injection. Maybe it is because she believes the medication is being used to “sedate” Mr. Halloran unnecessarily. As she recounts what happened, she can feel a seething rage rising up in her. She decides, on the spot, that she will talk to the group home administrator and announces that intention to Brenda.

Brenda listens attentively. When Amrou pauses for a few disinterested bites of her sandwich, she says, “Amrou, you have been here only 2 weeks. I can understand your uneasiness at what you thought you saw happening. And maybe you are right—maybe Mr. Halloran is not being treated with the respect he deserves. But remember, you are new here, and there is much that you don’t know. We are doing for him what we think is best, as well as trying to protect our staff from his dangerously aggressive behavior. He was worse before we started him on the benzodiazepines.”

Amrou does not feel any better after lunch. She wants to talk to someone and decides to call a colleague from graduate school who works as a social worker in another residential home.

As in most actual situations, Amrou’s first encounter with what appears to be an ethical problem has left many questions unanswered. The path from Amrou’s first perception to possible action consistent with a caring response traverses a six-step process of ethical decision making.

The Six-Step Process

Ethical decision making requires your thoughtful reflection and logical judgment (i.e., ethical reasoning, discussed in Chapter 4), although the situation usually presents itself in a “mumbo jumbo” of partial facts and strong reactions. The six-step process of ethical decision making provides a framework for working through ethical questions like the one Amrou is facing. The steps serve as practical tools to guide you through the intertwining of emotion, cognition, application, and action toward decision making. They allow you to take the situation apart and look at it in a more organized, coolheaded way while still acknowledging the intense emotions everyone may be experiencing about the situation and how these feelings factor into addressing the problem.

In Chapter 1, you learned that ethics is reflection on and analysis of morality. This step-by-step process is, overall, a formalized approach to both. In the context of healthcare, your professional ethics dictates that your reflection is directed toward arriving at a caring response in a particular situation. As a moral agent, your reflection and ensuing judgment are geared toward action.

Step One: Get the Story Straight—Gather Relevant Information

The first step in informed decision making is to gather as much information as possible. Anyone viewing this situation might ask the following questions:

• What clinical practice guidelines or research evidence support (or contradict) the use of benzodiazepines for clients with aggressive behavior?

• Does Mr. Halloran have cognitive changes from organic brain disease or other central nervous system dysfunction that might explain his agitation and aggressive behavior?

• What tests have been conducted to confirm the type and degree of neurologic involvement?

• What does his “violent” behavior consist of?

• Is he at risk of injuring himself or others?

• What might have happened in Mr. Halloran’s history to make him afraid of the nursing staff or the whole setting and therefore to react in a hostile manner?

• Has the medical director been made aware of Mr. Halloran’s complaints about the effects of the medication?

• What is the recent history of the exchanges between Mr. Halloran and the staff?

• What other approaches (besides medication) to Mr. Halloran’s ostensibly violent behavior have been, or could be, attempted?

• What resources/protections are in place for Mr. Halloran, given that he is a vulnerable client transitioning to residential care?

• What evidence is there that approaching the group home administration will create problems for Amrou, Ms. Rendazzo, or others?

• What other information about physical and chemical restraints (i.e., medicines that sedate the patient) in group residential settings should Amrou seek?

 Reflection

Did you think of other questions as you read the story?

_____________________________________________________________________________

__________________________________________________________________

_________________________________________________________________

The necessity for close attention to details takes you back to Chapter 4, which introduced the importance of the story or narrative. Without knowledge of as much as possible about the story, the attitudes, values, and duties embedded in it are impossible to ascertain. As you probably recall, the theories and approaches to ethics have important clues about how each of these is an important consideration if you will be able to arrive at a caring response. The fact-finding mission is absolutely essential as a safeguard against setting off on a false course from the beginning.

Some of the benefits of seeking out the facts in the situation described previously are that you may be able to determine whether Amrou’s perception of Mr. Halloran’s treatment is accurate and you may understand why the various players in this drama are acting as they are. Although Brenda Rendazzo’s comments are difficult to interpret, she may be implying that Amrou’s response would be tempered by more knowledge of the situation. Often, what initially appears to be a “wrong” act is, after all, a right or acceptable one once more of the story is known.

Fact finding also could help Amrou identify the focus of her anger more specifically. What triggered the response? Was it Mr. Halloran’s apparent helplessness in the situation? The nurse’s actions? What Amrou has read about the evidence surrounding the use and misuse of chemical restraints?1–3 Why has Mr. Halloran been labeled as “confused” and “violent” when Amrou believes he showed no signs of being either? Is Mr. Halloran’s assertion correct, that the staff are treating him differently because he is a disabled adult? Fact finding is an essential step in Amrou’s ethical reasoning process. She must clarify the known facts of the case versus the beliefs or stereotypes. All of the facts are needed to make a judicious and well-reasoned decision.

Attending to Evidence-Based Practice in Ethical Decision Making

Health professionals today are morally obligated to ensure their clinical decisions are informed and reflect best practice.4 Sound clinical reasoning integrates evidence-based practice with clinical expertise and the client’s preferences, beliefs, and values. Clinical research (reviews of data, metaanalyses, position papers) can lend substantial evidence to support ethical reasoning. Catlin puts this well when stating that “good ethics are based on good evidence.”5 Collecting all levels of evidence, from empirical studies to consultations with subject matter experts, is a key part of the gathering relevant information process to problem solve through step one of the ethical decision-making process.

The following general checklist for data gathering will help you organize your thoughts around your specific situation. The list is adapted from a handbook designed for clinicians.6

1. Clinical Indications

A. What is the diagnosis or prognosis?

B. Is the illness or condition reversible?

C. What are the patient’s symptoms?

D. What is the present treatment regimen?

E. What evidence supports this treatment regime? Does any evidence contradict it?

F. What is the usual and customary treatment for this type of condition?

G. What is needed to relieve suffering or to provide comfort?

H. Who are the primary caregivers?

I. What can you learn about this patient’s medical and social history?

J. Who are the members of the interprofessional care team that is treating this patient, and what are the results of their evaluations and treatments to date?

2. Preference of the Patient

A. What outcome does the patient want in this situation?

B. Who has communicated the realistic options to the patient?

C. What was the patient actually told?

D. What evidence do you have that the patient’s needs, wants, and fears have been heard by key decision makers?

E. Is the patient competent to make decisions about this situation?

F. Do any family or other cultural influences need to be taken into account? If the patient is not competent, is another person speaking as a legitimate legal substitute for the patient?

3. Quality of Life

A. What are the patient’s beliefs and values that make up his or her personal value system?

B. What quality-of-life considerations are professional and family caregivers bringing to this situation, and how are their biases influencing the decision processes?

C. Is there any hope for improvement in the patient’s quality of life?

D. Are there any biases that might prejudice the interprofessional care team’s evaluation of the patient’s quality of life?

4. Contextual Factors

A. What institutional policies may influence what can be done?

B. What are the legal implications (court cases, statutes, and so on) regarding this issue?

C. Are scarce resources an issue?

D. How will these services be paid?

E. Are there family caregiver issues that may influence the plan of care?

 Reflection

This general checklist is extensive but not exhaustive. Jot down some other types of information you think will help Amrou to accurately analyze this situation.

_____________________________________________________________________________

 Summary

Gathering as much relevant information as possible sets the essential groundwork for analysis and action consistent with arriving at a caring response.

When you have searched out the information you and others deem relevant or when you are convinced no additional helpful information is forthcoming, you are ready to proceed to the next step.

Step Two: Identify the Type of Ethical Problem

Even while the initial fact finding is taking place, Amrou can begin to determine the type of ethical problem (or problems) she is facing and in that regard make significant progress toward arriving at a caring response. In the beginning, her worry was the following.

Mr. Halloran is a human, and the gold standard of care (as introduced in Chapter 1) is that humans always should be treated with dignity. Part of being treated with dignity includes patients taking part in their own treatment decisions whenever possible; in Mr. Halloran’s case, this includes, at the very least, being treated with sensitivity to the anguish that he appears to be experiencing. To ignore his distress shows a lack of compassion, if not outright cruelty, and reduces him to the status of an object. Mr. Halloran is not being treated as a person ought to be treated, which blocks the goal of achieving a professional caring response.

This is where the prototypes of ethical problems you encountered in Chapter 3 begin to work for you.

Moral Distress

You know that Amrou is experiencing emotional distress. She has witnessed a scene that baffled her, and she finds herself unable to forget about it. Our guess about the fundamental basis of Amrou’s distress is her perception that Mr. Halloran is not being treated with the dignity he deserves as a human. The distress, then, is consistent with Amrou’s role as a professional with a moral responsibility to help uphold human dignity. In other words, she is a moral agent in a situation that she surmises involves morality, and that, because it is worrying her, merits further attention. If she tries, but fails, to put more information in place, she may confirm that her distress is, in fact, moral distress type B. You also can presume that she has the virtues of a compassionate person, otherwise she would not be worried about what she witnessed.

Ethical Dilemma

Goaded by her emotional responses, character traits, and the awareness that she is experiencing moral distress, Amrou is well positioned to assess whether she also has an ethical dilemma (or dilemmas). Do you think there is an ethical dilemma here?

Amrou learns that quite a few of the staff (but not all) believe the medications are being used disproportionately to the amount of “violence” Mr. Halloran has been demonstrating. In fact, some of the staff confide that they believe he is being sedated not to benefit him but to keep him more in line with the conduct of the other more docile and cooperative residents. Mr. Halloran has seemed very agitated and suspicious at times, and the medication has helped to improve his feeling of security, so that raises the possibility that it is benefiting him in that way. Of course, the group home is shorthanded, and the administrator points this out when Amrou finally goes to talk with her. Her argument is that if everyone took as much time and extra attention as Mr. Halloran did (when not medicated), no one would receive a fair amount of treatment. The principle of justice introduced in Chapter 4, and addressed more thoroughly in Chapter 14, is an issue.

Finally, the administrator mentions that some of the staff are afraid of Mr. Halloran and that she has a responsibility for their safety too. There are several issues here in which Amrou, as an employee and interprofessional team member, may be implicated as partial agent. Foremost of these is whether the employees, as a team, are acting ethically in the use of restraints under any circumstances. The one ethical dilemma that falls squarely on Amrou’s shoulders at the moment, however, is this: Amrou’s dilemma arises from the fact that she has become more persuaded that she was right about what she saw happening to Mr. Halloran. She believes the principle of beneficence to him is being compromised. But she can also agree with the points made by the administration and some of the staff regarding fairness to other residents. She is experiencing difficulty in deciding what to do to honor the several principles that guide professional action in this situation. In summary, she has an ethical dilemma.

Moral Agency

If Amrou decides that someone other than herself, the administration, or the other team members should be making decisions regarding any aspects of Mr. Halloran’s treatment (or the group home policies regarding treatment), she may face a locus of authority conflict. For instance, although the story does not give you the benefit of knowing whether Mr. Halloran’s input is being included in the decision, Amrou could decide that the authority for this decision should rest with Mr. Halloran. From what we have been told, we can assume that the staff and medical director have determined that the patient is not competent to make such a decision and therefore they are acting paternalistically. Regardless, it is important to remember that all members of the interprofessional care team share agency in ensuring that Mr. Halloran recieves the care he deserves. They must work together, with the patient and the administration, to navigate conflict and execute a safe, efficient, and effective plan of care.

 Summary

An essential step in analysis is to identify the type or types of ethical problems that you face.

Step Three: Use Ethics Theories or Approaches to Analyze the Problem

In Chapter 4, you were introduced to ethical theories and approaches. You have seen in the preceding pages that the narrative approach, which keeps relevant details of the story at the center of Amrou’s deliberation, is the most crucial for her eventual decision to be consistent with professional ethics. She also needs certain basic attitudes to help guide her on the path of a caring response as she deals with her own anger about what she observes. Therefore, virtues such as compassion are among her most fundamental resources. You learned that situations that require the health professional to be an agent (i.e., take action for which she or he is morally accountable) draw on ethical theories that focus on principles, duties and rights, and/or consequences. In other words, they are the tools for action.

Take a minute to review these action theories:

1. Utilitarianism

Focuses on the overall consequences

2. Deontology

Focuses on duty

Amrou’s story may make comparison of the two theories easier than when they were presented in Chapter 4.

If agent (A), Amrou, is like most health professionals and is guided by the principles of duty and rights in her professional role, she probably will decide that her weightier (i.e., more compelling) responsibility is to Mr. Halloran.

If agent (A), Amrou, approaches the dilemma from a utilitarian standpoint, she will spend less time thinking about duties to Mr. Halloran and will be guided by the desire to bring about the overall best consequences in this situation. The overall best consequences may be to “leave well enough alone” and ensure the safety of the other residents and her coworkers.

 Reflection

Which approach do you find yourself leaning toward in Amrou’s and Mr. Halloran’s situation? Why?

_____________________________________________________________________________

Recall the ethical principles you learned in Chapter 4. Which principles can be balanced when considering the use of chemical restraints for Mr. Halloran?

_____________________________________________________________________________

 Summary

In step three, you use ethical theories and approaches as the foundation for your ethical reasoning, which moves you toward resolution and action that is consistent with a caring response.

Step Four: Explore the Practical Alternatives

Amrou has decided what she should do. The next step is to determine what she can do in this situation. She must exercise her ingenuity and confer with her colleagues regarding the actual strategies and options available to her. Suppose she decides that her initial perceptions were correct and that she must act on behalf of Mr. Halloran, even though the staff sees no problem?

At this juncture, many people oversimplify the range of options available. They tend to fall back on old alternatives when under stress, a behavioral pattern you can probably recognize from your own stressful situations. Therefore, imaginative pursuit of options is a big challenge, but an invaluable resource, in resolving ethical problems. In recounting Amrou’s story, we learned that she believed her range of options was to confront the group home administrator or do nothing. A diligent search for other options can now make the difference between her doing the right thing or allowing a moral wrong to go unchecked.

 Reflection

Apply your own thinking to Amrou’s situation and list all the alternatives you believe she has. Try to identify a minimum of four.

1. _____________________________________________________________

2. _____________________________________________________________

3. _____________________________________________________________

4. _____________________________________________________________

After listing the alternatives, which one do you think is the best? Why?

Often, a good idea is to try out some of the more far-fetched alternatives with a colleague whom you trust and with whom you can share the situation without breaching the patient’s confidentiality. Amrou did this with the nursing supervisor. We do not know how the supervisor’s counsel helped in the end, but we are sure that her words led Amrou to further examination of what her next step should be.

It is also important not to limit your range of alternatives based on time. In some situations, an alternative is proposed as a time-limited trial. This allows the provider or interprofessional care team the opportunity to both negotiate and think innovatively about solutions that support a caring response. A time-limited trial must be aligned with the patient’s goals of care and be weighed for its benefits and burdens. Time-limited trials are further discussed in Chapters 12 and 13, when we explore ethical dimensions in chronic and end-of-life care.

 Summary

Imagination enhances ethical decision making by allowing you to think more creatively and expansively about the alternatives.

Step Five: Complete the Action

Think of all the work Amrou has already done. She responded to her initial feeling that something was wrong; followed her compassionate disposition that motivated her not to let the matter go unnoticed; thought about and decided on the type of ethical problem(s) she was encountering; applied one or more ethical theories and approaches to support her reasoning; and exercised her imagination to identify practical options needed to effect a caring response. She also shared her worry with at least one other person she knew commands her respect and that of others. Now she has one more task, but it is the crucial one, and that is to act.

If Amrou fails to go ahead and act, the entire process so far is reduced to the level of an interesting but inconsequential philosophic exercise; worse, it may result in harm to Mr. Halloran. Of course, Amrou may consciously decide not to pursue the situation any further, but insofar as it involved her deliberate intent, it is different than simply failing to follow what seems a correct course of action. If harm comes to Mr. Halloran or others because of Amrou’s inaction or unnecessarily narrow focus, she is an agent of harm by her own omission or neglect. The solid ethical foundation she laid in steps one to four will have been of no avail.

Why would anyone fail to act in this type of circumstance? Mainly because it is sobering to be an agent in such important matters of meaning and value in others’ lives.

 Summary

The goal of your analysis is finally to act!

Some decisions are literally life-and-death decisions, but all are of deep significance to the people who face the particular situation. Although the previous step required imagination, this final step requires courage and the strength of will to go ahead, with the knowledge that there may be risks or backlashes. As Amrou becomes more experienced, she will be increasingly aware that her integrity of purpose must be supported by her sound ethical reasoning, compassion, and courage.

Step Six: Evaluate the Process and Outcome

Once she has acted, it behooves Amrou to pause and engage in a reflective examination of the situation. The practical goal of ethics is to resolve ethical problems, thereby upholding important moral values and duties. The extent to which Amrou’s decision led to action that upheld morality, however, is knowable only by reexamining what happened in the actual situation. This evaluation is germane to her growth and development as an ethical professional and is essential if the outcome she hoped for was not realized.

In the traditional medical model, a widespread mechanism for addressing interventions that go awry in the clinical setting is morbidity and mortality (“m and m”) rounds. If you have not yet been in the clinical setting, the term “rounds” may be new to you. Rounds is the general term used for meetings of clinicians. Some rounds are held sitting in a room (sit-down rounds), and others are held walking from patient to patient (walking rounds). Morbidity and mortality rounds allow health professionals whose interventions did not yield the hoped-for results to present the case to their peers for further evaluation. Sometimes ethical committees or your own unit staff meetings conduct ethics morbidity and mortality rounds to have a group review of a particularly difficult situation that seemed not to meet the ethical goal of a caring response. Rounds are a means for reflective discernment. They are an explicit way for the interprofessional care team to reflect on practice. This type of activity promotes ethical reasoning, supports interprofessional communication, and helps ensure that care is individualized, just, and benevolent.7,8

Amrou’s case is not unique. Studies have shown that the topics of conflict around goal setting and dual obligations are among the most frequently cited ethical issues encountered by rehabilitation practitioners.9–12 Given this, suppose you, like Amrou, have just been through the process of arriving at a difficult ethical decision and have acted on it. Some questions you might ask yourself are the following:

• What did you do well?

• What were the most challenging aspects of this situation?

• How did this situation compare with others you have encountered or read about?

• To what other kinds of situations will your experience with this one apply?

• Who was the most help?

• What do the patient, family, and/or others have to say about your course of action?

• Overall, what did you learn?

• Do you think in retrospect that you failed to give adequate attention to anything?

• Did you miss the mark at one or more times? In what regard?

• What would you do differently if you were faced with the same situation again?

All of these will serve you well in your preparation for the next opportunity to decide what a caring response entails in that new situation. When you reflect, you advance your ethical reasoning and are better prepared for the next time you are faced with a challenging situation (Figure 5-1).

FIGURE 5-1 Critical reflection = clinical growth. (Copyright iStockphoto.com/MarilynNieves.)

 Summary

Reflection is the link to critical thinking. It allows you to reframe problems, extract meaning from experiences, and engage in lifelong learning to bring about best practice in a variety of settings.

Summary

If you studied this chapter carefully, you have identified the six-step process that anyone faced with an ethical question can apply in searching for a caring response.

1. Get the Story Straight

Gather as much relevant information as possible to get the facts straight.

2. Identify the Type of Ethical Problem

If step one confirms that there is one.

3. Use Ethics Theories or Approaches to Analyze the Problem

Decide on the ethics approach that will best get at the heart of the problem identified in step two.

4. Explore the Practical Alternatives

Decide what should be done and how it best can be done (explore the widest range of options possible).

5. Complete the Action.

Call upon your strength of will and moral courage to act.

6. Evaluate the Process and Outcome

Reflect on your experience to better prepare yourself for future situations.

Questions for Thought and Discussion

1. The first step in ethical decision making is to gather as much relevant information as possible. The information-gathering process, however, can become so extensive that it could become an end in itself and could actually deter one from proceeding to action at all. What types of guidelines would you use to decide that you have as much information as you need or can obtain?

2. A necessary step in ethical decision making is to act on one’s own conclusions about what ought to be done. Under what conditions, if any, would you decide not to act according to your own best moral insights and judgment? That is, what, if any, are the limits to your willingness to act ethically?

3. In your professional career, you would much prefer always to act ethically. What type of reflective practices will you integrate into your work life to ensure that you think critically about both the art and science of your patient care delivery? Who has served as a resource to you in the past to help you advance your thinking and level of reflection? Will that person continue to help you evaluate your decision-making process? If not, what structure will you need to ensure that you continually improve your practice through the reflective cycle?

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