Nur403class1.2019powerpointstudent (2) (1).pptx

Ethics and Public
Policy in Health
care
MARIANNE CHIAFERY, DNP,PNP-C,
MS Bioethics

Objectives for today
1. Identify situations that require thoughtful and deliberate
ethical analysis.
2. Introduce the Robichaux framework as a guide to fully
explore an ethical dilemma.
3. Develop and communicate a reasoned, rational
argument that provides support for a chosen course
of action.
Purpose: To prepare you to complete the Bioethics Paper
assignment and group project.

“What people believe prevails
over truth” Sophacles

Don’t
believe
everything
you
think.

Aristotle
MORAL EDUCATION
INTELLECTUAL MORAL
VIRTUES VIRTUES

Intellectual virtues
“capacities or powers of understanding,
judgment and reasoning which enables the
rational parts of the soul to attain truth.”
Aristotle, NEVI II. 1139922

Moral Virtues
The dispositions (character) to act as Reason
dictates. Right choice, apart of action, requires
intellectual virtues of reasoning and right desire
“ but intellect itself, however, moves nothing…”
Aristotle, NEVI II.113966

Aristotle asserts a Unity of Virtue thesis,
which holds there are interdependencies
between the possession of good judgment
and the possession of moral virtues.
R. Curren (2000)

Unity of Virtues Thesis
Actions
Perceptions
Memory
Testimony
Introspection
Reasoning
Rational Insights
Dispositions
and
Character

“It is that our judgment of particular cases and our
knowledge of how to “compose a scene” is itself
part of the moral response…
In this sense, character is expressed in what one
sees as much as in what one does. Knowing how to
discern the particulars, Aristotle stresses , is a mark
of virtue.”
N. Sherman, The fabric of Character: Aristotle’s theory of virtue

Ethical frameworks
Virtue ethics: Moral character of an individual determines action
and behavior
Deontologic ethics: Specific duties determine ethical actions
Consequentialism: Moral rightness or wrongness of an action is
determined by the outcome.
Divine Command Ethics: guided by higher being or force

Moral reasoning
CONSEQUENTIALISM
Rawls: Social Contract
Right action depends on the
consequences of the decisions
made and actions taken
Utilitarianism: Actions are aimed
at doing the most good.
DEONTOLOGIC
•Immanuel Kant
Identifies morality as certain
Duties and Rights, regardless
of outcome.
Categorical Imperative: to do
that which you would want
done to you or loved ones in a
similar situation. Universal.

Nightingale Pledge
I solemnly pledge myself before God and in the presence of this
assembly, to pass my life in purity and to practise my profession
faithfully. I will abstain from whatever is deleterious and
mischievous and will not take, or knowingly administer any
harmful drug. I will do all in my power to elevate the standards of
my profession, and will hold in confidence all personal matters
committed to my keeping and all family affairs coming to my
knowledge in the practice of calling. With loyalty I will endeavour
to aid the physician in his work and to devote myself to the welfare
of those committed to my care.
Lystra Gretter 1893

ANA Code of Ethics
Non-judgmental regard
“The nurse …practices with compassion and respect for
the inherent dignity, worth and uniqueness of every
individual, unrestricted by considerations of social,
economic status, personal attributes, or the nature of
health problems.”
ANA Code of Ethics for Nurses with Interpretive Statements ( 2016) Silver Spring MD

Non-maleficience
“Prevention of a specific harm often becomes the
duty of an individual or group of individuals, by
virtue of a role, profession, occupation or
circumstance.”
Gert and Clouser (2006) Bioethics: A Systematic Approach. Oxford. P 87.

Normative Ethics with specific duties for Nursing and
Medicine professions
( see Rhodes handout for full list)
* Beneficence: to do good
* Non-maleficence : to prevent or avoid harm
* Autonomy: individual right to determine destiny
* Justice: 1. Equitable distribution and allocation of resources
2. Fairness, treat all equally
Confidentiality
Fidelity : Do not abandon patient, to “stay with”
Veracity: truth-telling, honesty

What are our responsibilities as
team members in ethical decisions
and determining policy?
1. Interdependence
2. Participation
3. Objective evidence---
reasoned intervention or
recommendation based on
fact

Recognize an ethical dilemma:
Moral conflict between right and wrong, where
there are opposing views of the morally correct
response or action, or the correct action is not
readily evident
Veatch R (1997) Medical Ethics 2nd ed. Jones and Bartlett:MA
Tension between 2 or more ethical principles,
which indicates differing values between at least
2 stakeholders.

Argument
- A fact or assertion offered as
evidence that something is true
- A dispute where there is strong
disagreement
..Debate
….Taking a Stand (position statement)
……..Persuasion

A Good Argument:
Is based on fact, not emotion.
Expresses a point of view on a subject supported by evidence and
rational thought and reasoning.
Will take into account points of rebuttal an opponent might
make, and offers a response in anticipation of those counter
arguments.
Will be more likely to convince others of your conclusions.
Can be oral or written.

Generating, Translating, and Strengthening
Ethical Arguments and Counterarguments
D A V I D J . A L F A N D R E , M D M S P H
K E N N E T H A . B E R K O W I T Z , M D F C C P
B A R B A R A L . C H A N K O , R N M B A
L I S A S . L E H M A N N , M D P H D
N A T I O N A L C E N T E R F O R E T H I C S I N H E A L T H C A R E
A S B H P R E - C O N F E R E N C E
1 9 O C T O B E R 2 0 1 7

Disclaimer
The views and opinions of authors expressed herein do
not necessarily state or reflect those of the United
States Government.
The authors have no conflicts to disclose, financial or
otherwise.
24

Learning Objectives
• Identify ethical arguments and counterarguments
and describe the role they play in an ethical analysis.
• Categorize ethical arguments according to 3 types of
rationales: based on standards, consequences, and
comparisons.
• Identify arguments based on faulty reasoning.
• Strengthen ethical arguments by adding supporting
information to ensure the rationale is credible.
25

CASES Approach
• Clarify the Consultation Request
• Assemble the Relevant Information
• Synthesize the Information
• Explain the Synthesis
• Support the Consultation Process
26

CASES Approach
• Synthesize the Information
– Determine whether a formal meeting is necessary
– Engage in ethical analysis
• Apply ethics knowledge to the assembled information
• Generate and strengthen ethical arguments / counterarguments
– Identify the ethically appropriate decision maker
– Facilitate moral deliberation among ethically justifiable
options
27

Ethical Analysis: Definition
29
The use of systematic methods of reasoning to apply
relevant ethics knowledge to consultation-specific
information for the purpose of responding to an ethics
question.

Ethical Analysis: Steps
1. Articulate important ethical arguments and
counterarguments in a clear and compelling fashion.
2. Weigh the strength of each argument and balance
competing arguments to yield a conclusion that
responds to the ethics question.
30

Ethical Analysis: Steps
1. Articulate important ethical arguments and
counterarguments in a clear and compelling fashion.
A. Generating ethical arguments and counterarguments
B. Strengthening ethical arguments
2. Weigh the strength of each argument and balance
competing arguments to yield a conclusion that
responds to the ethics question.
31

What is an Argument?
33
Definition of an Argument
A set of claims that includes a conclusion and at least
one rationale to justify the conclusion.
Definition of a Claim
Assertion or declarative statement.
Handout 1-Q1

Example of an Argument
34
This patient is at high risk of suicide because he has
attempted suicide multiple times before.
Handout 1-Q2

What Is a Claim?
Definition
An assertion or declarative statement.
Descriptive Claim
A statement about how something is.
Normative Claim
A statement about how something should be.
Example of Descriptive Claim
Most patients have never discussed their life-sustaining
treatment preferences with their surrogates.
Example of Normative Claim
Surrogates should make life-sustaining treatment decisions
based on their knowledge of patients’ preferences. 35

Descriptive vs. Normative Claims
Descriptive Claim Normative Claim
What is What should be
Facts Value Judgments
True or False Better or Worse
Reality Ideal World
Informational Evaluative
Descriptive Prescriptive
Verifiable Justifiable
May be proven or disproven by
empirical evidence or observations
of the world
May not be proven or disproven by
empirical evidence or observations of
the world
36
Handout 1-Q3

What Is an Ethical Argument?
Ethical Argument
An argument that a particular decision or action is
(or is not) ethically justifiable.
Example of an Ethical Argument
It would be wrong to write a DNR order on this
comatose patient without involving the surrogate
because the surrogate has a right to decide whether
or not this patient should be DNR.
37

Identify Then Translate Ethical
Arguments
Definition of an Ethical Argument
An argument that a particular decision or action is (or is not) ethically
justifiable.
Standardized Format for Ethical Arguments
[Decision or action] is (or is not) ethically justifiable because [rationale].
It is ethically appropriate to write a DNR order on this comatose patient
without involving the surrogate since the patient previously indicated that
he wanted to be DNR.
Ethical Argument Translated Into the Standardized Format
[Writing a DNR order on this comatose patient without involving the
surrogate] is ethically justifiable because [the patient previously indicated
he wanted to be DNR.]
38

Translating Ethical Arguments into a
Standardized Format
1. Express decision or action as gerund (“i-n-g”).
Example: “Writing a DNR order on this comatose patient
without involving the surrogate.”
2. Determine whether argument is asserting decision or action is
(or is not) ethically justifiable.
Examples: “Should/should not,” “ought/out not,” “right/wrong,”
“appropriate/inappropriate,” “proper/improper,” “good/bad,”
value laden terms (e.g., murder).
3. Identify rationale for argument.
Examples: Preceded by “because,” “due to,” “for the reason
that,” “since,” “for,” “inasmuch as,” “in the view of the fact that.”
39

Arguments
The right thing to do is to involve the surrogate before writing
a DNR order in that failure to involve her will undermine trust.
Standardized Format for Ethical Arguments
[Decision or action] is (or is not) ethically justifiable because
[rationale].
Ethical Argument Translated Into Standardized Format
[Involving the surrogate before writing a DNR order] is
ethically justifiable because [failure to involve her will
undermine trust].
40

Arguments
It is better not to tell the patient that his wife has died.
It would only make his condition worse.
Not telling the patient that his wife has died is ethically
justifiable because it would only make his condition
worse.
41

Arguments
It’s the patient’s right to know so you shouldn’t
withhold the information.
Withholding the information is not ethically justifiable
because it’s the patient’s right to know.
42

Arguments
Patients often split their pills in an attempt to save
money.
Can’t translate = Not an ethical argument
43

Arguments
Surrogates should make life-sustaining treatment
decisions based on their knowledge of patients’
preferences.
Can’t translate = Not an ethical argument
44

Ethical Counterarguments
Definition of an Ethical Counterargument
An ethical argument that opposes another ethical argument.
It would be wrong to write a DNR order on this comatose patient
without involving the surrogate because the surrogate has a
right to decide whether or not this patient should be DNR.
Example of an Ethical Counterargument
It is ethically appropriate to write a DNR order on this comatose
patient without involving the surrogate since the patient
previously indicated that he wanted to be DNR.
45

Ethical Argument and Counterargument
It would be wrong to write a DNR order on this comatose patient
without involving the surrogate because the surrogate has a
right to decide whether or not this patient should be DNR.
Example of an Ethical Counterargument
It is ethically appropriate to write a DNR order on this comatose
patient without involving the surrogate since the patient
previously indicated that he wanted to be DNR.
Argument or Counterargument?
The right thing to do is to involve the surrogate before writing a
DNR order on this comatose patient in that failure to involve her
will undermine trust.
46

Group Activity Instructions
1. Work individually.
2. Read the examples on Handout 3.
3. Determine whether they are ethical arguments or
not. Hint: Translate the examples into the
standardized format in your mind.
4. Label them “Yes” or “No” in the column.
47

Example
Your health care system is trying to prevent the
transmission of flu from health care workers to
patients. Should the health care system mandate an
annual seasonal flu vaccination for all health care
workers?
49

Which Rationale Would You Choose
for the Ethical Argument?
Mandating flu vaccination for health care workers is
ethically justifiable because…
1. Health care workers have a duty not to harm patients by
exposing them to flu.
2. The vaccine is safe for most staff to take.
3. Our hospital is similar to others that require flu vaccination
for health care workers.
50

Which Rationale Would You Choose
for the Counterargument?
not ethically justifiable because…
1. Staff have a right to make choices about their own health
care decisions.
2. The vaccine is often not fully effective.
3. Other beneficial vaccines are not required.
51

Three Categories of Ethical Arguments
ethically justifiable because…
1. Health care workers have a duty not to harm patients by
exposing them to flu.
[Argument based on STANDARD]
2. The vaccine is safe for most staff to take.
[Argument based on CONSEQUENCE]
3. Our hospital is similar to others that require flu vaccination
for health care workers.
[Argument based on COMPARISON]
52

Three Categories of Ethical Arguments
not ethically justifiable because…
1. Staff have a right to make choices about their own health
care decisions.
[Argument based on STANDARD]
2. The vaccine is often not fully effective.
[Argument based on CONSEQUENCE]
3. Other beneficial vaccines are not required.
[Argument based on COMPARISON]
53

Ethical Arguments Based on Standards
Definition of an Ethical Argument Based on a Standard
An ethical argument with a rationale to the effect that the decision or action in
question is consistent or inconsistent with a standard.
Definition of a Standard
A statement intended to guide the ethical behavior of an individual or group over
time.
Types of Standards
- Legal standards - Principles
- Policy standards - Organizational values statements
- Professional standards - Mottos
- Religious standards - Personal credos
Ethical Theories
Deontological ethics, “rule-based” ethics, duty-based ethics
Catchwords
Right, obligation, duty, responsibility, standard, legal, policy, ethical standard,
principle
Handout 5
54

Basic Ethical Arguments Based on
Standards
It would be wrong to give John a bigger salary increase
than Mary. It wouldn’t be fair.
Giving John a bigger salary increase than Mary is not
ethically justifiable because it wouldn’t be fair.
55

Standards
The organization owes it to her to give her another
chance—it’s the right thing to do.
Giving her another chance is ethically justifiable
because the organization owes it to her.
56

Standard
It would be ethically problematic if you made that
phone call because you would be using your public
office for private gain which is against regulation.
Making that phone call is not ethically justifiable
because you would be using your public office for
private gain which is against regulation.
57

Strengthening Ethical Arguments
Based on Standards
Definition of an Ethical Argument Based on a Standard
An ethical argument with a rationale to the effect that the
decision or action in question is consistent or inconsistent
with a standard, i.e., a statement intended to guide the ethical
behavior of an individual or group over time.
Strengthen by adding supporting information to explain why you
think that the standard is true (ideally direct quotes from
authoritative sources).
Requires: Knowledge of standards and sources of standards.
58

Strong Ethical Argument Based on a
Standard
Basic Ethical Argument: Mandating flu vaccination for health
care workers is ethically justifiable because health care workers
should put the safety of patients ahead of their own concerns.
Ethical Argument with Strengthened Rationale: Mandating flu
vaccination for health care workers is ethically justifiable
because it is consistent with the professional duty to patients as
codified in the AMA Code of Ethics, Principle VIII, “A physician
shall, while caring for a patient, regard responsibility to the
patient as paramount.”
59

Ethical Arguments Based on
Consequences
Definition of an Ethical Argument Based on a Consequence
An ethical argument with a rationale to the effect that the decision or
action in question will or will not result in certain good and/or bad
effects.
Can Describe Consequences for
• Patients
• Families
• Health care teams
• Health care organizations
• Society in general
Ethical Theories
Teleological ethics, consequentialism, utilitarianism
Catchwords
Effect, result, cause, and if/then statements 60

Consequences
We should not let Mr. Jones have an MRI on his first
visit for back pain because if we do, everyone else
would want one too.
Letting Mr. Jones have an MRI on his first visit for back
pain is not ethically justifiable because if we do
everyone else would want one too.
61

Consequences
That level of budget cuts would compromise patient
care and therefore is completely unacceptable.
Making that level of budget cuts is not ethically
justifiable because it would compromise patient care.
62

Strengthening Ethical Arguments
Based on Consequences
decision or action in question will or will not result in certain
good and/or bad effects.
Strengthen by adding supporting information to explain why you
think that the consequence will result from the decision or
action in question (ideally empirical data or other clear
reasons).
63

Consequence
care workers is not ethically justifiable because the vaccine is
often not fully effective.
vaccination for health care workers is not ethically justifiable
because the vaccine effectiveness varies (historically between 10
and 60%) and it will reduce the program’s credibility if many staff
develop the flu despite the mandate to get vaccinated.
64

Comparisons
Definition of an Ethical Argument Based on a Comparison
An ethical argument with a rationale to the effect that the decision or
action in question is similar to or different from another decision or
action.
Can Compare/Distinguish
• Characteristics of the decision or action
• Moral actor(s), i.e., who is making a decision or taking an action
• Recipients or object of the decision or action
• Circumstances surrounding the decision or action
Ethical Theories
Casuistry, case-based reasoning
Catchwords
Like, similar, as if, unlike, dissimilar, different
65

Comparisons
Similar to the Cruzan case, even though there’s no
advance directive we should remove the feeding tube
because it’s clear the patient didn’t want to be kept
alive through artificial means.
Removing the feeding tube is ethically justifiable
because, similar to the Cruzan case, even though there
is no advance directive it’s clear the patient didn’t
want to be kept alive through artificial means.
66

Comparisons
It’s okay for employees to use their work computers on
occasion for personal matters, but this is different in
that the employee was being paid for her time by
another organization.
Using a work computer for personal matters in this
instance is not ethically justifiable because this is
different from other occasional uses in that the
employee was being paid for her time by another
organization.
67

Strengthening Arguments Based
on Comparisons
decision or action in question is similar to or different from
another decision or action.
Strengthen by adding supporting information to explain the
other decision or action and why you think it is similar to or
different from the decision or action in question, citing sources.
68

Comparison
care workers is ethically justifiable because our hospital is similar
to others that require flu vaccination for health care workers.
vaccination for health care workers is ethically justifiable
because our hospital is similar to other leading teaching
institutions and as of 2015 more than a third of The Council of
Teaching Hospitals members have implemented strict
vaccination policies.
69

How to Assess an Argument
• Identify the conclusion
• Identify the rationale
– The reasons for believing the conclusion
– Is the rationale true?
• Is the movement from rationale to conclusion logical?
– Is the rationale relevant to the conclusion?
– Do the rationales strongly support the conclusion?
• Are there counterarguments?
• Identify unstated rationales or assumptions
70

Ethical Arguments Based on Faulty
Reasoning
71
Ethical
Counterarguments
Ethical
Arguments

Reasoning
Almost all of the clinicians on the unit think we should
override the surrogate’s decision, so that’s what we
should do.
Ad populum
72

Reasoning
The chief of staff doesn’t disclose this type of medical
error, so there’s no reason to tell the family.
Inappropriate appeal to authority
73

Reasoning
You should eat everything on your plate. Some children
aren’t lucky enough to get nutritious food every day.
Appeal to emotion
74

Reasoning
We have to cut spending on social programs. Otherwise
we will have a huge deficit that will bankrupt the
country.
False dichotomy
75

Reasoning
People who object to requiring a photo ID must be
un-American.
Ad hominem
76

Reasoning
It’s legally permissible, so it must be ethical.
Confusing law and ethics
77

1. Work in pairs.
2. Match the arguments with their category:
• Standards
• Consequences
• Comparisons
3. Identify claims based on faulty reasoning.
78
Handout 5 & 6

1. Work in pairs.
2. Fill in the worksheet with your partner.
• Build your case by generating and strengthening
1 argument and 1 counterargument for each of
the 3 types of rationales for ethical arguments:
standards, consequences, and comparisons.
• Don’t spend too much time on any one
argument. The idea here is to think of multiple
arguments.
79

Takeaways-Generating Strong Ethical
Arguments and Counterarguments
• Ethical argument: A statement that helps to answer an ethics
question by asserting that a particular decision or action is (or is not)
ethically justifiable on the basis of a specific rationale.
• 3 rationales for arguments: Based on standards, consequences,
comparisons.
• Standardized format for ethical arguments:
[Decision or action] is (or is not) ethically justifiable because
[rationale].
• Ethical argument should be strengthened so the intended meaning is
understandable, not open to interpretation, and the rationale is well
supported and credible.
80

Ethical Analysis: Next Steps
• Determine the relative strength of each of the
arguments and eliminate those that cannot be made
clear or compelling.
• Weigh and balance remaining arguments and
counterarguments to determine what decisions or
actions are ethically justifiable.
• Write the analysis, including arguments and
counterarguments, in a logical sequence and
coherent narrative.
81

Weighing and Balancing Ethical
Arguments
82
Standard

Using a framework for analysis ….
What is a framework?
A framework is a broad overview or outline of
interlinked items which supports an approach to a
specific objective. A framework serves as a guide.
The Robichaux framework for ethical analysis provides
an outline of steps that serve as a guide to achieve the
objective of a reasoned and sound ethically justifiable
response to an ethical dilemma. 84

Robichaux’s ethical decision
making framework (2012)
•State the ethical issue or problem. State the dilemma as a question.
•Identify information needed to thoroughly analyze the case, and obtain
from reputable sources.
•Identify ethical principles in tension.
•Identify the key players and their values.
Who is most affected by the decision? What does that person value?
•Identify possible courses of action and probable consequences of each.
•Select the best course of action.
•Implement the action.
•Self-reflection

Using required reading “Good Reasons”
Background of the problem
State the ethical question

2. Identify Information Gaps
and find answers to those
gaps

What information sources should you
consider?
Law: Court cases, legal statutes
Science : Best practice, “what would another reasonable practitioner do
in this situation?”
Statistics: prognosis, outcome, complications, etc….
Research
Social situation: family, friends….
Culture/religion
Document your sources and rationale.

GOOGLE SCHOLAR AND
REPUTABLE SITES FOUND IN
SYLLABUS, RESEARCH……
WIKIPEDIA, WEBSITES THAT
ARE NOT ACADEMICALLY
RIGOROUS, OPINION PIECES

3. Determine who is involved
Who is most effected by the
decision?
Whose rights are paramount?
Are there power imbalances?
From Robichaux 2012

4. Determine prevalent values
•Values held by patient, staff,
institution, other
stakeholders
•Are there value conflicts?
Between whom?
•Are there cultural
perspectives? Who can
help with these?
Robichaux (2012)

5. Identify possible courses of
action the NP may take
•Compare the options.
•Identify potential or
likely consequences of
each action
•Choose the best
action.
•Robichaux, 2012

Structure—General Rules
Start from reliable facts
Distinguish premises, assumptions and facts
Present your ideas in a natural order
Use definite, specific, concrete language
Avoid jargon
Avoid loaded language
Use consistent terms
Avoid more than one meaning for each term you use

Before submitting your paper
reread it carefully and consider….
Is my argument rational ?
Does it come to a logical
conclusion, supported by the
evidence?
Does personal bias effect my
analysis?
Use the grading rubric to
analyze your work.

6. Implement selected course of
action
•Conduct ongoing evaluation
•Does actual outcome
correlate with the anticipated
outcome?
•Does the same problem keep
occurring? If so, why? Is this
a policy issue?
Robichaux, 2012

7. Self reflection, Evaluation
•What could have been
done differently?
•Should someone else
have been consulted?
•What insights were
gained? Should these
be shared with others?
Robichaux, 2012

Are legal and ethical the
same?
Legal
Ethical
Illegal
Ethical
Legal
Unethical
Illegal
Unethical

The LAW is the basic
standard.
Ethics is the
higher standard.

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