Ethics for Healthcare Professionals

100% of participants will apply ethical principles in decision making.

Upon completion of this course, the participant will be able to achieve the following objectives:

• Define four ethical principles commonly affecting healthcare professionals.
• Identify four causes of ethical dilemmas for healthcare professionals.
• Describe the most frequently used model for ethical decision making based on a clinical situation.
• Differentiate between capacity and competency when assessing an individual’s decision-making capacity.
• Identify three benefits of advanced care planning.

Ethics is set concepts and principles that guide the determination of behavior. Healthcare professionals are in a trusted position but are also human. That is why healthcare professionals must be able to promptly and fully self-disclose facts, circumstances, events, errors, and omissions when such disclosure could enhance the health status of patients or the public or could protect patients or the public from unnecessary risk of harm.

Healthcare professionals have a duty to the patient. That is the highest level of responsibility. Employers, other team members, and the healthcare professional's personal interests do not outweigh this fundamental responsibility. Healthcare professionals must be aware of their actions and feelings within the therapeutic relationship, identify the invisible boundaries, and act in the best interest of the patient.

Healthcare professionals are in a position of power. It is important to practice in an autonomous role with patients, their families, significant others, and members of the public during difficult times in their lives. Healthcare professionals are in a position to take advantage of vulnerable people and should avoid any abuse of trust.

A healthcare professional has an important role in maintaining professional boundaries and must be able to know, recognize, and maintain professional boundaries of the healthcare professional-patient relationship. Violating the professional boundaries of the healthcare professional-patient relationship includes, but is not limited to, physical, sexual, emotional, or financial exploitation of the patient or the patient's significant other.

Morality is social conventions about right and wrong agreed upon amongst a population.

Values include your beliefs, likes, dislikes, and preferences. Things that determine personal values are educational background, life experience, cultural beliefs, family beliefs, and religious beliefs. Different people have different values. Different cultures have different values and values are different even within cultures. Values change over time and in different situations.

Personal ethics and values differ from professional ethics and values. Your personal ethics and values affect your practice. Value and ethical conflict occur if you fail to recognize that values and beliefs are different for individuals of different cultures and within the culture.

Sources of professional values:

• professional organizations
• state healthcare professional practice act

Some areas where clinicians are faced with ethical dilemmas pertaining to healthcare include:

1. Balancing safety of health care with efficiency and limited resources
2. Improving access to healthcare
3. Addressing end-of-life issues in the context of increasing average life expectancies and aging populations
4. Access to medications which can be costly but life-saving
5. Allocation of limited donor organs
6. Patient confidentiality
7. Disclosure of medical errors
8. Religious or cultural beliefs that differ between patients and healthcare professionals

Many ethical dilemmas may have medico-legal implications. It is crucial that healthcare professionals:

• Use evidence-based practice
• Be aware of their legal duties to a patient
• Provides a reasonable standard of care that would hold up to professional review should there be any accusations of medical negligence
• Document thoroughly and timely

Ethical Dilemmas usually involve making difficult decisions. Decision making often requires recommendations by the clinician or provide information about the patient’s best interest. Criteria frequently used to determine best interest of the patient includes¹:

• Determining what the patient finds acceptable or unacceptable regarding quality of life
• Reviewing the benefits and risks of each reasonable intervention
• Characterizing the risk and the degree of suffering and pain associated with an intervention
• Giving the expected prognosis with and without treatment

Healthcare professionals that limit ethical decision making to one framework may cause conflict with the patient and their loved ones. Multiple ethical frameworks should be considered, particularly in complex clinical situations.

The most common framework for medical ethical reasoning in the United States is called principlism. It includes the four guiding principles in medical ethics¹:

• Respect for Autonomy
• Beneficence
• Non-maleficence
• Justice

Principlism decision making becomes stuck when principles contradict each other.¹ For example, a patient with end-stage cancer may have the personal belief that he or she must be told so that he/she can make decisions and use remaining time well. However, the patient’s family may insist that the patient not be told because they believe that knowledge will rob him or her of the will to live. In such a situation, the principles of respect for autonomy and principle of non-maleficence are at odds. So, who decides what happens with the patient?

Jonsen’s “Four Box Model” for clinical ethical decision making, helps clinicians prioritize the ethical principles of the clinical situation. This model balances medical decision-making elements that are important to health professionals with those patient-centered elements that are important to patient.¹

Utilitarian/consequentialist view stress acting in ways that maximize the balance of benefits and burdens.¹ For example, a utilitarian approach to deciding whether or not to offer cardiopulmonary resuscitation to a patient would weigh the likelihood of survival and subsequent quality and quantity of life against potential suffering and costs.

Deontological view is that some duties transcend calculations of net benefit.¹ For example, palliative care involves clinicians arguing for withholding or withdrawal of treatment based on a utilitarian assessment of futility, but the family members argue for continued treatment out of a sense of familial duty.

Communitarian view emphasizes communal values, the common good, social goals, traditional practices, and cooperative virtues.¹ For example, communitarians argue in favor of universal access to health care because it improves the quality of life for the entire community.

Principle of double effect (PDE) stipulates that³:

• the action taken is morally good or neutral
• the intended outcome is important enough to justify the unlikely but possible bad effect
• efforts are undertaken to minimize risk of the bad effect
• the unintended effect is not the means to achieve the desired effect

PDE is often used in the decision to give enough pain medicine at the end of life to relieve pain, even though it may suppress respiration. There is generally ethical consensus about the standard treatment of pain at the end of life. The position of the Catholic Church and the Supreme Court is that aggressive treatment of pain at the end of life is legally and morally acceptable.³ Even if death is hastened by the medication, provided that the intention of the action is to relieve pain and not to cause death.

Rights-based approaches emphasizes the rights of individuals.¹ For example, patients who are near the end of their lives have the right to participate and benefit from appropriate research.

Ethics of caring (or feminist ethics) holds that natural caring for others is the basis for moral behavior. It stresses caring relationships with others not based on individual rights, but rather on a strong sense of being responsible.¹ For example by explicitly taking the patient and his or her family as the unit of care, not just the patient.

Virtue ethics focuses on the moral character which informs behavior.¹ The virtues emphasized in hospice and palliative care practice include compassion/empathy, faithfulness, justice/advocacy, and practical wisdom.

Ethical relativism holds that morality is relative to the norms of one's culture. There are no absolute truths. What is morally right or wrong varies from person to person or from society to society. Variances in culture and society influence whether an act is moral.

Whatever approach is taken, utilizing the different perspectives and skills of the interdisciplinary team members to address ethical issues is needed.

Patient’s rights to make healthcare decisions is fundamental to the ethical principle of respect for autonomy and is a key component of informed consent to medical treatment.⁴ Determining whether an individual has adequate capacity to make decisions is, therefore, an inherent aspect of all patient interactions.

The main determinant of capacity is cognition.⁴ The patient’s condition or treatment that may affect cognition potentially impairs decision-making capacity. Determining whether a patient has adequate capacity is critical to respecting patient autonomy while acting in a patient’s best interest. Capacity assessment can determine the severity of a patient’s cognitive impairments and improve the effectiveness of conversations with patients and their families.

Capacity and competency are often used interchangeably, but there are differences. Capacity describes a person’s ability to decide. Competence refers to a legal judgment relating to whether individuals have the legal right to make their own decisions. Judges use a capacity assessment to reach a conclusion.

Advance care planning (ACP) helps avoid ethical dilemmas. It supports patients at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. ACP is often done by social workers or nurses as a part of case management or discharge planning. Studies show that ACP increased the quality of life for the patient and family.⁵

Documentation of the patient’s wishes helps ensure that people receive medical care that is consistent with their values, goals, and preferences. ACP facilitates the completion of Advance Directives and Do-Not-Resuscitate (DNR) order. The presence of a DNR order⁵:

• Decreases use of cardiopulmonary resuscitation
• Decreases in life-sustaining treatments
• Increases use of hospice and palliative care services
• Reduces the rate of subsequent hospitalizations

ACP interventions also decreased the number of in-hospital deaths, intensive care unit deaths, and increased the number of in-home deaths.⁵

Scenario 1:

Sue works the evening shift at a nursing home at 3:30 pm. Sue receives a call from her child's care provider, and her child is sick. She asks the charge healthcare professionals if she could go check on her child. This is the conflict between Sue's personal value of her child's health and her professional ethical responsibility of fidelity's in doing one's duty. If the charge healthcare professional allows Sue to go home, this resolves her conflict. If the charge healthcare professional does not allow Sue to go home the conflict remains unresolved.

Scenario 2:

Mr. X's physician has asked home health care to evaluate him for home health services. It is determined that Mr. X requires patient education related to his diet and medication. Physical therapy is also order. Mr. X allows the healthcare professional to come but refuses physical therapy. After Mr. X refuses to open the door for the therapist, the healthcare professional and therapists arranged to come together. Mr. X continues to refuse to participate in the physical therapy regimen. This is an ethical conflict between fidelity and beneficence in doing one's duty to carry out a beneficial patient care order and the patient's autonomy in his right to choose.

Scenario 3:

Ed recently received a concussion while participating in football practice one week prior to the final football game of the season which also happened to be a state playoff game. This concussion was his 3rd concussion within a year. The athletic trainer and team physician spoke to Ed and his father about the need to refrain from contact sports until being evaluated and cleared by a neurologist. Ed’s father, who also happens to be one of the coaches for the football team, felt the team needed him to win the game, and did not want Ed to miss his last ever football game. Ed felt he would be letting down his team if he missed such an important game; he really wanted to participate. This is a conflict between nonmaleficence in avoiding further harm to the patient and autonomy in the patient’s right to choose.

Scenario 4:

Gary, a 62-year-old diagnosed with squamous cell carcinoma with Mets to the brain, underwent a craniotomy to remove a large mass in his brain. Post-surgery it is recommended that Gary undergo short term intensive rehab followed by radiation and chemotherapy.   Gary's prognosis is fair due to the aggressiveness of his cancer.  Gary is admitted to the inpatient rehabilitation facility with an estimated length of stay of 21 days to achieve mod I level from the wheelchair to d/c to his home, where he lives with his wife who has MS.  Gary progresses nicely in Occupational and Physical Therapy. Achieving mostly mod I with occasional contact guard during mobility and ADL, family training is completed, and Gary is to be d/c’d the upcoming morning.  On the morning of d/c, Gary’s wife indicates that she is unable to provide the occasional contact guard needed for mobility and ADL and would like Gary to stay at the facility or go to a skilled nursing facility (SNF) for more therapy.  Gary’s insurance will not allow Gary to remain in the facility for continued therapy.  Gary desires discharge to home, stating “I need to get started with my cancer treatments” which cannot be provided in a SNF setting.  The healthcare team, discharging Gary to the SNF.  The team has utilized paternalism believing it is more beneficial for Gary to go to a SNF vs. autonomy and Gary's preference for d/c to home.

Healthcare professionals are in a position that requires personal believes and experiences to be put aside, and to place the patient’s interest as the highest priority.  Healthcare professionals face situations daily where they must make ethical decisions.  By employing different theories of ethical reasoning, such as principlism, healthcare professionals are better equipped to make the most ethical choice when facing complex clinical situations.  

1. Fromme, E. (2019). Ethical issues in palliative care Feb. 2019. UpToDate
2. Jonsen, A., Siegler, M. & Winslade, W. (2006). Clinical ethics: A practical approach to ethical decisions in clinical medicine (6th ed). New York, NY: McGraw-Hill.
3. Jackson, V. Nabati, V. (2019) Ethical considerations in effective pain management at the end of life. February 2019. UpToDate.
4. Karlawish, J. (2019) Assessment of decision-making capacity in adults. Feb 2019 UpToDate.
5. Detering, K. Silveria, M. (2019). Advance care planning and advance directives. UpToDate. Feb. 2019.