3.4.5 What can be agreed about ethics?
Even though every person has an idea about what acting ethically means, when faced with an ethically contentious problem, or when it is not clear what will bring about the best outcome, ‘good’ people will act in diverse, and often opposing, ways, while maintaining they are ‘doing the right thing’. While ordinary individuals also have ethical responsibilities to one another (for example, to tell the truth), the duties owed by professionals to their users go beyond everyday ethical responsibilities. For the reasons outlined above, users are in a uniquely vulnerable position when they are ill, which demands a higher standard of ethical propriety.
Professional ethics is about how responsible practitioners ought to act when faced with ethically contentious choices.
Practical ethics is about practitioners acting in an ethically appropriate way and being accountable for their actions.
It is worth reflecting on the idea that ordinary people are also accountable for their actions, in that they are held responsible for the outcome of their actions. A good example of this is acting within the law. When people seriously infringe the rules of society and break the law, they can be subjected to legal sanctions, such as a fine or even imprisonment. Mostly, though, people's decision to act ethically or not has little immediate comeback for them. It may affect how others think of them, but ordinary people are unlikely to be censured for acting unethically.
Health professionals are much more accountable for their actions because ethical duties form the foundation of their relationships with users. Infringements of those duties have serious consequences: for example, eroding the trust between users and practitioners. Accordingly, health professionals must be more accountable for their actions, because they have implicitly agreed to be bound by the rules and codes of their profession.
Accountability takes many forms, and practitioners are potentially answerable to their personal conscience, their professional body, an employment tribunal, or even a court of law. Being a practitioner is not easy. The freedom of health professionals to make choices goes hand in hand with being responsible for their consequences. The next activity shows how difficult these choices can be.
Activity ethical dilemmas
Consider the following three ethical dilemmas, which are drawn from real-life CAM practice. Each dilemma raises one or more of the ethical issues discussed so far in this extract. (To recap, they are respect for autonomy, a duty to benefit, a duty not to harm, respect for justice, and the concept of paternalism.) For each case, write a short paragraph saying what you would do if you were the practitioner. You do not need any technical knowledge to answer this. As you do this activity, try to take into account the aspects of good ethical practice that were discussed in Activity 9 ‘Acting ethically’.
A chiropractor knows from past experience that if she explains to a user what the technique known as a high velocity thrust feels like before she applies it, the user will probably become tense and stiff. This would make it harder to do and possibly even dangerous for the user. Although the chiropractor was taught to explain in detail, she now acts first and explains later.
A homoeopath treating a 14-year-old girl for recurrent urinary tract infection is concerned that the girl is being abused by her stepfather but is unsure whether this concern should be disclosed and, if so, to whom. The homoeopath asks the girl if she will agree to let him talk to her mother, but she adamantly refuses. What should the homoeopath do?
A reflexologist suspects that the person he is treating has bowel cancer, but thinks the person's spirits will be damaged by disclosing bad news, so he keeps his opinion to himself. Although he is not a doctor, he is certain from his own one-year training that the user has cancer.
In this scenario the main ethical issue is paternalism. The chiropractor is trying to act in the user's best interests (the duty of beneficence) and not cause the user harm (the duty of non-maleficence). This is why the chiropractor withholds the information about applying a high velocity thrust. However, by withholding this information the chiropractor is overriding the user's autonomy in not giving full information about what is being done (or, in this case, about to be done) to their body. Note that the chiropractor has been taught to give detailed explanations. Providing adequate information is essential if a practitioner is to gain a user's consent to treatment. Note, also, that the chiropractor's motivation for withholding the information is well intentioned but none the less ethically objectionable, since it removes the user's decision-making ability (in this case, to say they would rather not be given a high velocity thrust).
This case concerns both respect for autonomy and the duty of beneficence. The question is whether the homoeopath should respect the teenager's confidentiality as she insists. You may think that, if the teenager is old enough to consult the homoeopath and apparently give her consent to treatment, she is also old enough for her confidences to be respected. Respect for confidentiality is an aspect of respect for autonomy. A person being able to control who knows what about them is fundamental to their being in charge of their life. In UK law, a teenage or young person can consent to treatment as soon as they are sufficiently mature to understand fully what the treatment involves. However, at the same time, the homoeopath has a duty to benefit the user and a duty to protect from harm, which might be construed as a duty to report suspected abuse to the relevant authority. This case is an example of where ethical principles conflict. One solution might be for the homoeopath to persuade the young person to tell her mother. Certainly, the homoeopath ought to inform her whether he intends to disclose her personal information against her wishes. Remember, a paternalistic decision to go over the young person's head may be misguided. The homoeopath may not know all the facts and the decision to disclose these concerns could have unforeseen and bad consequences.
This case is also about paternalism and raises additional questions about the reflexologist's competence, an issue that goes to the heart of the duty of beneficence and the duty of non-maleficence. The reflexologist is acting paternalistically in withholding a suspicion that the user has bowel cancer. To withhold a potentially serious diagnosis from someone is a clear breach of their autonomy, even if it is aimed at protecting them from distress. It assumes that the practitioner knows better than the user: in this case, that the user would rather not know they have cancer, than know and be able to make decisions accordingly. Nowadays, in conventional medicine, withholding a serious diagnosis is almost always seen as unwarranted paternalism. In addition, in this case the reflexologist may be inadequately trained to diagnose bowel cancer (especially on the basis of one year of training). Unless the reflexologist has the necessary training to diagnose cancer, he is exceeding his limit of competence. To give a user an unsubstantiated diagnosis is a clear example of causing the user harm, and breaching the duty of non-maleficence.
So, knowing what to do or taking the ‘correct’ course of action is not always straightforward. In each situation, practitioners have to weigh up conflicting ethical issues and make an ethical deliberation, deciding what is the best course of action, allowing for all the circumstances. Practitioners are accountable for the decisions reached, and so have to be able to justify why they acted in this way. In each scenario, the problem is an ethical dilemma and not a technical problem. Being a ‘moral agent’ (someone who makes ethical decisions) requires the practitioner to consider the interests and rights of all relevant parties, any applicable laws, professional duties or regulations that might apply, and the likely outcome or consequences of choosing one course of action over another. The examples highlight that sometimes all the available options are problematic, in which case the best solution is to follow the course of action that will result in the least harm.
However, it is important to bear in mind that ethical dilemmas have cross-cultural dimensions. The comments on the three scenarios in the activity ‘Ethical dilemmas’ reflect western values. These stress individual autonomy and the rights of individuals to determine their own fates. The prevailing cultural preference in the UK and the USA is to respect an individual's right to self-determination. Accordingly, when health professionals override a patient's autonomy, it is seen negatively. However, not all cultures in the UK stress the rights of the individual in the same way. Some groups think of the family or even the community as the relevant decision-making unit. Here, ethical values may be interpreted differently, and a greater weight may be given to acting beneficently than to respecting the person's autonomy.