Ethical principles in Healthcare



Brief Primer on Ethics

Definitions

Ethics -- from the Greek ethos, originally of character -- concerns questions of good, right, duty, obligation, virtue

Morality, from the Latin mores, custom or habit, is Cicero’s transliteration of the earlier Greek, ethos.

Some people tend to use “moral” of personal conduct, and “ethical” of professional or institutional standards.

So ethics is concerned with questions of good and right, -- but alone that does not tell us very much. It is goodness and rightness of a particular type -- moral (ethical) goodness and rightness.

Every attempt to define ethics is controversial and contested, the definition and scope of ethics depends on the moral theory one is using at the time. That should not be cause for despair, but rather should prompt a recognition that discussions of ethics will always be challenging and should be conducted in such a way that we recognize the potential for disagreement but share the commitment to solutions.

There are however, some general points of agreement in the way we talk about and reason in ethics.

First, our moral decisions, judgments and reasoning should be consistent. That is, a moral judgment, statement, or obligation applies impartially to any relevantly similar person in any relevantly similar situation

Second, our moral judgments or conclusions are motivating -- a moral judgment, statement, or obligation provides a motivation for acting

Third, and this is one of the most significant features of ethical deliberation and judgment, ethical reasons are compelling. A moral judgment, statement or obligation supercedes other reasons for acting

If that is a word about the form or structure of ethics, what about the content? Ethical issues can arise in any aspect of our personal our professional lives. In our personal lives ethical issues or questions can arise in our dealings with other people (many of our ethical principles concern how we should treat others.) Many people also argue that our ethical commitments extend to our treatment of other animals too. In our professional lives ethical issues can arise in any aspect of health-care from the bedside to the boardroom.

Ethical principles and values

Our ethical reasons often get presented in the form of principles or values. A simple ethical principle would be “Do not lie,” and a corresponding value would be “honesty,” or truth-telling. Our ethical challenges often arise when we worry about the applicability of a principle in a particular situation. Yes, we accept the principle “Do not lie,” but what if lying was the only way to save an innocent person’s life? What happens if the principle “do not lie” comes into conflict with the principle “save a life where possible?”

This is the realm of ethical debate and discussion. What do we do, how do we choose, when our ethical principles or values come into conflict?

Ethical issues in health-care

Some ethical issues in health care are obvious. We all accept that there are important ethical decisions to be made about end-of-life care, resuscitation and so on. But the issues in patient care are far broader. For example, the very requirement that we gain “informed consent” before embarking on a course of treatment is an ethical requirement grounded in the principle that we should respect people’s personal autonomy, and not do things to them without their permission. But what are the limits of consent – and as important, what are the limits on a patient’s refusal to accept treatment?

The very process of priority setting in health-care, is a process of allocating scarce resources to one area rather than another. Given that there is always more that can be done in health-care, and given that resources are always limited. , any decision to do one thing entails a corresponding decision not to do something else. How do we decide that we value this service, for these patients, over that service for these other patients?

The Role of Reason

A couple of things should now be clear. Ethical issues, questions, choices, arise in any aspect of our personal or professional lives, and when they arise we are a faced with a choice. That process of choice-making is a reasoned process, where we seek to do the best that we can. In health-care we typically make these difficult decisions as professionals and members of teams, who have a commitment to the patients, clients and the communities we serve.

Any list of principles that may be applicable in reasoning about an issue in health care will necessarily be incomplete. Feel free to use what follows as a starting point, but also recognize first, that you may well express the same idea using completely different words, and that’s OK; and second you may well bring in other and relevant considerations – and that’s not just OK, it’s essential.

Ethical principles in Healthcare *

Delivery of health services is a continual process of balancing values, principles and interests in the allocation and delivery of health services. Commonly, principles or values come into conflict and must be reflected upon to help you decide how to proceed. Below are some of the important ethical principles that are prevalent in health care service delivery. These principles are not in order of priority:

1. • Autonomy: the right to self-determination, independence and freedom. It involves the provider’s willingness to provide information to the client so that they may make informed decisions and subsequently respect a client’s right to choose what is right for himself, even if the provider does not agree with the client’s decision. Informed Consent is an example of how this principle is applied.

1. • Beneficence: to “do good”. This requires that providers perform acts that will benefit clients. Good care requires that the provider understands the client from a holistic perspective that respects the client’s beliefs, feelings, wishes and values, as well as those of the client’s family or significant others. Beneficence involves acting in ways that demonstrate caring, listening, supporting and nurturing.

2.

1. • Non-Maleficence: protection from harm. This requires that providers do not harm their client, even if they cannot protect themselves. Hazards in the workplace may put the client at risk. Staff are expected to identify such risks and act to prevent harm.

1. • Justice: the obligation to be fair to all people, regardless of their race, sex, sexual orientation, marital status, medical diagnosis, social standing, economic level, or religious beliefs. The principle of justice can further be expanded to include distributive justice such as fair access to and fair allocation of resources and procedural justice, or shared decision-making; including people in the decisions that affect them.

1. • Confidentiality: the obligation to keep patient and organizational information confidential. Professional standards and privacy legislation provide guidance on the conditions under which health information can be ethically and legally disclosed.

1. • Sanctity of life: the principle that every life is of equal and infinite value. In its extreme form (vitalism), this principle would be upheld at all costs, no matter what its quality. A more moderate interpretation of this principle is that life has instrumental value (to carry out a purpose).

1. • Quality of life: the principle that mere biological existence does not in itself have value; rather that life gives rise to activities and experiences which provide pleasure, satisfaction and well-being. The person whose life is in question is the only reliable judge of that life’s quality. There are situations where the SDM is required to make that judgement based on their knowledge of the patient’s previously expressed wishes.

1. • Paternalism: the practice of controlling, monitoring or deciding what is good for an individual rather than letting him choose for himself (the opposite of autonomy). This includes restricting someone’s freedom to act to prevent him from harming himself (eg. Use of restraints, suicide prevention) and restricting someone’s autonomy. Paternalism is rarely justifiable with a mentally competent adult client.

1. • Veracity: being truthful or not intentionally misleading or deceiving clients.

Based on mutual trust and respect for human dignity, this would require open and honest communication in a way that helps clients deal with the anxiety this knowledge may create. Concealing or guarding clients from the truth to “protect” them is rarely ethically justifiable.

• Fidelity: faithfulness to the relationship and/or to your role. The sacred trust related to this relationship. Persons must act in accordance with their respective roles.

* Ethical Principles developed by the Hôpital Régional de Sudbury Regional Hospital (HRSRH)

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“We are discussing no small matter but how we ought to live.”

Socrates via Plato in The Republic

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