Basic Principles of Health Care Ethics #healthcare

Morality is concerned with what people believe to be right and good conduct. It is transmitted from generation to generation, evolving and being reinterpreted for each age. This broad understanding of what is right and wrong in human conduct is taught to us by our families, religion, national culture, and legal structure.

Ethics is that part of philosophy that deals with systematic approaches to questions of morality. It provides the intellectual framework that allows us to analyze and make decisions in regard to moral choices. In no area of our lives are we more pressed by value-laden decisions than that of health care. The enormous power gained by our scientific successes raises questions that have never previously been posed, such as

  • Should the elderly be provided the same level of healthcare as that provided for children?
  • Should patients with “Do Not Resuscitate” orders be treated in intensive care unit?
  • Must a healthcare provider who is HIV positive relate this to patients?
  • Who should live when not all can live?
  • Is there a morality to mercy killing?
  • Can healthcare practitioners work for the patient and be socially responsible for cost containment at the same time?
  • What constitutes life? What is a person?
  • Is there a right to health care? If there is a right, what is the limit of that right?
  • Is there a moral difference between removing a ventilator from a patient, and removing IV tubes and nasal gastric tube?
  • What is the meaning of confidentiality when, on the average, over seventy-five different individuals have access to information from our medical records?
  • Who shall be denied lifesaving treatment when there is not enough for all?

The increased used of high technology, the breakthroughs in scientific research, the adoption of team medicine, and the easy access to data have rapidly brought major changes to the delivery of health care and have created a host of new moral dilemmas for which there are no easy solutions.


Human Value Development

In his book, The Closing of the American Mind, Allan Bloom proposes that students entering the university may come from the left or right in regard to political views but will almost always share the position that truth is relative. This proposition is based on an accommodation to a pluralistic culture. History is viewed as a past in which men thought that they possess the truth, and even witch burning. The point that these students take from this reading of history is that the “true believer” is a dangerous person, and that only as we are able to avoid thinking that ours is the one right way can we survive. Openness and tolerance have become for these students the only plausible stance in the face of various claims to truth and an appropriate lifestyle. With this belief in relativism, the rational person then would not be concerned with correcting the mistakes from the past but rather would decide that all truth is relative and one view is equal to all other views.

In some sense, Massey subscribes to ethical relativism, a view that holds that there are no universal or absolute principles that bind human beings, and that the standards of right and wrong are always relative to the society or culture. In this light, the rightness or wrongness of customs or traditions that allow the placing of the aged on an ice floe to die, or the obligation of the brother to marry his dead brothers widow, could only be examined in reference to the Arctic Eskimo or African cultures from which they spring. The relativist would hold that there is no basis for saying that a particular act is right or wrong, independent of its cultural framework. Whatever we might believe in regard to relativism, and the lack of perfect truth, it would still seem reasonable that if we were in a position to do so, we would stop cannibals from eating missionaries and families from burning windows.

Few health care practitioners would be comfortable in taking a relativistic view of values. The decisions we must make are of such significance that the flip of a coin will not do. Some answers truly are better than others, and some decisions must not be made. To take an amoral position that somehow all answers to moral questions are equal would be unacceptable in health care practice. The philosopher Nietzsche was correct in his declaration that we are valuing animals. However, in regard to our values, humans are not programmed, as is the beast off the forest, to a proscribed set of correct actions but are condemned to lives of freedom and choice. In the practice of health care a position of “anything goes” is unacceptable. John  Steinbeck, in his book Of Mice and Men, pointed out how bankrupt we had become in regard to moral values when one of his characters commented, “There’s nothing wrong anymore”.

Modern health care is culturally overflowing with  value choices that must be made, and the choices we make will determine to great extent the shape of our careers and the pleasure we derive from the services we perform. There is a tradition of practice whereby health care providers will not conduct themselves in an egoist manner, but will consider the needs of the patients and the profession. Our patients are filled with expectations that we will perform in an ethical manner, even if it is unclear to them and us exactly what that entails.

Value theorists, such as Lawrence Kohlberg, Jean Piaget, and Carol  Gilligan have investigated the development of these worldviews and have provided models that show maturation and acquisition of value orientation throughout our childhood. The highest level of maturation described by Kohlberg and Piaget seems to be an autonomous decision-making system based upon legalistic equality. In recent years, Carol Gilligan has provided a feminist perspective and argues for separate developmental pathways for men and women , with the highest value for women being personal responsibility.

Decision Making in Value Issues

Over the course of our lives, each of us as human develops a coherent set of attitudes, feelings, and opinions, with which we judge the world of actions around us–in terms of good and bad, right or wrong, positive or negative. This value system or worldview is culturally shaped by the events of our lives and the traditions of our people.

Several ethical systems have been proposed to assist and bring order to value–laden decision making. Clearly the settling of these issues by flipping of a coin is unacceptable, as it will lead to an ethical pluralism, where any choice is as good as another. To allow a morally neutral society is not in keeping with social order and progress. Currently, the ethical systems with the highest level of acceptability are duty orientation, consequence orientation, divine mandate and virtue ethics. Each of these systems allow for the examination of ethical problems and provides a framework for decision making. Each of these general systems with which we look at ethical problems has contemporary theorists with varying models, which can be classed as being duty, consequence, divine mandate or virtue ethics oriented.

Each of the general ethical systems has been subjected to legitimate criticisms that they fail to overcome, and none of these point seems to have universal acceptance. When we examine our own personal value systems, we can be found to be duty oriented in some decisions, and consequentialistic in others. An individual could be very duty oriented in regard to an issue such as abortion, and yet approach the withdrawal or removal of life support from a consequence orientation. It has been noted that, just as in the fox hole there are no atheist, in the practice of healthcare, there is little comfort in decision making without a situational framework or the reliance on principle. Van Rensselaer Potter, who is credited with coining the word “bioethics”, explained that this new discipline had as it’s focus the traditional task of medical ethics, that of aiding the individual practitioner to make decisions and to live with them. Ethics, then, is a generic title that we give to systems that seek to bring sensitivity and method to the human task of decision making in the arena of moral values.

What ever ethical framework one chooses in order to solve problems, usually the method contain the six basic steps.

  • Step One— Identify the characteristics of the problem. Describe the problem and identify the principles involved? Who is charged with making the decision
  • Step Two — Gather the facts of the case. What is fact, what is opinion? What are the legal ramifications? Has the issue been decided by the courts before? What documentation exists that outlines the problem?
  • Step Three — Examine the options with initial credibility. The more options you can think, the more likely you are to find one you can support.
  • Step Four — Weigh and evaluate the potential options. What happens to the individuals involved, given each option? Has everyone been considered equally? “What principles are favored and which are sacrificed?” “What ethical systems are going to use to make the choice: utilitarianism, duty-oriented, or virtue ethics?”
  • Step Five — Make your decision and act upon it.
  • Step Six — Assess and evaluate the results.