Principles of Healthcare Ethics

The language of ethics related to healthcare, also commonly called bioethics, is applied across all practice settings, and four basic principles are commonly accepted. These principles include (1) autonomy, (2) beneficence, (3) nonmaleficence, and (4) justice. For Case managers, and other health professionals, veracity (truthfulness) and fidelity (trust) are also spoken of as ethical principles but they are not part of the foundational ethical principles identified by bioethicists (Drumwright, 2015) Principles of Healthcare Ethics.

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The Principle of Autonomy

Autonomy is an American value. It is the ability to make decisions for oneself, also known as self-government. We hold great respect for individual rights and equate freedom with autonomy. Our system of democratic law supports autonomy and, as such, upholds the right of individuals to make decisions about their own healthcare.

Respect for autonomy requires that patients be told the truth about their condition and be informed about the risks and benefits of treatment in order for them to make informed decisions. Under the law, they are permitted to refuse treatment even if the best and most reliable information indicates that treatment would be beneficial, unless their action may have a negative impact on the well-being of another individual. These conflicts set the stage for ethical dilemmas Principles of Healthcare Ethics.

The concept of autonomy has evolved, from paternalistic physicians who held decision-making authority, to patients empowered to participate in making decisions about their own care, to patients heavily armed with Internet resources who demand their own choice in any decision-making. This transition of authority has been slower to evolve in the geriatric population but, as the baby boomers age, they will assert this standard of independence.

Autonomy, however, does not negate responsibility. Healthcare is a partnership between the provider and the recipient of care. Each owes the other a position of partner and respect in healthcare decision-making (Veatch, 2016). An ethical surety is that the physician, or any other healthcare professional, cannot make a unilateral healthcare decision without the consent of that competent adult, or emancipated minor Principles of Healthcare Ethics.

Emancipated minors are persons under the age of 18 who can make legal decisions for themselves without a parent’s consent. Emancipation can occur in several ways, including (1) reaching age of majority [age 18], (2) emancipation by court order, (3) by marriage or parentage, or (4) by active military service. What makes someone an emancipated minor includes being under the age of 18 and legally married, financially independent, a parent, or responsible for his or her own housing, or having been kicked out of a home by abusive parents (Larson, 2018). Healthcare professionals need to be familiar with these legal issues in advocating for patients who fall within the emancipation category. Case managers may need to advocate for emancipated minors in healthcare issues Principles of Healthcare Ethics.

The Principle of Beneficence

The beneficent practitioner provides care that is in the best interest of the patient. Beneficence is the act of being kind. The actions of the healthcare provider are designed to bring about a positive outcome. Beneficence always raises the question of subjective and objective determinations, of benefit versus harm. A beneficent decision can only be objective if the same decision would be made regardless of who was making it.

Traditionally the ethical decision-making process and the ultimate decision were the determination of the physician. This is no longer the case; the patient and other healthcare providers, according to their specific expertise, are central to the decision-making process. For example, case managers have expertise in quality-of-life issues, and in this capacity can offer much to the discussions of lifestyle and life-challenging choices, particularly when dealing with terminal diseases and end-of-life dilemmas (Leuwenburgh-Pronk et al., 2015) Principles of Healthcare Ethics.

The Principle of Nonmaleficence

Nonmaleficence means doing no harm. Providers must ask themselves whether their actions may harm the patient either by omission or commission. The guiding principle of primum non nocere, “First of all, do no harm,” is found in the Hippocratic Oath. Actions or practices of a healthcare provider are “right” as long as they are in the interest of the patient and avoid negative consequences.

Harm by an act of omission means that some action could have been done to avoid harm but wasn’t done. Omission would be failing to raise the side rails on the patient’s hospital bed, upon which the patient fell out and was injured. An act of Commission is something actually done that resulted in harm. An example of an act of commission would be delivering a medication in the wrong dose or to the wrong patient.

Case managers can be accused of maleficence by omission if they failed to coordinate a patient’s care correctly—for example, discharging a patient to an inappropriate level of care or leaving a patient in a dangerous living situation. Principles of Healthcare Ethics A key role for the case manager is to be an advocate for the patient and neglecting this role could be maleficent. An unethical act of commission could be breaking confidentiality by releasing information that becomes harmful to the patient.

Patients with terminal illnesses are often concerned that technology will maintain their life beyond their wishes; thus, healthcare professionals are challenged to improve care during this end stage of life. Patients may even choose to hasten death if options are available. The right of the individual to choose to “die with dignity” is the ultimate manifestation of autonomy, but it is difficult for healthcare providers to accept death when there may still be viable options. Indeed, in most states it is still illegal to hasten death by any active means Principles of Healthcare Ethics.

Here we see the principle of nonmaleficence conflicting with the principle of autonomy as the healthcare providers or case managers desire to be beneficent or, at the least, cause no harm. The active choice to hasten death versus the seemingly passive choice of allowing death to occur requires that we provide patients with all the information necessary to make an informed choice about courses of action available to them.

A complicating factor in end-of-life decisions is patients’ concern that, even if they make their wishes clear (such as through an advance directive), their family members or surrogates will not be able to carry out their desires and permit death to occur. Treating against the wishes of the patient can potentially result in mental anguish and subsequent harm to the patient or family members Principles of Healthcare Ethics.

Euthanasia can be either active or passive. Currently active euthanasia, which is actively giving a medication to bring about death is illegal under federal law in the United States; however, passive euthanasia may be allowed. Removing ventilation equipment or withholding nutrition, which may cause a natural death, are permissible and currently identified in living wills or advance directives when patients state they desire no extraordinary measures be taken to sustain life Principles of Healthcare Ethics.

The Principle of Justice

Justice speaks to equity and fairness in treatment. Hippocrates related ethical principles to the individual relationship between the physician and the patient. Ethical practice today must extend beyond individuals to the institutional and societal realms. This means that, in addition to providing fairness in treatment to the patient, the institution and staff must also be treated fairly. For example, it is not fair if a patient cannot make payments and the institution has to pay for the treatments already given for the patient’s benefit Principles of Healthcare Ethics.

Justice may be seen as having two types: distributive and comparative. Distributive justice addresses the degree to which healthcare services are distributed equitably throughout society. Within the logic of distributive justice, we should treat similar cases similarly—but how can we determine if cases are indeed similar? Beauchamp & Childress (2013) identify six material principles that must be considered, while recognizing that there is little likelihood all six principles could be satisfied at the same time (see box).

Looking at the principles of justice as they relate to the delivery of healthcare, it is apparent that they do conflict in many circumstances. For example, a real-life system that attempts to provide an equal share to each person cannot distribute limited resources. There is a finite end to money and resources within the budget of an organization. When good patient care demands more than the system has allocated, there may be a need for adjustments within the marketplace Principles of Healthcare Ethics.

An example would be when an insurance company has exhausted its allocated and contracted funds to care for a hospitalized patient. The insurance company can then demand that the patient be transferred to another facility of lesser cost. If, however, the acuity of the patient is too high to be transferred, then the patient’s healthcare costs continue to exceed the budget, which is unequitable for the insurance company. Principles of Healthcare Ethics If the insurance company stops paying for services rendered, then it is unequitable for the hospital. If the hospital discharges the patient home before truly appropriate for the patient, it becomes unequitable for the patient. Clearly, these are unfortunately real-life ethical and moral dilemmas. Who is most important?

Comparative justice determines how healthcare is delivered at the individual level. It looks at disparate treatment of patients on the basis of age, disability, gender, race, ethnicity, and religion. Of particular interest are the disparities that occur because of age. Bias as a result of age compared to gender and race discrimination is referred to the practice as ageism (Chrisler et al., 2016). In our society, equal access to healthcare does not exist due to variations in health insurance, third-party payers, socioeconomic levels, and even availability of transportation to care facilities. There is valid concern about the distribution of resources, particularly as the population ages and the demand for services increases.

Currently those age 65 and older receive disproportionate levels of funding in healthcare because the number of individuals in that cohort continues to increase and because people tend to need more healthcare services when they are older. Equitable allocation of resources is an ever-increasing challenge as lives are extended through natural and technological means Principles of Healthcare Ethics.

Political trends and changes also impact the principle of justice in healthcare decisions. Democratic President Barack Obama introduced the first government sanctioned healthcare aimed at covering all Americans, nicknamed “Obamacare” or more correctly called the Patient Protection and Affordable Care Act (ACA) (PPACA, 2010). The ACA was an attempt to decrease disparities in healthcare benefits.

All of these factors place greater stress on an already overburdened healthcare system and result in more difficult ethical decisions about workforce allocation and equitable distribution of financial resources.

The Principle of Veracity

Veracity (truthfulness) is not a foundational bioethical principle and is granted just a passing mention in most ethics texts. It is at its core respect for all persons by being truthful. Veracity is the opposite of the concept of paternalism, which assumes patients need to know only what their physicians choose to reveal.

Obviously there has been a dramatic change in attitudes toward veracity because it forms the basis for the autonomy expected by patients today. Informed consent is only possible if patients have been well informed of options, which then allows them to exercise autonomy with full knowledge.

Decisions about withholding information involve a conflict between veracity and deception. There are times when the legal system and professional ethics agree that deception is legitimate and legal. Therapeutic privilege is invoked when the healthcare team makes the decision to withhold information believed to be detrimental to the patient. Such privilege is by its nature subject to challenge and is taken very seriously by ethics committees.

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The Principle of Fidelity

Fidelity is loyalty. It speaks to the special relationship developed between patients and their healthcare professionals. Each owes the other loyalty; although the greater burden is on the provider to be worthy of the patient’s trust and loyalty (Beauchamp & Childress, 2013). Fidelity often results in a dilemma, because a commitment made to a patient may not result in the best outcome for that patient (Veatch, 2016). Principles of Healthcare Ethics At the root of fidelity is the importance of keeping a promise and being true to your word. Individuals see this differently. Some are able to justify the importance of the promise at almost any cost, and others are able to set aside the promise if an action could be detrimental to the patient.

For example, if a physician promises the patient they will always be there to care for them, yet leaves the organization and joins another healthcare facility, the patient may feel the physician betrayed their loyalty. The same may occur with a case manager who promises the patient and family they will be available to help them, yet leaves the employment, which may make the patient feel abandoned Principles of Healthcare Ethics.

An Ethical Decision-Making Model

There are many models for ethical decision-making that help to organize the thoughts of the individual. Some are quite simplistic, for example, the tilt factor model.

Tilt Factor Model

The tilt factor model looks at the choices confronting the individual, with pros and cons defined and with the factors that would change the decision indicated as “tilt factors.” This simple model does not truly guide the practitioners’ actions, but it does help to frame the question.

Using this model to make ethical decisions provides the case manager with direction for collecting information about the problem, the facts of the situation, the identification of interested parties, and the nature of their interest: is it professional, personal, business, economic, intellectual, or societal? The healthcare professional then determines if an ethical question is involved and if there could be a violation of the code of ethics, or if there is a potential affront to personal moral, social, or religious values. This model also identifies any potential legal issue (eg, malpractice, a practice-act infringement). The case manager gathers more information if it is needed to make an appropriate decision. In the tilt model, this is the point where the case manager is encouraged to brainstorm potential actions and then analyze the course of the chosen action Principles of Healthcare Ethics.

The RIPS Model

A model for ethical decision-making that is popular with case managers and other healthcare professionals is the Realm, Individual Process, Situation (RIPS) model. The steps of the RIPS model bring forward many of the aspects of a problem confronting the interdisciplinary team. This method essentially involves four steps (Dale, 2016). To better illustrate the ethical decision-making process, we will work through a case that involves issues of utilization. You will see that the three primary components of the RIPS model are implemented in the case Principles of Healthcare Ethics