Ethics for Healthcare Professionals

What are ethics?

The concept of ethics began with the introduction of moral codes into the realm of human existence. Ethics comes from the Greek word "ethos," which represents character. Ancient Greece is considered the birthplace of Western theoretical ethics. Socrates, who is viewed as one of the foremost teachers of ethics, declared that "the unexamined life is not worth living."

The writings of the 19th-century German philosopher Immanuel Kant played a key role in shaping society's understanding of ethics. He espoused the belief that rational actions cannot be founded on personal desires but must agree with collective norms. Since the start of the 20th century, emphasis has been given to applying ethics to everyday problems (Singer, 2023).

Is there a difference between personal and professional ethics?

Our world is changing and evolving, and often, there are no simple "right" and "wrong" answers, which often places us as individuals and as organizations in ethical dilemmas. As Susan Liautaud points out, "everything you do matters," and each of us lives with the consequences of our actions (Liautaud & Sweetingham, 2021).

Personal ethics are our beliefs about what constitutes right and wrong and guide our actions. Personal ethics are used in decision-making in private life and the professional realm. Having a strong core of personal ethics influences our professional lives in several ways, such as setting a standard of behavior, enhancing decision-making ability, and allowing those in leadership positions to be more effective in their roles. The main difference between personal and professional ethics is that while personal ethics speaks to beliefs applicable in all aspects of life, professional ethics denotes values that must be adhered to within the work setting (Glassdoor, 2021).

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 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 healthcare professionals' 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 patient's best interest.

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 a vital role in maintaining professional boundaries and must be able to know, recognize, and maintain the 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.

Healthcare providers in multiple disciplines can turn to professional organizations to guide ethical decision-making in their respective roles. The American Medical Association Code of Medical Ethics provides advice on such topics as patient rights, ending the patient-physician relationship, physician exercise of conscience, and ethical practices in telemedicine (American Medical Association, 2017).

The American Nurses Association Code of Ethics, last revised in 2015, lists nine requirements. The first is that nurses must practice with compassion and respect for every person's inherent dignity, worth, and unique attributes. Other requisites include nursing responsibilities to patients, patient advocacy, practicing in collaboration with other healthcare professionals, and a commitment to professional growth.

The National Association of Social Workers (NASW) Code of Ethics was updated in 2021, and one of the new provisions added is the importance of professional self-care. Ethical standards include the social worker's ethical obligations to clients, coworkers, practice locations, and the wider community (NASW, 2023).

Other organizations with Codes of Ethics for healthcare professionals include the following:

• American Association of Medical Assistants
• American Chiropractic Association
• American Physical Therapy Association
• American Registry of Radiologic Technologists
• American Society for Clinical Laboratory Science
• Certified Nurse Assistants Code of Ethics
• National Association for Healthcare Professionals (Ritter & Graham, 2017)

Another important resource for healthcare professionals seeking guidance on ethical issues is the ethics committee in their facility. These committees became more widespread in the middle to the late 1980s when questions surrounding life-sustaining medical technology needed to be addressed. The three primary purposes of a hospital ethics committee are to provide education, create policies, and offer consultation on specific issues, such as concerns surrounding end-of-life decision-making (DiNova, 2020).

Ethical dilemmas usually involve making difficult decisions. Decision-making often requires recommendations by the clinician, information about the patient's best interest, or choosing suitable treatments and interventions. Criteria frequently used to determine the best interest of the patient include the following (Varkey, 2021):

• Determining what the patient finds acceptable or unacceptable regarding the 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 who 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 principlism. It encapsulates four comprehensive and basic ethical principles:

• Respect for Autonomy
• Beneficence
• Nonmaleficence
• Justice (Beauchamp & Childress, 2013)

Principlism decision-making becomes stuck when principles or their specifications contradict each other (Beauchamp & Childress, 2013). For example, a patient with end-stage cancer may have the personal belief that they must be told so that they can make decisions and use their remaining time well. However, the patient's family may insist that the patient not be told because they believe that knowledge will rob them of the will to live. In such a situation, the principles of respect for autonomy and nonmaleficence are at odds. So, who decides what happens to the patient?

Several frameworks exist to aid healthcare professionals in dealing with ethical questions that surface during clinical care. The framework introduced by Jonsen (2006), described as the "Four Box Model" for clinical ethical decision-making, helps clinicians prioritize the ethical principles of the clinical situation. The model balances medical decision-making elements that are important to health professionals with those patient-centered elements important to patients (Toh et al., 2018).

Utilitarians/consequentialists view stress as maximizing the balance of benefits and burdens, the greatest good for the greatest number. Consequentialism decides whether an action is right based on its consequences. 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. A criticism that is sometimes leveled at consequentialism is that it can be challenging or even impossible to identify the result of an action in advance (McCombs School of Business, 2020).

The deontological view focuses on an action's virtue rather than its outcome. The word deontological is derived from the Greek word "deon," which denotes "duty" or "obligation" (Barrow & Khandhar, 2022). For example, palliative care involves clinicians arguing for withholding or withdrawing treatment based on a utilitarian assessment of futility. Still, the family members argue for continued treatment out of familial duty.

The communitarian view emphasizes the importance of community, the common good, social goals, traditional practices, and cooperative virtues. It places stress on the effect that community has on the lives of human beings (Philosophy and Education, 2006). For example, communitarians argue in favor of universal access to health care because it improves the quality of life for the entire community.

The principle of double effect (PDE) goes back to medieval times and Thomas Aquinas. Today, it is used to appraise actions with multiple consequences, some of which are regarded as corrected from a moral standpoint. In contrast, others are regarded as erroneous or immoral (McCombs School of Business, 2013). Principles include the following:

• The action taken is morally good or neutral. A good outcome is intended from the action while recognizing the possibility of a negative outcome.
• The intended outcome is important enough to justify the unlikely but possible bad effect.
• Efforts are undertaken to minimize the 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 an ethical consensus about the standard treatment of pain at the end of life. The position of the World Health Organization and the United States Supreme Court is that effective treatment of pain at the end of life is legally and morally acceptable. It is seen as a fundamental right of the patient (Jackson & Leiter, 2023). Even if the medication hastens death, the action intends to relieve pain and not cause death.

Rights-based approaches emphasize the rights of individuals; for example, patients near the end of their lives have the right to participate and benefit from appropriate research. A necessary feature of rights-based approaches is treating people as ends, not merely as a means to an end. It ensures that people are told the truth, have a right to privacy, and are not harmed, exploited, or subjected to injustice or discrimination (Master Class, 2022).

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 on a strong sense of responsibility, for example, by explicitly taking the patient and their family as the unit of care, not just the patient. Another example of the ethics of caring is military nurses in war zones providing responsive, competent care to patients regardless of their backgrounds or affiliations (Hepler, 2022).

Virtue ethics focuses on the moral character which informs behavior. The character-based approach presupposes that individuals develop virtue through practice. According to the Greek philosopher Aristotle, practicing virtuous behaviors makes a person more apt to make the right choice when confronted with ethical challenges (McCombs School of Business, 2013). 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, no moral right or wrong. The approach maintains that the morals of society evolve and shift over a period of time depending on social standards (All About Philosophy, 2021). 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.

Scenario 1:

Sue works the evening shift at a nursing home at 3:30 p.m. Sue receives a call from her child's care provider, and her child is sick. She asked the charge healthcare professionals if she could check on her child; this conflicts with Sue's value of her child's health and her professional, ethical responsibility of fidelity 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 ordered. Mr. X allows the healthcare professional to come but refuses physical therapy. After Mr. X refused 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 season's final football game, which also happened to be a state playoff game. The concussion was his third 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 wanted to participate; this is a conflict between nonmaleficence in avoiding further harm and autonomy in the patient's right to choose.

Scenario 4:

A 62-year-old diagnosed with squamous cell carcinoma with metastasis to the brain, Gary, underwent a craniotomy to remove a large mass in his brain. Post-surgery, Gary must 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 21 days to be discharged to his home, where he lives with his wife, who has multiple sclerosis. Gary progresses nicely in occupational and physical therapy. Achieving most goals, and since family training is completed, Gary will be discharged the upcoming morning. On the morning of discharge, Gary's wife indicated she could not provide the occasional skills needed for mobility and activities of daily living. She wants 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 home, stating, "I need to get started with my cancer treatments," which cannot be provided in an SNF setting. The healthcare team discharged Gary to the SNF. The team has utilized paternalism, believing it is more beneficial for Gary to go to an SNF vs. autonomy and Gary's preference to be discharged home.

The issues surrounding mandatory treatments have become a topic for debate considering COVID-19 vaccine mandates for healthcare workers. The message to healthcare professionals in some settings and facilities was clear: comply with mandatory vaccination or face possible termination. Many healthcare professionals followed the vaccination mandate regarding it as part of their responsibility to protect society. Ethically, it was a decision to put the welfare of others above their self-interests. In this context, many healthcare workers who were dubious about the efficiency of the vaccine still decided to get it (Myers et al., 2023).

However, the validity and effectiveness of mandatory COVID-19 vaccines have been questioned. Some saw mandatory vaccine policies to be scientifically problematic. Arguments supporting this position included diminishing efficacy against infection and transmission at 12-16 weeks post-vaccination. Data also supported that once infected, vaccinated and unvaccinated persons transmitted the virus to others at comparable rates. It was also posited that a blanket mandate policy did not consider the significant risk variance across populations. The underlying concern was that vaccine mandates would infringe on human rights, erode public trust in the healthcare system, and negatively impact vaccine confidence (Bardosh et al., 2022).

Another area where ethical questions arise is compulsory treatments for mental health disorders. Compulsory outpatient treatment in mental health (COT), also called community treatment order, poses substantial ethical questions. It occurs globally in more than 75 jurisdictions; however, the evidence regarding COT's effectiveness is unclear (Martinho et al., 2022).

In the United States, many cities have created new policies to combat homelessness, serious mental illnesses, and substance use disorders. A proposal central to most of these policies is involuntary treatment. In November 2022, the mayor of New York City announced a proposal to employ mental health regulations to enable involuntary treatment when individuals are incapable of caring for themselves or when their behaviors pose a danger to others. Similar proposals have been approved in California and Oregon. Court-mandated treatments can incorporate therapeutic interventions, medication management either in a facility or on an outpatient basis, assistance from social workers, and housing referrals (Drabaik, 2023).

In Portland, Oregon, the base cause of homelessness is the high cost of accommodation and financial difficulties. Only one in three persons who are homeless in Portland state that they have a psychiatric illness, substance use disorder, or both. However, combining one or both of these disorders and homelessness has resulted in numerous public tragedies. Examples of these include persons with schizophrenia freezing to death on city streets. Homeless persons have given birth to premature infants that do not survive the ordeal. Research findings show that homeless people in Portland die thirty years earlier than the average adult in this country.

Civil commitment is not a new concept; it has existed for decades. However, it has recently gained attention as a means of tackling the juncture of homelessness, psychiatric illness, and substance use disorder. Two theories are invoked as the foundation for laws that permit civil commitment. The first is the principle of 'parens patriarch,' a Latin expression that translates as 'parent of the nation'; this principle asserts that states have a legal and ethical duty to step forward and assist vulnerable persons who cannot care for themselves. The second legal premise used is that states have an obligation to enact and apply laws to maintain public health and safety, which can be adversely impacted by homelessness (Drabaik, 2023)

States differ in the content of their civil commitment laws. Since these laws provide a civil process for courts to supervise treating persons with serious mental illness or substance use disorders, they do not criminalize homelessness or employ punitive measures. While 'homelessness' is an all-inclusive descriptor, this population includes several sub-groups with varying needs. However, the most noticed group is the chronically homeless lacking shelter, with the highest incidence of untreated mental illness and serious substance use disorders. A study conducted in California that looked at 64,000 persons within fifteen states who were homeless discovered that 78% of unsheltered homeless persons had a mental illness, and 75% suffered from a substance use disorder. 50% of those surveyed had both diagnoses. Healthcare providers know that psychiatric illness and substance use disorders play a role in homelessness and worsen the problem. The impetus for changing the civil commitment law in Oregon is to give physicians more flexibility in requiring treatment for patients who are too ill to recognize their need for care. The case put forward is that persons left without treatment for psychiatric illness and substance use disorders are caught in an endless cycle between life on the streets, county jails, and state mental hospitals (Drabaik, 2023).

50% of the United States homeless population is reported to live in California. While only around one-third to a quarter of this population suffers from severe psychiatric illnesses, they are the homeless people that residents in California's major cities are most likely to confront. The mayors of these cities, for example, San Francisco, San Jose, and San Diego have voiced their exasperation that the ceiling set for mental health intervention is too high. With mayoral support, lawmakers in California have introduced new laws that would assist in bringing more people into treatment, even if it contradicts their preferences.

While the objectives of civil commitment are to improve the health and safety of people and communities, it does introduce difficult ethical questions, especially around the issue of autonomy- the core belief that people have the right to make decisions for themselves. There is also the question of beneficence, which guarantees that interventions put in place are more beneficial than harmful. Some in authority oppose civil commitment laws and advocate that states should instead depend on voluntary services. They argue that voluntary treatment is equally effective as civil commitment while at the same time preserving the individual's autonomy and freedom to choose or reject treatment. Another argument is that civil commitment infringes on the principle of beneficence since it can stigmatize homeless persons with serious psychiatric illnesses and substance use disorders by suggesting they do not belong in society. There are still others who consider civil commitment as being cruel and intimidating (Drabaik, 2023).

Opponents of civil commitment in California object to the courts having the right to deprive people of their freedom and privacy. They advocate that the state should invest in improved voluntary psychiatric health services. Some of their major concerns center around race. African Americans form disproportionately high numbers of the homeless population and have been historically over-diagnosed with Schizophrenia (Kennedy, 2022). According to many against civil commitment, these more stringent processes will excessively pursue this group.

Those who support civil commitment believe that it successfully connects people with the help they need and satisfies a moral requirement that stops people from experiencing illness and hardship on the streets. Most healthcare professionals assume that individuals can make their own medical decisions in accordance with their values and requirements. But it must be kept in mind that those with serious psychiatric illness or substance use disorder can suffer from diminished ability to consider what is in their best interests and make effective decisions. In actuality, the person's state negates their autonomy. In these situations, it can be argued that involuntary commitment is a positive intervention that enables people to redeem their autonomy. Regardless of how they got there, they are now in an environment that stabilizes their condition and puts them on the road to recovery (Drabaik, 2023). However, there are limitations to this approach; for example, in California and Oregon, current laws do not include substance use disorders as justification for commitment.

Another factor that poses challenges is the inadequate capacity to provide needed treatments. In Oregon, there are long waiting lists with reports that the statewide capacity to provide services for prevention, treatment, and recovery is around 50% of what is required. Overall, in this country, there is a shortage of trained professionals who can provide mental health care; this includes psychiatrists, psychologists, social workers, and mental health and substance use disorder therapists. Data reveals that more than 50% of counties in the United States have no psychiatrists. One of the essential remedies for this problem is to create more residency openings. A positive finding is that more people are attracted to careers in mental health services. In 2022, there were almost twice as many applicants for psychiatric residency as available places (Weiner, 2022).

Moral distress can have serious consequences for healthcare providers on an individual level, the facilities they work in, and the communities they serve. A study conducted between May 2021 and August 2021 in a large urban facility exposed important findings related to moral distress and ethical decision-making. Several tools are used to measure moral distress; the most current is the Measure of Moral Distress for Healthcare Professionals (MMD-HP). The tool has been used by doctors, nurses, and other health professionals. The main mechanisms of the MMD-HP exam are three stages of root causes, which are patient, unit, and system, and comprises 27 different clinical settings with the choice to propose other clinical settings or events that pose a high risk for moral distress. Research in healthcare environments has shown that a more positive ethical environment and the higher degrees of interprofessional collaboration, the lower the level of moral distress (Silverman et al., 2022).

In the study cited above, there were 206 participants. Of these, about 73% were nurses, and a little over a quarter, 27% were physicians. The participants worked in several departments, including medical/surgical, intensive care, and neonatal/pediatric units. Nurses included management, clinical staff, and nurse practitioners. Physicians included attending, consultants, fellows, and residents (Silverman et al., 2022).

Around 25% of those surveyed considered their ethical environment as being average or poor. Only a little over 19% assessed their ethical environment as being good. Findings from the study indicate that nurses had greater intention to leave their profession than physicians, and nurses recognized their ethical situation as being more negative than physicians. Nurses who worked in medical and intensive care units expressed a higher rate of intention to leave compared to nurses who worked in neonatal and pediatric intensive care units. A greater percentage of nurses working in the surgical intensive care units ranked their ethical environment as poor compared with staff working in other units. Some of the issues that nurses cited as leading to moral distress included a lack of a voice and poor team communication (Silverman et al., 2022).

Healthcare professionals are in a position that requires personal beliefs and experiences to be put aside and 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. Research in healthcare environments has shown that the more constructive the ethical atmosphere is, the more significant the degree of interprofessional collaboration, resulting in diminished levels of moral distress. Current evidence suggests that the quality of the ethical atmosphere and levels of moral distress are significant factors related to an individual leaving their position (Silverman et al., 2022).

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