3. Describe an ethical dilemma that you or someone you know has faced. This dilemma does not have to be a problem that arose within the healthcare context. What did you have to take into consideration as you moved toward a decision about which of the two or more courses of action available to you should be taken? Did your decision result in a good outcome?

3

Prototypes of Ethical Problems

Objectives

The reader should be able to:

• Recognize an ethical question and distinguish it from a strictly clinical or legal one.

• Identify three component parts of any ethical problem.

• Describe what an agent is and, more importantly, what it is to be a moral agent.

• Name two prototypical ethical problems.

• Distinguish between two varieties of moral distress.

• Compare the fundamental difference between moral distress and an ethical dilemma.

• Describe the role of emotions in moral distress and ethical dilemmas.

• Describe a type of ethical dilemma that challenges a professional’s desire (and duty) to treat everyone fairly and equitably.

• Discuss the role of locus of authority considerations in ethical problem solving.

• Identify four criteria to assist in deciding who should assume authority for a specific ethical decision to achieve a caring response.

• Describe how shared agency functions in ethical problem solving.

NEW TERMS AND IDEAS YOU WILL ENCOUNTER IN THIS CHAPTER

legal question

disability benefits

ethical question

prototype

clinical question

agent

moral agent

locus of authority

shared agency

moral distress

moral residue

ethical dilemma

Topics in this chapter introduced in earlier chapters

Topic

Introduced in chapter

 

Ethical problem

1

 

Integrity

1

 

Interprofessional care team

1

 

Professional responsibility

2

 

A caring response

2

 

Accountability

2

 

Social determinants of care

2

 

Justice

2

 

Introduction

You have come a long way already and are prepared to take the next steps toward becoming skilled in the art of ethical decision making. The first part of this chapter guides you through an inquiry regarding how to know when you are faced with an ethical question instead of (or in addition to) a clinical or legal question. A further question is raised: How do you know whether the situation that raised the question is a problem that requires your involvement? This chapter helps you prepare to answer that question too. You will learn the basic components of an ethical problem and be introduced to two prototypes of ethical problems. We start with the story of Bill Boyd and Kate Lindy.

 The Story of Bill Boyd and Kate Lindy

Bill Boyd is a 25-year-old soldier who lives in a large city. Bill served in the U.S. Army for more than 6 years and was deployed to both Iraq and Afghanistan for multiple military missions in the past 4 years. During his final deployment, Bill suffered a blast injury in which he sustained significant shoulder and neck trauma and a mild traumatic brain injury (TBI) and posttraumatic stress. He was treated in an inpatient military hospital and transitioned back to his hometown, where he moved into his childhood home with his mother.

Kate Lindy is the outpatient psychologist who has been treating Bill for pain and posttraumatic stress. Bill is in a structured civilian reentry program. This competitive program is administered by a government subcontractor; its goal is to help injured veterans find meaningful careers or employment on return from the front lines. Bill reports that he is struggling with the transition to civilian life. He originally was prompt in keeping his appointments but recently has missed almost all of his sessions. Twice Bill has arrived for his appointment more than 30 minutes late and smelling of alcohol. Kate informed Bill that she could not treat him in this condition and that if he continued to arrive in this state, she would need to discontinue therapy. Bill responded to Kate and said “You have no idea what all of this is like. And don’t even go there on the alcohol; like you have never had a drink on a bad day.”

Kate is concerned about Bill. She calls his home and gets no answer. She then calls the case manager listed on his intake form. Kate tells the case manager about Bill’s regularly missed appointments (three in the last 4 weeks). She also tells the case manager that Bill has been charged for the missed visits because he has not called to cancel, which is the billing policy of the institution where Kate is employed.

The manager responds that Bill does not qualify for transitional career/employment services unless he is compliant with all outpatient care. She adds that in her experience patients like Bill have a hard time adjusting to the fact that they are no longer eligible for active duty.

The case manager says she will talk to Bill about the unacceptability of his failing to let the therapist know when he decides not to keep his appointment. In fact, if Bill keeps that up, the case manager continues, he will be kicked out of the civilian reentry program because the government cannot be expected to pay for his lack of responsibility. Kate responds that maybe Bill was unclear about the policy. The manager replies, “It doesn’t matter. He’s an army man; he knows better than that.”

A week goes by. At the scheduled time for Bill’s appointment, he again does not appear. Kate has been uneasy about the conversation with the manager, and when the time comes for her to fill out the billing slip for another missed appointment, she feels positively terrible.

 Reflection

Do you share Kate’s feelings that something is not right? If yes, what do you think the problem is? Jot down a few thoughts here and refer back to them as the chapter progresses.

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Recognizing an Ethical Question

Health professionals face all types of questions in clinical practice. Some are ethical questions, but others are not. Many times, what may appear to be an ethical question is in fact something else, such as a miscommunication or a question about a clinical fact or a legal issue. Often, complex clinical situations include clinical, legal, and ethical questions; part of your challenge is to distinguish them and sort them out for their relevance to the patient and the delivery of care.

The following exercise is designed to walk you through one example of an issue that includes clinical, legal, and ethical dimensions, with a description of why the last is an ethical question.

Is this an ethical question? Answer Yes or No:

Can a person status post TBI drive?

If you answered “no,” you are correct. This is a clinical question because clinical tests and procedures can help answer it. Patients who pass various cognitive assessments and an on-road driving evaluation have the clinical ability to drive, and those who fail do not. Refer back to the story at the beginning of this chapter. In the narrative about Bill Boyd, Kate Lindy, and the case manager, what additional clinical information can help you better evaluate the situation?

Now consider the following question:

Must patients with TBI comply with medical advice in this type of situation if they want to continue to drive?

Is this a clinical, legal, or ethical question? If you said “a legal question,” you are on the right track. A tip-off is the word “must.” As you learned in Chapter 1, the laws of the state and other laws are designed to monitor public well-being and enforce practices that protect the public good. Almost all states include procedures to help ensure road safety. Relevant information about people who are dangerous behind the wheel is found in part through clinical examinations. Clinical and legal systems are interdependent in that and other situations, so the decision to ignore clinical recommendations is not always up to an individual patient.

Now, go to the specific legal implications of Bill Boyd’s situation. When the physician referred Bill for therapy, she assessed that the patient’s discomfort was from a combat-related injury. The time may come when Bill wants to apply for disability benefits for his condition. Veterans disability benefits are legally enforced governmental programs in the United States to help protect members of the military from financial duress when injured during service duty. And so, a related legal question relevant to this situation is: Do patients have the right to benefits provided by the government if for any reason they miss prescribed treatment and the professional reports this?

Eligibility usually requires that a patient comply with treatments that are prescribed; the fact that Bill missed multiple treatments may compromise his case. The case manager may choose to fight Bill’s claim for disability benefits now that Kate has contacted the manager with this information.

Finally, consider this question, which is an ethical question. As you read it, think about why it is an ethical question.

Should people with TBIs who refuse to take a recommended onroad driving assessment be allowed to continue driving? If so, under what circumstances?

The word “should” is the tip-off here. It points to something in society all have agreed to support and each individual has a responsibility to help do so. Kate’s reflection on whether she should have talked with Bill’s case manager and her ambivalence about having to charge for treatments that she did not administer are examples of ethical questions about the wrongdoing or rightness of her actions that she was pondering.

 Summary

Ethical questions can be distinguished from strictly clinical or legal questions, although all of these questions often arise in health professional and patient situations. An ethical question places the focus on one’s role as a moral agent and those aspects of the situation that involve moral values, duties, and quality-of-life concerns in an effort to arrive at a caring response.

For your continued learning, we now introduce several prototypes of ethical problems, into which many different everyday ethical questions will fit.

Prototypes of Ethical Problems: Common Features

What is a prototype? Prototypes are a society’s attempt to name a basic category of something. Prototypes can be objects, concepts, ideas, or situations.1 Prototypes of ethical problems are recognizable as a group by three features they have in common. Each of the prototypes in this chapter appears different from the others; in fact, each has a different role to play when ethical questions have arisen. That said, the first step into this venture is to become familiar with the same basic structural features found in all the prototypes of ethical problems:

A: A moral agent (or agents)

C: A course of action

O: An outcome

Each feature is discussed in turn.

The Moral Agent: A

Which of the following best describes your idea of a health professional as an agent?

A. A person with more than one basic loyalty; a deeply divided loyalty (e.g., a double agent).

B. A person who has the moral or legal capacity to make decisions and be held responsible for them (e.g., a signee on a contract).

C. A person who plans schedules or events (e.g., a booking agent).

If you answered “B,” you are most clearly focused on the meaning of agency in the health professions roles you will assume. In ethics or law, an agent is anyone responsible for the course of action chosen and the outcome of that action in a specific situation. Obviously, being an agent requires that a person be able to understand the situation and be free to act voluntarily. Acting as an agent also implies intention: The person wants something specific to happen as a result of that action. A moral agent is a person who “acts for him or herself, or in the place of another by the authority of that person, and does so by conforming to a standard of right behavior.”2

 Reflection

This book emphasizes your role as a moral agent in the health profession setting because as a professional, you must answer for your own actions and attitudes. If you have observed a situation in which someone in your chosen field has had to act courageously, then you have observed a moral agent at work. Briefly describe what you observed and why you feel the responsibility fell to that person to be on the front line of the decision.

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A moral agent intends the morally right course of action. The idea of responsibility that you learned about in Chapter 2 is in fact the description of what an agent does; when faced with an ethical challenge in the health professions, the actor assumes the role of a moral agent. Professional responsibility is exercised through moral agency, and professional accountability and responsiveness to the patient through ethical action. Kate and the case manager are both agents whose actions influence the outcome of Kate’s efforts and affect Bill’s health. As a health professional, Kate clearly is in the role of a moral agent.

Agents and Emotion

Moral agency is grounded in a relational context. The moral agent must have not only cognitive ability but also emotional capacity to demonstrate an attitude of respect for the other.3 Both reason and emotion operate as part of your internal processor where you can go and search to find the appropriate tools to exercise your professional responsibility. Much is said about ethical reasoning and problem solving in this book. Through the years, considerable debate about the significance of emotion in an agent’s activity has taken place. Strict rationalists view emotion as too subjective and unpredictable to serve as a reliable guide. However, a burgeoning body of current professional and lay literature lends new knowledge about the role of emotion in decision making more generally to support the essential role of emotion in ethical decision making. Such well-regarded bodies as the Harvard Decision Science Laboratory conduct research on the mechanisms through which emotion and social factors influence judgment and decision making. From their work and the work of others, we find convincing arguments for assigning emotion at least two functions in ethics.

First, emotion is an “alert” system that warns you that you may be veering off the road of a caring response. When you encounter a morally perplexing situation, you, who will be accountable, feel discomfort, anxiety, anger, or some other disturbing emotion. Nancy Sherman, a contemporary philosopher who is working on the place of emotion in morality, proposes that emotions are “modes of sensitivity that record what is morally salient and… communicate those concerns to self and others.”4 Sometimes, an emotional response stirs a person out of lethargy and moves him or her into thinking and action on someone else’s behalf.5,6 In other words, your emotions help grab your attention and motivate you to “do something.” We saw this in the process Kate was going through as she faced the reality of Bill’s missed appointments.

Second, according to current research, emotion kicks in again at the point of decision making to complete the human picture of what is happening.7 Even if you have been logical in your assessment of the ethical problem, emotion puts the last strokes on the canvas and brings the decision into focus as one example of how humans actually conduct their lives all around. In the end, emotion, attention, and behavior interact with each other for real-time decision making.8 Effective moral agents work to integrate emotional responsiveness with critical thinking, so that rather than disregarding emotion, they develop the right emotion, suited to the situation.

 Summary

An agent has responsibility for an action. A moral agent has a responsibility to act in a way that protects moral values and other aspects of morality. An ethical problem requires attention to both reasoning and emotion in the process of decision making. Emotion alerts, focuses attention, motivates, and increases one’s knowledge about complex situations.

The Course of Action: C

The course of action includes the agent’s analysis, the judgment process of discerning the best likely resolution to the problem, and the decision to act in accordance with that judgment. The next two chapters explain how this process works within the context of ethical problem solving with ethical theories and approaches, so more detail about that is not necessary now. Kate Lindy used the information she had to analyze the situation. One attempt at resolution was to call the case manager looking for Bill. Kate’s emotional response afterward reflected a concern for her patient’s well-being, even though she was irritated when she made the call; her discomfort suggests she was unsure she had exercised the correct moral judgment in what she said to the case manager. As we know, Kate also felt a sense of responsibility to bill for the scheduled treatments Bill did not receive, although she did not like this policy in her workplace. This back-and-forth reflection about what she was feeling and doing kept the course of action alive to the possibilities of what should happen.

The Outcome: O

The outcome is the result of having taken a particular course of action. Of course, the goal is that a caring response is achieved in what actually happens as a result of the whole process. We need to have more information about what actually happened as a result of Kate’s conversation and what she thought about it to know whether she considered it a good outcome for her patient Bill Boyd.

Some ethical approaches that you will learn to use in the next chapter place much more weight on the outcome; others place moral priority on the course of action. In everyday descriptions of ethics, this tension is sometimes referred to as the “ends” one achieves and the “means” used. The important point is that real-life professional situations require your full participation in all three features of an ethical problem. The decision of which of the features takes precedence in a particular ethical problem depends in part on the approach or theory you adopt.

 Summary

The two prototypes of ethical problems share three features in common: a moral agent (or agents), a course of action, and an outcome.

Considerations in Moral Agency

Locus of Authority

The role of the moral agent is not always easy. At times, one may have the emotional and cognitive capacity to act as a moral agent; however, constraints in the practice environment limit one’s authority to respond. A locus of authority conflict arises from an ethical question of who should have the authority to make an important ethical decision. In other words, who is the rightful moral agent (A) to carry out the course of action (C) and be held responsible for the outcome (O)? Locus of authority problems most often arise when ambiguities exist about who is in charge (Figure 3-1). Schematically, the situation looks like this:



FIGURE 3-1 Locus of authority problem.

Note that two people assume themselves to be appropriate moral agents (A1 and A2) and proceed along parallel (or even conflicting) courses of action (C1 and C2). As each analyzes the situation, they may come to different conclusions about how to achieve the best outcome (O1 versus O2) for a patient.

This consideration of agency highlights that it does matter who has decision-making authority and say-so. In these situations, structural and team empowerment, which is discussed subsequently in this book, are vital to the nourishment of a moral culture.

 Reflection

In the story of Kate Lindy and Bill Boyd, who do you think should make the decisions about whether to charge for missed treatments?

The health professional who is providing the service?

The supervisor of the unit?

The institutional administrator?

The government or some other, larger societal regulating body?

The patient?

Give a brief explanation for your thinking that supports your position.

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Sometimes, no ambiguity or conflict exists, but reflection on the issue reveals that the wrong person has the authority. In that case, the situation creates moral distress. The challenge of determining the appropriate locus of authority is the topic of thoughtful reflection by ethicists and other individuals. In the context of the health professions, there are at least four ways of thinking about authority in healthcare decisions.

1. Professional expertise. You are in a professional role along with other people in different professional roles. This is the essence of interprofessional teamwork that characterizes so much of quality healthcare today. The role differences mean that you bring different spheres of expertise to the situation. In some areas of the patient’s care, each professional is an authority on a part of the whole picture. That alone should be a vote for the person who has the most relevant knowledge about the patient’s condition and other factors that influence the situation.

2. Traditional arrangements. Traditionally, in the healthcare system, the physician has been the authoritative voice in healthcare decisions. The physician is considered to be in authority because of his or her office or position rather than (or in addition to) an authority because of special expertise. From this perspective, the medical director of the unit unquestionably is the one to make a decision about what to do, although he or she may choose to invite advice and counsel from other individuals.

3. Institutional arrangements and mechanisms. Sometimes, the decision about the authoritative voice comes from special institutional arrangements. For example, some tasks may be delegated to committees. In these instances, the committees or designated individuals assume specific task-related roles. This is really a variation of the first two roles, with the designated individuals in authority because of their expertise and the positions they hold. For example, the authority for making a decision regarding billing for missed treatments may be referred to a committee designed to deal with humane treatment of patients in unusual situations rather than billing solely as a financial issue.

4. The authority of experience. A voice of authority may emerge because of the insight that comes from experience. Situations always exist in which we seek the advice of people who have been in similarly perplexing situations and defer to their judgment. Kate Lindy may wish to seek advice for the next step from a supervisor, senior member of the professional staff, or other person judged to have the benefit of experience. This is seldom institutionalized as a formal mechanism for dealing with locus of authority challenges and is a variation of the professional expertise approach, which assumes that expertise often is refined with experience in a wide range of situations.

None of these sources should be taken for granted as the appropriate authority for all situations. The ethical gold standard remains what will result in a caring response for the patient.

Shared Agency

Given that care is increasingly provided by interprofessional teams, another consideration in moral agency is shared agency. As you recall from Chapter 1, the interprofessional care team is a group of care providers (including licensed health professionals, assistive staff, and ancillary support staff) who work together to deliver quality, evidence-based, and client-centered care. These teams share day-to-day concerns as they arise and work together to navigate practice while upholding professional responsibilities, values, and duties. When faced with the moral dimensions of professional practice, sharing concerns among the team members can create an atmosphere that nurtures ethical reflection. One question that often arises is: Who is the moral agent? Because the goal is to achieve a caring response, the care team may give consideration to shared agency. Shared agency is not to be taken lightly because it requires high levels of engagement from all team members. It entails a commitment to group discussion, collaborative decision making, and mutual trust in the disposition to act on the intentions of the team over the individual, taking into account the previous discussion that at different times various members of the team may emerge as the appropriate authority when the actual decision making is imminent. A prerequisite for shared agency is that each team member is heard (including those with dissenting views), respected, and participatory in decision making and agrees to uphold mutual responsibilities when implementing a plan.9

 Summary

Considerations of locus of authority and shared agency are important features to attend to in a shared moral community. The goal in both considerations is to achieve an outcome consistent with a caring response.

Two Prototypes of Ethical Problems

Now that you have acquainted yourself with the common features of all prototypes, you are ready to learn more about the prototypes themselves: moral distress and ethical dilemmas.

Moral Distress: Confronting Barriers to Moral Agency

Moral distress focuses on the agents (A) themselves when a situation blocks them from doing what is right. Moral distress as a term came into the ethics literature primarily through nursing ethics and has become more generalized because of its usefulness in understanding ethical problems that all health professionals experience. Moral distress reflects that you, the moral agent, experience appropriate emotional or cognitive discomfort, or both, because of a barrier from being the kind of professional you know you should be or from doing what you conclude is right. Your emotional response and feelings play a major role in the recognition that you have moved from striding confidently along in your moral life to experiencing that something is wrong. You can see that your response to the situation comes from an awareness that your integrity is threatened because a threat to integrity arises when you cannot be the person you know you should be in your professional role or cannot do what you know for certain is right. Health professionals find that these emotional signals give rise to physical expressions that warn something is wrong: a knot in the pit of their stomach, a catch in the otherwise confident stride, or an awakening in the early hours of the morning with the haunting feeling that something is awry. Again, we are reminded that emotions and feelings are critical data of the moral life, trying to say, “Stop! Wait! Don’t! Think twice!”

Moral agents in the health professions encounter two types of barriers that create moral distress: type A and type B.

Type A: You Cannot Do What You Know Is Right

A common problem today is the barrier to adequate care of individual patients created by the mechanisms for the delivery and financing of healthcare, although other sources also exist. Recent studies have found that high percentages of moral distress occur over resource allocation and reimbursement constraints, goal setting, maintaining confidentiality, limiting autonomy, withdrawing and withholding care, prenatal testing, and balancing institutional needs versus what is best for the client.3,10–12 For example, a hospital policy may be to refuse admission of patients who do not have insurance to fully cover the cost of their treatment or to discharge patients who the interprofessional care team judges to be unsuited for the rigors of transition to the home environment. Here, the morally right course of action (C) that would lead to the desired outcome (O) is blocked by policies and practices, resulting in moral distress. Type A barrier is illustrated in Figure 3-2. The moral distress comes precisely because of the repercussions the professionals believe they may have to endure. Institutional and traditional role barriers keep them from exercising their moral agency for the good of patients.



FIGURE 3-2 Moral distress: type A.

This does not mean that you will never take into account the larger social context in which you are practicing. As you learned in Chapter 2, social determinants of a caring response sometimes do alter the course of action you would otherwise take. For instance, health professionals must always attend to the larger public health considerations in the case of a patient with a serious highly infectious disease. The patient may experience forced quarantine or be placed in isolation. The health professional’s emotional discomfort in such a situation that requires acting for the good of many other individuals is not an example of moral distress. The patient still can be the recipient of the best care possible. Only when you are quite sure you cannot be faithful to the basic well-being of the patient is there legitimate reason for moral distress.

Another powerful barrier to doing what is right is suggested in the previous paragraph but all too often fails to be included in discussions of moral distress. Moral distress often occurs because of internal barriers such as the fear of repercussion of one kind or another—real or imagined—that looms in the professional’s awareness, blocking action. Wanting to do the right thing and not having the knowledge, skill, or inner strength to do it while under the weight of anxieties and fears often results in heightened moral distress rather than leading to freedom through action (Figure 3-3). This process, faced time after time, can result in moral residue, an accumulation of compromises that takes a heavy toll on one’s integrity.13



FIGURE 3-3 Internal barriers. (From Purtilo R, Haddad A: Respect: the difference it makes. In: Health professional and patient interaction, ed 7, Philadelphia, 2002, Saunders, p 12.)

To face those uncomfortable feelings and emotions and remain motivated to do the right thing requires that each and every one of us receive support from others to step up, speak out, or stand firm as the occasion calls for it. In some other parts of this book, you will be introduced to team and institutional supports that can help you navigate out from under the burden of these internal barriers.

Type B: You Know Something Is Wrong But Are Not Sure What

Often the barrier may not be policies and practices or internal anxieties and fear but instead may be that the situation is new or extremely complex. Your only certainty is an acknowledgment that something is wrong; the rest is a big question mark. You may question how to arrive at the morally correct course of action (C) or how to work toward a specific outcome (O) that is consistent with your professional goal of achieving a caring response in this instance. Type B barrier is illustrated in Figure 3-4. The ethical challenge is to remove the barrier of doubt or uncertainty as much as possible, sometimes through probing deeper into the facts of the situation. When there is high uncertainty, doubt requires that the moral agent must seek advice and critically problem solve through the situation to better understand how to address its complexity. As you can readily see, emotions often play a major role in this type of situation too.



FIGURE 3-4 Moral distress: type B.

 Reflection

Think about Kate Lindy’s moral distress. We asked you to think about why you might feel uneasy too if you were in her situation. What subtype of moral distress is she facing? Explain your answer in a few words here.

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We assume that Kate’s discomfort partially stems from wanting to do what is best for Bill Boyd but being unsure what that is because she likely has not been faced with this set of issues before. She wants to show a caring response that befits a health professional, but she is not sure how to do that under the circumstances. Understandably, she also wants to honor the rules and policies of her workplace but is distressed about charging for Bill’s missed treatments given that his lack of adherence is likely associated with his clinical condition. Her moral distress is more of type B, as we read her situation.

 Summary

Moral distress occurs when the moral agent knows what the morally appropriate course of action is but meets external barriers, internal resistance, or a high level of uncertainty.

As she analyzes the situation, Kate thinks about whether her distress also is related to the fact that she is facing an ethical dilemma. So, join her now in that reflection, as we turn to the second type of prototypical ethical problem: the ethical dilemma.

Ethical Dilemma: Two Courses Diverging

Many people call all ethical problems ethical dilemmas. More correctly, an ethical dilemma is a common type of situation that involves two (or more) morally correct courses of action that cannot both be followed; that is, to take course C1 precludes you from taking course C2. As a result, you (the agent, the responsible one) necessarily are doing something right and also wrong (by not doing the other thing that is also right). You are between a rock and a hard place, between the devil and the deep blue sea (Figure 3-5).14



FIGURE 3-5 Ethical dilemma.

Ethical dilemmas involve both ethical conflict and conduct. Suppose that Kate Lindy has just read the previous paragraph and realizes that she had an ethical dilemma but did not recognize it at the time. She was aware of her moral distress and that further analysis was needed. Here is why she now knows she had a dilemma.

On the one hand, Kate is an agent (A) who has a professional duty to look after her patient Bill Boyd and to take the course of action (C1) that demonstrates her attempt to give Bill the best treatment possible. The desired outcome (O1) is psychological well-being and relief of the patient’s pain. On the other hand, Kate is an agent (A) who has a duty to abide by the policies of her place of employment. The course of action (C2) that expresses that duty is to charge for all treatments that are given or are not officially canceled. The desired outcome (O2) is the financial solvency of the psychotherapy practice. Both outcomes are ethically appropriate, taken alone. However, Kate Lindy probably caused some negative repercussions for Bill in her course of action that included sharing potentially damaging information with Bill’s case manager. The case manager did not sound pleased, either by Bill’s absenteeism from scheduled treatments or the fact that Bill was being charged for the missed treatments. In charging for the treatments, Kate maintained fidelity to her workplace at the price of protecting Bill Boyd from exposure that may cause him additional problems.

Of course, Kate might have thought that charging for missed appointments is wrong under any circumstance, a position that is periodically examined in the health profession literature.15

In subsequent chapters, you will have ample opportunity to work with several types of dilemmas because they are the most commonly confronted type of ethical problem.



Ethical dilemma in the story of Bill Boyd and Kate Lindy.

Justice Seeking as an Ethical Dilemma

A special ethical dilemma arises in regard to attempts to allocate societal benefits and burdens fairly and equitably. Recall that the one social determinant of healthcare often rests on the availability of a valued resource. As in all ethical problems, the agent (A) makes a judgment to take a course of action (C) that results in an outcome (O). The situation is this: Competition exists for cherished but scarce resources, such as a medication, health professionals’ time, money to pay for healthcare, or an organ or other types of lifesaving or quality-of-life–enhancing procedures. The agent’s (A) morally right course of action (C) is to give everyone a full measure of the resource to the extent their needs warrant it. In so doing, the outcome (O) is that the patient’s legitimate claims are honored and the professional can rest assured in having provided a patient-centered outcome. The scarce supply, however, requires that the agent take difficult, even tragic, courses of action, with the outcome that some claimants get the cherished goods and others do not, or they get less than an clinically optimal share.16 In short, it is morally right to give your own patients everything they need to benefit from your interventions. It is also morally right to spread resources around to the benefit of others. The question of how to treat each person fairly, and to treat groups equitably, becomes a challenge that involves a dilemma of justice, a problem that physical therapists in an important study of the meaning of caring in their professional practice found increasingly difficult in a healthcare system that values cost control and a high margin of profit.17 This dilemma is by no means limited to one profession; in fact, it is a common theme in health professions literature today. You will study this and how you can optimize your efforts in the face of contemporary justice dilemmas more extensively in later chapters of this book.

 Reflection

Describe an example in your chosen field of how you might become involved in a dilemma that requires you to make tough decisions because of scarce resources. One way to approach this is to think of the setting in which you are likely to work and the special, sometimes expensive, procedures that may be available to a range of patients. Another is to imagine conditions under which your worksite is short staffed and you must make difficult choices about where to cut corners.

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 Summary

An ethical dilemma occurs when a moral agent is faced with two or more conflicting courses of action but only one can be chosen as the agent attempts to bring about an outcome consistent with a caring response. A special case of a dilemma involves justice issues when a needed resource or service is in limited supply.

Summary

This completes the introduction to your role as a moral agent, the components of any ethical problem, and the two prototypes of ethical problems that will help you to be ready to act ethically. The prototypes of moral distress and ethical dilemmas, along with locus of authority and shared agency considerations, will guide you as you analyze and decide which course of action is the most likely to achieve an intended outcome consistent with honoring your professional responsibility.

Questions for Thought and Discussion

1. Jane is a health professions student who is pregnant and does not want to treat a patient admitted to the inpatient medicine service from a local prison for management of end-stage renal disease. Her clinical supervisor thinks her reluctance is because of her pregnant condition and assures her that she is safe because the prisoner is nonviolent and has a one-on-one guard assigned to his room. Jane still hesitates and says, “I know it’s irrational, but I’m afraid I will not be effective.” She pauses and then adds, “To be honest, I also feel it is God’s will when bad people get sick.”

Is Jane’s reason sufficiently compelling to warrant her being excused from assignment to this patient? Why or why not? What type of ethical problem faces her clinical supervisor? Describe how you have arrived at this conclusion with use of the three features of any ethical problem.

2. Loretta is a physical therapist specialized in diabetic foot care. She sees Mary monthly. Mary is quite down when she hobbles into the clinic today, with her ankles bandaged and blood oozing through the gauze. She tells Loretta, “I’m sure my feet are much worse this month. I haven’t been so good about my sugar, and it didn’t help that my husband hit my ankles with his cane twice last week. I think he is upset about my taxi fare to get here. I should stop coming.” She begins to cry.

What are the clinical, legal, and ethical questions that face Loretta in this case? What should she do?

3. Describe an ethical dilemma that you or someone you know has faced. This dilemma does not have to be a problem that arose within the healthcare context. What did you have to take into consideration as you moved toward a decision about which of the two or more courses of action available to you should be taken? Did your decision result in a good outcome?

References

1 Lakoff G. Women, fire and dangerous things: what categories reveal about the mind. Chicago: University of Chicago Press; 1987 p 12.

2 Taylor C.R. Right relationships: foundation for health care ethics. In: Pinch W.J.E., Haddad A.M., eds. Nursing and health care ethics: a legacy and a vision. Silver Spring, MD: American Nurses Association; 2008:163–164.

3 Lutzen K., Ewalds-Kvist B. Moral distress and its interconnection with moral sensitivity and moral resilience: viewed from the philosophy of Viktor E. Frankl. Bioethical Inquiry. 2013;10:317–324.

4 Sherman N. Emotions. In: Post S., ed. ed 3 New York: Thomson Gale; 740–748. Encyclopedia of bioethics. 2004;vol 2.

5 Purtilo R. Moral courage: unsung resource for health professional as friend and healer. In: Thomasm D., Kissell J., eds. The health professional as friend and healer. Washington, DC: Georgetown University Press; 2000:106–112.

6 Molewijk B., Kleinlugtenbelt D., Widdershoven G. The role of emotions in moral case deliberation: theory, practice and methodology. Bioethics. 2011;25(7):383–393.

7 Bechara A. The role of emotion in decision-making: evidence from neurological patients with orbitofrontal damage. Brain Cognition. 2004;55:30–40.

8 Xing C. Effects of anger and sadness on attentional patterns in decision making: an eye-tracking study. Psychological Reports: Employment Psychology Marketing. 2014;114(1):50–67.

9 Bratman M. Shared agency: a planning theory of acting together. Oxford: Oxford University Press; 2014.

10 Doherty R.F., Dellinger A., Gately M., et al. Ethical issues in occupational therapy: a survey of practitioners. In: Poster presented at the American Occupational Therapy Association 2012 Annual Conference, Indianapolis; 2012.

11 Slater D.Y., Brandt L.C. Combating moral distress. In: Slater D.Y., ed. Reference guide to the occupational therapy code of ethics and ethics standards. ed 2010 Bethesda, MD: AOTA Press; 2011:107–113.

12 Kinsella E.A., Park A.J., Appiagyei J., et al. Through the eyes of students: ethical tensions in occupational therapy practice. Can J Occupational Ther. 2008;75:176–183.

13 Hardingham L.B. Integrity and moral residue: nurses as participants in a moral community. Nurs Philos. 2004;5(2):127–134.

14 Beauchamp T.L., Childress J.F. Professional-patient relationships. Principles of biomedical ethics. ed 7 New York: Oxford University Press; 2012 pp 288–331.

15 Fay A. Ethical implications of charging for missed sessions. Psychol Rep. 1995;77:1251–1259.

16 Freeman J.M., McDonnell K. Making moral decisions: a process approach. Tough decisions: cases in medical ethics. ed 2 New York: Oxford University Press; 2001 pp 241–246.

17 Greenfield B.H. The meaning of caring in five experienced physical therapists. Physiother Theory Pract. 2006;22(4):175–187.

4

Ethics Theories and Approaches

Conceptual Tools for Ethical Decision Making

Objectives

The reader should be able to:

• Distinguish between an ethical theory and an ethical approach.

• Understand the process of clinical reasoning in the health professional.

• Distinguish the different modes of clinical reasoning.

• Describe ethical reasoning as a distinct mode of clinical reasoning.

• Describe the usefulness of the basic ethics theories and approaches as tools in analyzing ethical problems and attempting to resolve problems by arriving at the most caring response.

• Name five types of ethical theories and approaches that help illuminate what a caring response entails.

• Describe a narrative and what it means to take a narrative approach to an ethical issue or problem.

• Assess the contribution of psychologist Carol Gilligan and others who stress relationships.

• Relate the basic features of an ethic of care to a caring response, introduced in Chapter 2.

• Describe the role of moral character or virtue in the realization of a good life and its significance for health professionals faced with the goal of arriving at a caring response.

• Describe ways the various story or case approaches help one understand what a caring response involves.

• Describe the function of a principle (norm, element) in ethical analysis and conduct.

• Identify six principles often encountered in professional ethics that can help guide one in trying to arrive at a caring response to a professional situation.

• Discuss the meaning of autonomy in Kant’s and Mill’s theories and the relevance of each to ethical conduct.

• List five reasonable expectations a patient or client has because of the health professional’s responsibility to act with fidelity.

• Describe the principle of veracity as it applies in the professional context.

• Describe the basic difference between deontologic and utilitarian ethical theories of conduct and the role of each in the health professional’s goal of acting in accordance with what a caring response requires.

NEW TERMS AND IDEAS YOU WILL ENCOUNTER IN THIS CHAPTER

clinical reasoning

ethical reasoning

theories and approaches

story or case approaches

narrative approaches

ethics of care approach

virtue theory

character trait

moral character

principles

principle-based approach

nonmaleficence

beneficence

autonomy

self-determination

paternalism

fidelity

veracity

justice

deontology

deontologic theories

teleology

absolute duties

prima facie duties

conditional duties

teleologic theories

utilitarianism

rule utilitarians

Topics in this chapter introduced in earlier chapters

Topic

Introduced in chapter

 

Moral duty and character

1

 

Codes of ethics

1

 

Interprofessional care team

1

 

A caring response

2

 

Patient-centered care

2

 

Professional responsibility

2

 

Right(s)

2

 

Prototypes of ethical problems

3

 

Moral agency

3

 

Moral distress

3

 

Ethical dilemma

3

 

Introduction

In this chapter, you are introduced to a conceptual “toolbox” of ethical theories and approaches you can use to accomplish your professional goal of arriving at a caring response in the wide variety of challenges you may encounter. An ethical theory is researched and well developed and provides us with an assumption about the very nature of right and wrong. Most theories are historically based and have evolved for current usage according to a society’s or group’s development and a need for interpreting or addressing current moral challenges. In contrast, an approach does not propose to be a complete system or model but an aid to existing theories. For instance, the principle-based approach introduced in this chapter is more recent and has roots in ancient Western ethical theories. Both ethical theories and approaches provide you with a framework for diagnosing, communicating, and problem solving ethical questions you encounter in your clinical practice.1

If you are like us, you probably took a look at how many pages you have ahead of you for your assignment and quickly concluded that this is a very long siege of reading! The idea behind this chapter is to provide you with a “mini book” of ethical theory. Depending on your course of study, your professor may add to these pages with another more theoretic text or may split the chapter into smaller parts. We encourage you to work your way through the chapter carefully so that the rest of your study of this book is easier and your preparation in ethics more complete.

In Chapter 1, we suggested three general ways that ethical tools have usefulness in your everyday life: (1) to analyze moral issues, (2) to help resolve moral conflicts, and (3) to move toward action when faced with a problem. In Chapter 2, you learned about the caring response as the goal of professional ethical practice. In Chapter 3, you had an opportunity to learn the basic varieties (i.e., prototypes) of ethical problems you will encounter in your professional career. In this chapter, you will gain more knowledge and tools that will enable you to move skillfully from the identification of a problem, through its analysis, and, hopefully, to its resolution through action that achieves your goal of a caring response. Chapter 5 provides a simple six-step process you can follow as you apply everything discussed in this and the previous chapters. We set the stage for your thinking with the story of Elizabeth Kim, Max Diaz, Melinda Diaz, and Michael Leary.

 The Story of Elizabeth Kim, Max Diaz, Melinda Diaz, and Michael Leary

Elizabeth Kim is a speech and language pathologist who works in a large urban school system. She is responsible for performing many student evaluations and interventions each day and takes her job seriously. Elizabeth services the Richards Elementary School and two other schools in the Lakeview district. Students and parents who meet Elizabeth quickly learn that she is a bright spot in the otherwise anxiety-producing ordeal of navigating services for children with learning disabilities. Elizabeth prides herself on being thorough and always explains everything to both the students and the parents in language they can understand.

Two weeks ago, Elizabeth had an experience that upset her, and she is not sure what to do about it. A young student, Max Diaz, had met Elizabeth for his speech and language pathology evaluation at Richards Elementary School. Max has an expressive language disorder, and Elizabeth felt strongly that he would benefit from an augmentative communication device. She has used these devices in the past and has seen great success with them. Elizabeth had her quarterly supervision meeting with Michael Leary, the school principal, that afternoon. She talked about Max in the meeting because she was intrigued by his case. She told Principal Leary her evaluation results and that she would be recommending the augmentative device. Principal Leary told Elizabeth, “Please do not put that recommendation in your written report. Max’s mother has not been overly involved in advocating for his needs. If we can hold off on meeting with her for Max’s education plan until the end of the school year, I won’t have to buy the device until the next academic year. Those devices are really expensive, and I don’t know if we have the money right now. Besides, who knows if it will really even work for him, given English is his second language.” Elizabeth left the meeting feeling uncomfortable.

The speech and language pathology evaluation report was completed and submitted to the administration. Elizabeth did include the recommendation for the augmentative device in the report because she knew that it was in Max’s best interest. She was eager to train Max in how to use this type of device. All that was needed now was administrative and parental approval. As soon as the individualized education plan (IEP) could be scheduled, they could move forward. A copy was sent to Principal Leary, Max’s homeroom teacher, and his mother, and one was placed in his academic record in the administrative office.

Several weeks later, Elizabeth asked Principal Leary when Max’s IEP would take place. She wanted to get his mother’s and the team’s approval to move forward with various interventions, including the augmentative device. He told her that Melinda, Max’s mom, had been slow to respond to the school’s request for a meeting and said, “We offered her a date, but she could not make it. Since then, we have not been able to coordinate with a Spanish interpreter. I may just try to schedule her without one. Actually, the longer it is put off, the better, as we won’t have to bear the cost of the device you recommended on this year’s school budget.”

Elizabeth knew that the longer the meeting took to arrange, the longer Max would go without service; she wanted to say, “Aren’t you going to follow up and encourage her to get in soon?” but she did not. She knew Principal Leary would have to schedule the meeting and was also afraid he may be insulted by such a question.

Today, 3 months after the evaluation was completed, Elizabeth is walking another student to the after-school program when she sees Max with his mom, Melinda Diaz, in the corridor. Melinda says, “Oh, you must be the speech therapist. Thanks for the papers you sent to me about Max. It’s too bad that you and the teacher couldn’t meet a couple months ago. I was looking forward to talking with you all. I can’t read English that well, so I had a hard time understanding the papers.”

“Oh. Did Principal Leary talk with you about setting another meeting time sooner rather than later?” Elizabeth asks, feeling tense.

“No, he didn’t. He just keeps saying, ‘Don’t worry.’”

“Well,” Elizabeth says. “You have the right to set another meeting time sooner rather than later and to have an interpreter there if you want to.”

Melinda immediately looks concerned. Elizabeth wants to say something to reassure her, but the words fail her. The school bell rings, and Elizabeth says a hurried good-bye. She feels a gnawing in the pit of her stomach, but she cannot immediately figure out what, if anything, she should do next.

That Elizabeth Kim is distressed is not surprising because something definitely is wrong. In fact, we might wonder about a health professional who felt no emotion at all about this situation: a young child with a learning disorder who is not performing to his potential, and communication between his mother and the school staff that appears to have broken down. Maybe Elizabeth has said