The document discusses various topics related to health care ethics including ethical theories, principles of healthcare ethics like beneficence, nonmaleficence, and autonomy, virtues and values, religious and secular ethics, organizational and professional ethics, and the role of ethics committees. It provides information on these topics to help healthcare providers make difficult ethical decisions in patient care situations. The goal is to equip decision-makers with the knowledge and tools needed to thoughtfully consider all factors and perspectives involved in complex healthcare cases.

2. Chapter 16
Health Care Ethics
2

3. Any Good I Can Do
I expect to pass through the world but once. Any good
therefore that I can do, or any kindness I can show to
any creature, let me do it now. Let me not defer it, for
I shall not pass this way again.
Stephen Grellet, French/American religious
leader (1773-1855).
3

4. 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

5. 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

6. Scope of Ethics
• Micro-ethics: individual’s view of right &
wrong.
• Macro-ethics: global view of right & wrong
6

7. 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

8. 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

9. Codes of Ethics Provide for
• Standards – as guides to human conduct.
• Principles – describe responsibilities.
• Rules of expected conduct – no allowance for
individual judgment.
9

10. Morality
Aim above Morality.
Be not simply good;
be good for something.
−Henry David Thoreau
10

11. 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

12. Morals
• Ideas about what is right & wrong.
• Guides to behaviour that rational persons put
forward for governing their behaviour.
12

13. 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

14. 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

15. Moral Judgments - III
• No “universal morality.”
• Whatever guide to behavior an individual
regards as overriding & wants to be
universally adopted is considered that
individual's morality.
15

16. 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

17. 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

18. Ethics, too, are nothing but reverence for life.
This is what gives me the fundamental
principle of morality, namely, that good
consists in maintaining, promoting, and
enhancing life, and that
destroying, injuring, and limiting life are evil.
-Albert Schweitzer
18

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. Nonconsequential Ethics
Rightness or wrongness of an action is based on
properties intrinsic to the action, not on its
consequences
25

26. 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

27. 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

28. Principles of Healthcare Ethics
• Beneficence
– to do good
• Nonmaleficence
– avoid causing harm
28

29. 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

30. 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

31. Justice & Age
Should 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?

32. 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?

33. 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.

34. Justice: Emergency Care
Two 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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 person's actions are a
necessity for survival.

41. Differing Values
If mom’s estate is being squandered at the end
of life – a family member financially well-off
may want to hold on to mom despite the
financial drain on her estate. Another family
member financially struggling to survive may
more readily see the futility of expensive
medical care & find it easier to let go.

42. 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

43. Virtues & Values - I
Courage
Courage 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

44. 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.

45. Virtues & Values – III
The Courageous Person
A courageous person has good judgment, a
clear sense of his or her strengths, correctly
evaluates danger, & perseveres until a decision
is made & the right goal that is being sought
has been achieved.

46. Virtues & Values - IV
• Wisdom
• Temperance
• Commitment
• Compassion
• Conscientiousness
• Discernment
• Fairness
• Fidelity
• Freedom

47. Virtues & Values - V
• Honesty/Trustworthiness/Truth-Telling
• Integrity
• Kindness
• Respect
• Hopefulness
• Education/Learning as a Value
• Tolerance
47

48. 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.

49. Spirituality
• Spirituality in the religious sense implies that
there is purpose & meaning to life; spirituality
generally refers to faith in a higher being.

50. Varying Religious Beliefs - I
• Judaism
– Monothestic religion
• Hinduism
• Buddhism
– Falun Gong
• Taoism
• Zen

51. Varying Religious Beliefs - II
• Christianity
– Based on Jesus Christ as Savior
– Jehovah’s Witnesses
– Anointing of the Sick for Healing
• Islam
51

52. Secular Ethics
Secular ethics is based on codes developed by
societies that have relied on customs to
formulate their codes.
– Code of Hammurabi

53. Atheism
• Rejection of belief in God
• Claims the existence of God cannot be
scientifically proven.
• Belief that ethics is the product of culture &
politics

54. 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

55. Organizational Ethics II
• Conflicts of Interest Abound
– Accreditation of Hospitals and Conflicts of Interest
• The Joint Commission
55

56. 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

57. Professional Ethics - II
• Nurse’s Documentation Misconduct
• Psychologist’s Sexual Misconduct
• Attorney-Minister Misconduct
57

58. 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
patient's goal for care.
58

59. 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

60. 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:_______________________________________________________
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61. 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 _____________________
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62. Ethics Committee - V
• Serves as a Guardian
– Case: Woods v. Commonwealth
• Convening the Ethics Committee
– Bioethics Committee Not Convened
62

63. Reasoning and Decision-Making - I
Reason 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

64. Reasoning and Decision-Making - II
Reason 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

65. 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

66. 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 patient's
desires in an emergency situation should be
resolved in favor of preserving life.
66

67. 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.

68. 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

69. 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

70. Situational Ethics - IV
Discussion
1. 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.

71. Situational Ethics - V
Sustaining Life
A decision not to use extraordinary means to
sustain life of an unknown 84 year old “may”
result in a different decision if the 84 year old
is one’s mother.

72. Situational Ethics - VI
Ethical Decision-Making
Ethical decision-making is the process of
deciding, what the right thing to do is in the
event of a moral dilemma.

73. Situational Ethics - VII
Case: High in the Andes
Those 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).

74. 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.

75. Moral Compass Gone Astray - I
The 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
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76. Moral Compass Gone Astray - II
Hartford 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.

77. Moral Compass Gone Astray - III
The 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

78. Lack of a Moral Compass
Discussion
1. 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.

79. Practical Suggestions
• Be a good listener
– Listen with the intent to learn not to find fault or
argue.
– Listen to contribute & resolve ethical dilemmas.

80. Practical Suggestions, cont.
• Believe in good values
• Become virtuous
– by practicing good values until they become
habits.

81. 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.

82. What Can You Control?
Although you cannot control the amount of
time you have in this lifetime, you can control
your behavior by adopting the virtues & values
that will define who you are & what you will
become & how you will be remembered or
forgotten.

83. 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

84. 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.
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85. REVIEW QUESTIONS - I
1. 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

86. REVIEW QUESTIONS - II
6. 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

87. REVIEW QUESTIONS - III
10. 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

88. REVIEW QUESTIONS - IV
13. 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

89. REVIEW QUESTIONS - V
16. 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

90. REVIEW QUESTIONS - VI
21. 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