WV RURAL HEALTH EDUCATION PARTNERSHIPS

FACULTY DEVELOPMENT COMMITTEE

 

Training Manual for Interdisciplinary Session Facilitators

 

Health Care Ethics

Helen Marr Mitchell MD

Pineville Children’s Clinic

 

INTRODUCTION

It is important in interacting with patients (and with other health care professionals) that students have a good understanding of basic ethical principles or guidelines and some practice in ethical thinking.

 

It is equally important that students understand what ethics is not. An ethical decision/choice is not synonymous with what is legal or moral or done by one’s peers. A decision/choice is legal if it complies with the applicable laws. It is moral if it complies with the laws or principles based on a particular faith system or world view, and thus may be different for different persons in the same society. (For example, lifelong marriage may be the moral norm for some, divorce acceptable for others; monogamy for some, polygamy for others; abortion acceptable for some; morally reprehensible for others.) What a majority or preponderance of doctors in a given geographical area do in a given situation constitutes a “community standard of care”; it may or may not be “ethical”. Ethics is a system of thinking about choices or decisions based on widely accepted guidelines capable of working with different moral, religious, and cultural values.

 

It is rare in the USA that a decision arrived at through careful ethical thinking would be in conflict with the law. However, there are surely times when such a decision may be challenged by some interpretations of law. (For example: Is withholding/removing a feeding tube from a person who is in a vegetative or brain-dead state murder or simply letting nature take its course?) Since we are a society of multiple cultures and multiple faiths, ethical thinking can be very helpful in sorting out one’s own moral and cultural ideals from those of the patients’. This is not to suggest that health care professionals should violate their own moral judgments in their personal actions, but may indicate a need to transfer a patient’s care to someone who can in conscience honor the patient’s autonomy.

 

Although health profession students may have had ethics courses in school, experience of discussing real world cases with them often reveals that ethics, morals, and standards of professional behavior have been presented together in such a way that students confuse them. Also such courses often seem to have left students feeling that their content is highly theoretical and less important than their other studies. However, when faced with real people with real problems where the correct or best choice is not readily clear, discussion usually becomes quite lively. Thus, we as clinical field faculty, are in the best of positions to teach ethics! It therefore behooves us to be familiar with basic ethical principles, and to develop some facility in sorting them out from other considerations and in applying them.

 

BASIC ETHICAL PRINCIPLES

 

Autonomy: the innate right of a person to make choices affecting her/his own life and welfare free of coercion. (Please note the phrase: “free of coercion”; it is important!)

 

There are limitations on an individual’s right to exercise autonomy, for example:

Beneficence: The health care provider’s obligation to act in the best interest of the patient (the patient being, ordinarily, the person who decides what constitutes his/her “best interest”).

 

Confidentiality: The health care provider’s obligation to avoid both deliberate and careless disclosure of information a patient explicitly or implicitly wants kept private. (It is worth noting that trustworthy behavior on the part of individual practitioners tends to create a larger relationship of trust between whole communities and the health care professions.)

 

Informed Choice: This guideline goes beyond the older one of “informed consent” which meant that a treatment proposed by a physician and explained to the patient must be agreed to by her/him. The guideline of informed choice requires that all reasonable possibilities for care (including no treatment) together with the expected benefits and risks of each be explained to the patient. The patient then makes an informed choice from among the possibilities, or even more ideally in the opinion of many ethicists and practitioners, there is a process of shared decision making resulting in a meeting of minds between the patient and health care provider as to what is “best”. [Note that the concept of “benefit vs. burden (risks) has largely replaced the old “First do no harm.” concept in ethical thinking. This reflects the reality that almost all possible treatments (and withholding treatment) involve a potential for benefits and also a potential for harms (eg. side effects, adverse events), which must be weighed against one another.]

 

Decision Making Capacity: This guideline replaces the older one of “competence” vs “incompetence”, which carried the legal implication of persons able to manage their affairs—or not. However, persons unable to manage their financial and daily life affairs may well be able to understand their medical conditions, to comprehend the possibilities for treatment together with their benefits and risks, and to make the most appropriate choice for themselves and their goals. Such a person, although legally “incompetent” has decision making capacity.  Persons lacking decision making capacity fall into two categories: those who have had decision making capacity and lost it (eg. brain injured, mentally ill, unconscious, severe Alzhiemer’s,…); and those who have never had decision making capacity (eg. infants and very young children, severely mentally retarded persons,…). In the former situation, a substituted judgment may be made by a person previously designated by the patient or by someone who has known them and their thinking well. In the latter situation, no one can know what the patient’s preference might be, so no substituted judgment is possible. A surrogate decision maker (parents or other appointed guardian) must then make a decision based on beneficence and a “reasonable person’s” judgment.

 

Patient – Care Provider Relationships. Potential types of relationships between patients and health care providers are commonly classified into four categories:

Technician: The health care provider determines what the “problem” is and fixes it, much as a plumber restores hot water to a customer’s house by repairing the malfunctioning water-heater.

Authoritarian: The health care provider makes choices concerning diagnosis and treatment for his/her patients without significant consultation with the patient on the presumption that he/she knows what is best.

Contractual: The health care provider agrees with the patient to provide certain services and it is mutually understood that the rendering of such services discharges his/her duty to the patient.

Fiduciary: A relationship of trust in which the patient counts on the health care provider to care about him/her as well as care for him/her with expertise, honesty, on-going commitment, and sensitivity to the patient as an individual with unique circumstances and goals. There seems to be general agreement among medical ethicists that the fiduciary relationship is the desirable over-all relationship between patients and health care providers. It holds health care providers to very high standards of conduct in terms of the ethical principles already mentioned, and in others, which for the sake of brevity, will be only listed below. [There are reasons why the fiduciary relationship has been the preferred one. Society to this point in time (although this seems to be changing with alarming rapidity to some of us) has trusted physicians especially, and to considerable degree other health care providers, to set standards, to run their own education programs as well as choosing those who enroll in them, and to patrol their own ranks for unethical behavior and substandard practice. The appropriate response to such trust is to be trustworthy. In addition, health care providers are often dealing with patients who are in an unaccustomed state of vulnerability because of the stress of illness or injury, and who usually lack the expertise of the health care provider.

 

Other Ethical Principles Needing “Honorable Mention”:

·       Honesty includes:

1.    Truth Telling (ie. avoiding lying)

2.    Avoiding Deception

3.    Avoiding Misrepresentation

4.    Avoiding Nondisclosure (unless the patient definitely indicates he/she prefers not knowing and indicates understanding of the consequences of that choice)

     All the above apply to disclosure of mistakes, as well as to typically medical diagnostic and treatment information.        

·       Keeping secrets (this includes non-medical facts learned through the health care provider – patient relationship, which the patient does not want to become known

·       Keeping promises (N.B. This is a particularly relative, in contrast to absolute, principle. First, because promises made by others are not binding, and even one’s own promises if subsequently judged unwise because made in a moment of misjudgment, or without sufficient information, or with insufficient analysis of information, may be broken for the benefit of a patient. Honesty requires disclosure and trust recommends apology. The major lesson is to make promises judiciously!)

·       Treating all equally in terms of care and respect of person (which has implications re accepting inappropriate gifts from patients)

·       Avoiding conflicts of interest (which has implications re accepting gifts and/or subsidies from drug companies)

·       Avoiding use of one’s professional position to pressure or take advantage of a patient in any way (eg. financially, sexually,…)

·       Being willing to confront the problem of an impaired colleague in order to protect patients from potential harm

 

Finally, it should be noted that, as stated on the first page of this chapter, ethics is a system of thinking about difficult decisions, Ethical principles (or guidelines) help us to avoid leaving important considerations (and persons!) out of the decision-making process. Often there is tension between two principles in a certain situation, and caregivers and patients must determine which is paramount in that situation. Sometimes the particulars of a situation lead to a conclusion that one or another principle should be breeched; in general, however, ethical principles should be regarded as prima facie and should be broke only for compelling reasons which would be convincing in other cases where the same set of circumstances occurred.

 

 

NOTE: Several cases for discussion are provided in the Appendix to this chapter.

 

SUGGESTED REFERENCES and CONSULTANTS

 

A book: Resolving Ethical Dilemmas, A Guide for Clinicians by Bernard Lo. (second edition) 2000 Lippincott Williams & Wilkins; 530 Walnut Street; Philadelphia, Pennsylvania 19106. [Excellent as a read and as a reference. Exceptionally clear thinking and writing and lots of examples. A good addition for our Learning Resource Center libraries!)

 

There are two people familiar to West Virginia ethics circles who are recognized authorities in ethics, and who have been willing to give telephone consults on individual cases or issues in the past, and, hopefully, would do so in the future:

 

“Woody” Moss                                          “Jackie” Glover

 Helen Marr Mitchell MD

Pineville Children’s Clinic

P.O.Box 430    Pineville, West Virginia 24874

304-732-7069 (clinic)     304-294-6063 (home)

hmitchell@marshall.edu