© Springer International Publishing Switzerland 2017
Maggi A. Budd, Sigmund Hough, Stephen T. Wegener and William Stiers (eds.)Practical Psychology in Medical Rehabilitation10.1007/978-3-319-34034-0_33. Practical Ethics
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University of Florida, Gainesville, FL, USA
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Craig Hospital, 3425 South Clarkson Street, Englewood, CO 80113, USA
Keywords
EthicsEthics conflictDilemmaEthical practiceTopic
This chapter presents a proactive perspective of bioethics in clinical practice. The ethical foundations for this chapter can be found in Beauchamp and Childress’s Principles of Bioethics [1] and in Jonsen, Siegler and Winslade’s Clinical Ethics [2]. The ethics codes of every health care discipline comprising the rehabilitation treatment team provide the practitioner with a set of foundational principles and practice standards that act as field-tested guidelines for effective, efficient, and quality patient-centered care. The challenge for every practitioner is to translate the philosophically based tenets of bioethical principles into readily applicable referents that guide clinical practice. The practice standards embodied in ethics codes attempt to provide that translation from principle to application. However, becoming facile in the process of applying ethics standards requires both understanding and regular practice. To that end, we will endeavor to assist in skill building.
First, we provide the reader with an applied ethical decision-making tool with which to approach analysis of ethical conflicts. This clinical tool has been successfully implemented by individual practitioners and ethics committee consultation teams across several decades (see Kerkhoff and Hanson [3] for the latest iteration). Then we discuss various concepts that illustrate optimizing ethical practice in clinical settings. We then distill the content of the chapter into several practical tips gleaned from years of professional experience that emphasize the critical contribution of ethical thinking to provision of quality health care. Finally, a set of brief case scenarios will allow the reader to put into practice the ethics decision-making process. Accompanying commentary will clarify ethical issues embedded in the scenarios.
Importance
Each health care discipline in the United States has established and published discipline-specific ethics codes. These ethics codes, with which their members must comply to remain in good standing, and to attain and retain their licenses, have resulted in applied bioethics becoming almost indistinguishable from adherence to nationally accepted standards of care.
Contextual factors must be considered when ethics conflicts develop—supporting the ethical principle of Justice. Ethical conflicts do not arise in a social vacuum. However, it is easy to lose sight of contextual influences when the conflict to be resolved rises to the level of being noticed, often in dramatic fashion. A multiplicity of factors beyond the behavior of specific individuals contributes to situations in which ethical principles and/or standards are contravened. Consider broad-ranging issues like: business conflicts of interest, limits of confidentiality, financial constraints or incentives, allocation of scarce resources, issues of religious beliefs and values, clinical research and educational agendas, and public health and safety. Any or all of these seemingly peripheral factors may play roles of significance in the occurrence of ethical conflicts, and serve to increase the circle of key figures with personal or organizational interests in the conflictual situation . Thus, we urge the health care provider to be inclusive when initially evaluating the requirements of pursuing potential ethical conflicts to resolution.
Practical Applications
The first application of ethics concepts to everyday practice involves a useful tool for case analysis and decision-making, first published in Hanson, Kerkhoff, and Bush [4]. This tool remains a viable method for considering ethical implications of varied alternative solutions to ethical conflicts arising in the course of clinical service provision. The steps in this decision-making model are described in summary form below.
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Ethical Decision-making Model
Operationally defined, ethical conflicts involve a minimum of two ethical principles (e.g., autonomy, beneficence, non-maleficence, justice) being in opposition.
Step 1. Critical Incident —An event involving a potential ethical conflict. Evaluate a critical incident in light of two initial responses: a) the incident involves an ethics conflict ; b) the incident involves a difficult clinical decision. In the former instance, ethical analysis is warranted, whereas in the second situation the decision is referred back to the treatment team, often with supportive strategies appended.
Step 2. Ethics Principles or Concepts —Assistance with focusing investigative efforts is achieved when relevant factors in the critical incident are linked to ethical principles, concepts, or discipline-specific standards.
Step 3. Historical Context and Key Figures—Identifying biological, psychosocial, and physical environmental factors that may have influenced the situation under consideration provides a developmental and contextual view of the ethical conflict. Additionally, strategic inclusion of relevant figures or players helps to define and distribute decision-making roles and responsibilities.
Step 4. Organizational and Legal Issues —Identify organizational policy and procedure challenges [5], along with legal/statutory issues [6] that apply to the situation. Standards of care are pertinent in this analytical step, in order to address potential risk of negligent behavior. Involving organizational Risk Management or Legal Departments as consultants to the decision-making process may be appropriate in some instances.
Step 5. Resolution —After sufficient information regarding the facts of the situation has been amassed and shared for decision-making, the key figures are asked to propose potential strategic solutions to resolve the ethical conflict, along with pro and con arguments for each alternative resolution proposed. The goal is to reach consensus among the discussion participants regarding a desired outcome, keeping the welfare of the patient as the central focus of the process.
Step 6. Disposition —Implementation of the consensus resolution and tracking the actual outcome is the goal. If problems arise during implementation or the actual outcome differs significantly from the desired outcome, modifications of the resolution strategy can be proposed and attempts to resolve the conflict resume anew until an outcome satisfactory to the key figures is achieved.
While this ethical decision-making tool is described as a formal process potentially involving multiple individuals, a sole clinician can utilize this decisional rubric with ease, considering the relevant investigative steps, and then posing alternative resolutions with pro/con arguments for each. This single practitioner approach is most appropriate for use with narrow scope conflicts (e.g., a witnessed inadvertent breach of confidentiality to a single recipient; most ethics codes advocate a direct attempt by the clinician to rectify the situation). Nonetheless, the balanced decision-making process is preserved, simply reduced in scale. Finally, documentation of the pertinent details of the ethics decision-making process, outcome and recommendations to the treatment team should be entered into the patient’s medical record.
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Ethical Issues in Clinical Practice
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Informed Consent
Autonomy is the ethical principle underlying consent. The elements of informed consent include: a. Freedom from coercion and; b. Agency—the ability to act upon an unhindered decision. Given the highly technical and complex nature of many health-related decisions, being “fully informed” can be an unnecessary burden upon the patient. Rather, being “adequately informed” is the norm. In this latter instance, the patient’s ability to repeat the essential factors pertinent to the decision in his/her own words is sufficient. Emphasis upon understanding the factors inherent to any decision is the goal of health care provider communication. Only with adequately informed consent can the patient validly authorize evaluation and/or treatment. In the case of minors, the legal guardian has the sole authority to consent. However, assuming that the minor is capable of understanding the decision under consideration, seeking assent from the minor is strongly recommended. Assent simply increases the likelihood of compliance with and adherence to the requirements of a health-related intervention, while respecting the minor’s personhood.
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Treatment Refusal
This is a legal right supported in both federal and state statute, but it is also ethically supported in autonomous choice. Any reasonably prudent person has the right to refuse recommended treatment, even if the treatment is justified by standards of care. An important factor for the mindful health care professional is that the patient’s refusal should be knowing the benefits and risks attendant to the decision are clearly understood. An ethical caveat arises when there is a high likelihood of irreversible harm to the patient or others in the refusal (e.g., refusal to inform sexual partners in light of positive HIV test results). Only in such an extreme circumstance is the health care professional able to ethically exercise justified paternalism and intervene. Even then, the least autonomy-restrictive alternative action that will increase benefits and decrease risks is required. Finally, treatment refusal is most commonly observed when there is a lack of trust and understanding between the patient and health care professional—essentially framed as a self-protective response by the patient to perceived threat. Taking the time necessary to develop a truthful, honest, and open working relationship (rapport) is important to avoid such “reflexive” treatment refusals.
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Disclosure
The moral rule of veracity underpins disclosure. The paternalistic view that disclosure of bad news or use of deceptive disclosure when the information is negative is harmful to patients has been proven blatantly false. Communicating truthfully and effectively regarding the probabilistic nature of anticipated benefits and risks related to evaluation findings, diagnosis, treatment, and prognosis is expected by both patients/families and peers. However, consideration of nurturing hope may require staged or incremental disclosure of negative information across time. Additionally, cultural and spiritual values and beliefs vary among individuals, and among practitioners alike. These contextual factors need to be accounted for in the sensitive and respectful manner in which disclosure is accomplished. Assuming the patient is cognitively capacitated, never disclose to family members before communicating with the patient, before securing the patient’s release to talk with family.Related posts:
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