ETHICS FOR HEALTHCARE · • Ethics should be focused on maximizing good and minimizing bad in the...

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ETHICS FOR HEALTHCARE PROFESSIONALS: A REVIEW OF PRINCIPLES & PRACTICE

Christopher Owens, PharmD, MPH

Idaho State University

College of Pharmacy

[email protected]

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A. Great!

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Disclosure Statement

• I have no relevant financial relationships to disclose with respect to this presentation.

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Learning Objectives

• Describe the responsibilities of healthcare professionals when making ethical decisions, including the role of intuition, reasoning, and codes of ethics

• Compare and contrast key moral intuitions and associated bioethical principles, including nonmaleficience, beneficence, respect for autonomy, justice, veracity, confidentiality, and fidelity

• Apply an ethical decision-making process in a variety of contemporary practice and regulatory issues in healthcare and analyze the differing moral intuitions and principles that can be used to justify competing points of view

Learning Objectives -Technicians

• Define ethical terms such as nonmaleficence, beneficence, autonomy, and justice

• List the components of professional codes of ethics

• Discuss the role of the technician in handling ethical dilemmas in practice

• Ethics can be a controversial topic

• In this discussion, I will be defining key ethical terms, reviewing how ethics has been interpreted and codified by healthcare professionals, describing basic theories of ethics, and providing examples of ethical dilemmas for contemplation and discussion

• My goal is to help you better understand your own ethical point of view as well as how others might view ethical topic differently

• I will NOT be settling all controversial ethical subjects definitively or to everyone’s satisfaction…

Introduction

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"Deciding on the right thing to do in a situation is a bit like deciding on the right thing to wear to a

party. It is easy to decide on what is wrong to wear to a party, such as deep-sea diving equipment or a

pair of large pillows, but deciding what is right is much trickier. The truth is that you can never really be sure if you have decided on the right thing until

the party is over, and by then it is too late to go back and change your mind, which is why the

world is filled with people doing terrible things and wearing ugly clothing.”

-Lemony Snicket

“…It is always the person not in the predicament who knows what ought to have been done in it, and would unquestionably have done it too…”

-Charles Dickens

Are you an ethical person?

Yes, always

Yes, mostly

Yes, sometimes

No, rarely

No, never

0% 0% 0%0%0%

A. Yes, always

B. Yes, mostly

C. Yes, sometimes

D. No, rarely

E. No, never

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What is Ethics?• Ethics or Morality?

• The term “ethics” comes from Greek (ethos) and refers to character or custom

• The term “morality” come from Latin (moralis) and means custom or manner

• Both terms may be used interchangeably, although connotations may differ somewhat• Both refer to the study and practice of what is considered

“right” or “good” as it relates to human character, behavior, or goals

• Ethical theory and its application in clinical practice is an important part of health professionals’ education and continuing education

Moral Philosophy

• The ancient Greek Philosopher, Socrates, (469-399 BC) famously described ethics as “how we ought to live.”

• Ethics is normative, rather than descriptive• Tells us what kind of

people we should be, the kinds of things we shoulddo, and what goals we should have Jacques-Louis David. The Death of Socrates. 1787

Available at: www.abcgallery.com

An Analogy

• The Christian writer C.S. Lewis used an analogy of a fleet of ships to describe the three components of ethics

1. Aspirational• Goals and Mission

2. Relational• Rules of behavior in

groups3. Personal

• Individual character

• All three are necessary for a fleet to have a successful voyage

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• Continuing with this analogy, we may further describe the components of ethics as follows:

• Values• Goals and aspirations; what people should strive for, value,

or hold as important (in life, in society, as a profession)

• Obligations

• Actions between individuals that are expected or requiredvs. those that are discouraged or forbidden

• Virtues

• Personal traits of character that are good to have or qualities and attitudes that make a person “good”

The Three Parts of Ethics

NORMATIVE ETHICAL THEORIES

Normative Ethical Theories• Over time, philosophers have attempted to construct entire

theories of ethics using reasonable, coherent, and logical terms –they want to find the “truth-makers” of ethical claims

• Three main type of theories have been developed based on the three basic components of ethics:• Value theories

• Focus on what is important for people and societies to strive for and promote (usually states of pleasure, happiness, and human flourishing)

• Action theories• Focus on the actions between individuals and describes these

actions in terms of obligations and prohibitions• Virtue theories

• Focus on the individual and the need to possess and cultivate certain traits of character

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• Most famous example is consequentialism or utilitarianism

• Regards certain actions as ethical or unethical because of the consequences they produce• Identifies certain states of being or living conditions as good

or valuable and others as bad or harmful• Good states include: health, happiness, and pleasure• Bad states include: sickness, misery, and pain

• Ethics should be focused on maximizing good and minimizing bad in the world• “The Greatest Good for the Greatest Number”

• When making ethical decisions, the key question to be answered is mathematical, a comparison of the sum total of good vs. bad for a given decision

Value Ethics

• Also referred to as “deontological” ethics• The Greek word “deon” means obligation or duty

• Regards certain actions as ethical because they conform to universal duties or obligations

• Sources of these universal duties include:• Pure reason reflecting on universal principles

• Kant’s “Categorical Imperative” states that moral or ethical actions are those based on maxims that you could “will to be a universal law”

• Divine command • Religious teachings or commandments as revealed and taught

by prophets, sages, or gurus

Action Ethics

• Another important basis for ethics frequently cited by religious people is what has been called “Divine Command” ethics• This theory of ethics may be classified as deontological in

that it is based on the understanding that universal duties come from God

• Makes the claim that the truth of ethical claims is based on the proper understanding of what God has commanded human beings to do and not do• The Ten Commandments• The Golden Rule

Divine Command Ethics

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Virtue Ethics• One of the oldest ethical theories

• Promoted by ancient philosophers like Aristotle and Confucius

• Identified key virtues or personal characteristics that will lead to a successful or good life• For the Greeks: courage, temperance, justice, and wisdom

• For the Chinese: compassion, respect, filial piety

• These theories emphasize the cultivation of right character because ethical action and good consequences flows naturally from ethical character• True ethics should be to instill, promote, and practice behaviors

that will lead to these traits because that is what’s best for a person and for society (human flourishing will result)

Which ethical theory most appeals to you?

Virtue

Kantian deonto...

Divine Command

Utilitarianism

None of them

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A. Virtue

B. Kantian deontology

C. Divine Command

D. Utilitarianism

E. None of them

Beyond Normative Ethics• While normative theories can be helpful in reasoning through

ethical situations, there seems to more to ethics that lists of character traits, calculations of harm and benefit, religious considerations, and/or the rational application of universal principles• Psychologists and anthropologists studying human behavior and

culture have determined that ethical decision making is a complex activity that draws upon emotion and intuition as well as rationality

• It is interesting to consider the widespread agreement among cultures and religions when it comes to ethical behavior

• This apparent agreement has led to a theories of common human moral intuitions

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Reason & Intuition• When asked ethical questions, people generally

respond based on factors related to their cultural or religious background

• Consider the ethics of the following:• Euthanasia• Assisted suicide• Abortion• Contraception and emergency contraception• Universal healthcare• Human experimentation

• You probably have a “gut reaction” to each of these

Moral Intuitions• Researchers have identified 6 major moral intuitions that

are commonly cited when ethical questions are discussed:

• Care• Fairness• Liberty• Loyalty• Authority• Sanctity

• Normative ethical theories seem to have been derived from these basic intuitions with certain theories emphasizing one or more over the others

Haidt J. The Righteous Mind: Why Good People are Divided by Politics and Religion. (2012)

Care• Intuition related to people’s innate desire for pleasure and avoidance of pain• Probably the most universally agreed upon of the

intuitions –most people avoid pain and discomfort and can empathize with others in this regard

• Underlies the virtues of love, kindness, and nurturance

• The key intuition of consequentialists who seek to increase the net amount of happiness or pleasure in the world, while minimizing pain

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Fairness• Intuition related to people’s propensity for reciprocal altruism or doing good to others when others do good to them• Another almost universally agreed upon intuition –

most people intrinsically understand the need for fairness, order, and truth

• Underlies the virtues of justice, equality, and proportionality

• The key intuition of dentologists who seek to apply ethical principles universally

Liberty• Related to Fairness, this intuition accounts for people’s desire to be free to make their own decisions and have those decisions respected by others• This intuition is stronger in individualistic societies

(like the US), but can be found everywhere in the world

• Another key intuition of dentologists who hold that human beings are “creatures of dignity rather than price” and ought to live free from oppression or domination

Loyalty• Intuition that is correlated with universal human structures such as family, community, and nationality• The phrase “blood is thicker than water” denotes

moral importance of loyalty in family, community, or other group relationships

• Traitors are almost universally despised because they disregard this intuition

• Underlies the virtues of patriotism and self-sacrifice for the sake of the good of the group

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Authority• Related to Loyalty, this intuition is correlated with hierarchy that is found in family and community structures• Recognition and obedience to legitimate authority

to maintain social order is a universally recognized virtue

• Underlies the virtues of leadership and followership, and highlights the ethical value of respect for authority and respect for tradition

Sanctity• This intuition is more controversial than the others,

but also appears to be universal• Is shaped by religious traditions as well as the

psychology of disgust

• Recognizes ethical value associated with living a pure, virtuous, or noble life

• Regards certain objects, places, people, and ideas as “sacred” or “holy” –but may also be secular

• Recognizes a transcendent dimension of life that may not be apparent to everyone in exactly the same way

Your Morals

• It can be an interesting exercise to determine which of these moral intuitions is strongest for you

• Jonathan Haidt and colleagues have developed a number of different ethics and related assessments to help you know which of these you tend to emphasize most

• It is also interesting to see how your views related to the views of others

• Take the Moral Foundations Questionnaire (MFQ) for free at:• https://www.yourmorals.org/

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Ethical Questions & Intuitions

• Normative ethical theories and related moral intuitions are at the core of most ethical disagreements• Different people emphasize different principles and intuitions in

different ethical situations

• For example, the question of the ethical permissibility of euthanasia or physician-assisted suicide turns on deeply-held intuitions related to:

• Care and harm

• Individual liberty

• The sanctity of life

• Differences as to which of these intuitions is most important determines the ethical standpoint of opposing parties

Do you think that a person should be able to receive medical help to end his/her own life if he/she chooses?

Yes N

o

Maybe

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1. Yes

2. No

3. Maybe

FROM MORAL INTUITIONS TO MEDICAL ETHICS

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Medical Ethics

• Ethical questions have long been a part of medicine• Healthcare involves providing care to the sick and

injured, seeking to minimize harm, respecting individual choice, and protecting the sanctity of life

• At various points in history, practitioners of the medical arts have defined, described, and delineated professional virtues, duties, and values• Based upon reason and intuition• Set forth in codes and oaths• Shared with the public being served• Believed to be binding on the members

Professional Codes of Ethics

• Codes of ethics consist of groups of statements that describe the ethical responsibilities of the profession• Statements are often accompanied by commentary,

interpretations, and/or examples of application

• Examples include:• The AMA’s Principles of Medical Ethics

• The Code of Ethics for Nurses (ANA)

• The Code of Ethics for Pharmacists (APhA)

• The Code of Ethics for Pharmacy Technicians (AAPT)

• All are available online, see references at the end of this presentation for links

Bioethical Principles

• All codes of ethics emphasize the following basic bioethical principles:• Nonmaleficence (care, sanctity)

• Beneficence (care, sanctity)

• Justice (fairness, liberty)

• Respect for autonomy (fairness, liberty)

• Confidentiality (liberty)

• Fidelity (loyalty, authority)

• Veracity (loyalty, authority)

• Each of these correlates with one or more key moral intuitions

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Nonmaleficence & Beneficence

• Nonmaleficence imposes an obligation not to inflict harm on others• Associated with the maxim: Primum non nocere -

“First, do no harm”

• Beneficence requires that healthcare professionals actively do what will provide benefit to the patient• A continuum exists between nonmaleficence and

beneficence that ranges from not inflicting harm removing harm preventing harm conferring benefit

Bill Watterson. Calvin and Hobbes: Attack of the DMK Snow Goons, 1992

Justice• A term often described with words or phrases like

fairness, entitlement, appropriate, or what is owed, due, or deserved

• Different types:• Procedural (avoiding favoritism)• Distributive (appropriate share of goods)• Compensatory (injured receiving compensation)• Retributive (punishment)

• As it pertains to medical ethics, justice usually means allocation of healthcare goods and services to patients in a fair and equitable manner

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Respect for Autonomy

• The obligation to respect the decisions and actions of autonomous agents• To be autonomous:

• Must have goals, values, preferences, “life projects”

• Possess the capacity to reflect upon alternatives and recognize consequences

• Must have adequate information about a situation and be able to reason about it

• Derived from the intuitions related to liberty and fairness; people should be able to make informed decisions and have those decisions respected

Other Bioethical Principles

• Confidentiality• Includes the duty not to reveal private information

related to medical care

• Fidelity• Term used to denote the loyalty that should exist in the

patient/clinician relationship and how the professional ought to use his/her knowledge and skill for the benefit of the patient

• Veracity• A term that refers to being truthful with patients, not

withholding information and providing them with all the information necessary to make informed decisions

BRINGING IT ALL TOGETHER:ETHICAL DECISION MAKING

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Ethical Problem Solving• Like clinical problem solving, ethical problem solving is

best accomplished using utilizing a systematic process involving:• Awareness of specific contextual features• Best available evidence and objective reasoning• Intuition and past experience

• Many will say they “go with their gut” when facing an ethical dilemma but caution is warranted as emotion must be tempered with rational thinking and impartiality

• By using an established process you will be more sure of your decisions and be better able to defend them if necessary

Ethical Dilemmas

• Using case studies of ethical dilemmas is good practice for determining how you think and applying theories to practical situations

• The most difficult step will often be determining which obligations and values are most important

• It is important to realize that conscientious and reasonable people may and often do disagree over moral priorities

• This does not indicate that there is no right answer, but instead that several answers may be ethically acceptable, but some will clearly be unethical as well

Compromise

• Many difficult ethical decisions are decided using a process involving discussion and deliberation on the part of a group of healthcare professionals, lawyers, and lay people• Ethics committees are an example

• Since it is rare to come to a resolution that makes everyone happy, such deliberations often boil down to a decision in which not everyone is convinced or completely satisfied, but is something that people “can live with”• Often determined by majority vote

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PROCESSES FOR MAKING ETHICAL DECISIONS

Four-Step Process• Problem Identification

• Ethical attention step --Consider technical, legal, and competing values

• Develop alternative courses of action• Ethical reasoning step --Realize that there is typically more than

one way to deal with an ethical situation• Select a course of action, but consider alternatives and

objections• Ethical intention step --Before implementing your chosen course of

action, think careful through the best counter argument you can make

• Implement what has been decided• Ethical action step --How you carry out your chosen action is as

important as the decision itself

From: Rest J. Moral development: advances in research and theory. New York: Praeger Publishers, 1986

Eight-Step Process

1. What is the ethical question?

2. What is your “gut reaction”?

3. Do you have all of the relevant facts?

4. Who all is involved…do their values differ?

5. What could you do? Consider all options

6. What should you do? Why?

7. Consider alternatives. Are you sure?

8. Could this dilemma have been prevented? How?

From: Glover JJ. “Doing” ethics in rural health care institutions, Dartmouth College Press, 2009

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A Closer Look at Different Steps• All of the ethical decision making processes have these

4 main ideas in common• Characterize the situation

• Consider context, legal implications, and competing values of different parties

• Consider possible alternatives• There is usually more than one ethical response to a situation

• Choose the best action• Determine the most ethical course of action but consider

objections

• Carry out your chosen plan• Implement the chosen action in an ethical manner, keeping in

mind professional virtues and ways to prevent this type of dilemma in the future (if possible)

What about Conscience?

• Practitioners of different professions have historically invoked a right of conscience

• Believe that it is acceptable to refuse to perform a service if it violates “moral integrity” or if they have a “moral qualm”

• Some states have laws to this effect Kronk, The Emperor’s New Groove, Disney 2000

Do you agree with Conscience Laws?

Yes, healthcar...

No, healthcare...

0%0%

A. Yes, healthcare professionals should have the right to decide

B. No, healthcare professionals should be required to provided expected services

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Discussion

• Let’s take 5 minutes now to discuss this issue with the people sitting next to you

• As you discuss this issue, be sure to consider both sides and highlight the moral intuitions and ethical principles that should be included

• Some questions to consider include:• Should healthcare professionals be allowed to decline to provide

professional services to a patient based on their own conscience?

• What are the limits of such refusals (if any)?

• What is the impact on patient care and professional responsibility that must be considered?

ETHICAL DILEMMAS

THINK-PAIR-SHARE

• Let’s put into practice the concepts we’ve been discussing• Again, find someone close by to talk to about each of the

issues raised• Using a systematic process, characterize these issues,

consider alternatives, and identify important ethical intuitions and differing points of view on these issues

• What intuitions, values, and professional responsibilities are important to consider?

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WOULD YOU RECOMMEND A HOMEOPATHIC PRODUCT?

Yes

No

Maybe

Homeopathy Case• A tired-appearing young mother brings her crying 12-

week old baby into the pharmacy and asks for your medical advice

• She says her baby has been very fussy for the past week or so, hardly sleeps, and seems to be having terrible “tummy-aches”; she is frustrated and exhausted and of course, concerned for her suffering baby as well

• She heard from a friend that there are natural, drug-free, safe products for colic that really work for this condition –homeopathic colic drops

Case, continued

• Your pharmacy does stock a homeopathic colic product

• The label on the package includes the following information:• Active Ingredients: Carbo Vegetabilis 5C HPUS, Colocynthis 9C

HPUS, Cuprum Metallicum 5C HPUS

• Inactive Ingredients: Purified Water

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Would you recommend a homeopathic product in this situation?

Yes N

o

0%0%

A. Yes

B. No

Ethical Decision Making

• Characterize the situation• Consider context, legal implications, and competing values

of different parties

• Consider possible alternatives• There is usually more than one ethical response to a

situation


objections

• Carry out your chosen plan• Implement the chosen action in an ethical manner, keeping

in mind professional virtues and ways to prevent this type of dilemma in the future (if possible)

WOULD YOU BE WILLING TO PRESCRIBE, DISPENSE, OR ADMINISTER EMERGENCY CONTRACEPTION TO A PATIENT?

Yes

No

Maybe

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Would you prescribe, dispense, or administer emergency contraception to a patient?

Yes N

o

0%0%

A. Yes

B. No





situation


objections



DO YOU THINK PHARMACIES SHOULD SELL SYRINGES TO POTENTIAL DRUG ADDICTS?

Yes

No

Maybe

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Do you think pharmacies should sell syringes to potential drug addicts?

Yes N

o

Maybe

0% 0%0%

A. Yes

B. No

C. Maybe





situation


objections



IS HEALTH CARE A RIGHT THAT SHOULD BE PROVIDED BY THE GOVERNMENT?

Yes

No

Maybe

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Is health care a right that should be provided by the government?

Yes N

o

Maybe

0% 0%0%

A. Yes

B. No

C. Maybe





situation


objections



Summary

• Ethics is the study of the “good” with respect to individual character, actions, and goals

• Both intuition and reasoning play an important role in ethical decision making

• Common moral intuitions that have been identified include: harm, fairness, liberty, loyalty, authority, and sanctity

• Ethical dilemmas arise when there are conflicts in these intuitions

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Summary

• Codes of ethics have been established that contain references to major principles including nonmaleficence, beneficence, respect for autonomy, justice, fidelity, confidentiality and veracity

• Systematic processes for making ethical decisions have been developed that include steps such as characterizing the dilemma, considering different options, choosing the best one, and carrying out what has been decided in an ethical way –sometimes there is more than one ethically defensible course of action

References• Haidt J. (2012) The Righteous Mind: Why Good People

are Divided by Politics and Religion. New York, NY: Random House, Inc.

• Harris S. (2010) The Moral Landscape. New York, NY: Free Press.

• Lewis C.S. (2002) The Complete CS Lewis Signature Classics. San Francisco, CA: Harper Collins Publishers.

• Veatch R.M. (2012) The Basics of Bioethics, 3rd edition. Boston, MA: Pearson Publishers.

• Veatch R.M., Haddad A.M., and English D.C. (2015) Case Studies in Biomedical Ethics: Decision-making, Principles, and Cases, 2nd edition. New York, NY: Oxford University Press.

Websites

• Professional codes of ethics may be found at:

• http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/principles-medical-ethics.page

• http://www.nursingworld.org/DocumentVault/Ethics_1/Code-of-Ethics-for-Nurses.html

• http://www.pharmacist.com/code-ethics

• http://www.pharmacytechnician.com/?page=CodeofEthics

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