Ethics in Clinical Practice
Physicians are at the center of the health care process. In this central role, they use their knowledge, skills, and defined processes to provide or coordinate health care for patients. The success of the patient-physician relationship is determined by the way this relationship is valued, developed, nurtured, and maintained.
Changes in the health care process bring changes in stakeholders, relationships, structures, and values. Physicians must not only address traditional bioethical issues, but also business ethical issues. Furthermore, health care is no longer a local issue, but spans regions, states, even countries. The ethical values of many can affect any single health care decision.
The physician’s central position forces direct involvement with many ethical issues. Physicians thus witness and participate in decision-making that has important ethical implications. Because their position is central and influential, others may attempt to gain their support. Physicians must be familiar with ethical principles, recognize situations that involve ethical decision-making, have the ability to analyze the ethical dilemma, and select a solution from among several correct solutions.
Common examples of ethical situations include:
- Providing sensitive medical information to insurance companies and other providers
- Supporting patient requests for procedures not covered by health plan benefits
- Assigning intensity of care to patient office visits
- Billing practices that optimize income
- Justifying the need for a patient to use out-of-network services
- Obtaining payment for claims that have been wrongfully denied by the insurance company
Some decisions entail choices of ethical versus unethical behavior. More often, however, physicians must choose between several right choices. The challenge is to select the best choice from a number of good choices.
This course will address the basic principles of ethics, review the content of the one medical code of ethics, provide a model for referring ethical issues to an appropriate committee, and provide an individual model for addressing individual ethical issues.
CHAPTER ONE: Medical Ethics
A Definition of Ethics and Medical Ethics
Ethics is defined as a system of moral standards or values. Ethics derive from numerous sources, including religion, philosophy, law, institutions, professional codes, corporate mission statements, ethics committees, family, culture, friends, professional associates, and personal experience. In fact, nearly every aspect of society influences the ethical system.
Medical ethics comprise a subset of moral standards or values that medical practitioners use in the decision-making process. The sources of medical ethics include those listed above, and also encompass medical professional associations and teachings. Medical practitioners include physicians, nurses, technicians, hospitals, and even insurance companies. The standards and values that these groups promulgate are important because the practitioners’ actions affect the welfare of individual patients, the relationships with other practitioners and caregivers, and the general well being of health care organizations and the community. In this way, medical ethics play an important role in defining acceptable and unacceptable behavior.
The changes in health care technology and delivery have created new benefits to patient care, but have created new problems and challenges in ethical decision-making. Based on the knowledge that salience of ethical values influences behavior, some states have mandated ethics education as part of the re-licensure process.
The Effect of Medical Ethics on Clinical Practice
Medical ethics affects a broad spectrum of each physician’s professional and personal life. Everyday medical care issues can include the following ethical dilemmas: which critical patient to examine and treat first, what sensitive patient information to divulge to a family member, or how to deal with conflict. Ethical dilemmas arising from everyday business issues include contracting with a low-paying health plan in order to maintain continuity of patient care, or providing patient information to a health plan even though that information may result in denial of payment for a patient’s procedure. Ethical dilemmas arising from everyday personal issues include the dilemma of staying late at the office to provide care for a patient at the expense of missing an important family activity or limiting office availability to improve the quality of personal life. Each ethical dilemma involves a trade-off of benefits. It is up to the physician to make the decision.
Physicians face ethical dilemmas more often than other professionals, not because the physician has more training or experience, but because people and the community rely on physicians for critical decisions-decisions that have both uncertain consequences and personal implications. For example, if a barber turns down a customer who needs a haircut simply because the customer has no money, society probably does not experience significant harm. However, if a surgeon turns down a customer who needs an emergent appendectomy simply because the customer has no money, then society experiences harm.
Heterogeneity of Medical Ethics
Since there are numerous stakeholders in health care, it should be no surprise that there are numerous codes of ethics specific to each stakeholder group. Codes differ among stakeholders for example, among physicians, therapists, hospitals, and health plans. Each code represents a separate interpretation based on different sources of information and different emphasis of four principles of ethics: respect for persons, beneficence, nonmaleficence, and justice.
Thus, we must immediately give up the concept that there is one right way of doing things. Each of several stakeholder groups, using ethical guidelines and acting with the best intent, may come to a different conclusion. There may be more than one ethical solution.
Further, we must advance past the idea that ethics is only about right versus wrong. Decisions that involve doing right versus wrong may involve ethical issues but they are not ethical dilemmas because the answer is straightforward. True ethical dilemmas are dilemmas simply because the decisions require decision makers to choose one right alternative instead of another right alternative.
It is necessary for individual physicians to recognize ethical dilemmas, understand the conflict of ethical value, analyze issues, and use a sound decision making process. This course addresses each of these topics in subsequent chapters. In Chapter 2, we describe the four principles of ethics in detail. In Chapter 3, we discuss the relationship between laws, professional ethics, and codes of conduct. In Chapter 4, we describe when and how to refer issues to an appropriate group decision-making process. And in Chapter 5, we describe a model that physicians can use to analyze individual ethical dilemmas.
Ethical principles tend to be communicated in general terms. Nonmaleficence, for instance, has been stated as, First, do no harm. Probably, no physician would disagree with the underlying ethical principal or with the statement. However, when physicians are faced with right-versus-right decisions, the principle offers little practical or immediate guidance. When ethical principles are customized for specific practitioners and to specific situations, translated so to speak, they become more directly applicable. Therefore, most professional groups tend to translate the ethical principles into a code of ethics that defines acceptable and unacceptable behavior. In Chapter 3, we address the Principles of Ethics of the American Medical Association, and how this code applies to the clinical practice of a physician.
Besides the general principles of ethics, and the codes of conduct that help translate the four principles into acceptable and unacceptable behaviors, personal factors play an important role in ethical decisions. Our culture, for example, has condoned voluntary fetal abortions, as reflected by the legality of abortions in most states. The medical profession has also condoned voluntary fetal abortions, as reflected by the fact that practitioners who perform the abortions remain licensed to practice medicine, and are accepted members of medical professional associations. Nonetheless, there are individuals who, for one reason or another, find voluntary fetal abortion an unacceptable practice, and who will not recommend or perform the procedure. Their personal ethic is also acceptable because they, too, remain licensed and maintain memberships in professional associations. The application of personal opinion to medical ethics is thus acceptable, necessary, and desired.
Chapter One Summary
1. Medical ethics comprise a subset of moral standards or values that medical practitioners use in making decisions.
2. Medical ethics derive from numerous sources, including religion, philosophy, law, institutional influence, professional codes, corporate mission statements, ethics committees, family, culture, friends, professional associates, and personal experience.
3. Medical ethics affect a broad spectrum of each physician?s professional and personal life.
4. Physicians face ethical dilemmas more frequently because the community relies on physicians for critical services.
5. Medical ethics do not define the one right way of doing things. Ethics are a useful tool for organizing and systematically analyzing dilemmas.
6. There are numerous codes of ethics specific to each stakeholder group.
7. Personal factors play an important role in ethical decisions.
CHAPTER TWO: The Four Basic Principles of Ethics
Ethical principles tend to be established around four basic principles that have served humankind for generations. This is not to say that these principles are the only correct principles, but they are four that have been well accepted and form the basis of many codes of ethics across divergent cultures and organizations.
Respect for Persons:
Respect for others relates to how the physician interacts with people. Demonstrating respect for persons depends on the following 4 factors:
Autonomy states that each patient should be able to determine his or her own affairs. However, the basic principle that underlies informed consent states that for patients to determine their own affairs they must not be coerced. Informed consent requires that patients be provided with a basic understanding of key issues and information necessary to govern their own medical decisions. Informed consent is necessary from the standpoint of medical ethics because ultimately only the patient can give consent to invade the patient’s body. This principle causes ethical dilemmas when family members, the health care team, or an insurance company attempt to make decisions that remain the ethical right of the patient. The issue is complicated by the fact that the patient, by directly or indirectly joining a health insurance plan, gives up certain rights and agrees to abide by the values of the insurance company.
Consider the following scenario. For three days, a patient in previous good health experiences low back pain without radicular pain following a day of water skiing. She has a friend who had a lumbar laminectomy for herniated disc, and the patient requests an MRI to rule out disc herniation. Your assessment is that there is little likelihood that surgery would remedy the situation, based on the absence of radicular symptoms. Describe the ethical dilemma.
Response: There is a conflict between the physician’s respect for patient autonomy (which support the patient’s right to make decisions regarding their own welfare) and the physician’s respect for beneficence, the desire to do only those things beneficial for the patient. An MRI is likely to show no disc rupture, and thus will not influence the course of therapy. The issue is complicated by the fact that money not spent on this patient may be available to cover the cost of care for another patient.
Truth-telling states that the physician will tell the whole truth, not a half-truth or white lie. The truth is required even when, in the physician’s opinion, it would harm the patient’s psychological well-being. A dilemma arises when the patient’s desires run counter to truth-telling. Consider the situation of the unusual patient who says, I don’t want to know any bad news. Just figure out what is wrong, and treat me as best you can! You want to respect the patient’s request, but you also know that the patient has cancer and will need to make informed decisions about staging and treatments. You know that you cannot make the decisions for the patient because the decisions involve alternative approaches that depend on personal values and goals. You must balance the application of truth-telling with the application of autonomy.
Trust-which is built on truth-telling, beneficence, and nonmaleficnece?has additional implications in the patient-physician relationship. Trust allows for mutual win-win problem solving. It allows a patient to place his or her welfare in the hands of the physician, but also convinces patients that their physician is not directly responsible for sub-optimal medical outcomes.
Consider the following scenario: You have been the primary care physician for Mary for many years. Recently, she sought your advice for tiredness. Mary’s T4, T3RU, and TSH indicate normal thyroid function. She has a normal thyroid gland by palpation and scan. You advised that the thyroid was not a cause of her tiredness. Nonetheless, she sought advice from another physician who runs a weight loss clinic. He advised weekly tests of thyroid function, and thyroid supplementation. She asks your counsel. You should:
1. Terminate the physician-patient relationship, noting that you cannot provide care for her if she is consulting another physician.
2. Advise her to follow the recommendations of the other physician.
3. Advise her that you see no reason for weekly tests or supplementation, but will continue as her PCP even if she chooses to take advice from another physician.
4. Report the other physician to the state medical board for unethical practices.
Response: In this case, autonomy mandates that the patient is the ultimate decision-making authority. Even though you are her PCP, she has the right to seek advice from others. In a disagreement about appropriate treatment you should acknowledge the diversity of opinion in medical issues, but reiterate your position that she does not have a thyroid problem. You should also state that you support her right to obtain second opinions, and your willingness to continue as her advocate and PCP despite the difference of opinion. An ethical issue is involved if the other physician is intentionally giving false advice (as opposed to unintentionally giving bad advice).
Confidentiality is the third element of Respect for Persons. Physicians are expected to keep confidential what they know about patients. The advent of health insurance, utilization management, and disease management threaten this element. Patients, by virtue of their contracts with insurance companies or their use of legal entitlements, have given up some of their rights in order to get benefits (usually by signing an insurance form). These agreements allow all diagnoses and clinical information to be shared with insurers, the government, managed care organizations, and numerous others. However, each organization that receives information is expected to maintain the confidentiality so that none except those who need to know are provided with the information.
Consider the following scenario: Gary is a 13-year-old boy with abdominal pain, diarrhea, night blindness, and guiac positive stools. You think the symptoms and signs are likely due to inflammatory bowel disease involving the terminal ileum. You submit to the health plan a request for preauthorized payment for the patient to have an upper GI endoscopy performed by an out-of network gastroenterologist. The request is denied because the gastroenterologist is out- of-network. The employer has called stating their support of the patient’s interest, and requests a periodic update. Your office manager asks whether it is ethical and legal to divulge patient-specific data to the health plan without the patient’s written consent.
Response: Patient-specific information can be divulged only with the patient’s consent. When the patient signed for health insurance (either directly signing for it or indirectly choosing the insurance from a menu of plans offered by the employer), the patient likely agreed to the insurance company being given medical information for the purpose of utilization review or claims payment. The health plan has a legal right to the medical information. The patient’s consent, however, is limited to the health plan. You do not have a legal right, despite good intentions, to divulge the information outside the health plan network of physicians. Specifically, you do not have the right to divulge information to the employer. Doing so will place you in medical-legal liability.
The fourth element of Respect for Persons is fidelity. Fidelity means keeping one?s word. Physicians are expected to do what they say they will do with regards to treatment of the patient. Put another way, physicians need to keep their promises.
In summary the four parts of Respect for Persons are:
A useful pneumonic to remember the 4 parts of Respect for Persons is:
ACT w/ Fidelity
Beneficence is acting with charity and kindness. Medical care is intended to benefit the patient. This requires the physician to do all he/she can to aid the patient. Charity is love of one’s fellow human being, an act of good will or showing a caring attitude. It is from this principle that many of the not-for-profit charitable health care organizations were formed. The mission of charitable institutions requires that charity care be given even when patients cannot afford to pay for the service. Providing free care in your office is beneficence. Other acts of beneficence include opening the office for a patient who arrives after hours, providing services or advice for a community organization, or providing special services that benefit the community.
The third principle in ethics is nonmaleficence. This principle is similar to the Hippocratic Oath, First, do no harm. Physicians are expected to undertake those actions that are beneficial to the patient and to avoid those that are harmful to the patient. Though few physicians would disagree with this principle, its complexity is illustrated by situations where the patient may experience pain or potential harm from a treatment. The more dangerous or threatening the treatment, the more nonmaleficence plays a role in decision-making.
Consider this scenario: Besides his clinical practice, Dr Johns serves as director of the local blood bank, for which he receives a fair salary. Because the bank is recognized as an important community resource, Dr Johns has benefited from positive publicity, including a newspaper biography that describes his work for the blood bank as beneficent. Is it?
Response: Beneficence is characterized by kindness and charity. Beneficence is more a sate of mind, and demonstrated over time, rather than by a single act. It does not have to involve money. Since he has a salaried position, it is difficult to straightforwardly declare Dr. John’s work for the bank as beneficent. On the other hand, if the work is in addition to his clinical work, it may cost him more of his most precious commodity: time. The salary may be incidental. If he has given of his time, especially if it affects his personal life, then one could make an argument that his work is beneficent. If he later gives the salary to charity, then both the blood bank work and the cash gift demonstrate beneficence.
Webster defines justice, the fourth principle, as being righteous, impartial, and fair. Justice is applicable not only to the care of the individual patient, but also in the case of resource allocation decisions now required daily by Medicaid, Medicare, HMOs, insurers, and employers.
Equal treatment is also a concept that falls under justice. Justice requires that all patients with equal health insurance benefit or coverage (or who will pay their own bill) be offered equal treatment, regardless of the source or amount of payment. Justice does not require equal treatment if the patients have different benefits or will not pay their bill. Further, justice does not allow discrimination based on payment. If two patients have similar benefits, but you have contracted to accept different payments, the two patients have a right to equal treatment. Justice, in delivery of contracted health care, depends on the benefit, not on the payment methodology.
The physician is confronted daily with different payers who have various levels of coverage. This results in different expectations on the part of both payer and patient. From the insurer’s perspective, as long as the patients under one insurance benefit plan receive equal care, justice has been served for their beneficiaries.
Furthermore, justice does not imply that services should be provided even if the patient is unable to pay the bill directly or via health insurance coverage. Providing services for free would be at the physician’s discretion and expense, and would be an example of beneficence. In other words, justice also allows for fairness to the physician. If he/she treated every patient for free, then the clinical practice would probably fail financially. Not only would the physician be harmed, but also his/her services would no longer be available for community benefit.
Consider this scenario: Your medical clinic offers the only diabetes education resources within a 75-mile radius. The education service has been losing money since the new director you hired instituted guidelines to insure that all patients receive fair and equal treatment. You discover that the services are being provided to all patients regardless of their insurance coverage. Your director says she has an ethical responsibility to treat all patients equally, and that you have an ethical responsibility to accept the monetary loss incurred by provision of these services.
Response: Justice requires that you offer necessary services to all patients who require them. Justice does not require that you deliver the services for free. The director will benefit from education about the ethical principle of justice.
Chapter Two Summary
Medical ethics are derived from:
Respect for persons
Autonomy: Govern one’s own affairs
Truth-telling: Tell the whole truth
Confidentiality: Maintain privacy
Fidelity: Keep one?s word.
Charity: Toward the patient
Kindness: Toward the patient and the family
Do no harm
Equality in treatment
Fairness in dealings
Impartiality in treatment decisions
CHAPTER THREE: Laws, Professional Ethics, and Codes of Conduct
Laws are considered minimum standards to govern human behavior in society. Legislators and regulatory bodies establish these minimum standards. Those who do not abide by the minimum standards are subject to penalty appropriate to the unlawful act.
Physicians, however, are professionals. The professions are characterized, at least partially, by criteria for entry and standards of ethical conduct. Further, professions promote positive action on the part of their members toward meeting ethical standards. Not surprisingly, professional medical ethical standards for physicians, as a subset of general ethics, are based on the four principles of ethics: respect for persons, beneficence, nonmaleficence, and justice.
Physicians are expected to have higher standards than the law requires. These guidelines are expressed, for instance, in profession-specific standards and Codes of Ethics. Although a medical license is a legal requirement for physicians, once that license is obtained, employers, patients, peers, and society have expectations of the physician that are higher than the standards of the law. As a result, the physician is often faced with the dilemma: It may be legal, but it is unethical. Because ethical principles are stated in generalities, it is sometimes difficult to discern how physicians should act to be consistent with their principles. Oftentimes professional associations develop interpretations or explanations of ethical behavior. For instance, the ethical principle of confidentiality is explained in the American Medical Association?s ?Fundamental Elements of the Patient Physician Relationship as follows5:
The patient has the right to confidentiality. The physician should not reveal confidential communications or information without the consent of the patient, unless provided for by law or the need to protect the welfare of the individual or of the public interest.
The explanation goes beyond the simple concept of confidentiality at all costs, and actually describes when the physician should release information without patient consent. The statement also recognizes that patients, by providing consent for release, may give up part of their right to confidentiality. For instance when a patient signs to get health insurance, he/she usually provides consent to the insurance company to get information for specific purposes for utilization management or paying claims. This is why physicians do not have to get patient consent before putting a diagnosis on a claim form and submitting it for payment.
The American Medical Association Code of Ethics
Many physician professional associations have developed and documented principles of medical ethics or a code of medical ethics. Each is based on the four principles of ethics, and many are similar.
For this course, we have chosen to review a code of ethics published by the American Medical Association because the organization has the largest membership of any physician professional organization, represents all physician specialties, and has been in existence for decades. The document has two parts. The Principles of Medical Ethics is composed of 7 short statements, and the Fundamental Elements of the Patient-Physician Relationship is composed of 6 short statements. As you read the AMA Principles of Medical Ethics, determine which ethical principle it promotes.
American Medical Association
Copyright 1995-2000 AMA. All Rights Reserved
Principles of Medical Ethics
The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility not only to patients, but also to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct that define the essentials of honorable behavior for the physician.
Principles of Medical Ethics
1. A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity.
2. A physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception.
3. A physician shall respect the law and recognize a responsibility to seek changes in those requirements that are contrary to the best interests of the patient.
4. A physician shall respect the rights of patients, of colleagues, and of other health professionals, and shall safeguard patient confidences within the constraints of the law.
5. A physician shall continue to study, apply, and advance scientific knowledge; make relevant information available to patients, colleagues, and the public; obtain consultation; and use the talent of other health professionals when indicated.
6. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical services.
7. A physician shall recognize a responsibility to participate in activities contributing to an improved community.
Choose at least one ethical principle for each AMA principle:
Respect/ Autonomy/ Truth-telling/ Confidentiality/ Fidelity/ Beneficence/ Nonmaleficence/ Justice
Note that each of the AMA principles embodies one of the four principles of ethics. Most of the AMA principles address the welfare of the patient (I, II, and IV, for instance), but several address the welfare of the physician (VI,) or the community (VII). These ethical principles help define the relationship between the physician, his/her patients, and the community in which the physician works and lives.
American Medical Association
Copyright 1995-2000 AMA. All Rights Reserved
Fundamental Elements of the Patient-Physician Relationship
From ancient times, physicians have recognized that the health and well being of patients depends upon a collaborative effort between physician and patient. Patients share with physicians the responsibility for their own health care. The patient-physician relationship is of greatest benefit to patients when they bring medical problems to the attention of their physicians in a timely fashion, provide information about their medical condition to the best of their ability, and work with their physicians in a mutually respectful alliance. Physicians can best contribute to this alliance by serving as their patients’ advocates and by fostering these rights:
1. The patient has the right to receive information from physicians and to discuss the benefits, risks, and costs of appropriate treatment alternatives. Patients should receive guidance from their physicians as to the optimal course of action. Patients are also entitled to obtain copies or summaries of their medical records, to have their questions answered, to be advised of potential conflicts of interest that their physicians might have, and to receive independent professional opinions.
2. The patient has the right to make decisions regarding the health care that is recommended by his or her physician. Accordingly, patients may accept or refuse any recommended medical treatment.
3. The patient has the right to courtesy, respect, dignity, responsiveness, and timely attention to his or her needs.
4. The patient has the right to confidentiality. The physician should not reveal confidential communications or information without the consent of the patient, unless provided for by law or by the need to protect the welfare of the individual or the public interest.
5. The patient has the right to continuity of health care. The physician has an obligation to cooperate in the coordination of medically indicated care with other health care providers treating the patient. The physician may not discontinue treatment of a patient as long as further treatment is medically indicated, without giving the patient reasonable assistance and sufficient opportunity to make alternative arrangements for care.
6. The patient has a basic right to have available adequate health care. Physicians, along with the rest of society, should continue to work toward this goal. Fulfillment of this right is dependent on society providing resources so that no patient is deprived of necessary care because of an inability to pay. Physicians should continue their traditional assumption of a part of the responsibility for the medical care of those who cannot afford essential health care. Physicians should advocate for patients in dealing with third parties when appropriate.
Choose at least one ethical principle for each AMA principle:
Respect/ Autonomy/ Truth-telling/ Confidentiality/ Fidelity/ Beneficence/ Nonmaleficence/ Justice
Each of the fundamental elements of the patient-physician relationship addresses one of the four principles of ethics. These fundamental elements go a step further, however, because they delineate specific patient rights that accrue from the patient-physician relationship. Obviously, some address specific problems that have arisen in recent years, such as discontinuity of care (Element 5), which has been more frequent as more stakeholders have entered into the patient-physician relationship, and as patients either voluntarily or involuntarily select new insurance companies.
Scenario: Currently, the health care news is full of articles describing how Medicare beneficiaries are experiencing discontinuity of care as insurance companies terminate their Medicare HMO products secondary to financial losses. Which of the AMA principles and fundamentals apply directly to this situation?
Response: The AMA Fundamental 5 supports continuity of care and delineates specific action that the physician must take to support that care. When the HMO terminates its coverage, the physician may not discontinue treatment of a patient as long as further treatment is medically indicated, without giving the patient reasonable assistance and sufficient opportunity to make alternative arrangements for care.
The AMA Principle 6 provides that physicians, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical services. If it is acceptable for a physician to limit customers based on location or payers, then it is likely to be acceptable for an insurance company to do the same.
Summary of Chapter Three
1. Laws are considered minimum standards that govern human behavior in society.
2. Physicians, as professionals, are expected to have higher standards than the law.
3. Many physician professional associations have developed principles of medical ethics based on the four principles of ethics.
4. The AMA code of ethics is one description of ethical actions that address physician behavior in the context of the patient-physician relationship and the community.
CHAPTER FOUR: The Role of Ethics Committees
The Challenge of Ethical Decisions
The difficulty of ethical dilemmas is due to several factors. First, there are at least two stakeholder groups that will be potentially served or harmed by any given decision. Second, both groups think they are in the right and since ethical dilemmas are frequently about right versus right decisions, each group, from their own ethical standpoint, is right. Third, ethical issues often are emotional. Both group and individual ethics are built from a summary of social and personal experience. We are who we are at least in part from our immersion in the ethic predominant in our environment. In this way, a challenge to our ethics is a challenge to our very essence. As a consequence, ethical issues evoke the deepest of emotions, and provoke sacrifice in order to preserve the ethical ideal. Therefore, disagreements about ethical issues can be dangerous as well.
Advantages of Group Decision Making
Because ethical decision-making can be difficult and emotional, organizations frequently deem it beneficial to have committees deal with one or more of a variety of ethical issues. The use of a committee or group has several advantages:
- Involving a number of individuals increases sample size for determining ethical values, and increases the likelihood that the group?s decision will be aligned with the organization and community.
- Involving key stakeholders allows for introduction of all the important information that needs to be considered, and provides a formal, sanctioned decision-making group.
- If it is a chartered committee, a group provides documentation of the proceedings so that others will know what information was presented and how the decision was made.
- The decision of a group is more easily supportable than a decision by one individual.
- No one individual is responsible for the decision.
- A defined group has the opportunity to incorporate and/or develop technical and procedural expertise to enhance decision-making.
The roles of a group within an organization are as follows:
- Review institutional mission and value statement.
- Educate staff about selected ethical issues.
- Discuss individual ethical dilemmas.
- Undertake specific actions (in certain instances).
What is an Ethics Committee?
An ethics committee is any group chartered to undertake the above listed roles. This group may or may not be called a committee. In fact, many traditional medical committees address ethical issues and undertake ethical decision-making. Examples of committees that address ethical issues are included in the Table below.
When to Involve a Group in Ethical Decision Making
Often an organization or group mandates that certain groups be involved in ethical decision-making. For instance, the Credentialing Committee is chartered to assess each applicant physician in order to determine if the group will accept the physician as a practice peer. Similarly, a Pediatric Bioethics Committee might be activated whenever a nonviable infant is expected or delivered.
When a physician recognizes a potential ethical issue, one of the first considerations is whether there is a committee or group that is available to address the issue. Referring to the group is usually preferable because of the advantages listed above.
It is important, however, that some thought be given to defining the appropriate group. A good example is physical abuse of an elderly person. A hospital administrator, on hearing of the suspected abuse, might want to summon the hospital ethics committee. If, however, the ethics committee is a pediatric bioethics committee charged with addressing pediatric cases, the membership and experience will be inadequate to analyze the case of the elderly citizen. It is important to ensure that ethical issues are referred to a decision making body appropriate for the situation. The mere inclusion of the word ethics in a committee title does not infer that the committee is appropriate for all ethical issues.
The role of the administrative ethics committee is becoming more important. When health care was a cottage industry, there were few stakeholders involved in any one decision, so the traditional medical committees (Credentialing, Utilization Management, Quality Management) served the needs for ethical decision-making. However, as health care has evolved to the corporate model, many challenges to ethical decision-making have evolved:
- Stakeholders have increased. The diversity of organizations creates opportunities for improving patient care. However, the diverse organizations have their own set of ethical standards, often different from traditional medical ethics.
- New business methods create opportunities for efficiency, but also opportunities to impair the ethical rights of patients.
- New communication technologies create opportunities to improve access to information and care, but also opportunities to destroy patient autonomy and confidentiality.
How to Involve a Group in Ethical Decision Making
Remember, ethical issues are difficult and emotional. Therefore, diligence is required in identifying these issues. A few points deserve emphasis:
1. Make sure the issue is an ethical issue?that it affects respect for persons, beneficence, nonmaleficence, or justice and that it is not just a difference of opinion about how to do something.
2. Conduct respectful baseline research to substantiate the key facts. The emotionality of ethical issues creates a tendency for all parties to act or react emotionally rather than on a carefully considered basis.
3. Try to locate a group that has responsibility for the issue. Using general terms, and without identifying individuals, ask one person from the group if indeed the group does get involved in that type of issue. Ask how the group prefers to be notified of potential issues.
4. Plan your verbal or written presentation. Identify and factually describe specific situations or behaviors that are questioned. Search for and eliminate any phrases that identify judgments, opinions, or guesses. If you can still make the case without these phrases, then you have enough factual material to pursue. Phrases to eliminate include those that
1. Reflect personal opinion (In my judgment, I think)
2. Use hyperbole (She’s always slapping the child, He’s always drinking.)
3. Ascribe motivation (He likes the thrill, She does it because)
5. If you address the committee, keep the presentation factual and unemotional.
6. Delegate the issue to the committee. Once you have identified the issue and the proper group has addressed it, it is not necessary for you to continue to pursue it. However, ethical issues are difficult to lay aside because they are so emotional.
Summary of Chapter Four
1. There are advantages to group decision making for ethical issues.
2. An ethics committee is any group chartered to undertake review of ethical issues. These include Credentialing Committee, Quality Assurance Committee, Peer Review Committee, Neonatal Ethics Committee, Institutional Review Committee, Administrative Ethics Committee, and others.
3. Identifying an ethical issue is a delicate matter. Due diligence in preparation is worthwhile.
Consider this Scenario: University Hospital conducts human research, sponsored by the National Institutes of Health. You find that some patients are being entered into the protocol despite the fact that they do not meet criteria for the study, and that some are being treated with medication doses not described in the protocol. When you question a physician who is the lead researcher, he tells you to, Mind your own business! The best approach to the problem is:
1. Visit the hospital administrator and describe the problem to him.
2. Telephone the National Institutes of Health and report the problem.
3. Read the protocol and related documentation, then ask a member of the Institutional Review Committee how protocol-related concerns should be addressed.
4. Report you concerns to the Credentialing Committee.
Response: The correct response is c. You should substantiate factual information, select an appropriate committee, seek general guidance from one member, and prepare a factual presentation that relates concerns. Answer a is not optimal because the administrator does not have the direct involvement or decision making capability for medical research issues. Answer b is not optimal because it is usually best to first involve the next level of oversight responsibility. If you were convinced that the IRC, after reviewing the situation, did not act appropriately, then it would be acceptable to notify the NIH. Answer d is not optimal. The research issue, because it is not yet resolved, will likely not support a credentialing action.
CHAPTER FIVE: An Individual Model for Ethical Decision Making
Although ethics committees have advantages for ethical decision-making, sometimes a group analysis is not appropriate. This is the case when the decision is so personal that a committee will likely be able to have only limited insight, or when there is no committee appropriate for the ethical consideration. So individuals often find themselves alone addressing the ethical issue. In this chapter, we present a model that individuals can use when grappling with decisions that have ethical implications.
Since committees are composed of individuals, the individual model for ethical decision making may be useful for committees. Even though these committees have proscribed procedures or methodologies, each member must be aware of ethical principles and have a methodology (model) of analyzing the information presented to the committee.
Individual methodologies of ethical decision-making vary dramatically. Some individuals will choose to ?sleep on it.?8 This model is faulty in that we all know people who sleep soundly despite being unethical, and others who can’t sleep precisely because they are worried about making the right decision. Other individuals advocate, Do what is right for you. This model emphasizes the individuality of ethics and de-emphasizes the affect of decisions on other individuals, groups, and society. To have utility, a model must be simple, straightforward, based on accepted ethical principles, and include personal, organizational, and cultural aspects.
The model below incorporates the reasoning process described by Joseph Badaracco. It is simple and straightforward, comprised mainly of short questions. Each question is based on the teachings of one or more of the great ethicists, so the model encompasses accepted ethical principles. The answers to the questions will depend on the ethical perspective of the individualsthus incorporating personal, organizational, cultural, and temporal aspects that influence ethical decision-making.
Here is a model an individual may use to address ethical issues:
1. Make sure the issue is an ethical issue?that it affects respect for persons, beneficence, nonmaleficence, or justice.
2. Conduct baseline research to substantiate key facts.
3. Review a professional code of ethics if the code applies to the current issue; determine how the code influences your decision.
4. Review the four principles of ethics and how they apply to the situation.
5. Answer the following six questions:
1. What provides the most good for the most people? This question arises from the work of John Stuart Mills. Any action has positive consequences for some people and negative consequences for others. Social welfare is usually but not always supported when a decision is right for most people. The question helps to identify the stakeholders and how they will be influenced. However, we need to identify all the stakeholders. If we have not, then we have not identified all the positives and all the negatives.
2. Is the action right for everyone? This question encompasses Kant’s Categorical Imperative which states that if an action is not right for everyone, then it is not right for anyone. The question emphasizes that rightness is a relative thing, and allows us to double check that we have identified stakeholders and the effect of the decision on them.
3. Is it right for me or others to take the action repetitively? This question derives from Descartes? Rule of Change, which argues that if an action cannot be taken repeatedly, then it is not right to be taken at any time. Whenever we argue that we are going to do something just this once, it is a indicator that we recognize that doing it even once is not right. Furthermore, if we consider doing something that we would not want done to us, then we are considering an action with negative consequences to which we would not want to be the subject. This question contains the essence of the Golden Rule.
4. Does the action trample on any human rights? Any action that impairs human rights, namely life and liberty, should be avoided at any cost. However, do not be misled by the application of the word rights to legal entitlements such as right to health care or right to education.
5. What do I become if I undertake this action? Does this action make me into a potential monster in the eyes of others? If so, then it is a sign that this culture, and the ethics of that culture, will find the action unethical, regardless of the other arguments in its favor.
6. Will the action work in the real world? Ethical issues apply to actual people in the world. If the solution requires the world to change its opinion, then it is not a feasible solution for a real world problem.
This model and these six questions encourage gathering the data necessary to address ethical issues within the context of ethical thought. However, it also enables an overlay of personal, organizational, and cultural judgements that allow any decision to be the right decision for the time and culture in which it is made.
Summary of Chapter Five
1. Ethical decision-making is complex, and often involves right versus right decisions.
2. Individual methodologies (or models) of ethical decision-making vary dramatically.
3. Six questions useful to assess ethical issues include:
1. What provides the most good for the most people? 2. Is the action right for everyone? 3. Is it right for me, or others, to take the action repetitively? 4. Does the action trample any human rights? 5. What do I become if I undertake this action? 6. Will the action work in the real world?
Consider this Scenario: Tom Garrison is a 63-year-old retired engineer who, for over 20 years, has been a patient of yours with high blood pressure. He is a respected community leader, and has supported your role in a service organization, even making a generous contribution. He recently elected to have some surgery completed to change the shape of his ears. The cosmetic surgery is not a benefit of his insurance policy. He has just discovered that the insurance company will pay for the surgery if he can document hearing difficulty prior to the surgery. He asks you to write a letter documenting hearing impairment. He notes that he had suspected hearing impairment for some time. He wants you to accept this self-diagnosis out of respect for him and the longstanding relationship, and he wants you to write a letter saying he has hearing impairment. You do not remember any of mention hearing impairment. Discuss your approach to the issue.
1. Is it an ethical issue? Yes. It is right to support your friend and patient, but it is also right to be totally factual and honest in your dealings with the patient and insurance company.
2. Conduct research and try to find another alternative that avoids the ethical issue. If your office records do not show hearing impairment, he may be able to get past records from elsewhere that do document the problem. You may want to check with the insurance company to see exactly what kind of information is required. Perhaps the insurance company will accept documentation of current hearing impairment as presumptive evidence of past hearing impairment.
3. The AMA Principles of Medical Ethics include a principle to deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception. You decide you will not write the letter without documentation of hearing impairment.
4. The four principles of ethics advocate: 1. Respect for patients. You respect him, but lying for a patient is not necessary to reflect respect. 2. Truth telling. You will support him as long as you can do so while telling the truth. You can even write a letter reflecting that he claims to have had hearing impairment earlier, that you did not evaluate it, and that you have no records to document it. You could even go so far as to say you believe him. But the requirement for honesty requires that you not lie for him.
5. Ask the six questions. The most good derives from honest dealing between health care entities. You wouldn’t want employees or associates lying to you, so the action is not right for everyone. You would not want to lie repetitively, so doing it once is not right. The issue does not affect human rights. You do not become an inhumane if you refuse his request (though he may tell you that). Your decision to not write the letter will work in today’s world. In fact, your reputation may be enhanced by a straightforward approach to the problem.