Any Good I Can DoI expect to pass through the world but once. Any goodtherefore that I can do, or any kindness I can show toany creature, let me do it now. Let me not defer it, forI shall not pass this way again. Stephen Grellet, French/American religiousleader (1773-1855). 3
Words are “Tools of Thought”• As with the study any new subject: – New vocabulary & an understanding of abstract theories & principles of ethics will be necessary. – Such knowledge will arm the decision-maker with the information necessary to help make difficult care decisions. 4
Ethics• Ethics is the branch of philosophy that deals with values relating to human conduct with respect to rightness & wrongness of actions & goodness & badness of motives & ends.• Involves the study of morality, virtues, & values & how they affect one’s character.• Involves how individuals decide to live within accepted boundaries & how we live in harmony with one another & nature. 5
Scope of Ethics• Micro-ethics: individual’s view of right & wrong.• Macro-ethics: global view of right & wrong 6
Ethics from Various Perspectives• Ethics used in different but related ways – philosophical ethics, which involves inquiry about ways of life & rules of conduct – A general pattern or way of life (e.g., religious ethics) – moral codes 7
Why Study Ethics?• To recognize health care dilemmas.• To provide tools for constructive deliberation & conflict resolution.• To make sound judgments.• To better understand the goodness & badness of motives & ends. 8
Codes of Ethics Provide for• Standards – as guides to human conduct.• Principles – describe responsibilities.• Rules of expected conduct – no allowance for individual judgment. 9
Morality Aim above Morality. Be not simply good;be good for something. −Henry David Thoreau 10
What is Morality?• Morality is a code of conduct.• Implies quality of being in accord with standards of right & good conduct.• Describes class of rules held by society to govern the conduct of its individual members. 11
Morals• Ideas about what is right & wrong.• Guides to behaviour that rational persons put forward for governing their behaviour. 12
Moral Judgments - I• Judgments concerned with what an individual or group believes to be right or proper behavior in a given situation.• Involves assessment of another person’s moral character based on how he or she conforms to moral convictions established by the individual &/or group. 13
Moral Judgments - II• Lack of conformity typically results in: – moral censure – condemnation – possibly derision of the violator’s character• What is considered right varies from nation to nation, culture to culture, religion to religion, person to person . . . . 14
Moral Judgments - III• No “universal morality.”• Whatever guide to behavior an individual regards as overriding & wants to be universally adopted is considered that individuals morality. 15
Morality Legislated• Law is distinguished from morality in that – law has explicit rules, penalties, & officials who interpret laws & apply penalties• Laws created to set boundaries for societal behavior – laws are enforced to ensure expected behavior happens. 16
Moral Dilemmas• Moral dilemmas arise when values, rights, duties, and loyalties conflict• A caregiver must not only examine what he or she considers the right thing to do, but what are the alternatives, & what are the patient’s known wishes. 17
Ethics, too, are nothing but reverence for life.This is what gives me the fundamentalprinciple of morality, namely, that goodconsists in maintaining, promoting, andenhancing life, and thatdestroying, injuring, and limiting life are evil. -Albert Schweitzer 18
Ethical Theories• Ethical theories – attempt to introduce order into the way people think about life & action – are the foundation of ethical analysis and provide guidance in the decision-making process – various theories present varying viewpoints that assist caregivers in making difficult decisions that impact the lives of others 19
Normative Ethics• Attempt to determine what moral standards should be followed so that human behavior & conduct may be morally right. – General normative ethics is the study of major moral precepts of what things are right – Applied Ethics is the application of normative theories to practical moral problems – Meta-Ethics seeks to understand ethical terms and theories and their application 20
Consequential & Teleological Ethics - I• Morally right action involves – maximum balance of good over evil – involves the greatest good for the greatest number• Rightness or wrongness of an action is based on the consequences or effects of the action 21
Consequential & Teleological Ethics - II• Questions to be asked – What will be the effects of each course of action? – Will effects be positive or negative? – who will benefit? – what will do the least harm? 22
Utilitarian Ethics• A form of Consequentialism – philosophy that advocates the greatest good for the greatest number – everyone is obligated to do whatever will achieve the greatest good for the greatest number. 23
Deontological Ethics• Focuses on – duty to others – rights of others• Forms – Religious Ethics • based on religious beliefs – Secular Ethics • based on codes developed by societies that have relied on customs 24
Nonconsequential EthicsRightness or wrongness of an action is based on properties intrinsic to the action, not on its consequences 25
Ethical Relativism - I• The theory that holds that morality is relative to the norms of one’s culture.• That is, whether an action is right or wrong depends on the moral norms of the society in which it is practiced. 26
Ethical Relativism - II• What is morally correct behavior in one society may be morally wrong in another. – An action can be considered right or wrong depending on the accepted norms of the society in which it is practiced. 27
Principles of Healthcare Ethics• Beneficence – to do good• Nonmaleficence – avoid causing harm 28
Principles of Healthcare Ethics Justice• Obligation to be fair in the distribution of benefits & risks• Distributive Justice – requires that all individuals be treated equally• Justice & government spending – change is coming 29
Injustice for the Insured• Even if you’re insured, getting ill could bankrupt you.• Hospitals are garnishing wages, putting liens on homes & having patients who can’t pay arrested.• It’s enough to make you sick. – Sara Austin, SELF, October 2004, 247
Justice & AgeShould an 89 year old patient get a heart transplant because he or she is higher on the waiting list to receive a heart transplant than a 10 year old girl?
Justice and Age, cont.Should a pregnant 39 year old single parent get a heart transplant because he or she is higher on the waiting list to receive a heart transplant than a 10 year old boy?
Justice: Which Disaster Patients Get Treated First?• Room #1: Severely injured patients not expected to live.• Room #2: Severely injured patients most likely to live if treated.• Room #3: Injured patients will live but will suffer varying degrees of disability if not treated promptly.
Justice: Emergency CareTwo patients in critical condition, who gets treated first?• 1st patient who walks through door• Younger patient• Patient most likely to survive• Patient who can pay for services• Patient with most serious condition
Justice: Scarce Resources• What happens when resources are scarce & only one of two patients can be treated?• What should be the determining factors – age – position in life – patient wishes
Principles of Healthcare Ethics Autonomy• Right of a person to make one’s own decisions.• Patient has right to accept or refuse care even if it is beneficial to saving his or her life.• autonomy may be inapplicable in certain cases – affected by one’s disabilities, mental status, maturity, or incapacity to make decisions. 36
Virtues and Values• Virtue is normally defined as some sort of moral excellence or beneficial quality.• Virtue ethics focuses on the inherent character of a person rather than on the specific actions he or she performs.– A virtue describes moral excellence & that which has beneficial quality.– Virtues are habits. Once acquired, they become characteristic of a person 37
Virtues• Virtues such as honestly and justice are abstract principle• A morally virtuous person does the good and write thing by “habit,” not by a set of rules of conduct 38
Values• Moral value is the relative worth placed on some virtuous behavior – What has value to one person may not have value to another. – A value is a standard of conduct – Values are used for judging goodness or badness of some action – Values give purpose to each life. They describe one’s moral character. 39
Values Can Change• People make value judgments & choices among alternatives. – Values one so dearly proclaims may change as needs change. If one’s basic needs for food, water, clothing & housing have not been met, one’s values may change in such a way that a friendship, for example, might be sacrificed if one’s basic needs can be better met as a result of the sacrifice – Motivating power of a persons actions are a necessity for survival.
Differing ValuesIf mom’s estate is being squandered at the endof life – a family member financially well-offmay want to hold on to mom despite thefinancial drain on her estate. Another familymember financially struggling to survive maymore readily see the futility of expensivemedical care & find it easier to let go.
Intrinsic & Instrumental Values• Intrinsic Value – something that has value in and of itself• Instrumental Value – something that helps to give value to something else • money is valuable for what it can buy
Virtues & Values - I CourageCourage is the greatest of all virtues, because if you haven’t courage, you may not have an opportunity to use any of the others. SAMUEL JOHNSON
Virtues & Values - II What is Courage?• Courage is the mental or moral strength to persevere & withstand danger. “Courage is the ladder on which all the other virtues mount.”• Courage involves balancing fear, self- confidence, & values. Without courage, we are unable to take the risks necessary to achieve the things most valued.
Virtues & Values – III The Courageous PersonA courageous person has good judgment, aclear sense of his or her strengths, correctlyevaluates danger, & perseveres until a decisionis made & the right goal that is being soughthas been achieved.
Virtues & Values - V• Honesty/Trustworthiness/Truth-Telling• Integrity• Kindness• Respect• Hopefulness• Education/Learning as a Value• Tolerance 47
Religious Ethics• Religion provides a moral code for appropriate behavior.• The prospect of divine justice helps us tolerate the injustices in life.• There is a need to better understand cultural diversity & the importance of religion in the healing process.
Spirituality• Spirituality in the religious sense implies that there is purpose & meaning to life; spirituality generally refers to faith in a higher being.
Varying Religious Beliefs - I• Judaism – Monothestic religion• Hinduism• Buddhism – Falun Gong• Taoism• Zen
Varying Religious Beliefs - II• Christianity – Based on Jesus Christ as Savior – Jehovah’s Witnesses – Anointing of the Sick for Healing• Islam 51
Secular EthicsSecular ethics is based on codes developed by societies that have relied on customs to formulate their codes. – Code of Hammurabi
Atheism• Rejection of belief in God• Claims the existence of God cannot be scientifically proven.• Belief that ethics is the product of culture & politics
Organizational Ethics - I• Purpose: promote responsible behavior in the decision-making process.• Recent interest in part – result of government regulations (e.g., Sarbanes- Oxley Act, EMTALA) 54
Organizational Ethics II• Conflicts of Interest Abound – Accreditation of Hospitals and Conflicts of Interest • The Joint Commission 55
Professional Ethics - I• Standards or codes of conduct established by the membership of a specific profession• Healthcare professionals are governed by ethical codes• Codes of ethics are created in response to actual or anticipated ethical conflicts 56
Professional Ethics - II• Nurse’s Documentation Misconduct• Psychologist’s Sexual Misconduct• Attorney-Minister Misconduct 57
Ethics Committee - I• Hospital committee offering objective counsel when facing difficult health care issues & decisions resource to patients, families, & staff.• Committee structured to include wide range of community leaders.• Ethics committees analyze ethical dilemmas, advise & educate health care providers, patients, & families.• Its goal is to assist patient & family, as appropriate, in coming to consensus with options that best meet patients goal for care. 58
Ethics Committee-II• Committee function – Policy & procedure development – Educational role – Consultation and Conflict Resolution • Requests for onsultations – Expanding role of the ethics committee • Internal Role: Organizational & Patient Care Issues • External Role: Political Advocacy 59
Ethics Committee - III Consultaion• Date ________________ Time ______________ Caller __________________________________• Reason for call __________________________ Action taken _____________________________• Patient _____________________________ Age ___________ Medical Record # ______________• Consultation requested by ___________________ Relationship (e.g., caregiver or spouse) _______• Attending physician _______________________ Other physician __________________________• Patient participation in consultation: Yes No• Does patient have decision-making capacity: Yes No. Explain ________________________• Surrogate/legal guardian: Yes No If yes, name: _________________________________• Phone # ________________________ Advanced directives (e.g., living will) _________________• Advance directive: Yes No Describe: _________________________________________• Consultation participants:• Family/relationship__________________ Social Worker _____________________________• Physician(s) ________________________ Patient Advocate __________________________• Nurse RNs _______________________ Chaplain or other religious leader ______________• Administrator ______________________ Other ____________________________________• Ethics committee members:_______________________________________________________ 60
Ethics Committee - IV Consultation• Medical Treatment/Care Information• Diagnosis _______________________________ Prognosis _______________________________• Course of illness __________________________________________________________________• Contacts with administrative/legal representative(s)______________________________________• Treatment options ________________________________________________________________• Treatment options available _________________________________________________________• Treatment options beneficial ________________________________________________________• Known patient wishes _____________________________________________________________• Ethical issues/dilemmas ____________________________________________________________• Legal issues _____________________________________________________________________• Additional information needed: Yes No Explain ________________________________• Other persons to contact for input ____________________________________________________• Consultative guidance _____________________________________________________________• Guidance Communicated ___________________________________________________________• Consultation Noted on Medical Record: Yes No• Disposition _____________________________________________________________________• Form completed by ________________________________ Date/Time _____________________ 61
Ethics Committee - V• Serves as a Guardian – Case: Woods v. Commonwealth• Convening the Ethics Committee – Bioethics Committee Not Convened 62
Reasoning and Decision-Making - IReason guides our attempt to understand the world about us. Both reason and compassion guide our efforts to apply that knowledge ethically, to understand other people, and have ethical relationships with other people. Molleen Matsummura 63
Reasoning and Decision-Making - IIReason includes the capacity for logical inference and the ability to conduct inquiry, solve problems, evaluate, criticize, and deliberate about how we should act and to reach an understanding of ourselves, other people, and the world. 64
Reasoning and Decision-Making - III• Partial reasoning – Involves bias for or against a person based on one’s relationship with that person.• Circular reasoning – Describes a person who’s already made up his or her mind on a particular issue and sees no need for deliberation. 65
Reasoning and Decision-Making – IV• Ethical decision-making: is the process of deciding, what the right thing to do is in the event of a moral dilemma.• Patients have an obligation to make medical preferences known to treating physician.• Any glimmer of uncertainty as to a patients desires in an emergency situation should be resolved in favor of preserving life. 66
Situational Ethics - I• Situational ethics refers to a particular view of ethics, in which absolute standards are considered less important than the requirements of a particular situation.• The importance of a particular value may vary as one’s situation changes.
Situational Ethics - II• Moral character can be compromised when faced with difficult choices.• Good people behave differently in different situations.• Good people sometimes do bad things.• One’s moral character can sometimes change as circumstances change - thus the term situational ethics
Situational Ethics - III The Creation of Ignorance How Common is the Creation of Ignorance?It’s pretty common. I mean in terms of sowing doubt, certainly global warming denialists who for years have managed to say, “well the case is not proven. We need more research.” And what’s interesting is that a lot of the people working on that were also the people working on Big Tobacco. Interview with Robert Proctor, Professor Standford University Discover 2008
Situational Ethics - IV Discussion1. Why do people who do bad things in one job repeat their pattern of doing bad in another? What is their motive?2. Why do people watch bad things happen & then deny they are happening? Explain.3. What is often referred to as being the “root of all evil?” How does it apply in this case.
Situational Ethics - V Sustaining LifeA decision not to use extraordinary means tosustain life of an unknown 84 year old “may”result in a different decision if the 84 year oldis one’s mother.
Situational Ethics - VI Ethical Decision-MakingEthical decision-making is the process ofdeciding, what the right thing to do is in theevent of a moral dilemma.
Situational Ethics - VII Case: High in the AndesThose who survived the plane crash high in the Andes Mountains were faced with some difficult survival decisions. Their need to survive illustrates to what lengths one may go in certain situations in order to survive (see text for details).
Situational Ethics - VIII High in the Andes, cont.• How might you change as circumstances change?• Describe how your consultative advice might change based on the patient’s needs, beliefs, & family influences.
Moral Compass Gone Astray - IThe world is a dangerous place. Not because of the people who are evil; but because of the people who don’t do anything about it. Albert Einstein 75
Moral Compass Gone Astray - IIHartford Police Chief questions the city’s “moral compass” a week after bystanders & drivers maneuvered around the motionless body of 78- year-old victim of a hit-&-run crash.
Moral Compass Gone Astray - IIIThe continuing trend of awareness of declining value systems, coupled with increased governmental regulations, mandates that caregivers understand ethics and the law and the relationships. 77
Lack of a Moral Compass Discussion1. What moral principles might the sheriff have been referring to when he questioned the city’s lack of a moral compass? Explain.2. Discuss your thoughts as to why society in general is losing its moral compass.
Practical Suggestions• Be a good listener – Listen with the intent to learn not to find fault or argue. – Listen to contribute & resolve ethical dilemmas.
Practical Suggestions, cont.• Believe in good values• Become virtuous – by practicing good values until they become habits.
Summary Thought• Be careful of your thoughts, for your thoughts inspire your words.• Be careful of your words, for your words precede your actions.• Be careful of your actions, for your actions become your habits.• Be careful of your habits, for your habits build your character.• Be careful of your character, for your character decides your destiny.
What Can You Control?Although you cannot control the amount oftime you have in this lifetime, you can controlyour behavior by adopting the virtues & valuesthat will define who you are & what you willbecome & how you will be remembered orforgotten.
Helpful Hints• Be aware of how everyday life is full of ethical decisions and that numerous ethical issues can arise when caring for patients.• Help guide others to make choices.• Ask your patient how you might help him or her.• Be aware of why you think the way you do. Do not impose your beliefs on others. 83
Helpful Hints, cont.• Ask yourself whether you agree with the things you do. If the answer is no, ask yourself how you should change.• When you are not sure what to do, the wise thing to do is to talk it over with another, someone whose opinion you trust.• Do not sacrifice happiness for devotion to others.• Do not lie to avoid hurting someone’s feelings. 84
REVIEW QUESTIONS - I1. What is ethics?2. Why should one study ethics?3. What is morality?4. Describe the ethical theories presented above.5. Describe virtue ethics and values. How do virtues and values differ? 85
REVIEW QUESTIONS - II6. Discuss why “courage” could be considered as the greatest of all virtues.7. Discuss how religion can affect one’s character.8. Discuss why politicians sometimes use religion as a means for their own political aspirations.9. What is the basis of secular ethics? 86
REVIEW QUESTIONS - III10. Describe the various ethical principles reviewed and how they might be helpful in resolving health care ethical dilemmas.11. Describe the principle of Justice and how it can affect the decision making process.12. Discuss the ethical dilemmas involved in the allocation of scarce resources. 87
REVIEW QUESTIONS - IV13. How might the concepts learned in this chapter affect how you would allocate scarce resources in the provision of health care?14. What is “situational ethics?” Why do people behave differently in different situations?15. What is ethical relativism? What is the relevance of this concept to individuals of various cultures living in the same society? 88
REVIEW QUESTIONS - V16. Describe an ethical dilemma (e.g., euthanasia, abortion) and how the ethical theories, principles, virtues, and values discussed in this chapter apply.17. Discuss why you believe or do not believe this statement: “We no longer have a moral compass.”18. What is the purpose of an ethics committee?19. How should an ethics committee be structured? 89
REVIEW QUESTIONS - VI21. Discuss the educational role of the ethics committee.22. Discuss the ever-expanding role of ethics committees, including internal operational issues and external influences that affect internal operations.23. Discuss reasoning and decision making as reviewed in this chapter.20. Discuss the functions of an ethics committee.21.Discuss the consultative role of the ethics committee. 90