3.2 Ethics and health care relationships
Activity 9: Acting ethically
Write down a few sentences about what you think ‘acting ethically’ means.
Most people understand ‘being ethical’ as having something to do with people acting in ‘the right way’. ‘Acting ethically’ embraces ideas about what people ought to do or what they should do, which presupposes there are rules of conduct or behaviour by which people expressly or implicitly agree to be bound. In this sense, acting ethically is similar to acting legally: following a set of rules that determine how people ought to behave. However, whereas the law lays down hard-and-fast rules, ethics presumes that people have a degree of choice about the decisions they make: they can choose to act either ethically or unethically. The notion of choosing to do ‘the right thing’ is important because society largely holds people accountable for the actions they take. So when a person's actions are judged, the pertinent questions are why did they act in the way they did, what were their motivations, and what did they hope the consequences of their actions would be? To be held accountable, people have to understand what they are doing. So, a child would not necessarily be called to account for doing something wrong, on the basis that they are considered to lack the capacity to understand the fundamental difference between right and wrong.
The term ‘ethics’ is often used interchangeably with ‘morality’, although people sometimes draw a distinction between them on the basis that morality is personal to each individual or to a particular group, for example Christian morality. There is probably a more relevant distinction between individual ethics and professional ethics. Each profession has a set of rules and obligations that are central to how professionals acting within that sphere of practice must behave. Many of the requirements of professional practice reflect the expected obligations of the ordinary citizen, including:
a duty to tell the truth
a duty to act honestly and fairly
a duty to respect people's wishes, and not to treat people as a means to an end, but as individuals with rights
a duty not to harm people.
Another way of thinking about ethics is to concentrate on people's rights, both in everyday life and specifically as health service users. As individuals, people have a right:
not to be harmed
not to be lied to
not to be touched without their permission
to be treated fairly and justly.
The obligations of a health professional embrace all of these rights. Ethics is important in health care for several reasons, but primarily because failing to act ethically can harm someone. Also, the unique vulnerability associated with being a patient leads people to trust that health practitioners will act ethically, by putting their best interests first. This includes taking their wishes into account, and not doing anything without their express permission (for example, by obtaining informed consent). Health care ethics concerns both professionals’ duties and users' rights. Ethics in health care tends to concentrate on the following four key principles (Beauchamp and Childress, 1994).
The principle of respect for autonomy – giving competent adults the information they need to make their own decisions, based on their own values and their personal assessment of risk factors, free from coercion or undue influence.
The principle of beneficence – benefiting or acting in the patient's best interests.
The principle of non-maleficence – not deliberately causing the patient harm, or making sure that the benefits outweigh the harm if harm is unavoidable.
The principle of respect for justice – treating all patients equally and providing mechanisms for when care goes wrong.
While these four principles underpin the range of duties that health professionals owe their patients, they do not provide an exact blueprint for how a practitioner ought to act in every given situation. However, they do provide a good starting point for making decisions, so that a practitioner faced with an ethically contentious choice does not make a decision solely on personal preference (for example, a doctor refusing to agree to a woman's abortion because of their personal opposition to it).
Sometimes these four ethical principles clash. For example, a doctor might be reluctant to tell patients they are dying, believing this will cause distress. In the past, doctors could override patients’ autonomy by withholding that information from them in what they perceived were the patients’ best interests. These might include keeping hope alive and encouraging the dying person to take the prescribed medication. Nowadays, such an action would be regarded as unacceptably ‘paternalistic’.
‘Paternalism’ has a distinct meaning in health care ethics. It describes the actions of a health care practitioner who overrides or does not seek the wishes of a competent person (that is, someone who has sufficient autonomy to make their own decisions), believing that they are better able to decide what is in the patient's best interests. A paternalistic action is always well intentioned but is ethically unacceptable because it usurps people's rights to make their own decisions, based on their own values and beliefs. Since the 1970s, there has been a cultural shift towards respecting rights and promoting self-determination. This means it is now considered more preferable for people to make their own choices on the basis of all the relevant facts than for other people to make decisions for them. This example also demonstrates that ethics is not static but reflects what is considered ethically appropriate by a society at different points in time, and that different cultures may have differing views on what is ethical. This explains why euthanasia can be lawful in the Netherlands but not in the UK: in the Netherlands, the emphasis is on respecting people's autonomy, whereas in the UK, the emphasis is on not causing harm.
Historically, health care ethics tended to concentrate on the responsibilities owed by the practitioner to an individual person. However, the true scope of health care ethics is considerably wider. Practitioners have duties not just to the individual in front of them but to all of their clients. They may even have duties to the public in general. For example, a practitioner who treats someone for a sexually transmitted disease has a duty to act in that person's best interests, but may also have a duty to that person's sexual partner, who could be a client. The practitioner may have a duty to warn third parties, who may not be clients, that they are at risk. Practitioners have ethical duties not just to service users but also to their profession and their employers. Users have ethical responsibilities as well as rights. These include doing what they can to maintain their own health; not drawing inappropriately on health services (for example going to the accident and emergency department with a routine or trivial complaint); and providing all necessary relevant information to a practitioner to facilitate an accurate diagnosis.
In the next activity you will reflect on your experiences as a user of health services and consider some of the ethical issues that arise in everyday health encounters.
Activity 10: Ethics in health care
Reflect on your last health care consultation (for example, a routine check-up with your GP or practice nurse, a visit to the dentist, a hospital appointment or a consultation with a CAM practitioner).
Did any aspects of the encounter give rise to ethical issues? Focus on the positive as well as the negative aspects.
Try to consider as broadly as possible, for example, whether the receptionist was polite to you, whether you felt confident to discuss personal information, whether the practitioner seemed genuinely interested in your problem or whether your appointment was on time.
Ethics permeates every aspect of the health care encounter. Healing relationships are, at their heart, based on trust. When people are ill, they need to believe that everyone involved in providing their health care is acting appropriately and treating them in their best interests (for example, giving them the treatment that is best for their condition, not simply the cheapest or the quickest to administer). Acting ethically involves health carers respecting users' rights and supporting their choices (for example, giving them as much information as they want about the range of treatments available and the alternatives to treatment); being good at what they do (keeping up to date with and undertaking continuing professional development); refraining from actively harming users (by following approved and appropriate practices); and treating people in a fair and consistent manner (for example, not having ‘favourite’ users with whom they spend twice as long as they do with ‘difficult’ users).
In Activity 9, it was probably easier to think about instances of unethical practice than examples of ethical practice. The following list identifies some of the areas you may have considered as giving rise to ethical issues.
When you made your appointment did you feel that the initial contact with the receptionist or the professional was handled sensitively? Was the information you provided managed in a sensitive way, with respect for your privacy?
When you arrived for your appointment did the receptionist (if one was present) give you the chance to say why you were there (if relevant) and privacy in which to give your personal details?
Did the practitioner respect your autonomy, by asking you what you think is wrong and what you want to do about it, by gaining your consent to treatment, by respecting your personal health information as being confidential, by not discussing your details with anyone who does not need to know (other than to benefit your health), and by ensuring that written notes or computer records about you are kept safely?
Did the practitioner act in your best interests, by obtaining an adequate history from which to form a diagnosis and consider the right treatment plan, by providing treatment that should bring about the desired outcome with a minimum of side effects, and by keeping up to date with professional developments?
Did the practitioner act detrimentally towards you in any way: for example, being rude or dismissive, suggesting an inappropriate treatment, or charging you excessively for their services?
As far as you could tell, did the practitioner treat you fairly: for example, was the appointment on time, or were you or other people kept waiting? If your appointment was much later than the arranged time, were you given an explanation or apology? Did you feel that you could complain if there was anything you were unhappy about?
The above list shows that most interactions in health and social care have ethical dimensions, even if you did not necessarily consider them as ‘ethical’ issues. Most ethical issues concern the ordinary, everyday relationships between practitioners and users, although the media tend to focus on the more dramatic life-and-death issues, often presenting them in a highly polarised way. Almost all interactions have an ethical aspect, which spans encounters from what might appear to be simple questionnaires sent to people at home, through all the interactions they have with the service providers, including the treatment. There are ethics about how people are referred to a practitioner, and the treatment prescribed to them. As previously mentioned, users also have ethical responsibilities, for example telling their doctor they are also receiving treatment from a CAM practitioner, which might have a bearing on the doctor's recommended treatment and vice versa.