A View on Ethics of Health Care Part 2

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.

A View on Ethics of Health Care Part 1

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.

Client’s Right

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

1. ) Right to considerate and respectful care.
2. ) Right to be informed about illness, possible treatments, likely outcome, and to discuss this information with the physician.
3. ) Right to know the names and roles of the persons who are involved in care.
4. ) Right to consent and refuse a treatment.
5. ) Right to have advance directive.
6. ) Right to privacy.
7. ) Right to expect that the medical records are confidential.
8. ) Right to review the medical record and to have information explained.
9. ) Right to expect that the hospital will provide necessary health services.
10. ) Right to if the hospital has relationship with outside parties that may influence treatment or care.
11. ) Right to consent or refuse to take part in research.
12. ) Right to be told of realistic care alternatives when hospital care is no longer appropriate.
13. ) 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

1. ) Right to be treated with dignity and respect.
2. ) Right to communicate with persons outside the hospital.
3. ) Right to keep clothing and personal effects with them.
4. ) Right to religious freedom.
5. ) Right to be employed.
6. ) Right to manage property.
7. ) Right to execute wills.
8. ) Right to enter into contractual agreements.
9. ) Right to make purchases.
10. ) Right to education.
11. ) Right to habeas corpus (written request for release from the hospital).
12. ) Right to an independent psychiatric examination.
13. ) Right to civil services status, including the right to vote.
14. ) Right to retain licenses, privileges, or permits.
15. ) Right to sue or be sued.
16. ) Right to marry or  divorce.
17. ) Right to treatment in the least restrictive setting.
18. ) Right not to be subject to unnecessary restraints.
19. ) Right to privacy and confidentiality.
20. ) Right to informed consent.
21. ) Right to treatment and refuse treatment.
22. ) Right to refuse participation in experimental treatments or research.

 

Religions and Dietary Practices

Buddhism

• Alcohol is prohibited.
• Many are lacto-ovo vegetarians.
• Some eat fish and some avoid only beef.

Church of Jesus Christ of Latter-Day Saints (Mormons)

• Alcohol, tea, and coffee are prohibited.
• Consumption of meat is limited.
• The first Sunday of the month is optional for fasting.

Eastern Orthodox

• During Lent, all animal products, including dairy products are forbidden
• Fasting occurs during Advent.
• Exceptions from fasting includes illness and pregnancy.

Jehovah’s Witness

• Any foods to which blood has been added are prohibited.
• They can eat animal flesh that has been drained.

Judaism

• Orthodox believers must adhere to dietary kosher laws: meats allowed include animals that are vegetable eaters, cloven-hoofed animals, and animals that are ritually slaughtered. fish that have scales and fins are allowed, any combination of meat and milk is prohibited.
• During Yom Kippur, 24-hour fasting is observed.
• Pregnant women and those are seriously ill are exempt from fasting.
• During Passover, only unleavened bread is eaten.

Hinduism

• Many are vegetarians. Those who eat meat do not eat beef or pork.
• Fasting rituals vary.
• Children are not allowed to participate in fasting.

Islam

• Pork, birds of prey, alcohol, and any meat product not ritually slaughtered are prohibited.
• During the month of Ramadan, fasting occurs during daytime.

Pentecostal

• Alcohol is prohibited.
• Members avoids consumption of anything to which blood has been added.
• Some individuals avoid pork.

Roman Catholicism

• They avoid meat on Ash Wednesday and Fridays of Lent.
• They practice optional fasting during Lent season.
• Children and the ill are exempt from fasting.

Seventh Day Adventist (Church of God)

• Alcohol and caffeneted beverages are prohibited.
• Many are lacto0ovo vegetarians; those who eat meat avoid pork.
• Overeating is prohibited; 5 to 6 hours between meals without snacking is practiced.

 

Organ and Tissue Donation by Religious Affiliation Part 3

Islam

The Modern Religious council initially rejected organ donation by followers of Islam in 1983, but has reversed its position is provided that the donor’s consent is in writing in advance. The religion of Islam believes in the principle of saving human lives. According to A.Sachedina in his Transplantation Proceedings article, “Islamic Views on Organ Transplantation” “…the majority of the Muslims scholars belonging to various schools of Islamic law have invoked the principle of priority of saving human life and have permitted the organ transplant as a necessity to produce that noble end.”

Judaism

All four branches of Judaism (orthodox, conservative, reform, and re-constructionist) support and encourage donation. According to Orthodox Rabbi Moses Tendler, chairman of the Biology Department of the Yeshiva University in New York City and chairman of the Bioethics Commission of the Rabbinical Council f America, “If one is in the position to donate an organ to save another life, it’s obligatory to do so, even if the door never knows who the beneficiary will be. The basic principle of Jewish ethics–”the infinite worth of the human being–also includes donation of corneas, since eyesight restoration is considered a life-saving operation.” In 1991, the Rabbinical Council of America (Orthodox) approved organ donations as permissible, and even required, from brain-dead patients. Also, in Orthodox Judaism, where any part of the body is separated from the corpus, it requires burial. However, where an organ is to be transplanted to save the life of a patient or improve his health, then it is permitted.

The reform movement looks upon the transplant program favorably and Rabbi Richard Address, director of the Union of American Hebrew Congregations Bio-Ethics committee and Committee of Older Adults, states that “Judaic Response materials provide a positive approach and by the large North American Jewish community approves of transplantation.” Judaism teaches that saving a human life takes precedence over maintaining the sanctity of human body.

Shinto

In Shinto, the dead body is considered to be impure and dangerous, and thus quite powerful. “In folk belief context, injuring a dead body is a serious crime . . .,” according to E. Namihira in his article, Shinto Concept Concerning the Dead Human Body. ” To this day it is difficult to obtain consent fro bereaved families for organ donation or dissection for medical education or pathological anatomy . . .the Japanese regard them all in the sense of injuring a dead body.” Families are often concerned that they do not injure the itai, the relationship between the dead person and the bereaved people.

United Methodist

The United Methodist Church issued a policy statement regarding organ and tissue donation. In it, they state that, “The United Methodist Church recognizes the life giving benefits of organ and tissue donation, and thereby encourages all Christians to become organ and tissue donors by signing and carrying cards or driver’s licenses, attesting to their commitment of such organs upon their death, to those in need, as a part of their ministry to others in the name of Christ, who gave his life that we might have life in its fullness.” A 1992 resolution states, “Donation is to be encouraged, assuming appropriate safeguards against hastening death and determination of death by reliable criteria.” The resolution further states, “Pastoral-care persons should be willing to explore these options as a normal part of conversation with patients and their families.

Pentecostal

Pentecostals believe that the decision to donate should be left up to the individual.

Seventh Day Adventist

Donation and transplantation are strongly encourage by Seventh-day Adventist. They have many transplant hospitals, including Loma Linda in California. Loma Linda specializes in pediatric hearth transplantation. The individual and family have the right to receive or to donate those organs which will restore any of the senses or will prolong the life profitably.

United Church of Christ

Reverend Jay Lintner, director, Washington Office of the United Church of Christ Office for Church in Society, states, “United Church of Christ people, churches and agencies are extremely and overwhelmingly supportive of organ sharing. The general Synod has never spoken to this issue because, in general, the Synod speaks on more controversial issues, and there is no controversy about organ sharing, just as there is no controversy about blood donation in the denomination. While the General Synod has never spoken about blood donation, blood donation rooms have been set up at several general Synods. Similarly, any organized effort to get the General Synod delegates or individual churches to sign organ donation cards would meet with generally positive responses.”

Organ and Tissue Donation by Religious Affiliation Part 2

Greek Orthodox

According to Reverend Dr. Milton Efthimiou, Director of the Department of Church and Society for the Greek Orthodox Church of North and South America, ” The Greek Orthodox Church is not opposed to organ donation as long as the organs and tissue in question are used to better human life, i.e., for transplantation or for research that will lead to improvements in the treatment and prevention of disease.” Organ donation is the individual decision of each member.

Gypsies

Gypsies are a people of different ethnic groups without a formalized religion. They share common folk beliefs and tend to be opposed to organ donation. Their is connected with their beliefs about the afterlife. Traditional beliefs contends that for one year after death the soul retraces its steps. Thus the must remain intact because the soul maintains its physical shape.

Hinduism

According to the Hindu Temple Society of North America, Hindus are now prohibited by religious law from donating their organs. This act is an individuals decision. H. L. Travedi, in Transplantation Proceedings, stated that, “Hindu mythology has stories in which the arts of the human body are used for the benefit of other humans and society. there is nothing in the Hindi religion indicating that parts of humans, dead or alive, cannot be used to alleviate suffering of other humans.”

Independent Conservative Evangelical

Generally, Evangelicals has no opposition to organ and tissue donation. Each church is autonomous and leaves the decision to donate up to individual.

Jehovah’s Witnesses

According to the Watch Tower Society, Jehovah Witnesses believe donation is a matter of individual decision. Jehovah’s Witnesses are often assumed to be opposed to donation because of their belief against blood transfusion. However, this merely means hat all blood must be removed from the organs and tissues before being transplanted.

Lutheran

In 1984, the Lutheran Church in America passed a resolution stating that donation contributes to the well being of the humanity and can be “…an expression of sacrificial llove for a neighbor in the end.” They call on members to consider donating organs and to make any necessary family and legal arrangements, including the use of a signed donor card, The ability to transplant organs from a deceased to a living person is considered a genuine medical advance.

Mennonite

Mennonites have no formal position on donation, but are not opposed to it. They believe the decision to donate is up to the individual and his or her family.

Society of Friends (Quakers)

Organ and tissue donation is believed to be an individual decision. The society of Friends do not have an official position on donation.

Unitarian Universalist

Organ and tissue donation is widely supported by Unitarian Universalist. They view it as an act of love and selfless giving.

Moravian

The Moravian Church has made no statement addressing organ and tissue donation or transplantation. Robert E. Sawyer, President, Provincial Elders Conference, Moravian Church of America, Southern Province, states, “There is nothing in our doctrine or policy that would prevent a Moravian pastor from assisting a family in making a decision to donate or not to donate an organ.” It is, therefore, a matter of individual choice.

Mormon (Church of Jesus Christ of Latter-day Saints)

The question of whether one should will his bodily organs to be used as transplants or for research after death must be answered from deep within the conscience of the individual involved. Those who seek counsel from the Church on the subject are encourage to review the advantages and disadvantages of doing so, to implore the Lord if inspiration and guidance, and then to take the course of action which would give them a feeling of peace and comfort.

Organ and Tissue Donation by Religious Affiliation Part 1

AME & AME Zion (African Methodist Episcopal)

Organ and Tissue donation is viewed as an act of neighborly love and charity by these denominations. They encourage all members to support donations as a way of helping others.

Amish

The Amish will consent to transplantation if they know that it is for the  health and welfare of the recipient. They would be reluctant to donate their organs if the outcome was known to be questionable; however, nothing in the Amish Understanding of the Bible forbids them from using modern medical services, including surgery, hospitalization, dental work, anesthesia, blood transfusions, or immunizations. John Hostetler, world renowned authority on Amish religion and professor of anthropology at Temple University in Philadelphia, says in his book, Amish Society, “The Amish believed that since God created the human body, it is God who heals.”

Assembly of God

The church has no official policy regarding organ and tissue donation. The decision to donate is left up to the individual. Donation is highly supported by the denomination.

Baptist

Though Baptists generally believe that organ and tissue donation and transplantation are ultimately matters of personal conscience, the nations largest Protestant denomination, the Southern Baptist Convention, adopted a resolution in 1988 encouraging physicians to requests organ donation in appropriate circumstances and to “….encourage voluntarism regarding organ donations in the spirit of stewardship,compassion for the needs of others and alleviating suffering.” Other Baptist groups have support the organ and tissue donation as an act of charity and leave the decision to donate up to the individual. A transplant as an end in itself is not approved. It must offer the possibility of physical improvement and extension of human life.

Brethren

While no official position has been taken by the Brethren denominations, according to Pastor Mike Smith, there is a consensus among the national fellowship of Grace Brethren that organ and tissue donations is a charitable ac so long as it does not impede the life or hasten the death of the donor or does not come from an unborn child.

Buddhism

Buddhist believe that organ and tissue donation is a matter of individual consequence and place high value on acts of compassion. Reverend Gyomay Masao, president and founder of the Buddhist Temple of Chicago says, “We honor those people who donate their bodies and organs to the advancement of medical science and to saving life.” The importance of letting loved ones know your wishes is stressed.

Catholicism

Catholics view organ and tissue donation as an act of charity, fraternal love and self sacrifice. Transplant and morally and ethically acceptable to the Vatican. According to Father Leroy Wickowski, Director of the Office of Health Affairs of the Archdiocese of Chicago, “We encourage donation as an act of charity. It is something good that can result from tragedy and a way for families to find comfort by helping others.” Pope John Paul II has stated, “The Catholic Church would promote the fact that there is a need for organ donors and that Christians should accept this as a ‘challenge to their generosity and fraternal love so long as ethical principles are followed.”

Church of Christ (Independent)

Organ transplant should not be a religious problem.

Presbyterian

Presbyterians encourage and endorse organ donation. they respect individuals conscience and a person’s right to make decisions regarding his own body.

Christian Church (Disciples of Christ)

The Christian Church encourages organ and tissue donation, stating that we were created for God’s glory and for sharing God’s love. A 1985 resolution adopted by the General Assembly encourages”… members of the Christian Church (Disciples of Christ) to enroll as organ donors and prayerfully support those who have received an organ transplant.”

Christian Scientists

The Church of Christian Scientist takes no specific position on transplants or organ donation as distinct from other medical or surgical procedures. Members are free to choose whatever form of medical treatment they desire, including a transplant. Organ donation is the individual decision of each member.

Transcultural Health

It is important for health care providers to be sensitive to these transcultural differences among our patient population as they affect how willing the patient is to comply with our regimes or even whether the patient is willing to risk entry into our strange system.

Example of this is in United States which is in a period of dynamic social change in which hundreds of thousands immigrants from China, India, Cambodia, Mexico, Haiti, South America, the Middle East, Philippines, and Eastern Europe are flocking on it. Along with their hopes, aspirations, personal problems, talents and dreams, these new immigrants bring with them their views of health, illness, and appropriate practices. Although a review of traditional practices within the diverse homelands of these immigrants reveals the existence of meaningful health care traditions different from those practice in the west, their is a reluctance of many health care providers to see the benefits or to be willing to accept these differences.

Health care practice in the West is based on scientific reasoning and high technology. Western health care is a system of marvels: organs can be replaced, the blind can be made to see, and the dead can be revived. On the surface it would seem that modern medicine as taught and practice in the West should be embraced by all. What can one truly take from a health care traditions that is not built upon an understanding of germ theory.

Some patients do not seem able to follow prescriptions given, will not show up for appointments, do not comply with treatment regimes, and are not even willing to access the system until they are in severe distress and leave quickly as possible. Under current practice, something is being missed in regard to these patients and the system is failing them. Is it because the patients and practitioners have different views regarding health , illness, and appropriate practice? Can it be that the patients often believe that the care offered would make them sicker or is incompatible with their illness? In some sense what the patient believes is not as important as whether the provider is sensitive to the facts surrounding the belief system of the patient and is willing to respect the differences. It is important to come to understand how patients understand illness and their relationship to it and also what motivates them to seek  medical assistance and then to follow the advice given. There is an ethical and professional imperative to build the bridges of understanding that allows for successful practice among those with different view of health, illness, and appropriate practice.

Autonomy vs. Paternalism: A Contest Between Virtues

Providing health care is a shared practice, in which the expert and the consumer both work to be sure that what is delivered is satisfactory to each. As the expert, the practitioner knows what is needed in a pure medical sense, but does not know how the value preferences of the patient will affect what part of the care will be accepted.

Since there is a general agreement that, thorough the exercise of personal autonomy, the patient has the right to decide the nature of care, it is vital that the practitioner make sure that the decision is based on appropriate information. Informed consent is required for all invasive or risky procedures that have potential for harm. The physician must disclose pertinent details about the  nature and purpose of the procedure, its risks and benefits, and any reasonable alternatives to the recommended treatment.

There have been several standards for this disclosure of information, but today most practitioners recognized the reasonable patient standard, which requires that the information be explained in such a manner that a hypothetical reasonable person could understand and make decisions. Because all of us are unique in what we value, it may be time to develop a more subjective standard than that of a “reasonable” person.

While there is a general agreement that the autonomous adult has the right to decide these issues, there are times when the autonomy of the patient is limited by the pain, trauma, age, and mental competency. Competency is usually established in the ability to answer two questions in the affirmative: First, does the patient understand the nature of the condition and the various options available; and, second, is the decision making process rational? The second question is somewhat modified when the decision is based on a protected religious faith, rather than reason.

Paternalism in its best sense is based on the principle of beneficence and a desire to do well for the patient. In modern health care, this desire to do good is not a justification for overcoming a competent patient’s personal autonomy.

Professional Gatekeeping as a Function of Role Fidelity

Regardless of the level of practice, the ability and opportunity to participate in the provision of health care is an awesome and wonderfully engaging enterprise. The health professions are meaningful professional careers. To enter the practice of health care is to enter in to a social contract with other practitioners, your patients, and the community in general. This social contract calls not only for a particular set of clinical skills but also appropriate ethical, legal, and social behaviors.

Like any other professional endeavor, the common area of practice belongs to each and everyone of us.  It is unthinkable and unwise to believe that some other group of specialist such as physicians will maintain the health care arena. The obligations of ethical conduct, community service, and the refinement of knowledge are not the obligations of the few but the many. Health care is a team effort, and the team is responsible for the outcomes.s. It is a common field where we labor, and, like any other field, it requires that all those involved in the harvest maintain the space so that we can come again, and when we finally finished, leave it to others who will replace us in the labor.

We are in the time of great change for health care. Rapid technological and social change has pushed the frontiers of health into uncharted territory. Many of the legal and ethical issues faced by health care providers are new. To make matters more complicated, this is also a time of legislative reform to the health care system where at times it seems the only thing that is truly stable is change.

This is a litigious age. Out patient populations have come to expect miracles that cannot be always delivered . Practitioners at times find themselves seemingly between two forces: unhappy patients, aggrieved relatives, and their lawyers versus the risk management department, other health care providers, clinical institution, and insurance companies. Practitioners are expected to conduct themselves in a manner that protects the patients and the institution they serve.

This dealt with several functions that can be listed under the headings of ‘small ethics’. While they do not deal with great life and death issues such as euthanasia, justice, or withholding/withdrawing life support, they are the daily stuff of modern practice. They come as a function of our role duty and are the price one pays for being a professional. as practitioners of health professions we have an obligation to our patients, our colleagues, and our profession to perform these necessary-albeit unpleasant-gate keeping tasks.