Title of Course: Ethics for Occupational Therapists
CE Credit: 3 Hours
Learning Level: Intermediate
Authors: Bill Asenjo, PhD, CRC & Linda Bagby, OTR
Abstract:
Ethical and moral issues pervade our lives, especially in the healthcare arena. Occupational Therapists are
frequently confronted with a variety of ethical and moral dilemmas, and their decisions can have longrange effects both professionally and personally. Why does one decision win out over another? What does
the decision process involve? How do these decisions impact those involved? This course will address these
questions, as well as many of the common dilemmas that Occupational Therapists face in daily practice.
Learning Objectives:
1.
2.
3.
4.
5.
6.
7.
Recognize causes of ethical dilemmas in the healthcare industry
Discover the ethical factors that lead individuals to take action
Identify solutions to bioethical issues and dilemmas
Recognize models of decision-making processes for solving ethical dilemmas
Evaluate features of a “Code of Ethics” for healthcare professionals
List the obligations that an OT must address when faced with an ethical dilemma
Explain the features of a successful ethics committee
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Ethics for Occupational Therapists
Introduction
Ethical and moral issues pervade our lives, especially in the healthcare arena. Healthcare professionals are constantly
confronted with a variety of ethical and moral dilemmas. Their decisions can have long-range effects professionally and
personally -- for healthcare professionals, patients, clients, healthcare entities, and for society as a whole.
Why does one decision win out over another? What does the decision process involve? How do these decisions impact
those involved?
This course will address these questions, as well as many of the common dilemmas that Occupational Therapists face.
Topic 1: Causes of Ethical Dilemmas in the Healthcare Industry
Topic Description: Healthcare professionals, regardless of their role, have a responsibility to make reasoned ethical
decisions. Decisions have far-reaching consequences for all concerned. Upon completing this topic, you will be able to
identify the most common causes of ethical dilemmas in the healthcare industry.
Diversity Issues
Today’s workforce is more diverse then ever before, representing a rainbow of
nationalities, cultures, religions, ages, and levels of education and socioeconomic
status. We enter the workforce with unique backgrounds, values, goals, and
perceptions. Yet members of this increasingly diverse group are expected to work
together in a spirit of cooperation for the good of the organization and the
patient/client.
Cultural diversity can present ethical dilemmas for a healthcare provider when
presenting patients with medical treatment options. In the United States, for example,
emphasis is placed on individualistic rights and therefore the patient holds the ultimate
authority to decide which form of treatment to pursue. However, in many cultures,
health decisions are not made by an individual but by a group: family, community and/or society (Ludwick & Silva).
Socioeconomic Conditions
Rising healthcare costs, increasing numbers of uninsured Americans and growing frustrations among patients and
doctors are the inevitable result of distorted incentives and mechanisms in our current healthcare system. The ethical
dilemmas regarding access to healthcare is compounded by mounting pressure to work harder, faster, and with fewer
resources. As a result, healthcare professionals are often pressured to make compromises and engage in behavior that
others may consider questionable.
Technological Advancements
Healthcare technology now enables us to diagnose and treat illnesses that were lethal not too many years ago. Issues
involving human genetics, patient choice, quality of life, and prolonged life are at the forefront of publicized ethical and
political debates.
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It may be, as some have argued, that prolonging human life won’t make us any happier or fulfilled. It may even make us
more miserable by detaching us further from the compensations of our natural purposes. It makes sense to say that the
“freedom” we achieve by becoming autonomous individuals, independent of religion and sociobiology, will actually
make us less happy. The situation may also be, as Audrey Chapman contends, “the desires of some individuals for a
longer life may be in conflict with the best interests of their society and/or the human community.”
Topic Summary: Healthcare professionals are presented with ethical dilemmas that stem from diversity issues,
socioeconomic conditions, and technological advancements. When confronted with these dilemmas, healthcare
professionals often feel pressured to make compromises and engage in behavior that may be considered questionable,
discriminatory, or offensive by certain groups or individuals.
Topic 2: Aspects of Ethics and Related Concepts
Topic Description: The features and principles of ethics and ethical reasoning are useful tools for healthcare
professionals when confronted with difficult ethical decisions. In this topic, students will learn the various aspects of
ethics that contribute to their own ethical framework and decision-making processes.
Ethics Defined
The concept of ethics dates back to Aristotle and ancient Greece. The word ethics is
derived from the Greek word ethos, meaning character or customs. Ethics refers to
principles that define behavior as right, good and proper. These principles do not
necessarily dictate a single course of action, but involve evaluating and deciding
among competing options.
Ethics may be normative or descriptive. The normative approach attempts to bind a
professional's behavior and actions within certain parameters that are good and right
for clients and patients, healthcare professionals, and professional organizations. From
this normative approach evolve codes of ethics, organizational rules of conduct, and so on. The descriptive approach
attempts to describe or report on what people believe and the behaviors that follow those beliefs.
Therefore, when we focus on what a professional should be doing, we are talking about normative ethics. Conversely,
when we simply describe how people behave and/or describe the moral standards they claim to follow, we are referring
to descriptive ethics.
What Ethics Isn’t
To understand the aspects involved with ethics, it is helpful to recognize factors that are not specific to ethics. The
following factors should not be confused with ethics:
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•
•
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Our feelings: A person may not do what is right because of feelings to the contrary. Feelings can frequently deviate
from what is ethical.
Religion: Although religions promote ethical standards, if ethics were restricted to religion, then ethics would only
apply to religious people.
Law: Laws set forth ethical standards for people to follow, but laws can deviate from what is ethical. Two examples
are the Pre-Civil War slavery laws and women legally prevented from voting prior to 1919.
Whatever our society accepts: This concept requires social consensus on many different issues. One would have to
take a survey on each issue involved and then settle ethical dilemmas based on consensus. As you might guess,
there will likely never be consensus on all ethical issues.
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Moral Principles
The term “moral” implies conformity with the generally accepted standards of goodness or rightness in conduct or
character. Ethics is concerned with how a moral person should behave. Therefore, ethics are viewed as standards of
conduct that prescribe how one should act or behave based on moral obligations. A list of moral principles is displayed
below:
1. Morality involves traditional beliefs about right and wrong conduct.
2. Autonomy involves the right of self-determination (i.e., that the patient or client has a right to choose). In other
words, patients and clients have the right to be fully informed about everything involved in their care. They have the
right to make decisions about such matters based on accurate information.
3. Justice involves fairness to everyone, sound reason, rightfulness of decisions and actions. It insures, for example,
that all people have the same access to healthcare services regardless of their ability to pay, gender, ethnicity or
race, physical or mental ability, age, or any other factors, such as behavior or lifestyle. In other words, justice
demands equitable and appropriate distribution of resources.
4. Beneficence is the duty of ‘doing good.’ The duty of the healthcare practitioner is to benefit and promote the wellbeing of the patient or client.
5. Nonmaleficence is the duty to ‘do no harm.’
6. Advocacy or Loyalty involves standing up for a patient or client.
7. Veracity is simply telling the truth.
8. Confidentiality requires keeping confidences – knowing when, and what must remain confidential.
9. Ethic of Care gives rise to compassion, equity, fairness, and dignity and provides a framework for relationships.
10. Reciprocity involves respect for the client’s goals and values.
11. Fidelity is the duty to be true to others, as well as to keep promises.
12. Integrity speaks to moral steadfastness and wholeness of beliefs.
13. Concern for community as a whole considers costs to the community, as well as the values of the community.
14. Sanctity of Life refers to maintaining life rather than the intent to end life.
Universality
Most people base their convictions about what is right and wrong on religious beliefs, cultural roots, family background,
personal experiences, laws, organizational values, professional norms and political perspectives. However, these are not
the best ethical values upon which to make ethical decisions — not because they are unimportant, but because they are
not universal.
In contrast to consensus ethical values — such as trustworthiness, respect, responsibility, fairness, and caring —
personal and professional beliefs vary over time, among cultures and among members of the same society.
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Values & Beliefs
Values represent the inner judgments that determine how a person actually behaves. Values pertain to ethics when they
concern beliefs about what is right and wrong. The values one holds affects one's ethical position, which in turn affects
how one responds in situations in which ethics come into play.
One definition of values states that values are: Core beliefs or desires that guide or motivate attitudes and actions. Not
all beliefs are core beliefs or desires. Core beliefs play a large part in determining what attitudes we hold and how we
respond to people and situational events in our lives.
For the most part, values cannot be readily seen in everyday, ongoing interactions. Cottone and Tarvydas (1998)
observe, "Values are not directly observable, but are expressed verbally or in how they guide human choice and action
through the value preferences expressed in human choices and goals” (p. 123).
Cottone and Tarvydas (1998) discuss the way in which
counselor and client values affect the counseling process. In
this context, the counselor's values steer the course of the
counseling process, while the client’s values determine the
content of the counseling process.
On the issue of whether a healthcare provider's values should
visibly come into play during interactions with clients, many
are of the opinion that the healthcare provider's values
should not be imposed upon clients. However, through the
process of disclosure, a therapist's values can legitimately
come into play in the context of ongoing issues in counseling.
Values are indicators of what one holds in esteem. Values act
as standards that guide actions and judgments. Typically,
values are organized by priority into what is known as a value system, resulting in a continuum along which judgments
are made regarding behaviors and actions.
Values and resulting value systems operate at the individual or personal level, institutional or professional level, and
societal or national level. Personal values, for example, are values that do not necessarily involve interaction with others.
Personal values are expressed by an individual's behavior that generally brings about the value satisfaction, e.g.,
someone who works diligently because he or she values a strong work ethic.
Institutional or professional values, alternatively, may be described as a specified prioritization or constellation of values
that express and encourage the identification and advancement of the group's values. In this sense, professional values
serve as a group's standards and have the propensity to set the direction toward which an organization works. This
occurs whether values are clarified by the group and stated up front, or whether they are ambiguous because they have
not been formally identified.
When values are not articulated, assumptions are made about what is considered to be of value. Unspoken values and
assumptions about what is of value to the group, however, will continue to influence and shape the behaviors and
actions of the group.
Topic Summary: The ethical decisions we make are based on our moral principles, such as justice and beneficence.
These inner judgments rely on our accepted standards of right and wrong to identify the best alternative for a decision.
These inner judgments are represented by values, or value systems, which operate at the individual or personal level,
institutional or professional level, and societal or national level.
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Topic 3: Ethical Factors that Lead an Individual to Take Action
Topic Description: We are judged as individuals by our visible actions, not by our internal ethical beliefs. To translate
personal values into ethical behavior, we must be aware of all the motivational forces driving our behavior. This topic
presents the factors that lead an individual to take action.
From Values to Principles
We translate values into principles so they can guide and motivate ethical
conduct. Ethical principles are rules of conduct or behavioral guidelines that
derive from ethical values.
For example, honesty is a value that governs behavior in the form of
principles such as: tell the truth, don’t deceive, be candid, and don’t cheat.
In this way, values give rise to principles in the form of specific "dos" and
"don’ts."
When Values Collide
Because they rank our likes and dislikes, our values determine how we will behave in certain situations. But values often
conflict. For example, the desire for personal independence may run counter to our desire for intimacy. Our desire to be
honest may clash with the desire to be rich, or kind to others.
In such cases, we resort to our values system. The values we consistently rank higher than others are considered our
core values, which define character and personality.
Ethics and Action
Ethics involves putting principles into action. It is also about self-restraint, which includes:
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Not doing what you have the power to do. An act isn’t proper simply because it is permissible or you can get away
with it.
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Not doing what you have the right to do. There is a big difference between what you have the right to do and what
is right to do.
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Not doing what you want to do. An ethical person often chooses to do more than the law requires and less than the
law allows.
Why Be Ethical?
There are many reasons for being ethical:
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Reward -- Ethical behavior is its own reward.
Personal advantage -- It is prudent to be ethical. It’s good business.
Approval -- Being ethical engenders self-esteem, the admiration of loved ones and the respect of peers.
Religion -- Good behavior can please or help serve a deity.
Habit -- Ethical actions may agree with one’s upbringing or training.
There are also strong obstacles to being ethical, which include self-interest and happiness.
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Self-interest: When the motivation for ethical behavior is self-interest, decision-making is reduced to risk-reward
calculations.
If the risks from ethical behavior are high — or the risks from unethical behavior are low and the reward is high — moral
principles succumb to expediency. This is not a small problem: many people cheat on exams, lie on resumes, and distort
or falsify facts at work. The real test of our ethics is whether we are willing to do the right thing even when it is not in
our self-interest.
Happiness: Enlightenment philosophers and the American Founding Fathers considered the pursuit of happiness a basic
right of free men. But is this pursuit a moral end in itself? It depends on how one defines happiness.
Our values, what we prize and desire, determine what we think will make us happy. We are free to pursue material goals
and physical sensations, but that alone rarely (if ever) leads to enduring happiness. It more often results in a lonely,
disconnected, meaningless existence.
Topic Summary: We translate ethical values into principles to guide and motivate our conduct. Our principles lead us to
ethical action(s) for several reasons including: reward, personal, approval, religious, and habitual motives. To achieve
these ethical actions, we must often overcome our personal self-interest and happiness.
Topic 4: Bioethical Issues and Dilemmas
Topic Description: The field of bioethics attempts to address the pressing challenges and controversies that healthcare
professionals and organizations currently face. This topic identifies the bioethical issues and dilemmas of our day.
Bioethics
Bioethics can be defined as ethics that apply to healthcare, including moral rules, principles, and values that guide
healthcare professionals in their relationships with clients and families.
Activity: To learn more about current bioethical issues, go to the news section in the left menu of the Center for
Bioethics and Human Dignity website at http://bioethics.com. Select and read any two articles that interest you.
Privacy & Confidentiality
One of the most elementary content areas in bioethics is concerned with privacy and confidentiality issues. Privacy
involves the client’s right to keep their professional relationships with healthcare professionals a secret -- as far as the
professionals are concerned. For the therapist, privacy extends to the disposition and/or exposition of client records. For
example, refraining from leaving records where others can easily view them.
Confidentiality more specifically relates to information exchanged in interaction with other professionals. For therapists,
it focuses on the information communicated in the therapeutic relationship. Confidentiality, of course, extends to
information exchanged over the phone, correspondence concerning clients, and reports concerning clients, as well as
communication over the Internet. Cottone and Tarvydas (1998) note that confidentiality evolved as an anti-gossip
guarantee. Everything a client reveals to a therapist should be held in confidence.
There are limits and exceptions to confidentiality, i.e., sometimes it is permissible to break confidentiality. Cottone and
Tarvydas (1998) list several limits to confidentiality:
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Required revelations to authorities regarding any case of suspected child abuse or neglect
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Required revelation to authorities regarding intent to harm an individual or society
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Required revelation of information to the parent or legal guardian of a minor client at the request of the parent or
legal guardian
Rapid Change: A Double-Edged Sword
Perhaps there is no better example of the exponential growth of information and its access than the Internet. Of course,
any invention or technology has potential for both ethical and unethical use. Consider nuclear power, which can be used
to light a city, or decimate it.
While the Internet offers the potential to improve well-being by providing unprecedented access to health information,
products, and services, it also makes communication and practices possible that raise ethical, social, and legal concerns.
We are only beginning to develop an understanding of how to participate in the virtual environment of the health
Internet. We are only beginning to think carefully about which opportunities we can take advantage of, and which
opportunities, though technically possible, may be ones we should not pursue.
Trust is a fundamental concern in e-health. In fact, it is fundamental to healthcare. To receive the care they need,
patients must share private information. They rely on healthcare professionals to keep their personal information
confidential, to provide accurate and appropriate information about their conditions and possible treatments, and to
recommend the therapy they believe to be in the patient's best interests.
Yet trust can be particularly difficult to sustain in the anonymous,
virtual environment of the Internet and the World Wide Web. Anyone,
anywhere, who has access to a computer, a link to the Internet, and
modest technical skills can set up a web page offering health
information, products, or services, regardless of his or her
qualifications. And anyone, anywhere is able to present him- or herself
as a patient -- whether to a healthcare professional or to an online
patient community -- whatever his or her actual health status.
In addition, unlike traditional healthcare, the Internet is not restricted
by geographical or political boundaries, making it possible for users to
seek, and others to offer, health information, products, and services
across international or local borders -- where different languages may
be spoken, and different laws govern how medical professionals are
licensed, how health products or services may be advertised and sold,
and how personal information is handled. Determining which existing
national or local laws apply to online practices, and what new
regulation may be needed, is the subject of ongoing debate and
deliberation.
Given the technology currently available, healthcare professionals cannot examine a patient who seeks personal advice
or services over the Internet (though some hospitals are developing closed systems employing fiber optics and similar
Internet-related technologies). Instead, caregivers must rely on what an e-patient tells them -- about their symptoms,
health habits or concerns -- and thus work without much of the information that a physical exam and face-to-face
conversation would provide. While the technology will surely evolve, healthcare professionals must find ways to
compensate for this lack of information if they are to offer advice that is both medically and ethically sound.
The following scenarios focus on privacy and confidentiality:
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Scenario 1: A Father's Request
John, an occupational therapist, has a 21-year-old client. The client lives at home with
his parents but will move out when he begins to work steadily.
John receives an email from the client’s father regarding his son. The father is
concerned about his son's case. The father shares information with John about the
son's status at home and in the community. Then the father asks John for more
specifics regarding the son's progress in rehabilitation.
Should John comply? Why or why not?
Ethical Considerations: Autonomy appears as the salient issue in this scenario. Although the client is living under his
father’s roof, at 21 years of age he is legally an adult.
Perhaps the issue is more influenced by the content of the information that the father shares about his son’s status at
home and in the community. If there are concerns regarding behavior that may be detrimental to others, possibly illegal
or immoral activity, that’s one aspect. However, if the father is merely overprotective, that is not sufficient reason to
divulge personal information about a client.
Scenario 2: The Retirement Party
Joan, an occupational therapist, attends a retirement party for an individual in Service Delivery. She mills around the
crowded room among other conversing professionals and meets a social worker she has had professional conversations
with by phone. The social worker begins to discuss one of the clients he referred to Joan.
Should Joan discuss the case? Why or why not?
Ethical Considerations: One should consider whether the referring social worker is still involved with the client referred
to Joan. And, if so, the extent to which the social worker wishes to discuss the client. Is the social worker merely
inquiring how the client is doing in general? Is this an inquiry motivated by professional concern, or gossip fueled by
alcohol served at the retirement party? And, of course, no matter what is said, how confidential is the conversation? If
others are able to hear what’s said, that violates the client’s confidentiality. Joan’s best course of action is to politely
steer the conversation to another topic.
Scenario 3: The Cosmetologist
Karen, an occupational therapist, has had a rough day – an unusual number of clients have
called or visited her office with problems. After work, Karen goes to get her hair cut. She
has visited the salon many times and knows one of the cosmetologists well. Karen
unwinds, but she is careful to disguise names and identifying information about specific
clients as she talks with the cosmetologist.
Has anything unethical occurred?
Ethical Considerations: As an occupational therapist, Karen knows as well as anyone the
benefits of venting her emotions. However, in this situation one must consider how well
she has disguised her clients’ names and identifying information. The safe choice is to vent
her professional frustrations – particularly those concerning specific clients, with another
professional in a manner that will not risk compromising her clients’ confidentiality.
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Scenario 4: The Spouse
Larry, an occupational therapist working in a rehabilitation clinic, waits for his wife to come by after work for a dinner
date. A client displaying bizarre behavior leaves the clinic just as Larry’s wife arrives. The client exits the clinic and cannot
hear what is said inside. Larry’s wife points toward the closed door and asks, "What's his problem?"
Should Larry discuss the case with his spouse?
Ethical Considerations: No, Larry should not discuss the case. In spite of the fact that it’s Larry’s spouse asking the
question, that does not justify violating a client’s privacy or confidentiality. One must consider the motives, as well as
the potential for benefit and harm, in revealing anything pertaining to a client’s welfare. Larry should ask himself: What
good can come of discussing this client even briefly? Most likely, Larry’s wife is merely expressing curiosity and/or
concern, but it is still best to avoid possible ramifications. Would Larry, for instance, freely divulge any information about
the particular client if his supervisor or another nurse were present? Finally, disclosure would involve HIPAA regulations
(see section of this course describing HIPAA). Therefore, Larry should tactfully change the subject.
Scenario 5: Discussion in an Open Office
Two occupational therapists, Bill and Alice, are on break at a rehabilitation facility. Clients steadily flow through the
hallways. The door to the office is open as Bill and Alice openly discuss some of their problem clients.
Is this a breach of ethics?
Ethical Considerations: Many medical professionals would consider this a breach of ethics. Any risk of violating a client’s
confidentiality must be considered. Given this scenario, there is no way to guarantee that a passing client would not
overhear comments.
While all 5 of these scenarios often happen to therapists and other healthcare professionals, the overriding factor to
consider here is compliance with HIPAA (Health Insurance Portability and Accountability Act of 1996). This law invokes
strict penalties for violations of patient confidentiality and makes very specific exceptions with regards to gun shot
wounds, child abuse and other such legally mandated reporting requirements. Therefore, every communication in this
day and age should be absolutely confined to the strictest confidentiality as needed for patient treatment.
This author has personally seen hospitals and other healthcare entities
take HIPAA compliance so far as to dismiss employees immediately who
are in violation of HIPAA confidentiality requirements. Moreover, many
organizations no longer page healthcare professionals by name over the
PA. Some provide healthcare professionals with pagers, while others
have systems in place to locate personnel. Perhaps more important is
the location of “sensitive” patient information conversations by phone,
email or in person. These too are governed by HIPAA legislation and
require Fort Knox security and confidentiality. Indeed, the world in which
we practice has changed and for that reason it is vital for professionals
to understand the confidentiality requirements of HIPAA.
One can go to the following website to learn more about HIPAA requirements: http://www.hipaa.org.
Topic Summary: Protecting a patient’s privacy and confidentiality is often at the center of many bioethical issues. In
addition, technological and scientific advances in biology and medicine stir many concerns over the breadth of
acceptable healthcare practices and research.
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Topic 5: Codes of Ethics for Healthcare Professionals
Topic Description: Healthcare professionals develop and comply with codes of ethics to guide and set precedents for
acceptable practices and behavior. In this topic, you will learn the specific features of codes of ethics for healthcare
professionals.
Codes of Ethics
A code of ethics entails distinguishing right from wrong, and the commitment to do what is right, good, and proper as
established by a governing body. As Michael Josephenson of the Josephenson Institute of Ethics
(http://www.josephsoninstitute.org) points out:
•
Ethics is about right and wrong and how an honorable person should behave.
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Ethics concerns character and courage and how we meet challenges -- when doing the right thing will cost more
than we want to pay.
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Ethics are with us all the time.
Ethics vs. Regulations
Codes of ethics are not legally binding regulations. Rather, they are voluntary standards adopted by organizations,
professions, or industries that set expectations for behavior.
Codes of ethics don’t often require or forbid particular activities, though some do. Codes of ethics educate participants,
and the public, about what's at stake -- in providing health information, products, or services, or in other specific
professional activities or commercial endeavors. They identify the values that should shape best practices. In this sense,
they can serve as a foundation for more specific regulations.
Codes of ethics are not self-interpreting. As general statements of value and commitment, they provide fundamental
guides for thinking about practices; they must be general enough to apply meaningfully in many situations. Those who
adopt codes of ethics must think carefully and critically about how specific practices serve values.
All too often regulations are viewed as merely something that matters only to special groups, for example, lawyers, risk
managers, compliance officers, or privacy officials, rather than values that should guide everyone.
Codes of ethics and regulations are complementary. Codes of ethics help us to understand values. They promote best
practices as part and parcel of what it means to be involved in different kinds of activities.
Regulations, on the other hand, stipulate expectations in specific detail, and dictate specific consequences when
practices deviate from those expectations.
Codes of ethics alone cannot assure that our conduct conforms to our expectations for excellence. Similarly, regulations
alone cannot tell us enough about why and how our practices matter.
Code of Ethics for Occupational Therapists
Most professions have ethical codes. The American Occupational Therapy Association (AOTA) provides a code of ethics
for Occupational therapists. Take a few minutes to review the American Occupational Therapy Association's Code of
Ethics: http://www.aota.org/Consumers/Ethics/39880.aspx
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Topic Summary: Specific codes of ethics may vary across individual healthcare professions; however a proper code of
ethics should distinguish proper behavior as established by a legitimate governing body. Your profession’s code of ethics
stresses the fundamentals of ethical conduct in your professional behavior.
Topic 6: Common Ethical Dilemmas that Healthcare Professionals Face
Topic Description: To deal with ethical dilemmas, you need to identify all the factors that are at play before determining
an appropriate course of action. To prepare for these situations, it is helpful to familiarize yourself with everyday health
related predicaments. This topic identifies some common ethical dilemmas that healthcare professionals face.
Dilemmas
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A Dilemma is a situation or problem involving a difficult choice.
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An Ethical Dilemma involves a choice between two or more equally justifiable alternatives.
Scenario 1: ALF Resident
Genene, a healthcare professional in a hospital is working with a patient who resided in an assisted living facility prior to
her hospitalization. The patient informs Genene that she plans to return to her ALF after she is discharged from the
hospital. However, Genene learns from the patient’s case manager that the ALF cannot take the patient back because it
is not financially feasible. The case manger then explains to Genene that she was unable to persuade the facility to
change their decision, in spite of the fact that the elderly woman considers the ALF her home.
What ethical aspects should Genene ask the case manager to consider?
Ethical Considerations: The situation involving the ALF and the elderly woman poses an ethical dilemma. On one hand
there is a moral, ethical (and legal) obligation to the patient -- to let her return ‘home’. On the other hand, there are the
financial responsibilities, the choices dictated by the greater good – the existence of the ALF, the other residents, and
the job stability of the staff employed by the facility. No doubt there are other concerns, as well such as the concerns of
those who own the facility or stockholders of the company that owns the facility. Likely, the situation may be more
complex than simply fulfilling the wishes of an elderly woman, or, for that matter, abiding by the policies adopted by the
ALF. This scenario poses a dilemma by any definition.
Ethical Dilemmas
All ethical dilemmas are not necessarily about ending life. For example, what about the healthcare professional who
witnesses a colleague crossing the line with a patient or client? For that matter, what does it mean to cross the line with
a patient or client? The codes provided at the end of this course are clear regarding these matters.
As a healthcare professional you are in a position of power. Abusing that power for gain is most likely unethical, e.g.,
borrowing money, taking sexual favors, or selling something to clients or patients.
Scenario 2: Occupational Therapist under Scrutiny
An occupational therapist came under the scrutiny of an ethics review board when it was determined that she was
selling bricks from a home remodeling project to a client.
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Ethical Considerations: The first question one might ask is: who owns the bricks? Are they the occupational therapist’s
property to sell? If not, then a clear violation of the law, in addition to the moral principle of justice, is involved.
Secondly, even if the occupational therapist has the right to sell the bricks,
the act of selling something to a client compromises the integrity of the
professional relationship between the client and the occupational therapist.
Scenario 3: Forgotten Treatment
An occupational therapist is treating a patient in a hospital. The therapist
needs to hurry to pick up her child at school and is expected to attend a
parent-teacher conference that day. The patient’s treatment protocol
established by the physician includes 15 minutes of ultrasound, 15 minutes of
massage, and 15 minutes of therapeutic exercise/stretching following
shoulder surgery. The therapist decides to skip the massage treatment since it
is a “hands on” treatment like the stretching/exercise and exercise is deemed
more valuable given the time considerations. Therefore, the therapist decides
to deliver only 2 of the 3 treatments and goes on to the school.
Ethical Considerations: If the therapist does ignore the patient’s prescribed treatment protocol, one must wonder if she
will document that the following day. If she lies about it, that violates the moral principle of veracity. More importantly,
perhaps, does that erode her responsibility regarding other prescribed treatments that may be inadvertently
overlooked, or simply inconvenient to administer? Physician confidence can erode quickly when not following orders. If
by chance the therapist documents something that was not performed it becomes a clear case of fraud. And to what
extent is she familiar with the patient’s medical history? Is there a reason this specific treatment protocol had been
prescribed? Are there more serious consequences for this particular patient if she/he does receive that prescribed
massage treatment?
This situation involves the moral principles of beneficence, the duty to do good, as well as nonmaleficence, the duty to
“do no harm.” Finally, how would this therapist regard another therapist making the same decision? Would she feel
compelled to report the other person? One might argue that abiding by ethical principles without exception is too rigid,
but is it? And if one compromises their behavior in violation of an ethical principle, at what point does it become a
problem? And who decides? Does one make decisions while hoping the consequences do not come to the attention of a
supervisor or ethics committee? In short, this scenario represents more than just a skipped treatment.
Have you ever done anything similar? Would it matter if it were something other than a missed massage? Would it
matter if the patient were younger, older, dying or being discharged in the morning? While therapists have a duty to
treat the patient appropriately, there may indeed be excessive acute swelling that would contraindicate the massage
treatment. However, in this case the physician would need to be notified immediately to approve the change in
treatment protocol. What would you do if you couldn’t reach the patient’s attending physician?
Is this the same kind of ethical dilemma as, say, someone stealing money from a patient’s room?
If you witnessed any of these situations, what would you do? Do you know who to go to? If not, ask your supervisor
about the appropriate policy in your particular setting.
Scenario 4: New Diagnosis
One of your regular patients is Joe, an 85-year-old male in relatively
good health. Joe, who lives with his wife of 61 years, has not been
feeling well for the past few weeks. Normally, Joe spends his
afternoons sailing model boats with his youngest grandson at the local
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pond and volunteering his time reading to children at the library. But lately, he has just not been himself.
As a result of his latest checkup visit, Joe is told that he has cancer. The treatment recommended by the specialist (who
was recommended by the family MD) is radical in Joe’s opinion. It will require surgical intervention, radiation and
chemotherapy. Joe’s funding source is a Medicare HMO that has limited experience with this particular treatment
regime. Joe is not sure what to do. He feels he has had a full life and does not want to become a housebound invalid
depending on others. His wife say’s she will support her husband’s decision. The family physician says he can only offer
options. Joe’s children and grandchildren don’t understand why Joe is reluctant to undergo treatment. They want him to
survive.
Since you are the occupational therapist working with Joe, the Medical Director asks you for your opinion. What factors
influence your opinion? Might these factors include age, economical resources, family support, and/or religious beliefs?
What about the HMO’s policies?
What if you knew nothing about Joe; would that make a difference? What if Joe wasn’t a kindly grandfather? What if he
was in a nursing home because of Alzheimer’s? Would that make a difference?
What if Joe was only 35-years-old? What if he was mentally challenged; perhaps brain injured? Suppose Joe was a highly
esteemed scientist or an extremely wealthy businessman? How do the answers to these questions impact your opinion?
Why?
Ethical Considerations: In this situation, Joe has already made his choice known – he does not want to prolong his life at
the price of enduring what he views as radical procedures. His wife supports his decision. It appears that the only ones
voicing objections are the younger family members. One might wonder, are they willing to compromise Joe’s autonomy
– his right of self-determination – merely to satisfy their own needs? And wouldn’t this situation remain much the same
even if Joe were much younger? Isn’t he still entitled to his autonomy? If Joe’s religious beliefs conflicted with his
decision, wouldn’t that also be a matter for him to decide?
Certainly, if Joe was an Alzheimer patient, mentally challenged or brain injured, the family’s advocacy and loyalty would
become more of an issue. However, if Joe were wealthy or famous it might have some impact on the degree of care he
was able to afford. Yet, in my professional opinion, this case still hinges on the issue of Joe’s autonomy. As long as he is
of sound mind, he is quite capable and within his rights to decide to what extent he will go to prolong his life.
For more on Joe’s case, see the description of the Patient Self-Determination Act of 1990 in this course.
Topic Summary: Ethical dilemmas for healthcare professionals do not always concern extending human life. Ethical
dilemmas can entail abuses of power and crossing understood lines of appropriate behavior. As a healthcare
professional, you must be able to recognize appropriate models of the decision-making process for solving ethical
dilemmas.
Topic 7: Ethical Decision Making for Healthcare Professionals
Topic Description: It is difficult to keep everything in perspective when confronted with a decision regarding an
individual’s health. Your values and beliefs may be in conflict with those of the patient and their loved ones. It is helpful
to follow accepted decision models to ensure that your decision is objective. Upon completion of this topic, you will be
able to recognize models of decision-making processes for solving ethical dilemmas.
Ethical Decision Making
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How does one decide what to do in light of the principles and theories already reviewed? What steps does one take to
decide?
First, you need to discuss the situation with someone. Decisions made in haste without talking about it may not be the
best decisions. The worst decisions are often made in isolation. Usually you can go to your supervisor or manager for
help. If you don’t know who to speak with in your work setting, ask.
Many professionals rely on decision-making models to guide them in difficult situations. There are many. Let’s take a
look at some of them and discuss the steps that they include:
Aiken:
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•
•
•
•
Collect, analyze and interpret the data
Make a clear statement describing the situation
Consider the choices of action
Review all options available to the client
Analyze the advantages and disadvantages of each course of action
Make the decision
Stavros:
• Clarify
• Evaluate
• Decide
• Implement
• Monitor/modify
Rational Model:
• Identify
• Assess
• Evaluate potential action generated
• Consider consequences
• Implement
Blanchard & Peale:
• Clarify what decision is required
• Assess exactly what is involved
• Identify all the necessary resources including skills, time, and support
• Ask if it is legal
• Ask if the respect of others is considered
• Ask if you would be proud to make the decision in public
Reamer:
• Identify the ethical issues, including the conflicting values and duties
• Identify the individuals, groups, and organizations likely to be affected
• Tentatively identify all viable courses of action and the participants involved in each, along with the potential
benefits and risks for each
• Thoroughly examine the reasons in favor of, and opposed to, each course of action, considering relevant ethical
theories, principles and guidelines. You should also consider codes of ethics and legal principles, theory and
principles and personal values, particularly those that conflict
• Consult with colleagues and appropriate experts
• Make the decision; document the decision made
• Monitor, evaluate, and continue to document the results
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Note that the five models mentioned above employ essentially the same basic steps. Many models involve at least a few
of the following:
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•
•
•
Data collection, including background information on the situation and identification of those persons involved
in the decision
Rank credibility of sources and check for bias or self-interest
Identification and evaluation of all possible options and their projected outcomes
Application of ethical principles and theories
Considering cases similar to the case at hand
Treating others as you would want to be treated
Asking yourself if you would be comfortable reading about your decision on the front page of the newspaper
Resolution and decision through selection of an ethically justified option
Awareness and avoidance of a self-righteous attitude
Actions required to implement the decision
Reflection, after the fact, in order to learn and prepare for future dilemmas
Unfortunately, a number of situations are not handled in this manner. Time constraints, lack of support, and ill-prepared
healthcare professionals represent only some of the reasons. Healthcare professionals must be educated about
decision-making processes and their connection with everyday activities. Otherwise, how is one to know what course of
action to take?
Activity: What do you think are the most important ethical dilemmas in healthcare? Which ones impact you?
The Ethical Decision-Making Process in Action
Stan is a 26-year-old man with a diagnosis of chronic schizophrenia paranoid type. He has taught
high school computer science for three years. The last two years have been characterized by
hospital admissions and an inability to get along with co-workers and administrators.
Stan's rehabilitation plan was developed last year with a vocational goal of computer sales
person. That vocational goal was compatible with the psychiatric report at that time. He has not
had any hospital admissions for the past 6 months, continues medications and appears to have
stabilized.
A sales position has become available in a local computer store. Stan would like to acquire that
position. However, his psychiatrist currently believes that Stan is incapable of handling the
potential stress of a sales position at this time.
You must decide whether to assist Stan in applying for the open sales position or assist him to obtain employment the
psychiatrist would view as more suitable.
Step 1: Review the case situation and determine the two courses of action from which you must choose.
(A) Assist Stan in applying for the open sales position
(B) Assist Stan to obtain other employment that is more accommodating to his medical conditions
Step 2: List the factually based reasons supporting each course of action. These reasons will often represent
important consequences.
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Course of Action A
Course of Action B
Stan will have an opportunity to obtain the job he
desires.
Stan will be assisted to obtain the type of
employment in which he is likely to experience
success.
By remaining faithful to the jointly agreed upon
goals, Stan's trust in the therapist will be reinforced.
Step 3: Given the reasons supporting each course of action, identify the ethical principles that support each
action.
Course of Action A
Course of Action B
Autonomy
Fidelity
Beneficence
Step 4: List the factually based reasons for not supporting each course of action. These reasons will often
represent important consequences.
Course of Action A
Course of Action B
Stan will experience stress at work that he cannot
deal with and lose his job.
Stan will not be offered the opportunity to apply for
the job he desires and has the skills to perform
The stress associated with the job loss may also
compromise Stan’s progress toward stabilization, as
well as reduce the possibility of alternate
employment in the near future.
The goals of his rehabilitation plan will not be
adhered to.
Step 5: Given the reasons for not supporting each course of action, identify the ethical principles that would
be compromised if each action were taken.
Course of Action A
Course of Action B
Nonmaleficence
Autonomy
Fidelity
Step 6: Justification for Course of Action B:
Assist Stan to obtain employment the psychiatrist views as more suitable.
Course of Action A would lead us to assisting Stan in applying for the open sales position. This can be supported by the
ethical principles of autonomy and fidelity. The reasons for that course of action are:
1. Stan will have an opportunity to obtain the job he desires.
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2. By remaining faithful to the jointly agreed upon goals of the rehabilitation plan, Stan's trust in the therapist will
be reinforced.
However, Course of Action B (assisting Stan to obtain employment which his healthcare provider views as more
suitable) can be supported by the principles of nonmaleficence and beneficence for the following reasons:
1. Failure in the sales position may demoralize Stan to the point of destabilizing his adjustment to community life
and reducing the possibility of other employment.
2. Stan will obtain employment in which he is likely to succeed.
Of course, by choosing Course of Action A we would respect Stan's autonomy. This choice is consistent with Stan's
desire to take the sales position. Course of Action A is also supported by the principle of fidelity. By helping Stan to fulfill
the goals of his rehabilitation plan, you are fulfilling a professional commitment.
Course of Action B, however, will likely have a less destabilizing effect on Stan and increases the possibility that Stan will
have a successful work experience. The ethical principles of nonmaleficence and beneficence, respectively, support this
option.
Considering the possible negative consequences associated with Course of Action A and given the value of Stan's past
experience with computers for obtaining other less stressful jobs which may interest him, Course of Action B, which is
supported by both the principles of nonmaleficence and beneficence, appears to be the superior choice.
It is likely that Stan will experience stress and not succeed in the sales position. In addition, if Stan loses the sales job it
would likely be more difficult for him to obtain employment in the future (compromising nonmaleficence).
Furthermore, his psychiatrist’s objection suggests that if he loses the sales job, Stan may not be able to maintain his
current level of stability, and may be re-hospitalized.
Theories Affecting Decision Making
Every party to a dilemma brings a set of principles that is personal to him or her. Theories may be based on a philosophy
of life, education, religious beliefs, politics, values, and/or practice setting. Consider the following:
 Deontologic assumes the rightness or wrongness of an act does not depend on the consequence, rather that the
rightness or wrongness is inherent in the act. This theory emphasizes compliance to rules.
 Theologic or Utilitarian theories are based on the assumption that actions lead to maximizing the overall good.
This theory emphasizes consequences -- ’the greatest happiness’ or the ‘least unhappiness.’ This is sometimes
referred to as teleological.
 Intuitionist assumes that practitioners consider all points and uses their own moral intuition to determine what
is good and bad. This theory emphasizes integrity.
 Personalized suggests that practitioners should choose when to make compromises.
Scenario: The 101-Year-old Patient
A 101-year-old patient who is moderately independent (resides in assisted living setting) is admitted to the hospital with
a perforated bowel. Following surgery the patient is doing well, working with therapies and looking forward to returning
to her home setting. The day before discharge she falls while transferring from the bed to commode and her physician
immediately places her on an occupational therapy hold status. The physician has ordered that she remain in bed with
the arm immobilized. The therapist caring for the 101-year-old patient discovers the patient crying, “I just want to get
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dressed in my new outfit so I will look nice when my family comes this evening. I want them to see that I am fine. If they
see this sling, they will make me go to a nursing home. Will you help me?” When the therapist informs the physician of
the patient’s request, he states that he has an obligation to care for the patient and rule out a fracture. The therapist is
upset and feels obligated to help the elderly woman hide the injury; after all she doesn’t appear to be in much pain.
What would you do in this situation? What theories and principles are at work here? How about: Beneficence,
Autonomy, or Ethics of Care? Can you think of others?
Ethical Considerations: It is important to be aware of your prejudices. Poor quality of life may represent one thing to a
young, healthy, energetic person, yet quite another to an older, frail patient. Who knows best -- the patient, therapist or
physician? What is the right answer? Different ethical theories do not necessarily conflict, and people following diverse
philosophies may reach the same conclusions while using different reasoning.
Topic Summary: There are many decision-making models available to a healthcare professional when faced with an
ethical dilemma. Many models share common steps that include: data collection, identification and evaluation of all
possible options, and treating others as you would want to be treated. In addition, awareness of theories affecting
decision-making can also help a healthcare professional to identify the factors influencing their own decision making
process.
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Topic 8: Obligations OTs Must Address when Faced with an Ethical Dilemma
Topic Description: To provide quality healthcare during an ethical dilemma, all ethical obligations must be considered.
This requires not only recognizing the obligations, but also understanding the practices and procedures that must be
followed in meeting those obligations. In this topic, you learn the obligations that a healthcare professional must
address when faced with an ethical dilemma.
Patient Advocacy Obligations
Decreasing attention has been given to the everyday ethics of being good healthcare professionals. In large part, this is a
result of rapid scientific and technical advances that push for public and professional ethical concerns focused on science
and technology. Consequently, scientific protocols and technologies receive more attention in ethical discourse than
everyday ethical comportment and relationships between patients and healthcare professionals.
Yet, technical and scientific aspects of practice would be ineffective without good patient-healthcare professional
relationships. Many ethicists are calling for broader concerns to be addressed in professional ethics.
Meeting patients and their families, and recognizing their concerns comprise the everyday ethical comportment of the
healthcare professional. Patients and families, while encouraged to become empowered and take more responsibility
for their health, are often vulnerable due to lack of knowledge about healthcare or due to crisis and reduced capacities.
Therefore, patients rely on healthcare professionals to have a fiduciary relationship with them. That is, ethically and
legally, healthcare professionals are expected to act in the best interests of patients. This requires that commercial or
research interests, or any other sources of conflict of interest, not triumph over a patient's best interests.
Being faithful to a patient's best interests also requires advocacy for
patients and their families in complex healthcare settings. Healthcare
professionals need to focus on more than clinical case dilemmas and
ethical issues at the individual level. Advocacy for good everyday ethical
comportment, and social ethics and public policy that address social
inequities are also essential to ensuring that healthcare is a right, and
fulfills notions of good essential to a healthy society.
It is a broad social inequity that more than 40 million uninsured
Americans have little or no access to healthcare. Even the insured may
experience delays and refusals of coverage for certain medical and
psychiatric services. These access problems are compounded by the fact
that social problems are medicalized, causing social and essential caring
services to be legitimized and attended to through entry into the
medical system.
One ethicist, Charles Taylor, notes that our sense of moral obligation
depends on a broader and more fundamental sense of “what it is good to be.” He states:
“Ethics involves more than what we are obligated to do. It also involves what it is good to be. This is clear when we think
of considerations other than those arising from our obligations to others. The sense that such and such is an action we
are obligated by justice to perform cannot be separated from a sense that being just is a good way to be. If we had the
first without any hint of the second, we would be dealing with a compulsion, like the neurotic necessity to wash one's
hands or to remove stones from the road. A moral obligation comes across as moral because it is part of a broader sense
which includes the goodness, perhaps the nobility or admirability, of being someone who lives up to it.
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If we give the full range of ethical meanings their due, we can see that the fullness of ethical life involves not just doing,
but also being; and not just these two but also loving (which is short-hand here for being moved by, being inspired by)
what is constitutively good. It is a drastic reduction to think that we can capture the moral by focusing only on obligated
action as though it were of no ethical moment what you are and what you love. These are the essence of the ethical life.”
To ask ourselves what it means to be a "good" healthcare
professional entails more than asking about our moral obligations,
more than just examining patients' rights, and more than justifying
our past actions. Being a good healthcare professional requires that
we are moved by the patient's plight and that we respond to the
patient as a person.
Notions of good are more fragile and more pluralistic than ethical
and legal rights, and they come with risks of not doing or not being
good in a particular situation. It is usually easier to guarantee rights
than it is to ensure fidelity in particular situations.
Practical reasoning, (i.e., reasoning over time through changes in the
patient's condition or concerns) is underdetermined and has a
broader range than what can be reduced to prognostic scores.
Practical reasoning about a patient's rapidly changing condition or
about facing death and providing comfort and dignity cannot be
reduced to rights alone. They must be inspired by the notions of good
inherent in these ends of practice.
End of Life Obligations
Some consider end-of-life issues most important, such as quality of life and treatment goals for the end of life.
One ethicist wrote:
“Many more particular life goods are at stake [at end-of-life care] than choice: for example, the art of holding open
a life so that social death does not occur before physical death; so that leave-taking rituals and the human task of
facing death are possible. These are the fragile goods that require connection and discernment. They cannot be
guaranteed, but they can be nurtured by telling our practice stories where the good is actualized, and by creating
work environments that support and encourage caring practices between healthcare professionals and patients.
Rights are essential and remedial, but not the end of ethical concerns, and they must always be animated by the
notions of good that constitute them.
(Source: Benner P. Finding the good behind the right: a dialogue between nursing and bioethics. In: Miller FG,
Fletcher JC, Humber JM, eds. The Nature and Prospect of Bioethics, Interdisciplinary Perspectives. Totowa, New
Jersey: Humana Press; 2003.)
To broaden the public and clinical agendas of bioethics, we need to include the moral visions provided by notions of the
good as well as notions of patients' rights and entitlement to healthcare.
In every clinical encounter there are ethical issues at the personal, professional, and social level. Our fiduciary
relationship to patients extends to social justice and preventive public health measures to reduce human suffering and
vulnerability.
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Spirituality Obligations
The Joint Commission on Accreditation of Health Organizations (The Joint Commission)
requires the routine assessment of spiritual needs. Spiritual assessment should, at a
minimum, determine the patient's denomination, beliefs, and what spiritual practices
are important to the patient. This information assists in determining the impact of
spirituality, if any, on the care and services provided, and helps determine if further
assessment is needed.
The standards require organizations to define the content and scope of spiritual and
other assessments, as well as the qualifications of the individual(s) performing the
assessment. Examples of elements that could be, but are not required, in a spiritual
assessment include the following questions directed to the patient or his/her family:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Who or what provides the patient with strength and hope?
Does the patient use prayer in their life?
How does the patient express their spirituality?
How would the patient describe their philosophy of life?
What type of spiritual/religious support does the patient desire?
What is the name of the patient's clergy, ministers, chaplains, pastor or rabbi?
What does suffering mean to the patient?
What does dying mean to the patient?
What are the patient's spiritual goals?
Is there a role of church/synagogue in the patient's life?
How does your faith help the patient cope with illness?
How does the patient keep going day after day?
What helps the patient get through this healthcare experience?
How has illness affected the patient and his/her family?
Cultural Obligations
According to Silva and Cipriano, lack of communication is more likely to occur when nurses care for international and
culturally diverse persons. The resultant misunderstandings can lead to lack of respect for persons whose cultural values
are different from one’s own and to potential and real harm to those persons, whether culturally, psychologically,
physically, or spiritually.
Silva and Cipriano recommend the following suggestions to improve communication and nursing care and, thus,
decrease ethical conflicts:
•
•
•
•
•
•
Recognize that values and beliefs vary not only among different cultures but also within cultures
View values and beliefs from different cultures within historical, healthcare, cultural, spiritual, and religious
contexts
Learn as much as you can about the language, customs, beliefs and values of cultural groups, especially those
with which you have the most contact
Be aware of your own cultural values and biases, a major step to decreasing ethnocentrism and cultural
imposition
Be alert to and try to understand the nonverbal communications of your own and various cultures such as
personal space preferences, body language, and style of hair and clothing
Be aware of biocultural differences manifested in the physical exam, in types of illness, in response to drugs, and
in healthcare practices
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Social Obligations
Do healthcare practitioners have any social obligation specifically due to their roles as healthcare professionals? A
healthcare professional has joined a group that has made, both individually and collectively, commitments to the
community at large. This group has undertaken certain obligations -- not through commitments to specific individuals or
groups, but by a commitment to the community they serve. Consider the following fundamental principles:
1. Expertise -- The reason that special decision-making power was granted to the professionals was due to their
expertise. One social obligation is to assure competent and trained experts in a particular field. Does your profession
have standards? Licensing? Is there an obligation for continued education to increase, or at least maintain, a level of
expertise?
2. Individual and Collective Control -- The community affords the healthcare professional a great deal of unsupervised
control. Members of the healthcare profession are obligated by their commitments as professionals to use this
power for the well being of patients and clients. The obligation is for the individual and professions to self govern -manage its own affairs, primarily to benefit the patient/client.
3. Relationship to Clients & Patients -- Each profession’s code provides a description of the patient/client relationship.
Each profession has a social obligation to establish norms for a particular profession. For instance, it may be
appropriate, during a therapeutic session, for a nurse to see a patient/client without clothes. That is probably not
the appropriate situation for a case manager.
4. Central Values -- Every professional group assigns and abides by certain values as a guide to resolving complex
issues. Each profession is obligated to identify the central values for its specific practice and each individual
healthcare professional is obligated to guide their professional practice according to these set values.
5. Impact on Cultural Values -- Members of the healthcare profession have an obligation to be sensitive about its
cultural impact on the community. An individual practitioner’s values and beliefs are not necessarily those of the
patient/client.
6. Distribution of Care -- Healthcare practitioners must remain sensitive to the fact that they make decisions that
impact the distribution of healthcare resources.
7. Sacrifice and The Limits of Professional Obligation -- There are always limits. There will always be conflicts between
professional obligations that cannot be resolved within the norms of the profession. There are flaws in each
profession -- and a social obligation to work to rectify them rather than blindly adhere to them.
It seems that when professional obligations conflict, those grounded in the more fundamental and more broadly based
principles ought to take precedence over those grounded solely in our chosen commitments. However, if conflicts
between social obligations arise, those grounded in the fundamental principles listed above would take precedence over
a professional’s commitment to a profession.
Legal Obligations
In today’s litigious society, the healthcare professional must be cognizant of the numerous legal obligations regarding his
or her position. Some of the legal obligations that a healthcare professional needs to be aware of include the Patient
Self-Determination Act of 1990, HIPPA, and the responsibilities of the healthcare professional as a whistleblower. Each
of these legal obligations is described below.
Patient Self Determination Act of 1990 (PSDA): On November 5, 1990, Congress passed this measure as an amendment
to the Omnibus Budget Reconciliation Act of 1990. It became effective on December 1, 1991.
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The PSDA requires many Medicare and Medicaid providers (hospitals, nursing homes, hospice programs, home health
agencies, and HMO’s) to give adult individuals, at the time of inpatient admission or enrollment, certain information
about their rights under state laws governing advance directives, including: (1) the right to participate in and direct their
own healthcare decisions; (2) the right to accept or refuse medical or surgical treatment; (3) the right to prepare an
advance directive; and (4) information on the provider’s policies that govern the utilization of these rights.
The act also prohibits institutions from discriminating against a patient who does not have an advance directive. The
PSDA further requires institutions to document patient information and provide ongoing community education on
advance directives.
HIPAA: The Health Insurance Portability and Accountability Act of 1996 (implementation April 2003) insures privacy and
confidentiality of medical records (legal documents that identify patients, diagnoses, and justifications for treatment).
HIPAA holds all healthcare providers accountable for non-consented release of medical information. Healthcare
providers are responsible for hiring and educating personnel to be knowledgeable about HIPAA rules and regulations
governing privacy and security of medical records.
Responsibilities of a Healthcare Professional as a Whistleblower: A "whistleblower" is an employee who reports a
violation of the law by his or her employer. The federal government and many states have laws protecting
whistleblowers from retaliation. In addition, most states recognize a claim against an employer who takes action against
an employee after he or she has reported a violation of law.
In order to be protected by these laws, an employee must have a good-faith belief that the employer is violating the law,
and must complain either to the employer or to a federal agency about the apparent violation. The employee is then
protected, even if the employer is ultimately found to be in compliance. An employee, who feels that he or she has been
retaliated against for making a complaint, must bring a complaint to the Occupational Safety and Health Administration
within thirty days of the retaliatory action.
Employees are also protected in most states by general statutes or common law barring discrimination or retaliation
against whistleblowers. In order to qualify for this protection, an employee generally must, as under federal law, have a
good-faith belief that the employer or its employees are in some way violating the law, and must either complain about
that violation to the employer or to an outside agency, refuse to participate in the violation, or assist in an official
investigation of the violation.
Scenario: The Transplant Committee
As a cardiologist practicing at University Hospital, you also sit on the transplant committee. Your patient, Mike, is a 45year-old man with a damaged heart. Several weeks ago you had to hospitalize him due to heart failure. You now realize
that his only hope of survival is a heart transplant. Mike is now on the priority list along with two other patients. You and
Mike have had many conversations. He has asked you to promise him that, in the case of his death, you will remind his
family that he wants his body donated to the university for medical research -- and you have so promised. He has also
offered you a large financial bonus if you would use your position on the hospital’s transplantation committee, which
selects recipients of transplant organs, to make sure that the first available heart with a favorable tissue match will be
given to him.
If you were the cardiologist, how does the ranking of social obligations apply to your obligation in this situation? You
promised Mike you would speak to his family if he should die. Does that promise suggest any ethical and/or moral
issues? What if Mike’s family refuses and opposes the donation due to religious reasons? Had any legal documents been
drawn up prior to his death? If you had not made a promise to him, you could justifiably refrain from speaking to the
family. But, you voluntarily committed to Mike to do so, so you would be obligated to speak firmly to them.
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What about Mike’s second request to use your power and position to influence the committee to secure Mike the next
available appropriate organ for a large financial reward? If you had voluntarily agreed to such an arrangement, would
you be obligated to do so?
Ethical Considerations: As you might expect, the answer is no -- for several reasons:
 First, it would be unethical for a physician, or any healthcare professional to make such a promise and to carry it
out.
 Second, the moral criteria that should be used in determining the distribution of scarce, lifesaving resources,
including organs for transplant, should be predicated on fundamental moral principles, not an arrangement
between individuals.
 Let’s say you did not agree to Mike’s second proposal, however, you do sit on the transplant committee. How
should you act if his case comes up for review? You are supposed to be your patient’s advocate. What criteria
would you use to choose one of the other patients over the one you know best? Obligations grounded in
fundamental moral principles are to take precedence over obligations grounded in professional commitment.
Topic Summary: When faced with an ethical dilemma, the healthcare professional needs to consider their obligations to
the individual’s quality of life, spirituality, and cultural background. In addition to obligations as the patient’s advocate,
the healthcare professional must also consider the social and legal obligations of his or her area of practice.
Topic 9: The Features of Successful Ethics Committees
Topic Description: Complicated ethical issues often require the consensus of a group of individuals from various
professional backgrounds and beliefs to form an unbiased policy or practice. Ethics committees can examine complex
ethical issues from a variety of independent viewpoints. This topic describes the features of a successful ethics
committee.
Responsibilities of an Ethics Committee
Almost every healthcare setting has an ethics committee, or is in the process of establishing one. Perhaps you have been
asked to participate in your particular work setting.
Many hospitals, nursing homes, clinics, and private practices have established ethics committees. These committees
respond to a range of difficult ethical issues that arise from the advancements in healthcare.
The Joint Commission on Accreditation of HealthCare Organizations (The Joint Commission) has been a force in requiring
institutions to establish mechanisms for assisting physicians, nurses, patients, families, and healthcare professionals to
resolve ethical conflicts.
An ethics committee is a multidisciplinary group designed to address ethical dilemmas in a particular setting. This
committee has the responsibility of:
Education
•
•
•
For the committee members themselves
Continuing education and in-service for the facility’s staff
For the community
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Development and Review of Laws, Standards of Care, Policies and Guidelines
•
•
•
Withdrawing and/or withholding nutrition and hydration
Whether or not to resuscitate
Utilization of facility and/or community resources
Case Consultation
•
•
•
•
Provide information about ethical principles relevant to the case under discussion
Help clarify available options
Provide information about relevant facility policies
Offer advisory recommendations
Many Ethics Committees are expanding the scope of their activity to include organizational ethics, and are considering
questions regarding:
•
•
•
•
Finances
Administration
Organization
Human Resources
Structure of an Ethics Committee
Ethics committees usually consist of twelve to fifteen members representing multiple disciplines, including:
•
•
•
•
•
•
•
•
•
•
A representative from the Board of Trustees
The facility administrator
The facility’s director of Nursing
A staff nurse
A physician
A member of the clergy
A social worker
An attorney
An Ethicist (For example, a philosophy or theology professor)
Lay persons from the community
The American Society for Bioethics and Humanities (ASBH) has identified nine core knowledge areas that are required
for competent ethical consultation. The members of an effective ethics committee should be populated by individuals
who possess some level of knowledge and ability in these areas, which include an understanding of the following:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Moral reasoning and ethical theory
Common bioethical issues and concepts
Healthcare systems, which includes knowledge of managed care and governmental systems
Clinical context
Your healthcare organization, including the organization’s mission statement and structure
Your healthcare organizations policies
Beliefs and perspectives of the local patient and staff population
Relevant codes of ethics and professional conduct and guidelines of accrediting organizations
Relevant health law
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Obstacles to Ethics Committees
According to Dr. Paul B. Hofmann, a former visiting scholar at Stanford University Center for Biomedical Ethics, there are
several obstacles that can prevent an organization from fully utilizing its ethics committee. These obstacles may include:
Inaccurate understanding of the committee's role and potential contribution -- Some staff members may think the
committee's sole function is to provide case consultation when there is concern about an end-of-life dilemma. Others
may hesitate to ask for assistance because they do not want to be obligated to comply with the ethics committee's
conclusion, failing to realize that the committee is an advisory, not a decision-making, body. Still others may be
concerned about conveying extremely sensitive information, not recognizing the committee's efforts to preserve
nondisclosure and confidentiality.
 Low visibility -- Depending upon the location of your committee in your organizational structure, publicity about
its purpose, and periodic reports on its activity, many people may be unaware of its existence and the resource
it represents.
 Uncertainty about how to gain access to the committee -- If your committee has a low organizational profile,
and there is no convenient way to contact a committee representative and receive a timely response, it is
understandable why few requests for assistance are received.
 Inadequate committee representation -- The size, diversity (including cultural and religious), and number of
disciplines represented on your committee will certainly be related to your organizations size and mission, but
the group should not be composed only of physicians and nurses. Restricting the membership in this way can
bias perceptions of the committee's insight, credibility, and objectivity.
 Ineffectual leadership -- As is true of any committee, the effectiveness of your ethics committee will often be
directly related to the ability of its chairperson. Obviously, if this individual is disorganized, autocratic, or
ingenuous, there will be fewer requests for consultation and other assistance.
 Insufficient organizational support -- Although major funding is not required to facilitate a committee's
activities, there must be a reasonable budget to cover the cost of publications and similar resources to support
the continuing education of both committee members and stakeholders.
 Lack of initiative -- A failure to develop and implement a creative strategic plan could be the most prevalent
reason an ethics committee is underused and, as a result, marginally effective. Too many committees are simply
passive and reactive, instead of pursuing a formal set of goals and objectives to maximize their value to the
organizations they serve.
Topic Summary: An ethics committee is a multidisciplinary group whose responsibilities include addressing the ethical
dilemmas associated with laws and case consultation. In some healthcare environments, roles and responsibilities of
ethical committees are expanding to include issues such as finances, administration, and human resources.
Topic 10: Application and Ethical Scenarios
Topic Description: In this section you can put into practice what you have learned by assessing various ethically complex
scenarios. In this way you will have an opportunity to review the information you have obtained from the previous
topics. In this topic, you assess the ethical implications of intricate healthcare scenarios.
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Scenario 1: Respecting other Cultures
Mrs. Basso is an 86-year-old female resident in Arbor Lakes Nursing Home. Mrs. Basso was born in Italy and is the
mother of 4 sons and 5 daughters. Mrs. Basso lived in Italy until 10 years ago when her children moved her to the States
so that they could better care for her. Up until last year, Mrs. Basso had been living with one of her daughters. However,
Mrs. Basso’s children decided to move her to Arbor Lakes Nursing Home so that she could receive round-the-clock
services and care. Mrs. Basso speaks and understands some English but is not at all fluent.
In the past several months, Mrs. Basso has complained of abdominal pain, nausea and a 15-pound weight loss from her
usual 150 pounds. Her eldest daughter took her to a physician. After several days of tests, Mrs. Basso’s family returned
Mrs. Basso to Arbor Lakes Nursing Home. In a private conversation, two of Mrs. Basso’s daughters informed the facilities
director of Arbor Lakes, John Curr, that Mrs. Basso had stomach cancer. The daughters also informed Mr. Curr that they
did not want Mrs. Basso to know she had cancer. The daughters explained that in the Italian culture these serious
matters were restricted to the family and that the patients were not told since they might be harmed by the information
(i.e., due to fear and worry they might not try to get better.)
Mrs. Basso’s daughters continued to inform Mr. Curr that they had told their mother that she had stomach flu and that
it would eventually pass. The daughters requested that staff at Arbor Lakes continue with this explanation whenever
Mrs. Basso asked about her symptoms.
Mr. Curr did not feel comfortable lying to Mrs. Basso. The director also did not like the idea of instructing the Arbor
Lakes staff to lie to residents. However, Mrs. Basso’s children seemed unwavering in their decision not to tell their
mother of her condition and they made it very clear that they felt that this decision was best for their mother’s health.
Ethical Considerations: The scenario above requires the facility’s director to choose the ethical option that is best for
both Mrs. Basso and her family. Understanding the cultural differences of the Basso family is the first step towards
choosing the most ethical option. Another factor that the facility’s director needs to consider is the code of ethics that
Arbor Lakes follows and how that code of ethics addresses matters such as this.
Scenario 2: Healthcare Professional as Whistle Blower
Amber has worked for Lionel Pines Nursing Home for the last ten years. Until today she had always viewed the top
management at Lionel Pines as stellar individuals who combined business savvy with quality care. However, after her
most recent phone conversation with the VP of finance, she is reconsidering her impressions. The phone call concerned
their new accounting software that Lionel Pines implemented three months ago. In her conversation, the VP of finance
reminded Amber that the accounting system was a huge undertaking and that one could not expect its first edition to be
“bug-free.” Amber considered the issue much more than a “bug” and had no idea what her next appropriate step should
be concerning what she viewed as a serious accounting issue.
Amber began at Lionel Pines as a receptionist while attending college. Over the last 10 years Amber worked her way to
assistant to the VP of finance. Her responsibilities include overseeing the accounts payable for both patients and
reimbursement agencies. Her most recent responsibility has been assisting with the implementation on the company’s
new accounting program.
The accounting program is a custom-built software application designed to link the accounting records of all 17 of Lionel
Pines facilities into an all-encompassing system. The system took over two years to develop and the most extensive
phase of the project involving Amber was the quality-testing phase. In fact, Amber’s signature was one of the three
required to approve the full implementation of the software and payment of the remainder of the contract to the
software developers. The accounting system was in place for a month and the finance department received tremendous
recognition for the work they had accomplished.
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Amber thought that the release of the accounting program represented the
most significant accomplishment of her professional career until she stumbled
across an incorrect invoice to one of Lionel Pines’ vendors. While checking a
completely unrelated incident, Amber noticed that one of the vendors had been
billed twice for the same resident. After further review, Amber found that one
service was being charged twice under different names and two different fees.
There was no way to tell how often this error had occurred, but Amber felt that
Lionel Pines could easily be overcharging vendors by an extra three-to-five
percent for this month alone.
As soon as Amber found the error, she called her boss, the VP of Finance. Amber
was shocked to find out that her boss was already aware of the error and decided to add it to a list of requested changes
for the next update of the accounting software, which was not due out for another twelve months. Her boss told Amber
that even Microsoft releases software with some errors and that the vendors were not being overcharged a “significant
amount.” The conversation ended with her boss asking her not to tell anyone about the issue or document the issue in
any way until after the second version of the software was released.
Amber did not feel comfortable with her boss’s explanation. Based on her review, the overcharges were significant and
she felt that her company was defrauding the vendors. She knew that the top management was aware of the issue and
were steadfast in waiting for the next version of the software before addressing the problem. She also knew that the
error was so buried in the accounting records that it would be extremely unlikely that the vendors would ever find it on
their own. Amber was also aware that if she alerted the vendors of the error, she would likely be fired.
Ethical Considerations: Ethics and accounting are two areas that are often creatively combined to accommodate the
best possible bottom line for an organization. In the above scenario, Amber’s loyalties to her management are
conflicting with her loyalties to the other agencies and the individuals that her company serves. Amber’s next
appropriate course of action is to gather information on the ethical aspects that she is not aware of, specifically the legal
obligations for both herself and her company. By understanding how her issue is relevant under the law, she may have
more success guiding both her management and herself to an appropriate course of action.
Scenario 3: Privacy and Public Safety
Mr. Bishop is a new resident at Care Bridge Assisted Living Facility. He is 85 years old, active and lives alone. One
morning, the facility’s director, Nancy Cohen, sees Mr. Bishop walking in the parking lot and begins talking with him as
they enter the building. During a conversation, it becomes apparent to Ms. Cohen that Mr. Bishop is experiencing
memory problems. Mr. Bishop mentions that he got a little lost going to the grocery store, although it is less than a mile
from the facility. As they both walk into the facility, Ms. Cohen asks Mr. Bishop if he had recently taken a driver's
evaluation. But Mr. Bishop refused the idea. "Why do that? What if that test doesn't turn out so good? I've got to be
able to get out. Got to be able to get to the grocery and to the drug store."
Ms. Cohen explains her concerns to Mr. Bishop about his ability to drive safely. Mr. Bishop replies that he only drives
during the day and always for very short distances. He says he has no moving traffic violations. Still, Ms. Cohen worries
about Mr. Bishop getting lost, being injured or injuring others. Ms. Cohen is also concerned about his driving
responsiveness, especially in poor weather. "I don't think I would want him driving where my kids are walking home
from school," she says to herself. It becomes difficult to continue a candid conversation. Ms. Cohen makes a note to call
Mr. Bishop's only son in Arizona for more information.
The conversation with Mr. Bishop’s son does not go well. His son insists that his father is still a very safe driver and
should be able to keep going to the store and other local places as needed, as long as it is in the daytime. However, after
speaking with other workers in the facility, Ms. Cohen learns that others share the same concerns about Mr. Bishop’s
ability to drive.
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Upon reviewing the situation, Ms. Cohen feels that she is not left with many options concerning the situation. She could
call the police department and recommend that they schedule a new driver’s test. Or, she could let the issue go and wait
for a specific incident before further pressing the issue with Mr. Bishop or his son.
Ethical Considerations: Respect for an individual’s decision to choose driving as a method of transportation and as a
means of independence is important. Ethical issues of autonomy, beneficence and nonmaleficence, as well as public
health concerns, can be clearly identified in this scenario. There are also implications for Ms. Cohen’s relationship with
the resident and family. Quite often, the healthcare professional must balance the rights and privileges of an individual
with their responsibility to the community and the public health.
In the above scenario, a possible solution may be for Ms. Cohen and other workers to continue to question, examine
and counsel Mr. Bishop and his family with respect to driving safety.
(The above scenario was adapted from the April 2000 ACP-ASIM Observer, copyright © 2000 by the American College of
Physicians-American Society of Internal Medicine.)
Scenario 4: Supervision Ethical Dilemma
You are an experienced occupational therapist and have been asked to supervise a student occupational therapist in
their second clinical rotation. You agree to this request and the student appears very confident and competent in their
skills. Working in an acute care pod of a hospital the student is delegated to work with primarily hip replacement and
knee replacement patients. You observe the student and their skills are top notch. Safety is adhered to at all times.
The next day you receive orders from a physician who recently performed an ORIF on the left elbow of an 86-year-old
patient. The orders are to place the patient in an appropriate splint and begin hand ROM and edema control. Your other
staff OT calls in sick and the workload is unmanageable even with the student’s assistance. What are your options??
Ethical Considerations: All patients deserve the best quality treatment possible. While it would be tempting to treat this
complex surgery patient yourself, it would provide an excellent training opportunity for the student. Knowing this, you
may be unable to justify shorter treatments for other patients while you assist the student with this new UE patient.
Perhaps some might consider having the student therapist treat the UE patient independently while others may not.
The reality of professional staff shortages is real. The commitment to both patients and professional education and
development are equally challenging. Again, these and other similar ethical scenarios require consideration of multiple
issues in order to determine the proper course of action. Moreover, situations like these are often referred to as
“situational ethics”. While this term is a buzzword in the healthcare community, it is not meant to water down ethical
considerations or objective decision-making.
Topic Summary: Each ethical scenario that you encounter could require you to consider a unique set of ethical issues.
The decisions you choose should depend on a thorough examination of your spiritual, cultural, social, and legal
obligations.
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Further Reading
Academic and professional ethics literature is rich with resources that can help to illuminate the ethical issues facing the
health Internet. The following represents only a sample of the resources available for those who wish to explore issues
more in-depth.
The Health Internet
Science Panel on Interactive Communication and Health, Wired for Health and Well-Being: The Emergence of Interactive
Health Communication (Washington, D.C.: U.S. Department of Health and Human Services, 1999). Available online at:
http://www.health.gov/scipich/pubs/finalreport.htm
Eng, Thomas R. The e-health Landscape: A Terrain Map of Emerging Information and Communication Technologies in
Health and Healthcare (Princeton, N.J.: The Robert Wood Johnson Foundation, 2001). Available online at:
http://www.rwjf.org
Respect for Persons
National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, Belmont Report
(Washington, D.C.). Available online at: http://ohsr.od.nih.gov/guidelines/belmont.html
Trust
Baier, Annette C. "Trust and Antitrust." In: Annette C. Baier, Moral Prejudices: Essays on Ethics (Cambridge, Mass.:
Harvard University Press, 1994), pp. 95-129. See also, "Trust and Its Vulnerabilities" (pp. 130-182) and "Trusting People"
(pp. 183-202).
Informed Consent
National Bioethics Advisory Commission, "Ensuring Voluntary Informed Consent and Protecting Privacy and
Confidentiality." In: National Bioethics Advisory Commission, Ethical and Policy Issues in Research Involving Human
Participants (Bethesda, Md.: National Bioethics Advisory Commission, 2001), pp. 97-108. Available online at:
http://www.bioethics.gov
Codes of Ethics
Illinois Institute of Technology, Center for the Study of Ethics in Professions, Codes of Ethics Online. Available at:
http://ethics.iit.edu/codes/coe.html
Privacy
California Healthcare Foundation, Privacy: Report on the Privacy Policies and Practices of Health Web Sites (San
Francisco, Calif.: California Healthcare Foundation, 2000). Available at: http://chcf.org
Consumers International, Privacy@net: An International Comparative Study of Consumer Privacy on the Internet
(London: Consumers International, 2001). Available at: http://www.consumersinternational.org
Content Quality
RAND Health, Proceed with Caution: A Report on the Quality of Health Information on the Internet (San Francisco, Calif.:
California Healthcare Foundation, 2001). Available at: http://www.chcf.org/topics/hospitals/index.cfm?itemID=12641
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Healthcare Professionals Online
ISMHO/PSI Suggested Principles for the Online Provision of Mental Health Services. Available at: http://www.drbob.org/psi/suggestions.approved.html
Resources to Explore
EndLink: Resource for End of Life Care Education - The content of the site was written primarily for healthcare
professionals who work with dying patients and their families. The material presented on the site encompasses the
complex, multidimensional considerations involved in caring for individuals at the end of life:
endlink.lurie.northwestern.edu/
EPERC - End-of-Life/Palliative Education Resource Center: www.eperc.mcw.edu/
Center to Advance Palliative Care (CAPC): www.capc.org
Journal of Palliative Medicine: www.liebertpub.com/JPM
Massachusetts General Hospital Palliative Care Service: www.massgeneral.org/palliativecare/
San Diego Hospice & Palliative Care: www.sdhospice.com
The EPEC Project: www.epec.net
Palliative Care Fellowship List - Information about palliative care fellowships throughout the U.S. can be obtained
through the Palliative Care Fellowship List: www.aahpm.org/fellowship/directory.html
International Association for Hospice & Palliative Care (IAHPC): www.hospicecare.com/
The George Washington Institute for Spirituality and Health (GWish) - A university-based organization working toward
a more compassionate system of healthcare: www.gwish.org
The Center for Palliative Care Education - An educational resource center and training program to improve palliative
care for people with HIV/AIDS by increasing the knowledge, skills, and comfort level of clinicians to provide this care:
depts.washington.edu/pallcare/
The Hospice of the Florida Suncoast: A Rallying Points Regional Resource Center - Free resources, tips and helpful links
for those working to improve end-of-life care or build and sustain a community coalition:
www.thehospicerallyingpoints.org
University of Wisconsin Pain and Policy Studies Group: http://www.painpolicy.wisc.edu/
Palliative Care Program at Gran MacEwan Community College:
http://stats.macewan.ca/learn/students/program_info.cfm?programID=2
Alliance of State Pain Initiatives: http://aspi.wisc.edu/
Hospice and Palliative Nurses Association (HPNA): www.hpna.org/
National Hospice and Palliative Care Organization: www.nhpco.org/
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Beth Israel (Continuum Health Partners Inc.) Pain Medicine & Palliative Care: www.stoppain.org/
Project on Death in America Reader:
http://www.soros.org/initiatives/pdia/articles_publications/publications/report_20041122
Innovations in End-of-Life Care - An international on-line forum for leaders in end-of-life care: www.edc.org/lastacts/
American Academy of Hospice and Palliative Medicine: www.aahpm.org/
Dignity Resources - Not-for-profit educational service and website designed to assist people with serious and terminal
illnesses in understanding the assets and financial options available and to assist them in making the most informed
choices possible: www.DignityResources.com
GrowthHouse - The Internet's leading on-line community for end-of-life care, GrowthHouse's mission is to improve
quality of compassionate care for people who are dying through public education and global professional collaboration:
www.growthhouse.org/
American Board of Hospice and Palliative Medicine - The American Board of Hospice and Palliative Medicine website
provides information about board certification for hospice and palliative medicine and also provides eligibility
requirements, testing dates and locations, and registration information: www.abhpm.org/
References
Alvita, N. (2002). Moral Distress Among Nurses: The ANA Ethics & Human Rights Issues Update. Vol. 1(3) Spring.
American Nurses Association (2001). Code of Ethics for Nurses. Washington, DC: American Nurses Association.
Benner P. (2003). The Nature and Prospect of Bioethics, Interdisciplinary Perspectives. Totowa, New Jersey: Humana
Press.
Bradley ,L., Hendricks, B. Implementing Ethical Decision – Making Models. Texas Tech University
Corey, G., Corey, M., & Callanan, P. (2003). Issues and ethics in the helping professions (6th ed.). Pacific Grove, CA:
Brooks/Cole.
Cottone, R., & Tarvydas, V. (2002). Ethical and Professional Issues in Counseling (2nd Edition). Prentice Hall.
Flamm, A. (2003). An Ethical Decision Making Model for Case Managers. Collaborative Case Management May.
Habel, M. (1998). Bioethics: Strengthening Nursing’s Role. Nursing Ethics Network. June
Hofman, B. Paul (2001) Improving Ethics Committee Effectiveness. Healthcare Executive, 16 (1), 58-59.
Joffe, Manocchia, Weeks, & Cleary (2003). What do patients value in their hospital care? An empirical perspective on
Autonomy centered bioethics. Journal of Medical Ethics, 29:103 – 108
Kingston, M. Effective Decision Making for the Clinical Nurse. http://www.Nurse.com
Koepke, D. Challenges in Aging: Managing Loss, Complaining, Spirituality
Ludwick, R., Ludwick, S., Cipriano, M., (2000). Nursing Around the World: Cultural Values and Ethical Conflicts. Online
Journal of Issues in Nursing
Monagle, J., & Thomasma, D. (1998). Healthcare Ethics Critical Issues for the 21st Century. Aspen Publishers.
Schroeter ,K. (2002). Ethics in perioperative practice, patient advice. AORN Journal, May.
Schroeter, K., Derse, A., Junkerman, C., and Schiedermayer, D. (2002) Practical Ethics for Nurses and Nursing Students: A
Short Reference Manual. Hagerstown, MD: University Publishing Group, Inc.
Weed, R., Berens, D. & Patky, S. (2003). Malpractice and Ethics Issues in Private Sector Rehabilitation Practice: An
Update for the 21st Century. Rehabilitation Professional, 11 (1), 47-54.
Yeo & Moorhouse (1996). Concepts and Cases in Nursing Ethics. Broadview Press.
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About the Authors
Bill Asenjo, PhD, CRC
Dr. Asenjo has been a certified rehabilitation counselor (CRC) and vocational rehabilitation consultant since 1994. He
completed his PhD in the University of Iowa's Rehabilitation Counseling program, and received an MS in health science,
specializing in rehabilitation counseling, from the University of Florida.
Bill has provided expert testimony in more than 100 hearings, trials and depositions. As a consultant to attorneys in
disability-related cases, his reports have garnered glowing testimonials.
An internationally published and award-winning freelance writer with fifteen years of experience, Bill’s work appears in
numerous print and online publications, ranging from medical encyclopedias and health magazines, to trade
publications for attorneys and anthologies like Chicken Soup for the Soul. On the way to his PhD, Bill received a writing
award for his dissertation.
Bill conducts popular freelance writing workshops for Barnes & Noble and Kirkwood College, among others. WSUI
(public radio) recently asked Bill to record a number of his essays for their listeners.
To contact Bill or to view his written works, resume and testimonials, visit http://www.billasenjo.com.
Linda Bagby, OTR
Ms. Bagby received her degree in Occupational Therapy from Eastern Kentucky University. She has more than 20 years
of clinical experience in a variety of healthcare settings, including home health, long-term care and five years of work
hardening. Her area of specialization is the geriatric population. During her employment in various nursing homes and
rehabilitation treatment centers, she has been faced with a number of ethical situations and challenges. Her ability to
successfully cope with and overcome these challenges, make her uniquely qualified to write on this topic. Linda lives in
Punta Gorda, Florida with her husband and two beautiful teenage daughters.
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