Objective: The students will complete a Virtual Classroom Discussion Exercise that will Extend your knowledge beyond the core required materials for this class, Engage in collaborative learning with other students to improve the quality of the learning experience for all students and Apply the higher cognitive skills associated with critical thinking to your academic and professional work.

ASSIGNMENT GUIDELINES (10%):

Students will judgmentally amount the readings from Chapter assign on your textbook. This assignment is prearranged to help you to learning in all disciplines because it helps student’s process information rather than simply receive it.
You need to read the PowerPoint Presentation assigned for week 4 and develop a 2-3 page paper replicating your appreciative and competence to apply the readings to your ethics knowledge. Each paper must be typewritten with 12-point font and double-spaced with standard margins. Follow APA style 7th edition format when referring to the selected articles and include a reference page.

EACH PAPER SHOULD INCLUDE THE FOLLOWING:

1. Introduction (25%) Provide a brief synopsis of the meaning (not a description) of each Chapter and articles you read, in your own words that will apply to the case study presented.

2. Discussion Challenge (65%)

Health care in the 21st century is governed by a confusing array of rules, regulations, laws, and ethical standards. Issues that involve confidentiality, informed consent, and patient relationships can appear out of nowhere, even when health care workers have the best of intentions. What’s legal today might not be considered ethical, and there is the ever-present threat of being sued for negligence and malpractice. There are unresolved issues around doctor assisted dying that have yet to be worked out, while medical procedures considered ethical for adults might not be seen as ethical for minors.

Here are the top five ethical issues that health care managers of today and tomorrow will be facing in the course of delivering responsible and compassionate patient care.

a. Patient Confidentiality

b. Patient Relationships

c. Malpractice and Negligence

d. Informed Consent

e. Issues Related To Physician Assisted Suicide (PAD).

STUDENT CHALLENGE:

1. Describe, mention and define the five ethical issues that health care managers of today and explain your point of view relate with the ethical implication.

2. Designate and discussion how this five issues where affected by the COVID-19 pandemic?

Health Care Ethics CRITIC AL ISSUES FOR THE 21ST CENTURY

Third Edition

Edited by

Eileen E. Morrison, EdD, MPH, LPC, CHES Professor, School of Health Administration Texas State University—San Marcos San Marcos, Texas

Beth Furlong, PhD, JD, RN Associate Professor, Center for Health Policy and Ethics Creighton University Omaha, Nebraska

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Library of Congress Cataloguing-in-Publication Data Health care ethics : critical issues for the 21st century / [edited by] Eileen E. Morrison and Beth Furlong. —3rd ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4496-5737-6 (pbk.) ISBN 1-4496-5737-0 (pbk.) I. Morrison, Eileen E. II. Furlong, Elizabeth. [DNLM: 1. Bioethical Issues. 2. Delivery of Health Care--ethics. 3. Ethics, Clinical. WB 60] 174.2—dc23 2012039134 6048 Printed in the United States of America 17 16 15 14 13 10 9 8 7 6 5 4 3 2 1

iii

Dedication

EILEEN E. MORRISON

The third edition of Health Care Ethics: Critical Issues for the 21st Century is dedicated to all those who contributed their time and talent to update existing chapters or develop new ones. They shared their insights on topics that will help to balance ethics and healthcare practice in the 21st century. On a personal level, I would like to dedicate the third edition of this text to those who have provided both inspiration and advice. First, there is my family: Grant, Kate, Emery Aidan, and Morrigan Leigh, who listened, loved, and encouraged. There are also my colleagues, relatives, and friends—you each know how much you have meant to me during this process. Finally, there is my publisher, Michael Brown; my coeditor, Beth Furlong; and my Jones & Bartlett Learning editors, Chloe Falivene and Rebekah Linga, whose knowledge, guidance, and patience added so much to the quality and integrity of this work.

BETH FURLONG

Mentors facilitate one’s journey. My gratitude goes to Dr. Amy Haddad and colleagues at Creighton University’s Center for Health Policy and Ethics. I value the ever-present support of my husband, Robert Ramaley. Furthering the ethical education of others with this book is possible because of the collegiality and support of coeditor, Eileen Morrison. It has been a professional pleasure to work with her.

Contents

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

PART I—FOUNDATIONS IN THEORY . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 1 Theory of Healthcare Ethics . . . . . . . . . . . . . . . . . . . . . . . . 3 Jim Summers

Chapter 2 Principles of Healthcare Ethics. . . . . . . . . . . . . . . . . . . . . 47 Jim Summers

PART II—CRITICAL ISSUES FOR INDIVIDUALS . . . . . . . . . . . . . . . . 65

Chapter 3 The Moral Status of Gametes and Embryos: Storage and Surrogacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Glenn C. Graber

Chapter 4 The Ethical Challenges of the New Reproductive Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Sidney Callahan

Chapter 5 Abortion: The Unexplored Middle Ground . . . . . . . . . . . 97 Carol Petrozella

Chapter 6 Proposals for Human Cloning: A Review and Ethical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Kevin T. FitzGerald

Chapter 7 Competency: What It Is, What It Is Not, and Why It Matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Byron Chell

vi CONTENTS

Chapter 8 Older People and Issues of Access to Long-Term Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141 Janet Gardner-Ray

Chapter 9 Assisted Living and Ethics . . . . . . . . . . . . . . . . . . . . . . . . 159 Rosalee C. Yeaworth

Chapter 10 Ethical Issues in the Use of Fluids and Nutrition: When Can They Be Withdrawn? . . . . . . . . . . . . . . . . . . . 171 T. Patrick Hill

Chapter 11 Death, Medicine, and the Moral Significance of Family Decision Making. . . . . . . . . . . . . . . . . . . . . . . . 185 James Lindemann Nelson

Chapter 12 Ethical Issues Concerning Physician-Assisted Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 Barbara Supanich

PART III— CRITICAL ISSUES FOR HEALTHCARE ORGANIZATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209

Chapter 13 Healthcare Institutional Ethics: Broader Than Clinical Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211 Carrie S. Zoubul

Chapter 14 Hospital Ethics Committees: Roles, Memberships, Structure, and Difficulties . . . . . . . . . . . . . . . . . . . . . . . . 227 Michael P. West and Eileen E. Morrison

Chapter 15 Bioethical Dilemmas in Emergency Medicine and Prehospital Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 Kenneth V. Iserson

Chapter 16 Technological Advances in Health Care: Blessing or Ethics Nightmare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 Cristian H. Lieneck

Chapter 17 Spirituality and Healthcare Organizations . . . . . . . . . 277 Dexter R. Freeman and Eileen E. Morrison

PART IV—CRITICAL ISSUES FOR SOCIETY’S HEALTH. . . . . . . . . 299

Chapter 18 Health Inequalities and Health Inequities . . . . . . . . . . 301 Nicholas B. King

Contents vii

Chapter 19 Is Rationing of Health Care Ethically Defensible? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317 Chris Hackler

Chapter 20 Domestic Violence: Changing Theory, Changing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327 Carole Warshaw

Chapter 21 Ethics of Disaster Planning and Response . . . . . . . . . . 345 Eileen E. Morrison and Karen J. Bawel-Brinkley

Chapter 22 A New Era of Health Care: The Ethics of Healthcare Reform . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363 Richard L. O’Brien

Chapter 23 Healthcare Reform: What About Those Left Behind?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 Beth Furlong

Chapter 24 Looking Toward the Future . . . . . . . . . . . . . . . . . . . . . . . 391 Beth Furlong and Eileen E. Morrison

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425

Contributors

Karen J. Bawel-Brinkley, RN, PhD

Professor School of Nursing San Jose State University San Jose, CA

Sidney Callahan, PhD Distinguished Scholar The Hastings Center Garrison, NY

Byron Chell, JD Eugene, OR

Kevin T. FitzGerald, SJ, PhD Dr. David Lauler Chair in Catholic

Healthcare Ethics Associate Professor Center for Clinical Bioethics Georgetown University Medical

Center Washington, DC

Dexter R. Freeman, PhD Director Master of Social Work Program Army Medical Department Center

and School Army-Fayetteville State University Houston, TX

Janet Gardner-Ray, EdD CEO Country Home Healthcare, Inc. Charlottesville, IN

Glenn C. Graber, PhD Professor Emeritus Department of Philosophy The University of Tennessee,

Knoxville Knoxville, TN

Chris Hackler, PhD Professor of Medical Humanities Division of Medical Humanities College of Medicine University of Arkansas for Medical

Sciences Little Rock, AR

T. Patrick Hill, PhD Senior Policy Fellow Edward J. Bloustein School of

Planning and Public Policy Rutgers, The State University of New

Jersey New Brunswick, NJ

Kenneth V. Iserson, MD, MBA Professor Emeritus of Emergency

Medicine The University of Arizona Tucson, AZ

Nicholas B. King Assistant Professor Biomedical Ethics Unit McGill University Faculty of

Medicine Montreal, QC, Canada

x CONTRIBUTORS

Cristian H. Lieneck, PhD, FACMPE, FACHE, FAHM

Assistant Professor Texas State University—San Marcos San Marcos, TX

James Lindemann Nelson, PhD Professor of Philosophy Michigan State University East Lansing, MI

Richard L. O’Brien, MD Professor Emeritus Center for Health Policy & Ethics Creighton University Omaha, NE

Carol Petrozella, BSN, MSN, MSED, EdD

Professor Miami Dade College Adjunct Clinical Professor Nova Southeastern University Miami, FL

Jim Summers, PhD Professor Emeritus School of Health Administration College of Health Professions Texas State University—San Marcos San Marcos, TX

Barbara Supanich, RSM, MD Medical Director

Palliative Care Holy Cross Hospital Silver Spring, MD

Carole Warshaw, MD Director National Center on Domestic

Violence, Trauma & Mental Health Chicago, IL

Michael P. West, EdD, FACHE Executive Director and Fellow University of Texas at Arlington—

Fort Worth American College of Healthcare

Executives Chicago, IL

Rosalee C. Yeaworth, RN, PhD, FAAN

Professor Emeritus and Dean Emeritus

Medical Center and College of Nursing

University of Nebraska Omaha, NE

Carrie S. Zoubul, JD Borchard Fellow Center for Health, Science, and

Public Policy Brooklyn Law School New York, NY

About the Authors

Eileen E. Morrison, EdH, MPH, LPC, CHES is a professor in the School of Health Administration at Texas State University—San Marcos. Her academic background includes a doctorate from Vanderbilt University and a Master of Public Health from the University of Tennessee. In addition, she holds the credential of Associate in Logotherapy from Viktor Frankl Institute of Logotherapy and a clinical degree in dental hygiene.

Dr. Morrison has taught graduate and undergraduate ethics courses and provided professional workshops on ethics to physicians, nurses, clinical laboratory professionals, dental professionals, and counselors. She has authored articles and chapters on ethics for a variety of publications. In addition, she is the author of Ethics in Health Administration: A Practical Approach for Decision Makers, Second Edition, published by Jones and Bartlett Publishers.

Beth Furlong, PhD, JD, RN is an associate professor in the Center for Health Policy and Ethics at Creighton University in Omaha, Nebraska. Her academic background includes a bachelor’s degree and master’s degree in nursing, a master’s degree and doctorate degree in political science, and a law degree (JD).

Dr. Furlong has taught graduate ethics courses and led continuing education unit workshops for nurses on ethical issues. Her publications are in the areas of health policy, vulnerable populations, and ethics.

xiii

Preface

The writing of the third edition of Health Care Ethics: Critical Issues for the 21st Century occurred during a time of great change for the healthcare system. In fact, health care is facing its greatest changes since the advent of Medicare and Medicaid. In light of this fact, chapters are included that address healthcare reform and its ethical issues. In addition, authors have contributed new chapters to emphasize the impact of technology and new options in long-term care. Existing chapters were updated; some chapters underwent major revisions to connect better to the challenges faced by health professionals in the post-reform era.

The third edition keeps the organizational model of previous editions to assist students in building their knowledge base of ethics and ability to relate ethics to patient issues across the lifespan. It also provides organizational issues, as well as examples of ethical issues germane to society. In homage to those who greatly influenced ethical thought, the model of a Greek temple organizes the chapters in this new edition (see Figure FM–1). The foundation of the temple is ethical theory and principles. Students need this foundation so they can analyze future issues in their practices based on theory and principles and not just on opinion.

The three main pillars of the model illustrate the foundation for the other sections of the text: individual, organizational, and societal issues. An introduction to each section sets the stage for the issues presented in the chapters that follow. Authors with extensive experience in healthcare practice and in ethics contributed their insights in these chapters. At the end of each chapter, discussion questions provide the opportunity for thoughtful analysis and application of the issues raised in the chapter. In addition, a new feature,

Ethical Issues

Theoretical Foundations

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SocietyIndividualsOrganizations

Figure FM–1 Healthcare Ethics Organizational Model

“Food for Thought,” gives the student the ability to apply what he or she has learned to healthcare situations. These mini-cases can also lead to lively class discussions.

The authors of this new edition of Health Care Ethics: Critical Issues for the 21st Century are experts in their fields, but they are not clairvoyant. Therefore, they cannot predict what will happen in the next 5–10 years, as the Patient Protection and Affordable Care Act becomes the norm for health care. However, one can always apply the principles and theories of ethics to whatever new situation arises. We hope that students will continue to ask themselves, “Is this the best ethical decision to make?” and “How do I know that this is the best decision?” as they progress through their careers. Patients and the community rely on the answers.

xiv PREFACE

PART I

Foundations in Theory

With the advent of the Patient Protection and Affordable Care Act (PPACA), a new era of health care has begun. The changes and proposed changes associ- ated with this law increase the complexity of both patient care and the larger healthcare system. Because of this law, health care will receive even more scrutiny and must provide high-quality, patient-centered, research-based care with fewer or different types of resources. The community will continue to expect a high level of ethics from practitioners and healthcare organizations. In short, you are supposed to “know your stuff” at both a practice and an orga- nizational level if you want to be considered a professional in health care.

To be fully prepared, you need to know your ethics. In today’s complex healthcare setting, ethics is not just about doing the right thing, like your Mom taught you. The new healthcare era brings issues that often are exceedingly complex and far from black and white. In addition, society and the health professions themselves often have stringent expectations regarding ethics. In light of these challenges, it seems logical that one must have a solid foundation in the theory and principles of ethics in order to make appropriate professional decisions. The first part of this new edition of Health Care Ethics: Critical Issues for the 21st Century contains two chapters that provide this foundation.

The foundation in ethical theory and principles provided in Chapters 1 and 2 also gives you practical tools for analyzing ethics-related issues that you will encounter. Without this foundation in ethics, it would be difficult to develop plausible solutions that you can use to defend your actions or the policies that you help to create. A foundation in theory, principles, and decision making will also enhance your ability to reason and enhance your role as a professional in health care.

The chapters in this part should help you to ask the best questions. For example, as you face ethical dilemmas in the future, ask, “What theory or theories best apply here?” or “If I take this position, what principles will I support or violate?” or “What is the price of not being ethical?” Because ethical issues are usually broader in scope than they appear, you could also think about their effect on individuals, your organization, or on the society in which you live. This type of thinking is and will continue to be necessary in the healthcare environment, where even the smallest issue may have a large impact on professionals and the institutions in which they work.

In an immediate sense, a foundation in ethical theory and principles will be useful to you as a student of this subject matter. You will see the principles and theories explained in this section used in subsequent chapters to examine the issues presented. In addition, at the end of each chapter, there will be questions to encourage you to take your intellect beyond what you have read.

Many of these questions relate directly to the application of a particular theory or principle. By answering these questions, you will enhance the depth of your understanding not only of the specific issue but also of the application of ethical theory and principles. There is also a mini-case called Food for Thought at the end of each chapter that will help you apply ethics to the practice of health care.

In Chapter 1, Summers presents a well-researched overview of the theories commonly used in healthcare ethics. He begins with a model so that you can see where ethics fits into the study of philosophy. Following that, he reviews ethical theories that might not have as much relevance to healthcare practice as other theories, including authority-based ethics, egoism, and ethical relativism. He then presents the most commonly held ethical theories that are applied in healthcare practice. These include natural law, deontology, utilitarianism, and virtue ethics. In his discussions, he uses examples to help you better understand how these theories apply to your professional practice. In fact, he refers to them as part of your ethics toolbox.

In Chapter 2, Summers continues his scholarly discussion of ethics by pre- senting the four most commonly used principles: nonmaleficence, beneficence, autonomy, and justice. Because justice is the most complex of the four, he provides additional material about the types of justice. He also provides infor- mation on how you can decide what is just. At the end of Chapter 2, Summers also presents a decision-making model called the reflective equilibrium model. This model demonstrates the application of ethical theory and principles in the practice of making clinical and business decisions.

If you read these chapters thoroughly and think about their content, you should be well prepared to discuss the issues presented in the other chapters in this text in a rational way. Remember that many of the issues presented in this text evoke strong emotions in practitioners, patients, and society in gen- eral. However, decisions made based on emotions may not be the best decisions for the situation. Therefore, having a foundation in ethics based on these two chapters should be useful in deciding the most ethical thing to do for patients, the organization, the community, and your career.

2 HEALTH CARE ETHICS

CHAPTER 1

Theory of Healthcare Ethics

Jim Summers

INTRODUCTION

In this chapter, Summers presents a scholarly account of the main theories that apply to the ethics of healthcare situations. Why bother with such a dis- course? The answer is that without a foundation in ethics, you would have to make decisions without a structure to support them. You would not have the wisdom of the theorists to defend your decisions if you needed to do so. In addi- tion, you would not have a knowledge base to analyze the many issues that you will face in health care in the 21st century. For example, the uncertainty of healthcare reform and its impact on the system poses and will continue to pose new ethical issues. Without a foundation in theory, how can you respond to issues that have never occurred before? Therefore, this chapter and the one on the principles of ethics, which follows, will serve as your ethics toolbox.

ETHICS AND HEALTH CARE

From the earliest days of philosophy in ancient Greece, people have sought to apply reason in determining the right course of action for a particular situa- tion and in explaining why it is right. Such discourse is the topic of normative ethics. In the 21st century, issues resulting from technological advances in medicine and science will continue to provide challenges that will necessitate similar reasoning. Healthcare resource allocations will become more global and more vexing as new diseases threaten, global climate change continues apace, and ever more people around the world find their lives increasingly desperate as disease and poverty overtake them. Managers of healthcare organizations will find the resources to carry out their charge increasingly constrained by lack of money and labor shortages. A foundation in ethical theory and ethical decision-making tools can help in assessing the choices that we must make in these vexing circumstances.

Knowledge of ethics can also be valuable when working with other healthcare professionals, patients and their families, and policy makers. In this sense, ethical understanding, particularly of alternative views, becomes a form of cultural competence.1 However, this chapter is limited to a discussion of normative ethics and metaethics. Normative ethics is the study of what is right and wrong; metaethics is the study of ethical concepts. Normative ethics examines ethical theories and their application to various disciplines, such as health care. In health care, ethical concepts derived from normative theories, such as autonomy, beneficence, justice, and nonmaleficence, often guide decision making.2

As one might suspect, when normative ethics seeks to determine the moral views or rules that are appropriate or correct and explain why they are correct, major disagreements in interpretation often result. Those disagreements

influence the application of views in many areas of moral inquiry, including health care, business, warfare, environmental protection, sports, and engineering. Figure 1–1 lists the most common normative ethical theories. Each of these theories is considered in this chapter. Although no single theory has generated consensus in the ethics community, there is no cause for despair.

The best way to interpret these various ethical theories, some of which overlap, is to use the analogy of a toolbox. Each of these theories teaches something and provides tools that can assist with decision making. One advantage of the toolbox approach is that you will not find it necessary to choose one ethical theory over another for all situations. You can choose the best theory for the task, according to the requirements of your role and the circumstances. Trained philosophers will find flaws with this approach, but it is hoped that the practical advantages will suffice to overcome these critiques.

All of the theories presented have a value in the toolbox, although like any tools, some are more valuable than others are. For example, I shall argue that virtue ethics has much value for healthcare applications. Before explaining why this chapter has chosen to present particular theories, a quick overview is in order.

Authority-based theories can be faith based, such as Christian, Muslim, Jewish, Hindu, or Buddhist ethics. They can also be purely ideological, such as those based on the writings of Karl Marx (1818–1883) or on capi- talism. Essentially, authority-based theories determine the right thing to do based on what some authority has said. In some cultures, the author- ity is simply “that is what the elders taught me” or “that is what we have always done.” The job of the ethicist is to determine what that authority would decree for the situation at hand. Natural law theory, as considered here, uses the tradition of St. Thomas Aquinas (1224–1274) as the starting point of interpretation. The key idea behind natural law is that nature has order both rationally and providentially. The right thing to do is that which is in accord with the providentially ordered nature of the world. In health care, natural law theories are important owing to the influence of the Roman Catholic Church and the extent to which the Church draws on Aquinas as an early writer in the field of ethics. Several important debates, such as those surrounding abortion, euthanasia, and social justice, draw on concepts with roots in natural law theory.

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Natural law theories

Egoistic theories

Authority-based theories

Teleological theories

Deontolgical theories

Virtue ethics

Normative ethical theories

Figure 1–1 Normative ethical theories.

4 HEALTH CARE ETHICS

Teleological theories consider the ethics of a decision to be dependent on the consequences of the action. Thus, these theories are called consequentialism. The basic idea is to maximize the good of a situation. The originators of one such theory, Jeremy Bentham (1748–1832) and John Stuart Mill (1806–1873), called this maximization of good utility; thus, the name of this theory is utilitarianism. Deontological theories find their origins in the work of Immanuel Kant (1724–1804). The term deon is from the Greek and means “duty.” Thus, deontology could be called the science of determining our duties. Most authors place Kant in extreme opposition to consequentialism, because he argued that the consequences themselves are not relevant in determining what is right. Thus, doing the right thing might not always lead to an increase in the good.3 More contemporary deontologists, including John Rawls (1921–2007) and Robert Nozick (1938–2002), reach antithetical conclusions about what our duties might be. Virtue ethics has the longest tenure among all of these views, except for authority-based theories. Its roots can be traced to Plato (427–347 BCE) and to Aristotle (384–322 BCE). The key idea behind virtue ethics is to find the proper end for humans and then to seek that end. In this sense, people seek their perfection or excellence. Virtue ethics comes into play as people seek to live virtuous lives, developing their potential for excellence to the best of their ability. Thus, virtue ethics addresses issues any think- ing person should consider, such as “What sort of person should I be?” and “How should we live together?” Virtue ethics can contribute to several of the other theories in a positive way, particularly in the understanding of professional ethics and in the training necessary to produce ethical professionals. Egoistic theories argue that what is right is that which maximizes a person’s self-interests. Such theories are of considerable interest in con- temporary society because of their relationship to capitalism. However, the ethical approach of all healthcare professions is to put the interests of the patient above the practitioner’s personal interests. Even when patients are not directly involved, such as with healthcare managers, the role is a fiduciary relationship, meaning that patients can trust that their interests come before those of the practitioners. Egoistic theories are at odds with the value systems of nearly all healthcare practitioners.

Before exploring any of these ethical theory tools in depth, it is first neces- sary to confront the relativist argument, which denies that ethics really means anything.

ETHICAL RELATIVISM

Those who deal with ethical issues, whether in everyday life or in practice, will inevitably hear the phrase “It is all relative.” Given that the purpose of this text is to help healthcare professionals deal with real-world ethical issues, it is important to determine what this phrase means and the appropriate

Theory of Healthcare Ethics 5

course of action. Philosophers have not developed a satisfactory ethical theory that covers every situation. In fact, they are expert at finding flaws in any theory; thus, no theory will be infallible. In addition, different cultures and different groups have varying opinions about what is right and wrong and how to behave in certain situations.4

Does the fact that people’s views differ mean that any view is acceptable? This appears to be the meaning of such statements as “It is all relative.” In that sense, deciding that something is right or wrong, or good or bad, has no more significance than choices of style or culinary preferences. Thus, ethical decision making and practice is a matter of aesthetics or preferences, with no founda- tion on which to ground it. This view makes a normative claim that there is no real right, wrong, good, or bad.

One could equally say that there is no truth in science, because scientists disagree about the facts and can prove nothing, only falsify it by experiment.5 However, the intrinsic lack of final certainty in the empirical sciences does not render them simply subjective. As one commentator on the rapid changes in scientific knowledge put it, these changes reveal “the extraordinary intel- lectual and imaginative yields that a self-critical, self-evaluating, self-testing, experimental search for understanding can generate over time.”6 Why should we expect any less of ethics?

Sometimes there is a claim made that, because there are many perspectives, there cannot be a universal truth about ethics. Therefore, we are essentially on our own. Hugh LaFollette argued that the lack of an agreed-upon standard or the inability to generalize an ethical theory does not render ethical reason- ing valueless.7 Rather, the purpose of ethical theories is to help people decide the right course of action when faced with troubling decisions. Some ethical theories work better in some situations than others. The theories themselves provide standards, akin to grammar and spelling rules, as to when something is properly executed using that theory.

Thus, even though ethics might not produce final answers, we still must make decisions. Ethical theories and principles are tools to help us in that nec- essary endeavor. The lack of absoluteness in ethical theory also does not elimi- nate rationality. Often, we simply must apply our rationality without knowing if we are correct. The better our understanding of ethics, the more likely it is that the decision we reach will be appropriate.

ETHICAL THEORIES

Let us begin to examine the tools in the toolbox, knowing that we are fallible, but also that we are rational.8 The first tool has little application to healthcare ethics; however, it is widely believed and therefore needs to be addressed. It involves the idea of egoism in ethics.

Egoism

Egoism operates from the premise that people either should (a normative claim) seek to advance solely their own self-interests or that (psychologically) this is actually what people do. The normative version, ethical egoism, sets as its

6 HEALTH CARE ETHICS

goal the benefit, pleasure, or greatest good of the self alone.9 In modern times, the writings of Ayn Rand10 and her theory of objectivism11 have popularized the idea of ethical egoism. For example, Rand said, “The pursuit of his own rational self-interest and of his own happiness is the highest moral purpose of his life.”12 This is a normative statement, and a reasonable description of ethical egoism.

Although this theory has importance to the larger study of ethics, it is less important in healthcare ethics, because the healing ethic itself requires a sub- limation of self-interests to those of the patient. A healthcare professional who fails to do this is essentially not a healthcare professional. No codes of ethics in the healthcare professions declare the interests of the person in the profes- sional role to be superior to those of the patient.

Although occasionally healthcare professionals do not put the patient’s best interest first, it is not a goal of the profession to put one’s self ahead of the client or patient. A realist might complain, “Yet this is the way most people behave!” Although that may be true, the fact that many people engage in a particular kind of behavior does not make it into an ethical theory. Ethical egoism con- stitutes more of an ethical problem than anything else. Most people who think of an ethical theory consider it something that is binding on people. However, ethical egoism is not binding on anyone else beyond self-interest. It is not bind- ing on all (i.e., normative), and thus does not meet the criteria of a true ethical theory but is simply a description of human behavior. As such, ethical egoism, if widely adhered to, would lead to a breakdown in social cohesion. How could we trust anyone if they really were ethical egoists and we were as well? Could patients really have confidence in our care for them? Indeed, to care for someone else above your own self-interest, as required by codes of ethics in health care, is antithetical to truly pursuing only your self-interest. The only escape at the societal level leads into the realm of contract theories of the state. Later, we shall see how John Rawls uses the idea that people pursue their own self-interest to develop a theory of a just society in which solidarity seems to be the outcome, as opposed to the extreme individualism ethical egoism typically suggests.

Authority-Based Ethical Theories

Most teaching of ethics ignores religion-based ethical theories, much to the chagrin of those with deep religious convictions. There are several reasons to avoid the use of religion-based ethics in healthcare practice.

A major problem is determining which authority is the correct one. Authority- based approaches, whether based on a religion, the traditions or elders of a culture, or an ideology, such as communism or capitalism, have flaws relative

A healthcare professional who does not understand the need to sublimate his or her own interests to those of the patient or his or her role has not yet become a healthcare professional.

Theory of Healthcare Ethics 7

to the criteria needed to qualify as a normative ethical theory. Each of the authority-based approaches, to be an ethical theory, must claim to be norma- tive relative to everyone. Because many of these authority-based approaches conflict, there is no way to sort them out other than by an appeal to reason. Not only do we have the problem of sorting through the ethical approaches, but also arguments inevitably arise concerning the religion itself and its truth claims. If two religions both claim to be inerrant, it is difficult to find a way to agree on which of the opposing inerrant authorities is correct.

In spite of the philosophical issues arising from the use of religion in health- care ethics, it is quite important for healthcare providers to understand the role of religions and spirituality in healthcare delivery. All religions provide explanations of the cause or the meaning of disease and suffering. Many theologies also encourage believers to take steps to remove or ameliorate causes of disease and suffering. Over the millennia, some of these religions have even formalized their positions by becoming involved with healthcare delivery.

In addition, patients often have religious views that help them to understand and cope with their conditions. Understanding a person’s faith can help the clinician provide health care that is more patient focused.13 For some patients, an ethical issue arises if their faith or lack of faith is neither recognized nor respected.

Beyond direct patient care, a second reason to understand the authority- based philosophies common in the healthcare environment is their effect on healthcare policy. The role of authority-based ethical positions appears to be gaining importance in the 21st century. To be effective working within the health policy arena, whether at the institutional, local, regional, state, fed- eral, or international level, requires an understanding of the influence of the religious views of those involved in the debates and negotiations, which can only serve to strengthen your ability to reason with them. In other words, it is important to understand the “common” morality of those engaged in the debate. The more diversity in beliefs and reasoning, the more important the need for understanding what those beliefs and reasoning might be.

Religion also plays an important role in the creation of healthcare policy because religions have provided a multiplicity of philosophical answers to questions about the nature and truth of the world and how we should act in the world. They explain what is right or wrong and why it is right or wrong. They also help people define their identities, roles in the world, and relation- ships to one another. Religions explain the nature of the world relative to our place in it.

Thus, as a tool, understanding authority-based philosophical systems has value because it can help in the treatment of patients. It also increases your understanding regarding the positions of persons who may be involved in debates over healthcare issues, such as resource allocations, or clinical issues such as abortion. In addition, it is important to understand authority-based philosophical systems relative to yourself. As a healthcare professional, your role requirements dictate that you do not impose your religious views on patients. At the same time, it is not part of the role for you to accept the imposition of another’s values, even those of a patient.

8 HEALTH CARE ETHICS

These complex issues relate to professional ethics and are not part of the scope of this chapter. However, it does seem incumbent on all healthcare professionals to evaluate their own faith and to recognize the extent to which they might impose it on others. From the earliest tradition of Hippocrates, the charge was to heal the illness and the patient. More recently, the Declaration of Geneva from the World Medical Association stated that members of the medical profession would agree to the following statement: “I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient.”14 Let us now turn our attention to the oldest non-authority-based ethical theory—virtue ethics.

Virtue Ethics

Virtue ethics traces its roots most especially to Aristotle (384–322 BCE). Aristotle sought to elucidate the highest good for humans. Bringing the potential of that good to actualization requires significant character development. The concept of character development falls into the area of virtue ethics because its goal is the development of those virtues in the person and the populace.

Aristotle’s ethics derived from both his physics and metaphysics. He viewed everything in existence as moving from potentiality to actuality. This is an organic view of the world, in the sense that an acorn seeks to become an oak tree. Thus, your full actuality is potentially within you. As your highest good, your potential actuality is already inherent, because it is part of your nature; it only needs development, nurture, and perfecting. This idea is still with us in many respects as part of the common morality.

Finding Our Highest Good

Just what did Aristotle conclude was our final cause or our highest good? The term Aristotle uses for this is eudaimonia. The typical translation is “happiness.” However, this translation is inadequate, and many scholars have suggested enhancements. Many prefer to use the translation “flourishing.” However, any organic entity can flourish, such as a cactus, so the term is not an adequate synonym.

The major complaint about translating eudaimonia as “happiness” is that our modern view of happiness would render it subjective. No one can know if you are happy or not; you are the final arbiter. Aristotle thought eudaimonia applied only to humans, because it required rationality that goes beyond mere happiness. In addition, eudaimonia includes a strong moral component that is lacking from our modern understanding of happiness. In this sense, “ happiness” would necessarily include doing the right thing, being virtuous. Others could readily judge if you were living a virtuous or “happy” life by observing your actions. For Aristotle, happiness is not a disposition, as in “he is a happy sort.”

Eudaimonia is an activity. Indeed, children and other animals unable to engage self-consciously in rational and virtuous activities cannot yet be in the state translated as “happy.”15 Because it is commonplace to describe children as being “happy,” this is clearly not an adequate translation. Given these transla- tion problems, I shall use the term eudaimonia rather than its translations of,

Theory of Healthcare Ethics 9

“happiness” or “flourishing.” Essentially, eudaimonia can be understood best as a perfection of character nurtured by engaging in virtuous acts over a life of experience.

The most important element of eudaimonia is the consideration of what it takes to be a person of good character. Such a person seeks to develop excellence in himself or herself. To be excellent, what sort of person should I be? Because Aristotle recognized the essential social and political nature of humans, the answer to this question would necessarily have to include consideration of how we should live together.

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