The word ethics originates from the Greek word ethos, which means a person’s character or natural disposition (Leathard and McLaren 2007). Ethics is not merely concerned with dilemmas, it is about how individuals make sense of the world they live in, based on their beliefs, values and experiences, which influence the moral judgements we make (Hendrick 2004). However, respecting the values of others which often differ from our own is vital and is essential for collaborative, person-centred practice. Ethics is not just about dilemmas but these may arise when a situation occurs and there appears to be no acceptable resolution. Options may be limited to selecting between unsatisfactory choices. However at some point, a moral judgement has to be made, which will be influenced by the values and beliefs of those making the decision.

THEORIES ABOUT ETHICS

Different philosophical schools of thought have developed theories to explain how moral judgements are made. It is not within the scope and remit of this chapter to critically explore philosophical theory in detail. However, it is important that occupational therapists have some basic understanding of the three main theories of ethics as each offer a different perspective. Their relevance to contemporary practice is often the centre of much discussion, so none of the theories should be used uncritically.

Virtue Theory

Originating from the work of Aristotle (384–322 BC) who suggested individuals possessing particular character traits, for example compassion, honesty and courage, will conduct themselves in a virtuous way, this theory has been developed further over time but the central tenet remains; a virtuous person is a person of good moral character and does good for others. One of the main criticisms of a virtue-centred approach is that it is vague and provides no guidance for practitioners to follow when they have to make difficult decisions (Begley 2005). Conversely, Hursthouse (1999) suggests that virtue ethics can provide guidance on how to act in a given situation because each virtue generates rules and standards about how to behave. Gallagher and Hodge (2012) note there is no definitive list of which virtues are significant. Sieghart (1985) identified that the altruistic component of professional identity develops in parallel with the development of the knowledge for practice. Professional identity is rooted in the ethical ethos of that profession. However, one of the difficulties with this contention is that, if occupational therapy students are supposed to acquire specific ethical values through their professional education, whether they actually acquire this is questionable. This is because of the indiscriminate way in which the ethos of the profession is taught and assessed (Terry 2007).

Consequentialism (Utilitarianism)

Jeremy Bentham (1748–1832) and John Stuart Mill (1806–1873) suggested that good or bad actions are determined by their foreseeable consequences. Decisions are made on the basis of the greatest good for the greatest number and, if only undesirable choices are available, the least undesirable should be implemented. It is based on the pursuit of happiness and pleasure. However, this theory fails to take into account the needs of individuals who are in the minority, that some consequences are not foreseeable and happiness and pleasure are subjective experiences. Within occupational therapy education and practice, there is great emphasis placed upon considering the person as an individual, whereas this particular theory does not focus on individual need but may be useful when considering how finite resources are distributed.

Deontology

Deontology was developed by the philosopher, Immanuel Kant. It is a duty-based theory, where the emphasis is placed upon the nature of the actions rather than the consequences. Certain duties are mandatory, for example not to lie. A duty-based ethicist would claim telling a lie to an individual, even where this may have better consequences, is morally wrong to do so, because lying is unacceptable. There is no rationale for identifying an individual’s duties to another or guidance on how to resolve situations when duties conflict. This approach does not consider personal feelings or consequences for an individual or group which, again, is not compatible with the core values of occupational therapy practice. However, within healthcare roles it is helpful to have some sense of what duties are required of each professional group, many of which can be found in professional codes.

ETHICAL PRINCIPLES

By contrast, Beauchamp and Childress (2009) present a principled approach to bioethics, outlining a framework of four principles: autonomy, beneficence, non-maleficence and justice. It is suggested that these are the basic values which underpin common morality and these also form the foundation of many professional codes. Application of the principles facilitates the identification of, and reflection on, moral problems. In practice, these principles become prima facie duties, which professionals are required to uphold, such as respecting confidentiality. However, if there is conflict between principles, for example respecting autonomy and beneficence, it is assumed that the dilemma can be addressed through careful consideration (Reamer 1995). Beauchamp and Childress (2009) acknowledge no theory or framework can provide absolutes but identify their guidance at least provides a basis for discussion. This approach to resolving ethical dilemmas has been widely adopted in the health literature and has proved popular with members of the medical and nursing professions. As with the ethical theories (above), there are criticisms of this stance. Wright St Clair and Seedhouse (2005) suggest that this view is overly simplistic; it is not sufficiently adequate to facilitate the resolution of ethical dilemmas due to the lack of detail and absence of an underpinning theoretical basis and does not provide specific guidance for moral behaviour. Therefore, it cannot guarantee ethical practice but provides a useful starting point for occupational therapists to reflect upon their decision-making process. This is illustrated by considering the principles as features of being an ethical practitioner.

BEING AN ETHICAL PRACTITIONER USING A PRINCIPLED APPROACH

As there is an ethical dimension to most of what takes place at work (Hendrick 2004), professionals working in psychosocial practice need to be able to recognize these matters and consider the implications for the individual, their families and carers. It is important to remember that healthcare ethics is not the concern of one professional group or discipline but is a matter which should be approached from a multidisciplinary perspective (Campbell et al. 2007). Occupational therapists, as members of the multidisciplinary team, are well placed to contribute to such discussions regarding ethical matters. However, conflict may occur as a result of different professional groups having diverse values, beliefs and approaches to practice. Each of the four principles, set in the context of ethics as a multidisciplinary concern, are considered in turn.

Ethical Principle: Respect for Autonomy

Autonomy refers to a person’s ability to make his/her own decisions based on their own values and beliefs (Beauchamp and Childress 2009). An autonomous person is someone who can evaluate and consider information, whose decisions and action reflect their goals, has the mental capacity to make decisions and the freedom to act upon choices (Tschudin 2006). If an individual has limited autonomy, it does not necessarily indicate that they are unable to make any autonomous decisions independently (Hendrick 2004). For example, an individual may not be able to consider the most effective intervention options available to them but could exercise some choice over daily occupations, e.g. what to eat and what clothing to wear. However, it is important that autonomy is not reduced to just facilitating choices.

In some cultures, individual autonomy is not acknowledged, for example where a husband makes most of the decisions, and some individuals prefer to involve families in the decision-making process (Arnason et al. 2011). The concept of autonomy is still applicable but needs to be respected in-keeping with an individual’s culture. However, respecting cultural diversity does not mean an individual cannot make their own choices should they choose to do so (Arnason et al. 2011). Occupational therapists should promote the individual as an autonomous person, allowing them to consider their own ideas, principles and wishes and how these inform their plans, how they want to live their life now and in the future (Wright St Clair and Seedhouse 2005). In relation to ethical practice, a consideration of autonomy is fundamental, for example when obtaining consent.

Consent

According to the Oxford English Dictionary Online (2012), consent can be defined as ‘voluntary agreement to or acquiescence in what another proposes or desires; compliance, concurrence, permission’. One of the basic ways in which autonomy is respected is by obtaining consent to assessment or intervention. It is universally accepted that obtaining consent is a legal requirement to ensure that individuals understand the consequences of what they are being offered and to protect the professional from criminal charges (Hendrick 2004), such as battery or trespass. Busy hospital environments may not be conducive to an individual giving informed consent and, visiting individuals in their home environment can be just as challenging (Moreno et al. 1998). Communication plays a vital role in an individual providing consent and this involves the occupational therapist in listening and supporting the individual concerned; not merely conveying information (Arnason et al. 2011).

Securing Consent

Consent is only legally valid when the person is acting voluntarily. Occupational therapists are obliged to ensure they clarify their role, identify what they can offer and listen to the individual’s concerns. Sufficient time should be given to allow an individual to consider all the details before making a decision and information should be conveyed in a way that they can understand, for example when seeking consent from an individual with a learning difficulty, pictorial cues may be required (DoH 2001a). However, when challenging behaviour is an issue, an individual may be unable to provide consent to the intervention, which is problematic, especially if the aim of the intervention is to prevent harm to the individual or another. It is imperative that all team members work within the ethical and legal boundaries of the countries where they practice and adhere to The Human Rights Act (1998), to ensure that their interventions are in-keeping with legislation and that individuals’ needs are at the centre of their care.

To provide consent for interventions, an individual must have mental capacity. Mental capacity can be defined as having the ability to make decisions, based on understanding facts at the same time as considering the various options and the effects of different interventions (Hendrick 2004). There is always a risk of assumptions being made about a vulnerable person’s mental capacity without it being assessed. For example, older adults, especially those with dementia, may not always be given the opportunity to exercise their autonomy and are prone to having decisions made for them because of their age (Hendrick 2004).

An occupational therapist needs to be able to differentiate between confusion, irrational decisions and mental capacity (see Box 10-1). Capacity can fluctuate and may be impaired by other factors such as medication, vitamin deficiency or infection. Loss of capacity can be temporary and therefore should be assessed for each intervention. There are also different levels of capacity. Some individuals may not be able to make decisions independently regarding more complex issues but can make decisions regarding everyday matters. Poor practice can occur when an individual is deemed lacking capacity and consequently, is not consulted regarding any matter, irrespective of how simple it may be. In the UK, occupational therapists have a duty to ensure that they assess mental capacity, under the Mental Capacity Act (2005) and a code of practice has developed to help practitioners with this (Carr 2011). (See Ch. 24, for a discussion of mental capacity in relation to older people.)

BOX 10-1

ETHICAL ISSUES RELATED TO DIOGENES SYNDROME

‘Diogenes syndrome’ (Clark 1980; Pavlou and Lacks 2006; Pickens et al 2006) is a term used to refer to older adults who live in the community and present with extreme self-neglect. Consequently, occupational therapists may encounter a range of ethical dilemmas when supporting older adults to live at home. Difficulties may include loss of housing, marginalization within the community and hoarding behaviour, which may give rise to increased risks from fire and tripping hazards (McDermott et al. 2009). Unsanitary living conditions may promote illness and infection, either exacerbating existing health problems or creating new ones. An ethical dilemma may occur when an individual has mental capacity to make decisions but may lack insight into the problems their current living conditions present.

Occupational therapists, like other health and social care staff, will strive to respect autonomy and support an individual to make decisions which reflect their values and beliefs. An occupational therapist should avoid, at all costs, making judgements about an individual’s living conditions and avoid imposing their standards on to others. To embark upon a cleaning process, against the older person’s wishes, conflicts with respecting autonomy. It also may result in the breakdown of the therapeutic relationship, when perhaps energy and resources should be focused on establishing trust and trying to develop an understanding of the issues which have given rise to the situation in the first place (McDermott et al. 2009).

This principled approach does not take into consideration the impact that poor levels of self-care and environmental neglect can have on those who live around them or own the properties where individuals reside (McDermott et al. 2009). Occupational therapists need to recognize when an individual’s choices are not conducive to their health and wellbeing and have consequences for the wider community. Positive solutions when working with an older adult in this situation, may take a long time to achieve. Additional resources may be required, for example agencies to cleanse the environment and alternative temporary accommodation (McDermott et al. 2009). Ongoing support may be needed to enable an older person to maintain their self-care skills, their environment and participate in other occupations, which would provide structure, routine and social contact.

Recording Consent

Implied consent is the weakest form of consent because it is indicated by the individual’s behaviour, such as turning up for an appointment or nodding their head (Hendrick 2004). Verbal consent is commonly used in practice but is not reliable because it is difficult to prove at a later date, unless documented. It is good practice for services to have consent forms for individuals to sign in order to provide written consent, after consideration and discussion regarding what is being proposed. If forms are not available, occupational therapists should always document when consent has been obtained or if consent has been withheld/withdrawn, outlining the reasons for the decision taken by the individual. This decision should always be respected; it is unethical to coerce or persuade an individual to consent to assessment or interventions. Any person has the right to exercise their choices.

Restrictive Practice

A challenge for occupational therapists working in psychosocial services, particularly forensic mental health settings, is the practice of restraint. Restraint involves keeping someone under control or within limits and is applied in health and social care settings, to restrict freewill for the individual’s safety or that of others. Organizations and services use a range of terminology, e.g. ‘control’ and ‘restraint’, so it can be confusing as to what actually constitutes restrictive practice. Wolverson (2004) suggests these generic terms encompass a broad range of interventions, all of which seek to reduce an individual’s autonomy and encourage paternalism. The practice of restraint conflicts with the principle of respecting autonomy and can produce feelings of unease in professionals but it is required in a minority of situations, in order to protect the individual or those around them.

It is important to recognize that many interventions and practices may not be recognized as restrictive but may have this impact (Wolverson 2004). Horsburgh (2003) asserts that some types of restraint can take more subtle forms, for example denying access to equipment, which could promote independent living. Restraining an individual involves suppressing their freedom. This can be achieved in many ways, including using medication, seclusion, locking doors and surveillance technology (Hughes 2009) (see also Box 10-2). Other practices include using baffle locks in care homes for individuals with dementia, to complete physical restriction, to holding a person’s hand to prevent them from lashing out at another (DoH 2002). However, it needs to be recognized that when restraint is not indicated this becomes abuse and is immoral (Hughes 2010).

BOX 10-2

ETHICAL ISSUES ASSOCIATED WITH ASSISTIVE TECHNOLOGY AND TELECARE

Assistive technology and Telecare refers to a broad range of equipment and systems, including environmental controls, sensors, falls detectors and communication aids, which may help to facilitate independent living for a range of individuals who, for example, may have a learning disability or dementia.

There is an increasing body of evidence identifying that a proportion of vulnerable individuals benefit from increased safety and independence, as a result of assistive technology; furthermore, it provides reassurance for families and carers (Loader et al. 2009; McCreadie and Tinker 2005). However, some concerns have been highlighted with individuals with dementia, especially in relation to privacy and stigma and the use of tracking devices. Potentially, there is a conflict with respecting autonomy, as individuals may feel under scrutiny and their sense of welfare diminished (Morris 2004). However, Welsh et al. (2003) identify that it is perhaps the method in which some devices are implemented, rather than the device itself that is harmful and the need for clearer guidance regarding best practice is required. Interestingly, Welsh et al. (2003) suggest that agitation and ‘wandering’ behaviour in individuals in 24-hour care facilities may be the result of ‘cabin fever’ and that individuals should have access to outside space. This may be an aspect of intervention that occupational therapists could develop as part of a person’s care plan and could encompass previously enjoyed occupations, for example walking or sitting in a garden, as opposed to being confined indoors.

Every effort must be made to explain what technology is being proposed to the person, this may include showing pictures or photographs, obtaining consent and arranging for the individual to try the technology in their home or a demonstration centre (Perry et al. 2009). The individual’s ability to understand needs to be clarified by asking simple questions in order to protect their interests. Furthermore, the risks associated with the application of assistive devices and equipment interventions warrants serious deliberation. Assistive technology is becoming increasingly sophisticated but can still malfunction, so it should not be used to replace contact with carers and the delays in staff responding to alerts or technological problems need to be taken into account (Perry et al. 2009).

If an individual lacks the mental capacity to consent to such technology being installed in their home, decisions should be made following consultation with family and friends to establish the individual’s views on privacy. Decisions should reflect the person’s best interests, as outlined in the Mental Capacity Act (2005), together with the consequences of not having the devices for carers (Nuffield Council on Bioethics 2009).

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