Questions involving ethical positions are often intensely felt by those involved. These are not just armchair discussion but reach to the very heart of our perceptions of ourselves as individuals. Practitioners quickly become aware that the value given to their opinions is directly linked to the quality of reasoning and rationales that they can provide for them. Specialists who know that something is wrong but cannot articulate their reasons or the methods by which they derived their beliefs are at a real disadvantage. Not only do they fail to provide appropriate advocacy for their ideas or the patients they serve, but also inflict upon themselves and their colleagues an incredible level of stress and discomfort.
One of the frustrating aspects of reasoning through those questions is that the people who you know and respect will often come to different opinions regarding the best answer. In that, values are not subject to scientific analysis or deal with areas that are easily quantifiable, value arguments are deeply felt and rarely won. Because of their personal nature, those who disagree with your personal value system are often not only classified as being wrong but are also somehow evil in their wrongness. Consider the two sides currently involved in the abortion debate.
Yet, we are entering professions where there is an abundance of value questions that must be dealt with on a daily basis. As professionals, even in out opposition our standing up for our position–and if necessary our becoming a majority of one–it is important that we remain constructive and appropriate in our actions.
To acknowledge that individuals can come to different opinions in regard to ethical issues is not the same as saying that all opinions are equal and have the same worth and credibility. In health care, there are decisions that must not be made. Whereas tolerance is generally considered a virtue, there are actions that must not be tolerated.
There are some in our society that subscribe to a philosophy of moral nihilism. Adherents to this philosophical position believe that there are no moral truths, no moral facts, no moral knowledge or responsibilities. For those that hold this position, nothing can truly be be wrong or right in a moral sense. For the moral nihilist, morality, like religion is a mere illusion. If you followed this reasoning to its conclusion, heinous acts such as the rape and torture of children would not necessarily be wrong. This is, fortunately, a position that most would feel uncomfortable in accepting.
A moderate form of nihilism is ethical relativism, which holds that morality is relative to the society in which one is is brought up. In this sense nothing can truly be right or wrong without a consideration of the culture and social context. Ethical relativists go beyond just recognizing differences between cultures, and hold that in questions of mortality rightness or wrongness is always relative to and determined by culture.
Others in our society ground their personal philosophy solely in a hedonistic worldview. For such an individual the major guidepost for decision making are desire and aversion, and nothing can be right or wrong apart from them. This attitude of self-absorption was captured in the slogan, “He who dies with the most toys wins”. Gross, personal self-interest provides an inadequate framework for ethical decision making in health care. In health care provision an attitude of “any thing goes” is unacceptable.
To involved ourselves in unethical practice harms the patients we serve; by association it harms all fellow practitioners; and in that it lowers the level of rust and esteem in which health care providers are held, it harms the community at large. An oft-used analogy is that health care practice can be considered an community commons. All practitioners in the community use the field and are responsible for its continued upkeep. It is unthinkable and unwise to believe that the maintenance of health care commons is the responsibility of some other group practitioners.
The obligation to provide ethical care, refine the quality of practice, and provide community service are not the obligations of few but of the many. it is our privilege to labor in the community commons; it is our obligation to maintain the space so that we can come again, and when we finally leave, leave the commons healthy so that others can replace us in labor. Nothing damages the health care commons more than unethical practice.
Every man should expend his chief thought and attention on his first principles; are they or are they not rightly laid down? And when he has duly sifted them, all the rest will follow.
Socrates, Greek philosopher (496-399 B.C.)
There are many occupations that one may choose, but few will find their choices as rewarding, exchanging, exciting, meaningful, frustrating, and overwhelming as those who take up the practice of health care provision. Health care practice is the best of science, the noblest of human arts, and offers careers that never stop growing, challenging and providing opportunities for personal development.
If one were to examined the health care team prior to the twentieth century one would find a few assigned practitioner roles. The role of the physician, dentist, nurse, and pharmacist was reasonably well established though evolving. During the century, as a result of technological and therapeutic advances, over 100 specialists were added to the health care team under the umbrella title known as Allied Health. Some of these specialists, such as physical therapist and dietitians, are well known to the public, while others (cytologists, extracorporial perfusionist, athletic trainers, and music therapies) provide meaningful services but are virtually unknown outside of their specialty areas. The growth of the allied health specialists is the important aspect of health care as they , along with nursing personnel, provide over 80 percent of the direct patient care.
To enter the practice of health care provision is to enter into a social compact not only with the patients you serve but with all other practitioners and the community at large. The honoring of this social compact will require a commitment to excellence in clinical practice and a commitment to a set of appropriate moral, ethical, and social behaviors. For those that meet this obligations , the practice of health care is personally and physically rewarding.
Often in clinical practice the appropriate answer is the product of evaluating, understanding, and utilizing scientific information. Many of the clinical questions have been reduced to formulas, and when one plugs in the appropriate volume, tidal volume, rectal temperature, or whatever data you are collecting a reproducible answer comes forward. This is the science of our practice, and advances in health technologies and therapeutics in the twentieth century have brought the practice of health care from folk nostrums to magic bullets. And, as it has been said, “the best is yet to come”.
Prior to the twentieth century, the patient has less than an even chance of benefiting from an encounter with a physician. Often early health care practitioners had little else to offer than a caring attitude as they sat by the beds of the afflicted and watched disease processes mankind for ages have been brought under control and some even eradicated. Yet, for all the advances of the last century, as we face the new millennium it appears that even greater wonders lie ahead. Will the puzzle of cancer be solved? Will genetic engineering allows us to live longer and healthier? What are the future implications of technology of cloning? Will we find the mechanism for aging and have a longevity of Methuselah? Where will the science of health care takes us in the twenty-first-century?.
The wonders of scientific advances are not just interesting questions that exist in a vacuum but rather have implications for our practices, our patients, the health of our communities, and for the very fabric of our common humanity. the uses of science and technology in health care must always be assessed. We must not only ask where will the science of health care take us, but do we really want to go?.
For most of us, to clone or not to clone is not a question. Our practice will be filled with for more mundane ethical dilemmas.
- When, if ever, is it permissible to take a gift or gratuity from a patient?
- When is it legitimate and perhaps mandatory to break a patient’s confidentiality?
- Is it permissible to lie to a patient if it is for his or her own good?
- Can i worked at a hospital and refer a patient to a durable medical supply company that I have contracted with to provide outpatient services?
- What must I do if I make a medication error that no else knows about and it appears harmless to my patient?
- What obligations do I have as a colleague and fellow practitioner when I suspect that the therapist that I am working with is abusing alcohol or appears chemically impaired?
- What if I come upon a practice that is legal but appears to me personally to be unethical?
Unlike matters of science, where the scientific method will often reveal reproducible answers, the answers to questions regarding values are not subject to comfortable formulas, and rarely will you come to an answer with which everyone agrees. Health care ethics reside in the realm of human values, morals, individual culture, intense personal beliefs, and faith. Often the individual finds the answer not by examining and substantiating the external facts but by checking within their particular worldview.
Ethics is the branch of philosophy concerned with the distinction between right and wrong based on a body of knowledge, not just based on opinions.The behavior in accordance with customs or tradition, usually reflecting personal or religious beliefs is called morality. Ethical principles are the code that directs or govern nursing actions.
- Autonomy – respect for an individual’s right to self-determination.
- Nonmalifecence – the obligation to do or cause harm to another.
- Beneficence – the duty to do good to others and to maintain an balance between benefits and harms; paternalism is an undesirable outcome of beneficence, in which the health care provider decides what is best for client and encourages the client to act against his or her own choices.
- Justice – the equitable distribution of potential benefits and task determining the order in which client’s should be cared for.
- Veracity – the obligation to tell the truth.
- Fidelity – the duty to do what one has promised.
Values are beliefs and attitudes that may influence behavior and the process of decision making. Values clarification is the process of analyzing one’s own values to understand more completely what is truly important.
Ethical codes provide broad principles for determining and evaluating client care. These codes are not legally binding but, in most states, the board of nursing has authority to reprimand nurses for unprofessional conduct that results from violation of the ethical codes. Specific ethical codes are as follows.
- The Code for Nurses develop by the International Council of Nurses
- American Nurses Association Code of Ethics
- The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
- The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.
- The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the client.
- The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care.
- The nurse owe’s the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
- The nurse participates in establishing, maintaining and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.
- The nurse participate in the advancement of the profession through contributions to practice, education, administration, and knowledge development.
- The nurse collaborates with other health professionals and the public in promoting community, national, international efforts to meet health needs.
- The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.
Ethical dilemma occurs when their is a conflict between two or more ethical principles. Their was no correct decision that exists. The nurse must make a choice between two alternatives that are equally unsatisfactory. Such dilemmas may occur as a result of differences in cultural and religious beliefs. Ethical reasoning is the process of thinking through what one should do in an orderly and systematic manner to provide justification for actions based on principles.
Advocate is the person who speaks up for the acts on the behalf of the client, protects the client’s right to make his or her own decisions, and upholds the principle of fidelity. An advocates represents the client’s viewpoint to others. An advocates avoids letting personal values influence advocacy for the client and support the client’s decision, even when it conflicts with his or her own preferences or choices.
Ethic committees take a multidisciplinary approach to facilitate dialogue regarding ethical dilemmas. These committees develop and establish policies and procedures to facilitate the prevention and resolution of dilemmas.
The client’s right document, also called The Patients Bill of Rights, reflects acknowledgement of a clients right to participate in his or her health care with emphasis on client autonomy. The document provides a list of the rights of the client and responsibilities that the hospital cannot violate. The client’s rights affect the relationship between the client and health care provider and between the client and health care system and protects the client’s ability to determine the level and type of care received.
Patient’s Right When Hospitalized
- ) Right to considerate and respectful care.
- ) Right to be informed about illness, possible treatments, likely outcome, and to discuss this information with the physician.
- ) Right to know the names and roles of the persons who are involved in care.
- ) Right to consent and refuse a treatment.
- ) Right to have advance directive.
- ) Right to privacy.
- ) Right to expect that the medical records are confidential.
- ) Right to review the medical record and to have information explained.
- ) Right to expect that the hospital will provide necessary health services.
- ) Right to if the hospital has relationship with outside parties that may influence treatment or care.
- ) Right to consent or refuse to take part in research.
- ) Right to be told of realistic care alternatives when hospital care is no longer appropriate.
- ) Right to know about hospital rules that affect treatment and about charges and payment methods.
The Mental Health System Act also creates right for the mentally ill. The Joint Commission on Accreditation of Health Care Organizations has develop policy statements on the rights of the mentally ill. Psychiatric facilities are required to have a client’s bill of rights posted in a visible area.
Right for the Mentally Ill
- ) Right to be treated with dignity and respect.
- ) Right to communicate with persons outside the hospital.
- ) Right to keep clothing and personal effects with them.
- ) Right to religious freedom.
- ) Right to be employed.
- ) Right to manage property.
- ) Right to execute wills.
- ) Right to enter into contractual agreements.
- ) Right to make purchases.
- ) Right to education.
- ) Right to habeas corpus (written request for release from the hospital).
- ) Right to an independent psychiatric examination.
- ) Right to civil services status, including the right to vote.
- ) Right to retain licenses, privileges, or permits.
- ) Right to sue or be sued.
- ) Right to marry or divorce.
- ) Right to treatment in the least restrictive setting.
- ) Right not to be subject to unnecessary restraints.
- ) Right to privacy and confidentiality.
- ) Right to informed consent.
- ) Right to treatment and refuse treatment.
- ) Right to refuse participation in experimental treatments or research.