Think about the reflection in your textbook regarding the sources of your moral beliefs. Who or what are 3 sources that have influenced your moral beliefs? Describe the impact of those beliefs on your nursing practice.
Book below must be used as one of the reference:
READ!!! Purtilo, R. & Doherty, R. (2016). Ethical Dimensions in the Health Professions (6th ed.). St. Louis, MO: Elsevier. ISBN: 9780323328920
Chapters 3, 4, and 5
Prototypes of Ethical Problems
The reader should be able to:
• Recognize an ethical question and distinguish it from a strictly clinical or legal one.
• Identify three component parts of any ethical problem.
• Describe what an agent is and, more importantly, what it is to be a moral agent.
• Name two prototypical ethical problems.
• Distinguish between two varieties of moral distress.
• Compare the fundamental difference between moral distress and an ethical dilemma.
• Describe the role of emotions in moral distress and ethical dilemmas.
• Describe a type of ethical dilemma that challenges a professional’s desire (and duty) to treat everyone fairly and equitably.
• Discuss the role of locus of authority considerations in ethical problem solving.
• Identify four criteria to assist in deciding who should assume authority for a specific ethical decision to achieve a caring response.
• Describe how shared agency functions in ethical problem solving.
NEW TERMS AND IDEAS YOU WILL ENCOUNTER IN THIS CHAPTER
locus of authority
Topics in this chapter introduced in earlier chapters
Introduced in chapter
Interprofessional care team
A caring response
Social determinants of care
You have come a long way already and are prepared to take the next steps toward becoming skilled in the art of ethical decision making. The first part of this chapter guides you through an inquiry regarding how to know when you are faced with an ethical question instead of (or in addition to) a clinical or legal question. A further question is raised: How do you know whether the situation that raised the question is a problem that requires your involvement? This chapter helps you prepare to answer that question too. You will learn the basic components of an ethical problem and be introduced to two prototypes of ethical problems. We start with the story of Bill Boyd and Kate Lindy.
￼ The Story of Bill Boyd and Kate Lindy
Bill Boyd is a 25-year-old soldier who lives in a large city. Bill served in the U.S. Army for more than 6 years and was deployed to both Iraq and Afghanistan for multiple military missions in the past 4 years. During his final deployment, Bill suffered a blast injury in which he sustained significant shoulder and neck trauma and a mild traumatic brain injury (TBI) and posttraumatic stress. He was treated in an inpatient military hospital and transitioned back to his hometown, where he moved into his childhood home with his mother.
Kate Lindy is the outpatient psychologist who has been treating Bill for pain and posttraumatic stress. Bill is in a structured civilian reentry program. This competitive program is administered by a government subcontractor; its goal is to help injured veterans find meaningful careers or employment on return from the front lines. Bill reports that he is struggling with the transition to civilian life. He originally was prompt in keeping his appointments but recently has missed almost all of his sessions. Twice Bill has arrived for his appointment more than 30 minutes late and smelling of alcohol. Kate informed Bill that she could not treat him in this condition and that if he continued to arrive in this state, she would need to discontinue therapy. Bill responded to Kate and said “You have no idea what all of this is like. And don’t even go there on the alcohol; like you have never had a drink on a bad day.”
Kate is concerned about Bill. She calls his home and gets no answer. She then calls the case manager listed on his intake form. Kate tells the case manager about Bill’s regularly missed appointments (three in the last 4 weeks). She also tells the case manager that Bill has been charged for the missed visits because he has not called to cancel, which is the billing policy of the institution where Kate is employed.
The manager responds that Bill does not qualify for transitional career/employment services unless he is compliant with all outpatient care. She adds that in her experience patients like Bill have a hard time adjusting to the fact that they are no longer eligible for active duty.
The case manager says she will talk to Bill about the unacceptability of his failing to let the therapist know when he decides not to keep his appointment. In fact, if Bill keeps that up, the case manager continues, he will be kicked out of the civilian reentry program because the government cannot be expected to pay for his lack of responsibility. Kate responds that maybe Bill was unclear about the policy. The manager replies, “It doesn’t matter. He’s an army man; he knows better than that.”
A week goes by. At the scheduled time for Bill’s appointment, he again does not appear. Kate has been uneasy about the conversation with the manager, and when the time comes for her to fill out the billing slip for another missed appointment, she feels positively terrible.
Do you share Kate’s feelings that something is not right? If yes, what do you think the problem is? Jot down a few thoughts here and refer back to them as the chapter progresses.
Recognizing an Ethical Question
Health professionals face all types of questions in clinical practice. Some are ethical questions, but others are not. Many times, what may appear to be an ethical question is in fact something else, such as a miscommunication or a question about a clinical fact or a legal issue. Often, complex clinical situations include clinical, legal, and ethical questions; part of your challenge is to distinguish them and sort them out for their relevance to the patient and the delivery of care.
The following exercise is designed to walk you through one example of an issue that includes clinical, legal, and ethical dimensions, with a description of why the last is an ethical question.
Is this an ethical question? Answer Yes or No:
Can a person status post TBI drive?
If you answered “no,” you are correct. This is a clinical question because clinical tests and procedures can help answer it. Patients who pass various cognitive assessments and an on-road driving evaluation have the clinical ability to drive, and those who fail do not. Refer back to the story at the beginning of this chapter. In the narrative about Bill Boyd, Kate Lindy, and the case manager, what additional clinical information can help you better evaluate the situation?
Now consider the following question:
Must patients with TBI comply with medical advice in this type of situation if they want to continue to drive?
Is this a clinical, legal, or ethical question? If you said “a legal question,” you are on the right track. A tip-off is the word “must.” As you learned in Chapter 1, the laws of the state and other laws are designed to monitor public well-being and enforce practices that protect the public good. Almost all states include procedures to help ensure road safety. Relevant information about people who are dangerous behind the wheel is found in part through clinical examinations. Clinical and legal systems are interdependent in that and other situations, so the decision to ignore clinical recommendations is not always up to an individual patient.
Now, go to the specific legal implications of Bill Boyd’s situation. When the physician referred Bill for therapy, she assessed that the patient’s discomfort was from a combat-related injury. The time may come when Bill wants to apply for disability benefits for his condition. Veterans disability benefits are legally enforced governmental programs in the United States to help protect members of the military from financial duress when injured during service duty. And so, a related legal question relevant to this situation is: Do patients have the right to benefits provided by the government if for any reason they miss prescribed treatment and the professional reports this?
Eligibility usually requires that a patient comply with treatments that are prescribed; the fact that Bill missed multiple treatments may compromise his case. The case manager may choose to fight Bill’s claim for disability benefits now that Kate has contacted the manager with this information.
Finally, consider this question, which is an ethical question. As you read it, think about why it is an ethical question.
Should people with TBIs who refuse to take a recommended onroad driving assessment be allowed to continue driving? If so, under what circumstances?
The word “should” is the tip-off here. It points to something in society all have agreed to support and each individual has a responsibility to help do so. Kate’s reflection on whether she should have talked with Bill’s case manager and her ambivalence about having to charge for treatments that she did not administer are examples of ethical questions about the wrongdoing or rightness of her actions that she was pondering.
Ethical questions can be distinguished from strictly clinical or legal questions, although all of these questions often arise in health professional and patient situations. An ethical question places the focus on one’s role as a moral agent and those aspects of the situation that involve moral values, duties, and quality-of-life concerns in an effort to arrive at a caring response.
For your continued learning, we now introduce several prototypes of ethical problems, into which many different everyday ethical questions will fit.
Prototypes of Ethical Problems: Common Features
What is a prototype? Prototypes are a society’s attempt to name a basic category of something. Prototypes can be objects, concepts, ideas, or situations.1 Prototypes of ethical problems are recognizable as a group by three features they have in common. Each of the prototypes in this chapter appears different from the others; in fact, each has a different role to play when ethical questions have arisen. That said, the first step into this venture is to become familiar with the same basic structural features found in all the prototypes of ethical problems:
A: A moral agent (or agents)
C: A course of action
O: An outcome
Each feature is discussed in turn.
The Moral Agent: A
Which of the following best describes your idea of a health professional as an agent?
A. A person with more than one basic loyalty; a deeply divided loyalty (e.g., a double agent).
B. A person who has the moral or legal capacity to make decisions and be held responsible for them (e.g., a signee on a contract).
C. A person who plans schedules or events (e.g., a booking agent).
If you answered “B,” you are most clearly focused on the meaning of agency in the health professions roles you will assume. In ethics or law, an agent is anyone responsible for the course of action chosen and the outcome of that action in a specific situation. Obviously, being an agent requires that a person be able to understand the situation and be free to act voluntarily. Acting as an agent also implies intention: The person wants something specific to happen as a result of that action. A moral agent is a person who “acts for him or herself, or in the place of another by the authority of that person, and does so by conforming to a standard of right behavior.”2
This book emphasizes your role as a moral agent in the health profession setting because as a professional, you must answer for your own actions and attitudes. If you have observed a situation in which someone in your chosen field has had to act courageously, then you have observed a moral agent at work. Briefly describe what you observed and why you feel the responsibility fell to that person to be on the front line of the decision.
A moral agent intends the morally right course of action. The idea of responsibility that you learned about in Chapter 2 is in fact the description of what an agent does; when faced with an ethical challenge in the health professions, the actor assumes the role of a moral agent. Professional responsibility is exercised through moral agency, and professional accountability and responsiveness to the patient through ethical action. Kate and the case manager are both agents whose actions influence the outcome of Kate’s efforts and affect Bill’s health. As a health professional, Kate clearly is in the role of a moral agent.
Agents and Emotion
Moral agency is grounded in a relational context. The moral agent must have not only cognitive ability but also emotional capacity to demonstrate an attitude of respect for the other.3 Both reason and emotion operate as part of your internal processor where you can go and search to find the appropriate tools to exercise your professional responsibility. Much is said about ethical reasoning and problem solving in this book. Through the years, considerable debate about the significance of emotion in an agent’s activity has taken place. Strict rationalists view emotion as too subjective and unpredictable to serve as a reliable guide. However, a burgeoning body of current professional and lay literature lends new knowledge about the role of emotion in decision making more generally to support the essential role of emotion in ethical decision making. Such well-regarded bodies as the Harvard Decision Science Laboratory conduct research on the mechanisms through which emotion and social factors influence judgment and decision making. From their work and the work of others, we find convincing arguments for assigning emotion at least two functions in ethics.
First, emotion is an “alert” system that warns you that you may be veering off the road of a caring response. When you encounter a morally perplexing situation, you, who will be accountable, feel discomfort, anxiety, anger, or some other disturbing emotion. Nancy Sherman, a contemporary philosopher who is working on the place of emotion in morality, proposes that emotions are “modes of sensitivity that record what is morally salient and… communicate those concerns to self and others.”4 Sometimes, an emotional response stirs a person out of lethargy and moves him or her into thinking and action on someone else’s behalf.5,6 In other words, your emotions help grab your attention and motivate you to “do something.” We saw this in the process Kate was going through as she faced the reality of Bill’s missed appointments.
Second, according to current research, emotion kicks in again at the point of decision making to complete the human picture of what is happening.7 Even if you have been logical in your assessment of the ethical problem, emotion puts the last strokes on the canvas and brings the decision into focus as one example of how humans actually conduct their lives all around. In the end, emotion, attention, and behavior interact with each other for real-time decision making.8 Effective moral agents work to integrate emotional responsiveness with critical thinking, so that rather than disregarding emotion, they develop the right emotion, suited to the situation.
An agent has responsibility for an action. A moral agent has a responsibility to act in a way that protects moral values and other aspects of morality. An ethical problem requires attention to both reasoning and emotion in the process of decision making. Emotion alerts, focuses attention, motivates, and increases one’s knowledge about complex situations.
The Course of Action: C
The course of action includes the agent’s analysis, the judgment process of discerning the best likely resolution to the problem, and the decision to act in accordance with that judgment. The next two chapters explain how this process works within the context of ethical problem solving with ethical theories and approaches, so more detail about that is not necessary now. Kate Lindy used the information she had to analyze the situation. One attempt at resolution was to call the case manager looking for Bill. Kate’s emotional response afterward reflected a concern for her patient’s well-being, even though she was irritated when she made the call; her discomfort suggests she was unsure she had exercised the correct moral judgment in what she said to the case manager. As we know, Kate also felt a sense of responsibility to bill for the scheduled treatments Bill did not receive, although she did not like this policy in her workplace. This back-and-forth reflection about what she was feeling and doing kept the course of action alive to the possibilities of what should happen.
The Outcome: O
The outcome is the result of having taken a particular course of action. Of course, the goal is that a caring response is achieved in what actually happens as a result of the whole process. We need to have more information about what actually happened as a result of Kate’s conversation and what she thought about it to know whether she considered it a good outcome for her patient Bill Boyd.
Some ethical approaches that you will learn to use in the next chapter place much more weight on the outcome; others place moral priority on the course of action. In everyday descriptions of ethics, this tension is sometimes referred to as the “ends” one achieves and the “means” used. The important point is that real-life professional situations require your full participation in all three features of an ethical problem. The decision of which of the features takes precedence in a particular ethical problem depends in part on the approach or theory you adopt.
The two prototypes of ethical problems share three features in common: a moral agent (or agents), a course of action, and an outcome.
Considerations in Moral Agency
Locus of Authority
The role of the moral agent is not always easy. At times, one may have the emotional and cognitive capacity to act as a moral agent; however, constraints in the practice environment limit one’s authority to respond. A locus of authority conflict arises from an ethical question of who should have the authority to make an important ethical decision. In other words, who is the rightful moral agent (A) to carry out the course of action (C) and be held responsible for the outcome (O)? Locus of authority problems most often arise when ambiguities exist about who is in charge (Figure 3-1). Schematically, the situation looks like this:
FIGURE 3-1 Locus of authority problem.
Note that two people assume themselves to be appropriate moral agents (A1 and A2) and proceed along parallel (or even conflicting) courses of action (C1 and C2). As each analyzes the situation, they may come to different conclusions about how to achieve the best outcome (O1 versus O2) for a patient.
This consideration of agency highlights that it does matter who has decision-making authority and say-so. In these situations, structural and team empowerment, which is discussed subsequently in this book, are vital to the nourishment of a moral culture.
In the story of Kate Lindy and Bill Boyd, who do you think should make the decisions about whether to charge for missed treatments?
The health professional who is providing the service?
The supervisor of the unit?
The institutional administrator?
The government or some other, larger societal regulating body?
Give a brief explanation for your thinking that supports your position.
Sometimes, no ambiguity or conflict exists, but reflection on the issue reveals that the wrong person has the authority. In that case, the situation creates moral distress. The challenge of determining the appropriate locus of authority is the topic of thoughtful reflection by ethicists and other individuals. In the context of the health professions, there are at least four ways of thinking about authority in healthcare decisions.
1. Professional expertise. You are in a professional role along with other people in different professional roles. This is the essence of interprofessional teamwork that characterizes so much of quality healthcare today. The role differences mean that you bring different spheres of expertise to the situation. In some areas of the patient’s care, each professional is an authority on a part of the whole picture. That alone should be a vote for the person who has the most relevant knowledge about the patient’s condition and other factors that influence the situation.
2. Traditional arrangements. Traditionally, in the healthcare system, the physician has been the authoritative voice in healthcare decisions. The physician is considered to be in authority because of his or her office or position rather than (or in addition to) an authority because of special expertise. From this perspective, the medical director of the unit unquestionably is the one to make a decision about what to do, although he or she may choose to invite advice and counsel from other individuals.
3. Institutional arrangements and mechanisms. Sometimes, the decision about the authoritative voice comes from special institutional arrangements. For example, some tasks may be delegated to committees. In these instances, the committees or designated individuals assume specific task-related roles. This is really a variation of the first two roles, with the designated individuals in authority because of their expertise and the positions they hold. For example, the authority for making a decision regarding billing for missed treatments may be referred to a committee designed to deal with humane treatment of patients in unusual situations rather than billing solely as a financial issue.
4. The authority of experience. A voice of authority may emerge because of the insight that comes from experience. Situations always exist in which we seek the advice of people who have been in similarly perplexing situations and defer to their judgment. Kate Lindy may wish to seek advice for the next step from a supervisor, senior member of the professional staff, or other person judged to have the benefit of experience. This is seldom institutionalized as a formal mechanism for dealing with locus of authority challenges and is a variation of the professional expertise approach, which assumes that expertise often is refined with experience in a wide range of situations.
None of these sources should be taken for granted as the appropriate authority for all situations. The ethical gold standard remains what will result in a caring response for the patient.
Given that care is increasingly provided by interprofessional teams, another consideration in moral agency is shared agency. As you recall from Chapter 1, the interprofessional care team is a group of care providers (including licensed health professionals, assistive staff, and ancillary support staff) who work together to deliver quality, evidence-based, and client-centered care. These teams share day-to-day concerns as they arise and work together to navigate practice while upholding professional responsibilities, values, and duties. When faced with the moral dimensions of professional practice, sharing concerns among the team members can create an atmosphere that nurtures ethical reflection. One question that often arises is: Who is the moral agent? Because the goal is to achieve a caring response, the care team may give consideration to shared agency. Shared agency is not to be taken lightly because it requires high levels of engagement from all team members. It entails a commitment to group discussion, collaborative decision making, and mutual trust in the disposition to act on the intentions of the team over the individual, taking into account the previous discussion that at different times various members of the team may emerge as the appropriate authority when the actual decision making is imminent. A prerequisite for shared agency is that each team member is heard (including those with dissenting views), respected, and participatory in decision making and agrees to uphold mutual responsibilities when implementing a plan.9
Considerations of locus of authority and shared agency are important features to attend to in a shared moral community. The goal in both considerations is to achieve an outcome consistent with a caring response.
Two Prototypes of Ethical Problems
Now that you have acquainted yourself with the common features of all prototypes, you are ready to learn more about the prototypes themselves: moral distress and ethical dilemmas.
Moral Distress: Confronting Barriers to Moral Agency
Moral distress focuses on the agents (A) themselves when a situation blocks them from doing what is right. Moral distress as a term came into the ethics literature primarily through nursing ethics and has become more generalized because of its usefulness in understanding ethical problems that all health professionals experience. Moral distress reflects that you, the moral agent, experience appropriate emotional or cognitive discomfort, or both, because of a barrier from being the kind of professional you know you should be or from doing what you conclude is right. Your emotional response and feelings play a major role in the recognition that you have moved from striding confidently along in your moral life to experiencing that something is wrong. You can see that your response to the situation comes from an awareness that your integrity is threatened because a threat to integrity arises when you cannot be the person you know you should be in your professional role or cannot do what you know for certain is right. Health professionals find that these emotional signals give rise to physical expressions that warn something is wrong: a knot in the pit of their stomach, a catch in the otherwise confident stride, or an awakening in the early hours of the morning with the haunting feeling that something is awry. Again, we are reminded that emotions and feelings are critical data of the moral life, trying to say, “Stop! Wait! Don’t! Think twice!”
Moral agents in the health professions encounter two types of barriers that create moral distress: type A and type B.
Type A: You Cannot Do What You Know Is Right
A common problem today is the barrier to adequate care of individual patients created by the mechanisms for the delivery and financing of healthcare, although other sources also exist. Recent studies have found that high percentages of moral distress occur over resource allocation and reimbursement constraints, goal setting, maintaining confidentiality, limiting autonomy, withdrawing and withholding care, prenatal testing, and balancing institutional needs versus what is best for the client.3,10–12 For example, a hospital policy may be to refuse admission of patients who do not have insurance to fully cover the cost of their treatment or to discharge patients who the interprofessional care team judges to be unsuited for the rigors of transition to the home environment. Here, the morally right course of action (C) that would lead to the desired outcome (O) is blocked by policies and practices, resulting in moral distress. Type A barrier is illustrated in Figure 3-2. The moral distress comes precisely because of the repercussions the professionals believe they may have to endure. Institutional and traditional role barriers keep them from exercising their moral agency for the good of patients.
FIGURE 3-2 Moral distress: type A.
This does not mean that you will never take into account the larger social context in which you are practicing. As you learned in Chapter 2, social determinants of a caring response sometimes do alter the course of action you would otherwise take. For instance, health professionals must always attend to the larger public health considerations in the case of a patient with a serious highly infectious disease. The patient may experience forced quarantine or be placed in isolation. The health professional’s emotional discomfort in such a situation that requires acting for the good of many other individuals is not an example of moral distress. The patient still can be the recipient of the best care possible. Only when you are quite sure you cannot be faithful to the basic well-being of the patient is there …
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