*A Primer for Teaching Health Care Ethics Using A Multicultural/Interdisciplinary ApproachInstitute for Ethics In Health CarePresents:

* Objectives: To Understand:

The dynamics between ethics and the law.How to implement contemporary ethical principles by examining the difference between ideas(duties). Actions (consequences) as they pertain to the principles and principles of ethics.The common terms and principles of modern bioethics.

*Objectives ContinuedWhy ethics may differ among different cultures and why this knowledge is important.Why bioethics needs to be integrated through conscious design in order for the health care provider to deliver ethical care. The importance of ethics in modern medicine in todays culturally diverse health care environment.

To Understand:

*Objectives ContinuedThe case study method of examining everyday bioethical problems to enhance the students understanding and implementation of contemporary bioethic principles and principles. How to utilize ethical principles as guidelines for decision making when caring for clients. To Understand:

*Objectives ContinuedHow to recognize and utilize a decision making model approach to solving ethical dilemmas. How to identify the ethical duties and actions of the health care professional when obtaining an informed consent from a client/family.

To Understand:

*Objectives ContinuedHow to explore positive communication techniques which can be used in obtaining informed consent (feature benefit check)!How to recognize the health care providers ethical responsibilities in safe guarding the contents of medical records.

To Understand:

*Objectives ContinuedWhy ethics may differ among different cultures and why this knowledge is important.Why bioethics needs to be integrated through conscious design in order for the health care provider to deliver ethical care. The importance of ethics in modern medicine in todays culturally diverse health care environment.

To Understand:

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Ethics and Morality

Ethics is a set of moral principles and a code for behavior that govern an individuals actions with other individuals and within society.

Morality is what people believe to be right and good, while ethics is a critical reflection about morality.

*LawLaws are brought about by tension, agitation and conflict by dramatic situations.

Laws are societal rules or regulations that are obligatory to observe.

*Law ContinuedLaws protect the welfare and safety of society, resolve conflicts, and are constantly evolving.

Laws have governed the practice of medicine for over one hundred of years.

*BioethicsBioethics refers to the moral issues and problems that have arisen as a result of modern medicine and medical research.Issues in bioethics are usually life-and-death issues!Ethical and bioethical principles can be personal, organizational, institutional or worldwide.

*Comparing Law and EthicsLaw, ethics, and bioethics are different but related concepts. Laws are mandatory to which all citizens must adhere or risk civil or criminal liability. Ethics relate to morals and help us organize complex information and competing values and interests to formulate consistent and coherent decisions.

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Value conflicts, no clear consensus as to the right thing to do. A conflict between moral obligations that are difficult to reconcile and require moral reasoning. Ethical Dilemma:

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Situations necessitating a choice between two equal (usually undesirable) alternatives. Ethical Dilemma:

*Ethical Issues in Modern Healthcare In modern healthcare and research, value conflicts arise where often there appears to be no clear consensus as to the Right thing to do. These conflicts present problems requiring moral decisions, and necessitates a choice between two or more alternatives.Examples: Should a parent have a right to refuse immunizations for his or her child? Does public safety supersede an individuals right?

*Ethical Questions, Cont.Should children with serious birth defects be kept alive?Should a woman be allowed an abortion for any reason?Should terrorists be tortured to gain information possibly saving hundreds of lives?Should health care workers be required to receive small pox vaccination?Who should get the finite number of organs for transplantation?

*Ethical Theories: Ideas and ActionsDeontology (duty)Consequentialism (actions)Virtue Ethics/Intuition (morals and values) Beliefs Rights Ethics (individuality and the American culture)

*Ethical TheoriesDeontology /Nonconsequentialism: Derived from the Greek word, Deon, meaning duty. Considers that some acts are right or wrong independent of their consequences. Looks to ones obligation to determine what is ethical and answers the question: What should I do and why should I do it?

*An Individuals Ideas and Actions Deontology: A dutyExample: Zelda, a practitioner, believes she has a duty to give cardiac clients detailed information on the pathology involved in their condition even though the client has indicated that they are not ready or may be terrified to hear the information causing the client distress.

*Ethical Theories ContinuedConsequentialism: Also called Teleological, Greek word, Telos, meaning end or consequence. Actions are determined and justified by the consequence of the act. Consequentialists consider all the consequences of what they are about to do prior to deciding a right action. This also answers the question: What should I do and why should I do it?

*An Individuals Ideas and ActionsConsequentialism: Action Example: Had Zelda respected the wishes of her clients, she would have given them only the information which would have been a benefit to them and not caused them undue stress. She would have been motivated by her desire to do good (beneficence), rather than her sense of duty. This is a Deontological betrayal.

*Ethical Theories ContinuedUtilitarian Ethics: Considers the greatest good for the largest number of people. Also answers the question: What should I do and why should I do it?Intuitionism: Resolves ethical dilemmas by appealing to ones intuition, a moral faculty of a person which directly knows what is right or wrong. (A gut feeling of knowing what is right).

*Ethical Theories ContinuedRights: This popular American theory resolves ethical dilemmas by first determining what rights or moral claims are involved and take precedence, (consider the abortion debate- personal mom vs. fetus/child, societal- womens choice vs. murder.

*Ethical Theories ContinuedVirtue Ethics: Contrary to other ethical theories, virtue ethics tells us what kind of person one ought to be, rather than what they do. The focus is on the character (goodness) of the person.

*Two questions when faced with a dilemma:Behavior: What should I do? Motivation: Why should I do it?

*The Identity ArgumentPremise 1: What is understood to be morally right depends (at least in part) on ones identity as a moral person. Premise 2: Ones race ethnicity and culture is central to ones identity as a moral person.Conclusion: Thus, what is understood to be morally right by an individual depends (at least in part) on that persons race, ethnicity, and culture.

*Cultural Diversity and EthicsIncreased recognition,interest and respect for diverse societal values. Why?Fundamental question: What place, if any, do race, ethnicity, and culture have in moral theory? Why Now?

*What exactly do we mean by race, ethnicity and culture? Race Genetically there is only one race, which is the human race. Society makes judgments about the varieties of biological characteristics. Eventually, biological characteristics are seen as socially constructed which often leads to stereotyping.

*What exactly do we mean by race, ethnicity and culture?

Ethnicity - An individuals identification with a particular cultural group to which they are biologically related.

*What exactly do we mean by race, ethnicity and culture?

Culture - A set of beliefs, values and traditions that are socially transmitted from one generation to another. It defines a groups norms or communitys identity.

*Cultural AssimilationA process by which persons of different backgrounds adopt Another groups main values, traditions and mores. Cultural Assimilation:Often occurs in different stages.It may never be complete due to the groups efforts in maintaining their identity.May occur in degrees by choice.

* Cultural DifferencesValue the family over the individual.Engage and expect the familys support in their self-care.Value the institutions that are sensitive to their cultural needs.MAY INCLUDE:

*Cultural Differences

Liberal visiting hours and an un-limited number of visitors (Family based care).Incorporation of religious beliefs and cultural traditions in tandem with Western medicine.

*Cultural DifferencesCan effect the quality of client careCan have a negative effect on the familyShould be evaluated carefully to improve healthcare outcomes and prevent:MisunderstandingsStereotyping BarriersConflict

*Stereotypes:Are oversimplifications to conceptions or images of what a particular group or person should look like, or how they should act by disregarding each persons uniqueness. Represent the end-point of ones understanding (all members of a particular group fit the same pattern or mold).Do not encourage further exploration of the individual or assimilation into the majority group.

*GeneralizationsGeneralizations Statements that represent common trends in a group with the understanding that further information needs to be gathered to verify its application to a particular person. Represent a starting point and have been used by anthropologists whenever they see broad patterns of similarities among groups of people.May lead to inaccuracies in their application to a specific client

*GeneralizationsCan assist the health care professional to introduce open-ended guiding questions. This may help the healthcare professional to identify the individuals values and cultural needs. This may profoundly improve healthcare outcomes.

*Diversity & BioethicsContemporary bioethical principles are all derived, directly or indirectly from the principle of autonomy. Within the world, no two people are exactly alike. Therefore, their values, motivations, moral beliefs, and moral characters may differ much more than their physical appearances.

*Organizational Ideas and ActionsCultural Relativism: Everyone does it.CheatingStealing office suppliesConducting personal business at work

*Organizational Ideas and Actions

Although everyone does it, it still comes down to an individuals decision about how one is going to act using or not using ethical principles.

*What Are Ethical Principles, and How Do They Help With Decision Making?

*Ethical Principles Conflict is inevitable. Ethical principles provide the framework/ tools which may facilitate individuals and society to resolve conflict in a fair, just and moral manner.

*Ethical PrinciplesAutonomy/FreedomVeracityPrivacy/ConfidentialityBeneficence/NonmaleficenceFidelityJustice

*AutonomyThe right to participate in and decide on a course of action without undue influence. Self-Determination: which is the freedom to act independently. Individual actions are directed toward goals that are exclusively ones own.

*VeracityThe duty to tell the truth. Truth-telling, honesty.

*Privacy/ConfidentialityRespecting privileged knowledge.Respecting the self of others.

*Beneficence/NonmaleficenceThe principle and obligation of doing good and avoiding harm.This principle counsels a provider to relate to clients in a way that will always be in the best interest of the client, rather than the provider.

*FidelityStrict observance of promises or duties.This principle, as well as other principles, should be honored by both provider and client.

* Justice The principle that deals with fairness, equity and equality and provides for an individual to claim that to which they are entitled. Comparative Justice: Making a decision based on criteria and outcomes. ie: How to determine who qualifies for one available kidney. 55 year old male with three children versus a 13 old girl.Noncomparative Justice: ie: a method of distributing needed kidneys using a lottery system.

*Why Employ Ethical Principles?

*Respect for the Individual In our pluralistic society individuals often misunderstand each other. Even when they do understand each other, it is possible for them to disagree.The Healthcare arena, in common with every other segment of society has found it necessary to find ways to create understanding and agreement.

*How to Create Understanding and Agreement? Common ground must be created or found.A function of Ethics, in our society, is to make agreement possible. As healthcare professionals and patients meet, they meet as strangers from diverse backgrounds therefore, their ways of looking at and approaching the world are usually quite different.

*Creating Harmony is Difficult In The Healthcare Arena.PowerSelf esteemCommunicationPersonality/AttitudeEducation LevelSocioeconomic ClassCulture (which constitutes the most profound difference).Values

* Changing Healthcare EnvironmentManaged CareIncreased Healthcare CostsTechnologyBaby BoomersYoung and Old Life SpansDecrease in Healthy LifestylesLack of Healthcare Access/InsuranceFeelings of Entitlements for Healthcare at a minimal personal cost

*External Forces Political Influences/ForcesImmigration/Migration of the elderly Medicare/Prescription drugs life style drivenDecrease in extended familiesDecrease in resourcesWork forceFamily CaretakersSupport/Finances Services in the CommunitySocio-economic Disparities healthcare right or privilege?

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How May Harmony Be Achieved? Through ethical principles/behaviors, because they:Provide a unique opportunity for personal fulfillment and self respect.Serve to make it possible for professionals to deal with each other on a human level with respect across all disciplines.

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Ethical Principles/Behaviors Continued:

Serve to make it possible for professionals and clients to deal with each other on a human level with respect across all cultures and communities.Make it possible for strangers to achieve understanding (if agreement is not reached, toleration may be achieved).

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Ethical Principles/Behaviors Continued:

May make it possible for professional and clients to agree on and respect each others rights. May make it possible for this agreement to carry over into other aspects of life outside the healthcare setting where the idea of Ethics may be first introduced to the professional.May make it possible for provider and patient to interact on the basis of shared goals.

* Cultural Values Influence Decision Making

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Ethical Dilemma: Deciding Peoples Fate

*You are on a sinking ship and there is only ONE lifeboat available. Posted on the side of the lifeboat is a sign which reads, Maximum Occupancy - 8 personsthis boat will sink if over occupied. Standing on the deck and waiting on board the lifeboat are nine adults and one child. You must decide who dies. Be prepared to defend your decision.

* Persons on deckYou A young mother and her infant sonA 75 year old retired physicianHis 68 year old wifeA 17 year old, pregnant girl (this counts as one person)A professional athlete (male) A member of the clergyA middle aged school teacher and Her husband, a banker

*Who Boards the Lifeboat? Why?1. 2.3.4.5.6.7.8.

*Who goes down with the ship? Why?1. 2.

*Does Ethics Drive the Law or Does the Law Drive Ethics?

* How Ethical Principles and Laws Interface Patient Self Determination Act of 1990 (PSDA)

Health Insurance Portability and Accountability Act of 1996 (HIPPA) (Implementation April 2003)

*HIPAAHealth Insurance Portability and Accountability Act of 1996 (Implementation April 2003)

Ensures privacy and confidentiality of medical records (a legal document that identifies the patient, diagnoses, and justification for treatment).

Healthcare providers are responsible for hiring, and educating personnel to be knowledgeable of HIPAA rules and regulations governing privacy and security of medical records.

*HIPAA - ContinuedHolds 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.

*Research Driven Ethical IssuesWith the advent and benefits of modern research, moral conflict is inevitable now and in the future.Stem Cell ResearchResearch CloningGenome Project ResultsFertility Research

*Ethical Questions for DiscussionShould children with serious birth defects be kept alive?Should a woman on Medicaid be allowed an abortion for any reason?Should organs for transplantation be able to be purchased?

*Ethical Questions for Discussion

Should people suffering from a genetic disease, where future misery is predicted, be allowed to have children?

Should individuals be allowed to use scarce healthcare resources when death is inevitable?

*An Example of A Decision Making Model(ADPIE)Assessment Gather the facts/collect information from a variety of sourcesDiagnosis Identify the problem or issue

*Plan Explore alternatives and/options. Identify the consequences of actions/non-actions. Analyze the values and professional issues at stake. Select the course of action/make a decision. Justify the decision.

*ADPIE ContinuedImplementation Carry out the plan. EvaluationDetermine how this ethical problem could possibly have been prevented. Lessons learned.Assessment of outcomes.

*Decision Making Model: (ADPIE)

AssessmentEvaluateDiagnosePlanningImplementationOn-going AssessmentOn-going DiagnosisOn-going Planning On-going ImplementationOn-going Evaluation

*Ethical CommunicationHow to explore positive communication techniques which can be used in obtaining consent for treatments (Feature Benefit Check)!

*Ethics CommitteesDecision making in health care often involves more than just medical facts of the caseEthical principles and values will be the determining factor in which course of action to take.Many health care facilities have established Ethics committees.

*Ethics Committees Found in most health care facilitysUsually twelve to fifteen membersMultidisciplinary membersA representative from the Board of TrusteesThe facility administratorThe facilitys director of NursingA staff nurseA physicianAn area clergyA Social WorkerAn Attorney An Ethic ist (Usually a philosophy or theology professor)Lay persons from the community

*Functions of the CommitteeEducation To committee members themselvesContinuing education and inservice to facilitys staffTo the community

*Functions continuedDevelopment and review of laws, standards of care, institutional policies and guidelinesAbout withdrawing and withholding nutrition and hydrationDo Not ResuscitateUtilization of facilitys/communities resources

*Functions continuedCase Consultation with:Family membersPatientsHealth care providers StaffAnd their own clergy

*Case Consultation May:Provides information about ethical principles relevant to the case under discussionHelp clarify what options are openProvide information about relevant policies of the facilityMake a recommendation that is advisory in nature

*Changing Scope of Ethics CommitteesCommittees are expanding their scope of their activity to include organizational ethics, considering questions regarding:FinancesAdministrationOrganizationHuman Resource

*Expanding ScopeIn the future, ethics consults may provide for the management of a health care facility just as ethics consults are now available to patients, family members, and staff for particular medical treatment decisions.

*Husteds Formal Ethical Decision Making ModelHusted, G.L., & Husted, James H. Ethical Decision Making In Nursing, 1991, Mosby St. Louis, MO, pp. xi.

***Different cultures have different moral codes. Thus, there are no universal truths in ethics because it is difficult to say that customs are either correct or incorrect.*Today federal and state governments have constitutional authority to create and enforce laws.*Some examples of laws that protect society are DUI laws, safety belts, child car seats and bicycle helmets.Laws that have governed the practice of medicine are exemplified in obtaining and maintaining licensure. Also, the Hippocratic oath is an example of the intersection of ethics and the law. *Medicine and technology are rapidly changing and offer choices to individuals. Although challenging and even exciting, the choices can be difficult for each of us.For example should medications known to be effective, be withheld from homeless or incompetent people because they dont have the means to store or manage the medication properly?*There are penalties for failing to follow the law. This includes professional practice acts. Although there are no penalties for not following the principles of ethics, there are consequences to self, organizations and the community at-large. **Update examples for this slide as current issues arise.Select questions of your choice for class discussion.

*There are certain ethical theories that are employed that serve as a framework to respond to a myriad of ethical questions which we will explore in the next several slides. *The problem with employing Utilitarian theories is determining who decides the definition of greatest and good. The difficulty with Intuitionism is in deciding whos moral position is more valid. For example, even though abortion is legal and considered ethical (upholds the principles of autonomy (self) and privacy rights) in most states, people still have a moral ambivalence in their gut about the law and are actively working towards overturning th law.*Who determines what kind of person one ought to be? Consider the values of some of the worlds leaders, do you agree with their actions or values? *Why increase interest and respect for diverse societal values?Civil Rights MovementFeminist MovementGender EquityAffirmative ActionInteraction-exposure among diverse groups (fertilization of new ideas)Increase access of diverse populations to health careGreater access to higher education amongst minorities and various socio-economic groups and faculty members.*An example of stereotyping is all Latinos are loud, all Irish people are alcoholics, all New Yorkers are crass and loud, all Southerners are prejudiced, all Sicilians are not members of the Mafia. *Ethnicity can misleading as for example all Latinos do not necessarily share the same cultural values as they come from different countries. Even though one may identify with a certain cultural group, they may not share all the values often associated with that group. For example all Italians are not Catholic. *An example of a misunderstanding which may be a barrier to healthcare is assuming that all people of color have poor dietary habits that lead to poor health, (hypertension, obesity and stroke). *All Chinese have very similar physical appearances, however, their views about their government and procreation may differ. *I need a note.*Starting at the life boat exercise, the small group activity should take about an hours time. This exercise can be used by itself and can be expanded. At the end of the exercise, some questions and reflections to focus on may be: How did decision making and consensus building occur within the groups/class. Who is the leader, how did that happen? Are you requiring 100% consensus or majority rule? Have the student who had the minority opinion explain how he/she felt? How and why did the student acquiesce? Examine the individual values of the group as to why they choose the survivors. During the process explore whether students changed their minds, and why?*Feel free to add characteristics and situations to the persons on deck. For example, at the end of the discussion, ask if any of the groups had considered: The seventeen year old was raped.The girl is 9 months pregnant.The retired physician was an emergency room physician.Unbeknownst to the other persons on deck, the professional athlete has AIDS.

*Do we want to add questions: Is healthcare a right or a privilege? Etc.etc.*Why is there a renewed focus on privacy and confidentiality? This has arisen due to the electronic sharing of data of client records and the increased risk of sharing client information. For example, employees in the hospital could access anyones records for personal use. Ie: fraud and abuse through identity stealing,celebrities or local public figures and selling personal information to the media. Because insurance companies are accumulating data bases, there is a potential for misuse of client information. *Day to day operations in healthcare facilities are impacted by this law. Examples of potential violations of the law include: Unauthorized personnel overhearing telephone conversations and leaving client records unattended in visual sight of unauthorized personnel. Student or professional abuses may include the unauthorized duplication of client records and inappropriate discussion of client data. Teaching rounds can create potential violations.*There are many more ethical questions and dilemmas we have to deal with today and none has an easy answer.*Assessment, Diagnosis, Planning, Implementation, Evaluation (ADPIE) Decision Making ModelThis model was developed as an on-going evaluation tool. The strategic plan is an ongoing living process. As soon as the organization initiates the assessment process and, therefore, determines the needs of the organization (diagnosis), it is time to move on to the planning phase where the stake holders determine (plan) the strategies to meet the needs of fixing or addressing the problems within the organization (diagnosis). After this phase is completed, it is time to put into action the plans (implement) determined by the organizations stake holders. It is then imperative to see if the organization has met the goals of the plans and programs that were implemented (evaluate). Upon finishing the evaluation and discovering the success and failures of the implemented plans, (take note already a new organization is emerging), it is time to begin assessing the new organization with its new strengths and weaknesses that are a net result of implementing the initial ADPIE process. To do this effectively, it is necessary to initiate the ADPIE process again. At the end of this next ADPIE process, the result will again be a new organization with its new strengths and weaknesses that are a net result of implementing the second ADPIE process. ADPIE then starts again, and so on and so on. This process is ongoing through out the life of the organization. This helps to prevent inertia, stagnation, and non-growth which is inherent in many organizations who have not put in place an on-going evaluation processes to use as a metric for the on-going outcomes measurements needed for the on-going success of the organization.

*When communicating with patients it is helpful to approach the subject in an orderly systemic manner. An example of Feature Benefit Check can be identified in this example of a nurse communicating with a patient.Example:Good morning Mr. Gonzales. I would like to give you and injection that will help fight your infection.(Feature) As your infection clears up your fever will go away and youll start to feel better. (Benefit). May I proceed with the injection? (Check). *Ethics consults are confidential. Any recommendations made are purely advisory in nature. Patients, family members, and health care providers remain responsible for making their own decisions.*Ethics consultation services are not intended to replace the normal lines of communication among health care providers, patients, and families. An ethics consult may be helpful when:A patient or family member want help in talking through ethical issues involved in patient care. There is a serious ethical disagreement between healthcare providers, among family members, between health care providers and a patient or between health care providers and family members.Ethically, the case is unusual, unprecedented, or very complex.A patient, family member or health care provider would like to have the benefit of other perspectives in working through an ethical problem.*The importance that ethics committees have attained is indicated by the mention of them as a mechanism for protecting patients rights in the standards for patient care developed by the Joint Commission on Accreditation of Health Care Organizations (JCAHO)