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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.

Ethics

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.

Ethical Principles

  • 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.

  1. The Code for Nurses develop by the International Council of Nurses
  2. 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.

Religion and End-of-Life Care

AMISH AMERICANS

  • Funerals are conducted in the home without a eulogy, flower decorations, or any other display; caskets are plain and simple, without adornment.
  • At death, a woman is usually buried in her bridal dress.
  • One is believed to live on after death, either with eternal reward in heaven or punished in hell.

BUDDHISM

  • A shrine to Buddha may be placed in the client’s room.
  • Time for meditation at the shrine is important and should be respected.
  • Client’s may refuse medications that may alter their awareness (such as opioids).
  • After death, a monk may recite a prayer for 1 hour (need not be done in the presence of the body).

CHRISTIANITY (Catholics and Orthodox religions)

  • A priest anoints the sick.
  • Other sacraments before death include reconciliation and holy communion.

CHURCH OF JESUS CHRIST OF LATTER-DAY SAINTS  (Mormons)

  • May administer a sacrament if the client requires.

JEHOVA’S WITNESS

  • Do not believe in sacraments.
  • Will be excommunicated if they receive a blood transfusion.

JUDAISM

  • Prolongation of life is important (a client on life support must remain so until death)
  • A dying person should not be left alone (a rabbi’s presence is desired).
  • Autopsy and cremation are forbidden.

HINDUISM

  • Rituals include tying a thread around the neck or wrist of dying person, sprinkling the person with special water, and placing a leaf of basil on their tongue.
  • After death, the sacred thread is not removed and the body is not washed.

ISLAM

  • Second degree male relatives such as cousins or uncles should be the contact person and determine whether the client or family should be given information about the client.
  • Client may choose to face Mecca (west or southwest in United States).
  • The head should be elevated above the body.
  • Discussions about death usually are not welcomed.
  • Stopping medical treatment is against the will of Allah (Arabic word for God).
  • Grief maybe expressed through slapping or hitting the body.
  • If possible, only a same-gender Muslim should handle the body after death; if not possible, non-muslim should wear gloves so as not to touch the body.

PROTESTANT

  • No last rites (anointing of the sick is accepted by some groups).
  • Prayers are given to offer comfort and support.

 

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.

Ethical Issues and Genetic Science

The advances in scientific expertise bring with them moral dilemmas. Genetic research offers great promise; we may soon be able to cure many of the genetically determined diseases and predispositions to disease. We may even be able to improve upon Mother Nature. The question is to whether humankind has the wisdom to utilize this knowledge for good without violating moral rules. Only time will tell. Genetic screening will allow  parents to know whether their offspring will be afflicted with disease, but in some cases this does nothing more than begin the misery sooner. Prenatal genetic testing will give parents the choice to terminate pregnancies that will lead to defective infants. Genetic testing may also justify discrimination in the minds of many. Eugenics as a state of policy is unlikely and will make such proposals. The human genome project will rank among humankind’s greatest achievements once it is completed, and by itself presents no real moral difficulty; but the applications of the knowledge may be more than human wisdom can handle. Recombinant DNA maybe the most dangerous as it puts us in the position of creators of whole species that may or may not coexist with humanity and the rest of natural world. In spite of dangers, we will proceed, as we should. We may not turn away from the pursuit of knowledge even if some would misuse it.

Genetics as Social Policy

Ethical issues arise when we consider the possibility of turning genetic testing into social policy. Some suggest that all parents be tested for genetic diseases in order to avoid the social and personal costs of genetic impairment. Others worry that this will lead to a coercive policy of abortion or of preventing parents from having children. Such policies raise still further issues when they are directed to certain ends, as they are with eugenics. Eugenics is the practice of manipulating the genes of offspring through either breeding or genetics alteration.  Should we attempt to eliminate some or all genetic abnormalities? Should we attempt to improve the race of human being by increasing intelligence through genetic selection?

Scientist are not only involved with genetic testing, they are also engage in an enterprise called “the human genome project”  The task is to ‘map’ the 100,000 genes that make up the 46 chromosomes, which altogether comprise the ‘human genome’. The genome is the blueprint contained in each cell that guides the development of of human being. The ethical worries regarding this issue is more vague; they have as much as to do with the idea of human possessing such “God-like” knowledge as they have to do with application of knowledge. From certain theological points of view, the mere possession of such profound knowledge is immoral; only God should have such knowledge. The idea is that the attempt to gain such knowledge is hubris or excessive pride. It is suggested that we leave such knowledge to God and concern ourselves with more mundane task.

Ethical Issues of AIDS

I remember that weekend when no patient in the intensive care unit was over the age of forty. i remember the intern who tearfully refused to come to the emergency room to see the fourth AIDS patient I had admitted to her in as many hours. She never did meet him; he died before she calmed down.

Abigail Zuger, M.D.,1986

Hundreds of thousands of lost lives later, the initial impact is over. The thunderbolt of AIDS are starting to become a fact of life. Some sense of continuity with the rest of history has become possible.  AIDS continues to be a source of uniquely complex medical, legal, and social dilemmas; nonetheless, it has evolved into an entity provoking fewer immediate panicked reactions and more measured, mature analysis.

Abigail Zuger, M.D.,1993

 Acquired  Immune Deficiency Syndrome (AIDS) continues to grow as a worldwide epidemic. The disease, which at one time was centered within certain high-risk groups, has now spread into all segments of the population. The study of high-risk groups is no longer the best way to identify those at risk for the disease; rather, risk should be measured through the observance of certain high-risk behaviors.

Due to the frightening consequences of the disease and its relative newness, the public has reacted very negatively toward those infected. Victims of the disease have been stigmatized, exposed to humiliation,  and have experienced loss of work, insurance, and housing. The issue of confidentiality and the attempts to sustain a level of privacy beyond that provided for other diseases often create problems for the patient and health care provider. AIDS is the only disease about which there is any question as to whether health care providers should be told the diagnosis of their patients.

Ethical issues involved with this disease include confidentiality, the duty to treat infected individuals, the need for universal screening, the duty of infected health care providers to warn patients , and the need for equitable distribution of medical care and research dollars. It is clear that the resources that will be needed to care for these patients threatens to overwhelm an already burdened health care delivery system.

None of these issues has yet been satisfactorily addressed. How we finally addressed  and resolve this problems will speak either well or ill of the ethical foundations of the American health care system. Because of the scope of the ethical problems associated with the AIDS epidemic, our actions in response to it will leave either a proud or a shameful heritage for future health care providers.

Abortion

There has been little information with regard to the health provider’s role in abortion. The reason for this is that the abortion issue is not essentially a health issue but rather a social issue that take place in the health care arena. Abortion, in most instances where it is performed, is legal. The American Association in it’s Code of Medical Ethics, Current Opinions document, 2.01 states

The Principles of Medical Ethics of the AMA do not prohibit a physician from performing an abortion in accordance with good medical practice and under circumstances that do not violate the law.

One’s attitude toward abortion is often very intense, close, and personal. As a matter of professional autonomy, it would seem that health care providers with deeply held beliefs with regard to this matter would not be required to participate in the process. However, this may require that the provider ascertain the philosophical view of the institution where he desires employment prior to accepting duty there. Its make very little sense to look at only the salary and fringe benefits of a hospital and then find yourself working at an institution where the daily practice of abortion creates for you severe moral distress.

Health care providers, regardless of their personal feelings concerning abortion, cannot ignore the social realities of our time., such as the liberation of women and the problems of teenage mothers. There is very little indication that the abortion controversy will end anytime soon. As a matter of role duty, we must come to understand that people of intellect and honor have come to very different decisions regarding the issue. As health care providers, we do not have the luxury of treating patients with whom we have formed a patient/provider relationship with anything but the highest level of professional concern , regardless how we may feel about their decisions on this issue.

Abortion is an extremely emotional issue in that it makes us consider some very important and deep moral concepts, such as person-hood and the value of human life. While it is important to understand the facts of fetal development, there is no getting around the problem of philosophical disagreement over fundamentals. Noe can we ignore important social realities such as the liberation of women and the problem of teenage mothers. Abortion also requires that we review our moral intuitions. We discussed various analogies in order to determine whether our intuitions can yield a consistent moral position on abortion.

whatever your view of abortion, it should be clear that issue is a difficult one that reaches to the depths of our most profound thoughts on what is important in life. Nothing indicates that the controversy will end anytime soon, so how is a sensitive person to regard her opponents on the issue? If one imagines that a fetus is a baby, how much effort on it’s behalf is rational? An adult who rushes into the street to save a toddler who has entered the pathway of an onrushing car would be considered hero. What, then, is so extraordinary about blocking a doorway or lying down in front of an abortion clinic, if what you see yourself doing is saving babies? If, on other hand , your view of a fetus is that of a piece of tissue–even one with remarkable potential, but still only a piece of tissue–jumping in front of cars or blocking doorways is a very strange behavior indeed.

Perhaps what is missing in the debate is a level of tolerance and civility that considers the opposing view to be wrong but perhaps rational. The pro-choice advocates began to call the pro-life advocates”terrorist” while the pro-life movement continued to cast the pro choice side as “baby killers”. It is not likely that “baby killers” and “terrorist” are the kinds of people who will be able to sit down and reason together. Confrontations have become increasingly violent and costly as one town after another becomes a battleground.