Ethics and Values in Long Term Health Care

Patricia Villani

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317837466
• Edition: 1
• Topic: Medicina
• Subtopic: Teoría, práctica y referencia médicas

Here is an overview of many of the ethical challenges facing health care practitioners today. Health providers striving for the appropriate balance between human rights and values and the objectives within their professions confront many ethical dilemmas. This helpful book explores such dilemmas from practical and philosophical perspectives and helps practitioners successfully navigate through the maze of concerns they face on a daily basis. With Ethics and Values in Long Term Health Care, readers can develop new modes of ethical thinking that will enhance their practice as they improve the quality of life of the elderly they serve. The book presents information that can be used as a catalyst for innovative thinking and a guide for positive action. Readers are encouraged to apply the lessons contained in this book to practical decisionmaking in their respective health professions. Chapters assist health practitioners and others in thinking more in-depth about the impact of their personal ethics and values on service delivery, and help them to broaden their views and enhance their decisionmaking skills. The book has a broad scope and is divided into four sections which address:

• Practitioner Knowledge
• Caregiving
• End of Life Choices
• Health Care Reform Ethics and Values in Long Term Health Care helps prepare health care professionals to confront some of the major ethics and values challenges of the 1990s and beyond. This book can be used as a guide to ethical awareness, as well as a tool for teaching ethics and values or for developing programs and workshops.

PRACTITIONER KNOWLEDGE

A Beginner’s Guide to Ethical Awareness in Long-Term Care Services

Priscilla Kimboko
Eva Jewell

SUMMARY. This article provides a basic overview of key ethical concepts relevant to long-term care. It recommends steps to follow in establishing an ethics committee in long-term care settings. The purpose of such a committee is to assist professionals and decision makers in evaluating the choices and decisions they face in their own long-term care or aging service setting on a daily basis. Case studies are included as an appendix to the article to illustrate ethical concepts and dimensions and to provide a new group with starting points for ethical discussions.

THE CONTEXT FOR ETHICAL DILEMMAS OF LONG-TERM CARE

Health and human service professionals have shown a growing interest and attention to the ethical aspects of long-term care in recent years. The trend to deal with “ethics” in care began with medical professionals in acute care settings who were seeking to address the many dilemmas they face in providing appropriate care, given the interface of sophisticated life-prolonging technologies and the increasing age and activism of patients. Such ethical conflicts and dilemmas in the acute care setting are routinely addressed through the auspices of the biomedical ethics committee, now present in most hospital settings.

More recently professionals in other domains of care to the elderly and disabled, including nursing home, home care, and managed care providers and settings, find themselves confronting many similar conflicts regarding the proper nature and type of care and the role of the clients, family members and professionals in deciding on appropriate care. Conflicts often revolve around who has the right to choose (or refuse) different services and related options, and to decide on behalf of individuals about questions of when and how an individual will live or die. While there have been many recent legal or regulatory decisions that impact on professionals providing care in nursing homes, private homes, and community-care settings, the legal responses are not always equivalent to the ethical response. Ethical issues are often more complex questions about what is the right or wrong thing to do, even within the legal options.

In their day to day encounters with clients, families, and professional colleagues, a human service or health professional cannot avoid questions about right and wrong (Downie and Caiman, 1987). How people define right and wrong is often a function of their own personal values or their own profession’s code of ethics. Few professionals engaged in long-term care service delivery have received formal training in ethics, which allows them to assess and evaluate decisions or actions of others in a larger framework of ethical decisions. By the very nature of long-term care, however, no one profession is prepared to meet all the service needs of the clients. Multiple professions must work together. Yet, the professional codes which guide the practice of different professionals are often contradictory and incomplete, particularly when it comes to issues of conflicts among professionals and clients regarding health and social service needs and options.

Confronted with such ongoing daily dilemmas, professionals in long-term care services often experience “bum-out,” skepticism, despair, and anger. These are normal responses to the stress of dealing with life and death issues, with confronting conflicts in values and beliefs, and with realizing that resource limitations and regulations prevent doing all that one’s professional judgment demands.

It is important to the well-being of professionals and clients in the long-term care system, that such issues get addressed collectively rather than individually. More and more community service providers and nursing homes are adopting the bioethics committee model of hospitals to more effectively address these moral and ethical issues in long-term care.

The purpose of this paper is to provide some guidance to those who are interested in beginning such a committee in their facility or community. In this paper we review some of the basic moral concepts and rules to establish the basis for the common language required for persons working together in the broad medical-social context of long-term care. We suggest some ways that professionals can effectively articulate their thoughts and feelings about moral issues. We discuss the nature, purpose, development and operating procedures of an ethics committee, with some precautionary observations provided about possible pitfalls in this process. And, finally, we present several case studies in which we begin to use this common ethical language, to illustrate the types of issues an ethics “group” would face.

STRATEGIES FOR RESOLVING MORAL DILEMMAS IN LONG-TERM CARE

Resolving the moral dilemmas which arise in long-term care services requires professionals to have a forum for an open and frank discussion of the contradictions, conflicts, and differences in values that they confront in their interdependent daily caregiving decisions. In order to resolve dilemmas, it is important that caregivers from different professions have “a systematic, principled manner of clarifying the issues (Denver Community Bioethics Committee, 1993) and that they have a dialogue about ethical choices and actions. Abramson (1985) suggested the following guidelines for beginning such a dialogue:

1. All those working together must learn a common “moral” or “ethical” language dealing with the basic moral concepts and rules.

2. Members of the groups must “learn to articulate their thoughts and feelings about these important moral issues in ways that reduce the ambiguity…” (p. 37).

3. Group members should, individually and as a group, spend time clarifying and prioritizing values and moral principles.

4. The group should have regular procedures for analyzing complex ethical dilemmas when they arise.

In a similar vein, the American Association for Retired Persons (AARP, 1990) suggests that institutions and agencies in the long-term care system can benefit from a well-conceived ethics committee. In a brochure on this topic, they suggest that an important first step is to form an ad hoc group to list the problematic issues and cases that raise moral or ethical concerns, to develop a mission statement regarding the need for and purpose of the ethics committee, and then to develop the plan, to include membership, resource needs and specific operational guidelines.

DEVELOPING A COMMON LANGUAGE OF ETHICAL CONCEPTS

For the novice who has no prior experience in ethical discussions, and, particularly for professionals from diverse backgrounds whose professional codes of ethics differ in their assumptions, role definitions, and guiding principles, it is important and helpful to seek to establish a shared understanding of the principles and concepts that guide ethical practice. These concepts are briefly defined below, and are presented more from the perspective of the helping professional than from that of a philosopher. The goal is not to become philosophically “correct” and “erudite,” but to use the concepts developed in ethics to enlighten our ability to identify and frame the dilemmas we face in the helping professions. As noted by Downie and Caiman (1987), “development of moral consciousness requires more than reading a book … it requires active participation” (p. 4).

For proposes of this paper, ethics comprises a set of principles that should guide the actions of an individual, in deciding about issues of right and wrong actions, which arise in every-day encounters with “clients” and other care-providers. Ethics is the application of moral principles to daily practice decisions, to choice of action. Moral principles help people to live together harmoniously and cooperatively in society and help us distinguish between right and wrong actions.

There are four key moral principles that most ethicists and, in particular, most biomedical ethics committees, apply to the provision of medical and social care. These four principles are: (1) respect for autonomy, (2) beneficence/compassion, (3) nonmaleficence, and (4) justice. Derived from these four principles are several rules of ethical care provisions which should guide the professional-client relationship. The rules include (1) veracity or truth-telling; (2) confidentiality and privacy; and (3) fidelity (Beauchamp & Childress, 1989; Downie & Caiman, 1987).

Respect for Autonomy

A basic assumption of moral philosophy is the inherent autonomy of each individual. Autonomy refers to the individual’s personal self-determination and ability to act, free from controlling interference by others and from personal limitations. The concept of personal autonomy presumes the right and ability to make one’s own voluntary, intentional choices, to maintain bodily integrity, and to live according to one’s religion and beliefs (Wetle, 1987). It assumes that a person acts freely, not under duress. It also assumes that the individual’s actions are not unduly constrained by the available choices, by his/her own weaknesses or limitations, or by the wishes of others.

Autonomy, thus, relates to individuals (the autonomous person) and to behaviors (autonomous actions). An autonomous person is someone who is ‘competent’ and ‘of sound mind,’ who, as a result, is able to make his/her own choices, to consent to, or reject ‘care,’ and to act in ways supported by his/her own desires, beliefs, plans, and preferences. Autonomous actions are those behaviors and acts that are intentionally taken by an individual, given the available information, the individual’s understanding of the situation, and his/her own beliefs and desires, and that are taken without undue external influences or restrictions on options.

Professionals and others show respect for autonomy when, through their behavior, they take account of that person’s own desires, feelings, and reasons and right to choose and decide for themselves. Professionals also respect the autonomy of others by providing individuals with any information available to them (the professional), that is needed to enable the client to make an informed decision, whereby his/her intentions and desires are supported. Respect is shown through the use of skill, shared wisdom, and support for the individual in making what are often very difficult choices.

Beneficence

While individuals are autonomous, there are many times when, due to human vulnerabilities and/or situational factors, the individual is not able to take the desired actions or achieve the desired ends. At such times it is morally appropriate (good, right) to act in such a way as to benefit the other person. These actions may prevent harm, remove harm, or actively promote good. Downie and Caiman (1987) note that in the health and social care professions this behavior might more appropriately be referred to as “compassion,” a combination of “emotion, positive help, and imaginative understanding,” tempered with respect for the dignity of the individual (p. 55).

The moral requirements of compassion may be constrained. On the one hand, one’s own beliefs and values about what is in the best interests of another person may be in conflict with that person’s beliefs and values and, consequently, with their autonomy. In addition, beneficence in health and social care is constrained by the limitations on social resources available to provide help. Beneficence by professionals is a ‘moral obligation,’ to help another when certain conditions are met: Only when the helper (A) is aware of the relevant facts that helpee (B) is at risk of significant harm or loss, and that A’s action is needed to prevent that harm, with a high probability of preventing or minimizing it, and that A’s action would not create significant risks or harm for A, or that the benefit to B outweighs any burden or harm to A (Beauchamp & Childress, 1989).

Conflicts often arise between the moral principles of beneficence and autonomy in long-term care services. To some extent professional codes of ethics have put primary emphasis on the morality and necessity of beneficence, often to the neglect of individual autonomy. Physicians and others are taught to promote the ‘best interests of the client.’ However, the tendency is to define ‘best interest’ according to the professional judgment, knowledge and values, and in regard to the specific domain for which the professional provides care, e.g., health. Clients have a wider range of human values and concerns, such that their independent judgment about their needs or best interests differs from the needs or interests as defined more narrowly from the professional’s framework.

Professionals, acting out of their commitment to beneficence, may make related decisions about disclosure and consent based on their medical care values, failing to recognize that the individual and not the professional is the ‘pivotal decision-maker’ (Beauchamp & Childress, 1989). Paternalism involves an individual, often a professional, taking actions that he/she deems to be in the best interest of the other (e.g., client), rather than letting the client make those choices or judgments. The underlying assumption of the professional is that he/she has superior knowledge and insight with regard to the potential harms or benefits. If the client disagrees or questions the decisions made, professionals may assume that the individual is not ‘competent’ to make a reasoned, informed choice, i.e., is not able to act autonomously.

Non-Maleficence

Related to the concepts of beneficence or compassion is that of non-maleficence, which suggests that individuals (i.e., professionals) have an obligation not to inflict harm or injury to others (Beauchamp & Childress, 1989). Harm can be defined to include actions that injure, disable, kill another person or those that undermine another’s reputation, property, privacy, or liberty.

The obligation not to cause harm encompasses acts of ‘commission’ (actual actions taken) and acts of ‘omission’ (failing to take necessary action). Ethicists refer to a standard of due care, suggesting that carelessness and/or negligence may cause harm to others. To achieve the appropriate standard of care, professionals should have proper training, skills, and diligence, and should adhere to professional standards of practice. If that is done, then mistakes which inevitably occur cannot be considered to be negligence. Even if it is easier to do things for persons than to let them do for themselves, impairing a person’s ability to make an informed choice is considered to be a form of harm. Pity, with its passive sympathy and element of condescension, also can harm the dignity of another (Downie & Caiman, 1987).

Non-maleficence also underlies certain arguments that raise the issue of the “slippery slope,” typically used to question the morality of mercy killing or passive euthanasia. As Beauchamp and Childress (1989) note, these arguments force us to examine “whether unacceptable harms may result from attractive and apparently innocent first steps” (p. 139). The overriding thread in the moral fabric of society is ‘respect for human life,’ so ethicists argue that any steps which remove barriers to killing may unravel the moral fabric.

However, in the same vein, the termination of treatment which has proven ineffective should not typically be considered harmful. The moral stance with regard to treatment falls into three categories: those treatments which are obligatory (or right), which offer a reasonable hope of benefit without excessive expense, pain or inconvenience; nonobligatory treatment, where the expense, pain, and/or inconvenience outweigh potential benefits, if any. Finally, treatments which are clearly not in the client’s best interests are wrong; this may be pointless treatment which cannot offer a benefit, or where the burden or harm caused far outweigh benefits (Beauchamp & Childress, 1989).

Justice

This moral concept suggests that the distributio...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Introduction
• Practitioner Knowledge
• Caregiving
• End of Life Choices
• Health Care Reform