Written codes of ethics for health care practitioners

Judson, K., & Harrison, C. (20 16). Law and ethics for the health professions. (7th ed.). New York: McGraw- Hill.

Law&Et • ICS FOR HEALTH PROFESSIONS

KAREN JUDSON CARLENE HARRISON

Introduction to Law and Ethics

LEARNING OUTCOMES After studying this chapter, you should be able to:

LO 1.1 Explain why knowledge of law and ethics is importan-

to health care practitioners.

LO I .2 Distinguish among law, ethics, bioethics, et iquette ,

and protocol.

LO I .3 Define mora/ values and explain how they relate to law. ethics, and etiquette.

LO I .4 Discuss the characteristics and ski lls most likely to lead to a successful career in one of the health care

professions.

FROM THE PERSPECTIVE OF . .. ~========~~-~--=====---~-----=~~==~-~-~~~===-

BARBARA, AN EXPERIENCED CERTIFIED MEDICAL ASSISTANT (CMA) (AAMA) in a medical office with a walk-in clinic, instructs new employees in the reception area of the office to follow the medical office procedures whenever possible and prudent, but, above all, to use common sense in dealing with patients.

Barbara told Elaine, a new receptionist in the medical office, to politely ask walk-in patients why they needed to see a doctor. Elaine had been on the job for two weeks when an elderly man who was hard of hearing approached her, and she dutifully asked him the purpose for his visit He was obviously too embarrassed to reply, but Elaine persisted, finally raising her voice. When the man shouted "I can't pee," all heads in the busy waiting room turned toward Elaine and the patient A red-faced Elaine turned to arrange for the man to see a physician, but he quickly left the building. Barbara criticized Elaine's patient-handling technique, but the crux of the matter was that the patient left without seeing a doctor for his medical problem.

"Patients' needs always trump office routine," Barbara emphasizes. "If we somehow hurt or hinder a patient while doggedly sticking to a set routine, we may have risked legal liability, but more important, we haven't done our job."

From Barbara's perspective as the person responsible for training medical office personnel, Elaine failed to use common sense in com- municating with a patient, and as a result, the man did not receive the medical treatment he needed.

From Elaine's perspective, she followed Barbara's instructions to the letter, and she failed to understand why Barbara had criticized her. She hadn't meant to embarrass the man, so was it her fault that he left without making an appointment?

From the patient's perspective as an elderly gentleman who seldom discussed personal matters, the young woman who was his first con- tact in the medical office embarrassed him, and he left rather than face further humiliation.

As you progress through Law & Ethics for the Health Professions, try to interpret the court cases, laws, case studies, and other examples or situations cited from the perspectives of everyone involved.

Why Study Law and Ethics? There are two important reasons for you to study law and ethics:

•

•

To help you function at the highest possible professional level, providing competent, compassionate health care to patients.

To help you avoid legal entanglements that can threaten your abil- ity to earn a living as a successful health care practitioner.

We live in a litigious society, where patients, relatives, and others are inclined to sue health care practitioners, health care facilities, manu- facturers of medical equipment and products, and others when

'

! ;

'

I :

. ~--~--------:,

I

LO 1.1 Explain why knowledge of law and eth ics is important to health care practitioners.

health care practitioners Those who are t rai ned to ad minister medical or hea lth care to patients.

litigious Pro ne to engage in lawsuits .

Chapter I !Introduction to Law and Ethics 3

medical outcomes are not acceptable. This means that every person responsible for health care delivery is at risk of being involved in a health care-related lawsuit. It is important, therefore, for you to know the basics of law and ethics as they apply to health care, so you can recognize and avoid those situations that might not serve your patients well, or that might put you at risk of legal liability.

In addition to keeping you at your professional best and helping you avoid litigation, knowledge of law and ethics can also help you gain perspective in the following three areas:

1. The rights, responsibilities, and concerns of health care consumers. Health care practitioners not only need to be concerned about how law and ethics impact their respective professions, but they must also under- stand how legal and ethical issues affect the patients they treat. With the increased complexity of medicine has come the desire of consum- ers to know more about their options and rights and more about the responsibilities of health care providers. Today's health care consum- ers are likely to consider themselves partners with health care prac- titioners in the healing process and to question fees and treatment modes. They may ask such questions as, Do I need to see a special- ist? If so, which specialist can best treat my condition? Will I be given complete information about my condition? How much will medical treatment cost? Will a physician treat me if I have no health insurance?

In addition, as medical technology has advanced, patients have come to expect favorable outcomes from medical treatment, and when expectations are not met, lawsuits may result.

2. The legal and ethical issues facing society, patients, and health care practi- tioners as the world changes. Nearly every day the media report ne\\· events concerning individuals who face legal and ethical dilemmas over biological/medical issues. For example, a grief-stricken hus- band must give consent for an abortion in order to save the life oi his critically ill and unconscious wife. Parents must argue in court their decision to terminate life-support measures for a daughter whose injured brain no longer functions. Patients with HIV I AIDS fight to retain their right to confidentiality.

While the situations that make news headlines often in\·olw larger social issues, legal and ethical questions are resolved dail~:. on a smaller scale, each time a patient visits his or her physician dentist, physical therapist, or other health care practitioner. Ques- tions that must often be resolved include these: Who can legaJ:· give consent if the patient cannot? Can patients be assured of con5.- dentiality, especially since telecommunication has become a \\·ay ci life? Can a physician or other health care practitioner refuse to t:rea: a patient? Who may legally examine a patient's medical records.

Rapid advances in medical technology have also influence.- laws and ethics for health care practitioners. For example, rec-- court cases have debated these issues: Does the husband or :::-..2 wife have ownership rights to a divorced couple's frozen embryo:;- Will a surrogate mother have legal visitation rights to the c..~ ­ she carried to term? Should modem technology be used to ~--: those patients alive who are diagnosed as brain-dead and har e :- hope of recovery? How should parenthood disputes be reso>·· - for children resulting from reproductive technology?

4 Part One I The Foundations of Law and Ethics

3. The impact of rising costs on the laws and ethics of health care delivery. Rising costs, both of health care insurance and of medical treat- ment in general, lead to questions concerning access to health care services and allocation of medical treatment. For instance, should the uninsured or underinsured receive government help to pay for health insurance? And should everyone, regardless of age or life- style, have the same access to scarce medical commodities such as organs for transplantation or very expensive drugs?

COURT CASES ILLUSTRATE RISK OF LITIGATION

As you will see in the court cases used throughout this text, sometimes when a lawsuit is brought, the trial court or a higher court must first decide if the plaintiff has a legal reason to sue, or if the defendant is liable. When a court has ruled that there is a standing (reason) to sue and that a defendant can be held liable, the case may proceed to resolution. Often, once liability and a standing to sue have been estab- lished, the two sides agree on an out-of-court settlement. Depending on state law, an out-of-court settlement may not be published. For this reason, the final disposition of a case is not always available from published sources. The published cases that have decided liability, however, are still case law, and such cases have been used in this text to illustrate specific points.

In addition, sometimes it takes time after the initial trial for a case to be settled. For example, perhaps a patient dies after surgery in 2010, and the family files a wrongful death suit soon after. The case may go through several appeals and finally be settled in 2014.

It is also important to remember that while the final result of a case is important to the parties involved, from a legal standpoint the most

COURT CASES Patients Sue Hospitals

plaintiff The person bring ing cha rges in a lawsuit.

defendant The person or party against whom criminal or civil charges are brought in a lawsu it .

liable Legal ly responsible o r obligated.

In 2013, lawsuits against hospitals that were moving through

various courts included:

• A man entered a hospital emergency room suffering from severe headaches, dizziness, nausea and vomiting that were found to be connected to a fall the patient had just over two weeks earlier when

• A woman who underwent a thyroid biopsy had to undergo the procedure again, when hospital staff lost the first specimen. The woman alleged insufficient staff training and supervision were responsible for her having to undergo a second biopsy.

he lost consciousness. A nurse gave the patient an enema, administered a sedative, and placed him on a bedpan. The patient fell asleep on the bedpan as the sedative took effect, and when he was discovered 4 Yz hours later, the man's lower extremites were swollen and painful. In his lawsuit, the man alleged that he developed deep vein thromboses in both legs.

• A woman visiting a hospital patient slipped on a spill caused by the other patient in the room and claimed she was injured. Hospital staff were notified, but allegedly failed to adequately clean up the spill.

• A hospital employee underwent minor surgery only to awaken and find that her anaesthesiologist and another person had drawn a moustache and tears on her face and snapped photos with their cell phones. Since the patient knew the plaintiffs, they said they thought she would be amused. The patient alleged a violation of her privacy, among other charges.

(All of the above cases were still in litigation as the y th

edition of Law & Ethics for the Health Professions was pre- pared for publication, but perhaps the underlying reasons

for filing the lawsuits are already apparent to you.)

Chapter I II ntroduction to Law and Ethics 5

COURT CASE 911 Operators Sued

In 2006, just before 6 PM , a five-year-old boy called 91 I .

He told the 91 I operator that his "mom has passed out."

When the operator asked to speak to the boy's mother, he said , "She's not gonna talk." The operator scolded the

boy and logged the call as a child's prank. Three hours later

the boy called 91 I again. A different operator answered ,

and she also scolded the boy for playing a prank, but she

did send a police officer to the boy's home. The officer

discovered the boy's mother lying unresponsive on the floor and summoned emergency medical services. The

EMS workers arrived 20 minutes later, and determined

that the woman was dead, and had probably died within

the past two hours.

The boy's older sister sued the two 91 I operators on

behalf of the dead woman's estate and on behalf of her

son. The lawsuit alleged gross negligence causing a death and intentional infliction of emotional distress.

The 91 I operators argued that they were entitled to

government immunity, that they owed no duty to provide

assistance to the woman who died , and that their failure

to summon medical aid was not gross negligence.

A trial court and an appeals court found for the

plaintiff, and the case was appealed to the Michigan Supreme Court, where in Jan uary 2012, the court denied

further appeals.

Estate of Turner v. Nichols, 807 N.W.2d 164, 490 Mich. 988 (20 12).

precedent Decisions made by judges in t he various courts t hat become rule of law and apply to fut ure cases, even though they were not enacted by a leg islatu re; also known as case law.

summary judgment A decision made by a court in a lawsuit in response to a mot ion that p leads there is no basis fo r a trial.

fraud Dishonest or deceitful p ractices in depriving, or attempting to dep rive, another of his or her rights.

important aspect of a court case is not the result, but whether the case represents good law and will be persuasive as other cases are decided.

Although the most recent cases published have been sought for illustration in this text, sometimes a dated case (1995, 1985, 1970, etc.) is used because it established important precedent.

Court cases appear throughout each chapter of the text to illustrate how the legal system has decided complaints brought by or against health care service providers and product manufacturers. Some of these cases involve summary judgment. Summary judgment is the legal term for a decision made by a court in a lawsuit in response to a motion that pleads there is no basis for a trial because there is no genu- ine issue of material fact. In other words, a motion for summary judg- ment states that one party is entitled to win as a matter of law. Summary judgment is available only in a civil action. (Chapter 4 dis- tinguishes between criminal and civil actions.)

The following court cases illustrate that a wide variety of legal questions can arise for those engaged directly in providing health care services, whether in a hospital, in a medical office, or in an emergency situation. Health care equipment and product dealers and manufac- turers can be held indirectly responsible for defective medical devices and products through charges of the following types:

• Breach of warranty.

• Statements made by the manufacturer about the device or product that are found to be untrue.

• Strict liability, for cases in which defective products threaten the personal safety of consumers.

• Fraud or intentional deceit. (Fraud is discussed in further detail in Chapter 4.)

The extent of liability for manufacturers of medical devices and products may be changing, however, since a 2008 U.S. Supreme Court decision held that makers of medical devices such as implantable defi- brillators or breast implants are immune from liability for personal

6 Part One I The Foundations of Law and Ethics

COURT CASE Supreme Court Shields Medical Devices from Lawsuits

An angioplasty was performed on a patient, Charles

Riegel , in New York. During the procedure, the catheter

used to dilate the patient's coronary artery failed, causing

serious complications. The patient sued the catheter's

manufacturer, Medtronic , Inc ., under New York state law,

charging negligence in design, manufacture, and labeling

of the device, w hich had received FDA approval in 1994.

Medtronic argued that Riegel could not bring state law

negligence claims because the company was preempted

from liability under Section 360k(a) of the Medical

Device Amendments (MDA) of the U.S. Food , Drug, and

Cosmetic Act. State requirements are preempted under

the MDA only to the extent that they are "different from,

or in addition to" the requirements imposed by federal

law. Thus, 360k(a) does not prevent a state from provid-

ing a damages remedy for claims premised on a violation

of FDA regulations; the state duties in such a case "paral-

lel," rather than add to, federal requirements (Lohr, 518 U.S., at 495, I 16 S.Ct. 2240).

The Riegel case reached the U.S. Supreme Court, where the question to be decided was this: Does Section 360k(a)

of the Medical Device Amendments to the Food, Drug,

and Cosmetic Act preempt state law claims seeking dam-

ages for injuries caused by medical devices that received

pre market approval from the Food and Drug Administration?

In February 2008, the U.S . Supreme Court held in this

case that makers of medical devices are immune from

liability for personal injuries as long as the FDA approved

the device before it was marketed and it meets the FDA's

specifications.

Appeals Court Case: Riegel v. Medtronic, Inc., 451 F.3d I 04 (2006); Supreme Court Case: Riegel v. Medtronic, Inc., 552 U.S. 312, 128 S.Ct. 999, 2008.

injuries as long as the Food and Drug Administration (FDA) approved the device before it was marketed and it meets the FDA's specifica- tions. (See the previous Medtronic Inc. case.)

Drugs and medical devices are regulated under separate federal laws, and an important issue in deciding drug injury cases is whether or not the drug manufacturer made false or misleading statements to win FDA approval. For example, the case Warner-Lambert Co. v. Kent, filed in 2006, involved a group of Michigan residents who claimed injury after taking Warner-Lambert's Rezulin diabetes drug. The case was brought under a Michigan tort reform law that said a drug company could be liable for product injury if it had misrepresented the product to win FDA approval. In this case, the question before the court was, Does a federal law prohibiting fraudulent communications to govern- ment agencies preempt a state law permitting plaintiffs to sue for faulty products that would not have reached the market absent the fraud?

A federal appeals court eventually heard the case and ruled that the Michigan "fraud on the FDA" law was preempted by a federal law that allowed the FDA itself to punish misrepresentations. This decision was appealed to the U.S. Supreme Court, and in a March 2008 decision, the Roberts Supreme Court affirmed the appeals court, thus leaving the previous state of the law unchanged and unclarified.

In this case, the people who sued the drug manufacturer were not allowed to collect damages. But when courts find that drugs are mis- represented so that developers can win FDA approvat drug manufac- turers could be held legally responsible and forced to pay damages.

Examples of how drug manufacturers could be held legally respon- sible before any Supreme Court decision protecting them from liability were the many lawsuits filed against Merck & Company, a pharma- ceutical firm that manufactured the drug Vioxx, once widely recom- mended for pain relief for arthritis sufferers. The drug was suspected of causing heart attacks and strokes in some patients, and from 1999,

Chapter I I Introduction to Law and Ethics 7

COURT CASE Patient Sues over Drug Labeling Issue

In 2000, Diana Levine, a Vermont woman in her fifties,

sought medical help for migraine headaches. As part of

the treatment, the antinausea drug Phenergan, made by

Wyeth, was injected in her arm. An artery was acciden-

tally damaged during the injection, gangrene set in, and

Levine's right arm was amputated. The amputation was

devastating for Levine, a professional musician who had

released 16 albums, and she filed a personal injury action

against Wyeth in Vermont state court.

a new trial. Levine was awarded $7 million in damages

for the amputation of her arm. The Supreme Court -= Vermont affirmed this ruling on appeal , holding that tfle

FDA requirements merely provide a floor, not a cei ling, for

state regulation. Therefore, states are free to create more

stringent labeling requirements than federal law provides.

The U.S. Supreme Court eventually heard the case

and issued a decision in March 2009. Wyeth had arguee

that because the warning label had been accepted by the

FDA, any Vermont state regulations making the label

insufficient were preempted by the federal approval.

The U.S. Supreme Court affirmed the Vermont Supreme

Court, holding that federal law did not preempt Levine's

state law claim that Wyeth's labeling of Phenergan fa iled

to warn of the dangers of intravenous administration.

Levine asserted that Wyeth should have included a

warning label describing the possible arterial injuries that

could occur from negligent injection of the drug. Wyeth

argued that because the warn ing label had been deemed

acceptable by the FDA, a federal agency, any Vermont state

regulations making the label insufficient were preempted

by the federal approval. The Superior Court of Vermont

found in favor of Levine and denied Wyeth's motion for Wyeth v. Levine, 555 U.S. 555, 173 L.Ed.2d 51 (2009).

LO 1.2 and LO 1.3

Distinguish among law, ethics, bioethics, etiquette, and protocol.

Define moral values and explain how they relate to law, ethics, and etiquette.

the year Vioxx went on the market, to 2007, Merck faced lawsuits from 47,000 plaintiffs, including patients, health providers, unions, and insurers. Many of the lawsuits alleged that Merck knew of the drug's potentially harmful side effects when the company placed the drug on the market.

In November 2007, Merck agreed to settle most of the lawsuits relat- ing to Vioxx for a total of $4.85 billion. The settlement was open to plaintiffs who filed cases before November 8, 2007, who could provide medical proof of their heart attack or stroke, and who could prove they had used at least 30 Vioxx pills within 14 days prior to their ill- ness. In March 2010, Merck and the Securities and Exchange Commis- sion (SEC) announced that all payouts through the settlement process would be paid out by the end of June 2010.

Merck anticipated that some plaintiffs would opt out of the settle- ment, continuing to fight the company on a case-by-case basis. The company projected that remaining claims could cost the firm between $2 and $3 billion, and as of 2012, claims against Vioxx were still mov- ing through the courts.

Federal preemption-a doctrine that can bar injured consumers from suing in state court when the products that hurt them had met federal standards-has become an important concern in product lia- bility law. One such case, Wyeth v. Levine, decided by the U.S. Supreme Court in 2009, will become precedent for future cases involving drug manufacturers and consumers.

Comparing Aspects of Law and Ethics To understand the complexities of law and ethics, it is heipful to define and compare a few basic terms. Table 1-1 summarizes the terms described in the following sections.

8 Part One I The Foundations of Law and Eth ics

Table 1-1 Comparing Aspects of Law and Ethics

Definition

Main purpose

Standards

Penalties of violation

Definition

Main purpose

Standards

Penalties of violation

LAW

Law

Set of governing rules

To protect the public

Minimal-promotes smooth function- ing of society

Civil or criminal liability. Upon convic- tion: fine, imprisonment, revocation of license, or other penalty as deter- mined by courts

Bioethics

Discipline relating to ethics concern- ing biological research, especially as applied to medicine

To allow scientific progress in a man- ner that benefits society in all pos- sible ways

Leads to the highest standards possible in applying research to medi- cal care

Can include all those listed under "Law," "Ethics," and "Etiquette"; as current standa rds are applied and as new laws and ethical standards evolve to govern medical research and development, penalties may change

Ethics

Principles, standards, guide to conduct

To elevate the standard of competence

Builds values and ideals

Suspension or eviction from medical society membership, as decided by peers

Etiquette

Courtesy and manners

To enable one to get along with others

Leads to pleasant interaction

Ostracism from chosen groups

A law is defined as a rule of conduct or action prescribed or formally recognized as binding or enforced by a controlling authority. Govern- ments enact laws to keep society running smoothly and to control behavior that could threaten public safety. Laws are considered the minimum standard necessary to keep society functioning.

Enforcement of laws is made possible by penalties for disobe- dience, which are decided by a court of law or are mandatory as written into the law. Penalties vary with the severity of the crime. Lawbreakers may be fined, imprisoned, or both. Sometimes law- breakers are sentenced to probation. Other penalties appropriate to the crime may be handed down by the sentencing authority, as when offenders must perform a specified number of hours of vol- unteer community service or are ordered to repair public facilities they have damaged.

Many laws affect health care practitioners, including criminal and civil statutes as well as state medical practice acts. Medical practice acts apply specifically to the practice of medicine in a certain state. Licensed health care professionals convicted of violating criminal, civil, or medical practice laws may lose their licenses to practice. (Medical practice acts are discussed further in Chapter 3. Laws and the court system are discussed in more detail in Chapter 4.)

Moral Values

Beliefs formed through the influence of family, culture, and society

To serve as a guide for personal ethical conduct

Serves as a basis for forming a personal code of ethics

Difficulty in getting along with others

Protocol

Rules of etiquette applicable to one's place of employment

To enable one to get along with others engaged in the same profession

Promotes smooth functioning of work- place routines

Disapproval from one's professional col - leagues; possible loss of business

law Ru le of conduct or action prescribed or formally recognized as binding or enforced by a controlling authority.

Chapter I !Introd uction to Law and Ethics 9

ethics Standards of behavior, developed as a result of one's concept of right and wrong.

moral values One's personal concept of right and wrong, formed throug h the inf luence of t he fam ily, cu lture, and society.

code of ethics A list of p rincip les intended to govern behavior- here, t he behavior of those ent rust ed wit h providing care to the sick.

ethics guidelines Publications that detai l a w ide variety of ethical situat ions t hat professionals (i n th is case, health care practitioners) might face in their work and offer principles for dealing wit h the situations in an ethical manner.

ETHICS

An illegal act by a health care practitioner is always unethical, but an unethical act is not necessarily illegal. Ethics are concerned with stan- dards of behavior and the concept of right and wrong, over and above that which is legal in a given situation. Moral values- formed through the influence of the family, culture, and society-serve as the basis for ethical conduct.

The United States is a culturally diverse country, with many resi-: dents who have grown up within vastly different ethnic environ- ments. For example, a Chinese student in the United States brings to his or her studies a unique set of religious and social experiences and moral concepts that will differ from that of a German, Japanese, Korean, French, Italian, or even Canadian classmate. Therefore, moral values and ethical standards can differ for health care practitioners, as well as patients, in the same setting.

In the American cultural environment, however, acting morally toward another usually requires that you put yourself in that individ- ual's place. For example, when you are a patient in a physician's office, how do you like to be treated? As a health care provider, can you give care to a person whose conduct or professed beliefs differ radically from your own? In an emergency, can you provide for the patient's welfare without reservation?

CODES OF ETHICS AND ETHICS GUIDELINES

While most individuals can rely on a well-developed personal value system, organizations for the health occupations also have formalized codes of ethics to govern behavior of members and to increase the level of competence and standards of care within the group. Included among these are the American Nurses Association Code for Nurses, American Medical Association Code of Medical Ethics, American Health Informa- tion Management Association Code of Ethics, American Society of Radiologic Technologists Code of Ethics, and the Code of Ethics of the American Association of Medical Assistants. Codes of ethics generally consist of a list of general principles, and are often available to layper- sons as well as members of health care practitioner organizations.

Many professional organizations for health care practitioners also publish more detailed ethics guidelines, usually in book form, for

I . Name two important reasons for studying law and ethics.

2. Which state laws apply specifically to the practice of medicine?

3. What purpose do laws serve?

4. How is the enforcement of laws made possible?

5. What factors influence the formation of one's personal set of ethics and values?

6. Define the term moral values.

7. Explain how one's moral values affect one's sense of ethics.

10 Part One I The Foundations of Law and Ethics

members. Generally, ethics guideline publications detail a wide vari- ety of ethical situations that health care practitioners might face in their work and offer principles for dealing with the situations in an ethical manner. They are routinely available to members of health care organizations, and are typically available to others for a fee.

One of the earliest medical codes of ethics, the code of Hammurabi, was written by the Babylonians around 2250 B.C.E. This document dis- cussed the conduct expected of physicians at that time, including fees that could be charged.

Sometime around 400 B.C.E., a pledge for physicians known as the Hippocratic oath was published. The oath was probably not actually written by Hippocrates, the Greek physician known as the Father of Medicine. Authorship has been attributed to one or more of his stu- dents and to the Pythagoreans, but scholars indicate it was probably derived from Hippocrates's writings (see Figure 1-1).

. '

HippooP

----------··~··---------- I ~~r 6y ~oCfo, the pliysician, ruuiAescufapius, cuuf Hea£tli, a.rufA.CLheaf, a.ru£

a[[ ~godS tine( !JOcUfe.sses, tliat, according to my avi[iJy a.ru£ jud"gment, I wi[ keep i!his·oatfi aru£ sttpufation, to recKon liim who tauglit me tliis art equaCly dear to me as my parents, to slia.re~ su6stance 'Nitti liim a'iuf reCieve his necessities if reqmreif; to regard his rsprinq_ as on tlie same footing witli tn;):' own Grotfiirs,. ruu£ to teach tliem tliis cut i tliey ShouUf wish to (earn it, without Jee or stipu.Cation, .and tlia.t 6y e.rr;cept;, (ectu.re, aru£ every otlier mocCe of instruction, I wif[ tmpart a knowfe;fge OJ tlie art to tTl)!, own sons ruu£ to those Of mr. teacliers, aru£ to cfiscipfes Gou.ru£ ~ a. stipu{ation and oath, a.ccording to tlie liiw Of medkine, Gut to none otlier.

· I wi[ foCCow that method of treatment wliicli, a.ccording to nt); a&iCifY aru£ "jl}-lfqment, I consicCer for tlie Genejit of my patients, cutd a& stain from wliiitever is

dclcterious ruu£ miscrtievous. I wi[ give no d'eadry medicine to anyone if asked, nor _sugqest aJ!.y s:~eh cou.nseC; fo.rtliernuire, I wi.f! not give to a woman.a.n instrument to proifu.ce a.Oortwn. _

With pu1ity aru£ ho[iness I wi[ pass my Ciffi ruu£ practice my art. I -wi[ not cut a person who 1.s suffering witli a stone, Gut wt[ Ceave tfiis to Ge cfone &v practitioners

Whatever, in connection witli my pr9.fessionaC practice, or not in connection Vllitli it, I n:_wy see or hear in tfie (ives ~of men wliiffi 9119ftt not to Ge spoken a&road, I wif[ not diVul9e, as recKoning tlia:t a[( such shouUf Ge kept secret.

WliiCe I continue to liap tliis oatli u.nviofated, may it Ge granted to me to enjoy Cife and tfie practice of tlie art, respected 6y a[[ men at ali times, 6ut shouUf I trespass cutcf viofa.te tliis oatli, IJtlo/ tfte reverse Ge my Cot.

Hippocratic oath A pledge for physicians, influenced by the practices of the Greek physician Hippocrates.

FIGURE 1-1 Hippocratic Oath

Chapter I ! Introduction to Law and Ethics 11

American Medical Association Principles A code of ethics for members of the American Medical Association, written in 1847. (American Medical Association Web site: www.ama-assn.org/ ama/pub/physicianresources/ medical-ethics/code-medical-ethics/ principles-medical-ethics.page.)

Percival's Medical Ethics, written by the English physician and philosopher Thomas Percival in 1803, superseded earlier codes to become the definitive guide for a physician's professional conduct. Earlier codes did not address concerns about experimental medi- cine, but according to Percival's code, physicians could try experi- mental treatments when all else failed, if such treatments served the public good.

When the American Medical Association met for the first time in Philadelphia in 1847, the group devised a code of ethics for mem- bers based on Percival's code. The resulting American Medical Association Principles, currently called the American Medical Asso- ciation Principles of Medical Ethics, has been revised and updated periodically to keep pace with changing times (see Figure 1-2) . The American Medical Association Principles of Medical Ethics briefly summarizes the position of the American Medical Association (AMA) on ethical treatment of patients, while the more extensive Code of Medical Ethics: Current Opinions with Annotations provides more detailed coverage.

When members of professional associations such as the AMA and the AAMA are accused of unethical conduct, they are subject to peer council review and may be censured by the organization

FIGURE 1-2 Codes of Ethics for Health Care Practitioners Generally Subscribe to the Following Principles

0 The welfare of the patient must be foremost in all decisions and actions.

• Patients have the right to make their own decisions, and that right must be respected .

4D First, do no harm. 0 Make fair and equitable decisions. • Be loyal, honest, and reliab le in dealing with patients, their families, and with other health care professionals.

• Be truthful.

G Keep patients' medical concerns and treatment confidential and priva te. Source: American Medical Association, Code of Medical Ethics, Current Opinions with Annotations, current issue.

12 Port One I The Foundations of Law and Ethics

FIGURE 1-3 Code of Ethics and Creed of the American Association of Medical Assistants (AAMA)

The Medical Assisting Code of Ethics of the AAMA sets forth principles of ethical and moral conduct as they relate to the medical profession and the particular practice of medica l assisting.

Members of AAMA dedicated to the conscientious pursuit of their profession, and thus desiring to merit the high regard of the entire medical profession and the respect of the general public which they serve, do pledge themselves to strive always to:

A. Render service with full respect for the dignity of humanity.

B. Respect confidential information obtained through employment unless legally authorized or required by responsible performance of duty to divulge such information.

C. Uphold the honor and high principles of the profession and accept its disciplines.

D. Seek to continually improve the knowledge and skills of medical assistants for the benefit of patients and professional colleagues.

E. Participate in additional service activities aimed toward improving the health and well-being of the community.

The Medical Assisting Creed of the AAMA sets forth medical assisting statements of belief:

0 I believe in the principles and purposes of the profession of medical assisting. G I endeavor to be more effective. • I aspire to render greater service.

G I protect the confidence entrusted to me. • I am dedicated to the care and well-being of all people.

• I am loyal to my employer.

e I am true to the ethics of my profession. 0 I am strengthened by compassion, courage and faith.

Source: http://www.aama-ntl.org/about/overview#.UzRbqiXLJBA.

(see Figure 1-3). Although a professional group cannot revoke a member's license to practice, unethical members may be expelled from the group, suspended for a period of time, or ostracized by other members. Unethical behavior by a medical practitioner can result in loss of income and eventually the loss of a practice if, as a result of that behavior, patients choose another practitioner.

BIOETHICS

Bioethics is a discipline dealing with the ethical implications of biological research methods and results, especially in medicine.

bioethics A discipline dealing with t he ethical implications of biological research methods and results, especially in medicine.

Chapter I II ntroduction to Law and Ethics 13

medical ethicist or bioethicist Special ists who consult w ith phys icians, resea rchers, and others to help them make difficult ethica l decisions regard ing patient care .

ethics committee Committee made up of ind ividuals who are involved in a patient 's care, incl uding health care practitioners, family members, clergy, and others, wit h t he purpose of reviewing ethical issues in difficult cases.

As biological research has led to unprecedented progress in medicine, medical practitioners have had to grapple with issues such as these:

• What ethics should guide biomedical research? Do individuals own all rights to their body cells, or should scientists own cells they have altered? Is human experimentation essential, or even permissible, to advance biomedical research?

• What ethics should guide organ transplants? Although organs suitable for transplant are in short supply, is the search for organs dehumanizing? Should certain categories of people have lower priority than others for organ transplants?

• What ethics should guide fetal tissue research? Some say such research, especially stem cell research, is moral because it offers hope to disease victims, while others argue that it is immoral.

• Do reproductive technologies offer hope to the childless, or are they unethical? Are the multiple births that sometimes result from taking fertility drugs an acceptable aspect of reproductive technology, or are those multiple births too risky for women and their fetuses and even immoral in an allegedly overpopu- lated world?

• Should animals ever be used in research?

• How ethical is genetic research? Should the government regulate it? Will genetic testing benefit those at risk for genetic disease, or will it lead to discrimination? Should cloning of human organs for transplantation be permitted? Should cloning of human beings ever be permitted?

Society is attempting to address these questions, but because the issues are complicated, many questions may never be completely resolved.

THE ROLE OF ETHICS COMMITTEES

Health care practitioners may be able to resolve the majority of the ethical issues they face in the workplace from their own intuitive sense of moral values and ethics. Some ethical dilemmas, however, are not so much a question of right or wrong but more a question like, "Which of these alternatives will do the most good and the least harm?" In these more ambiguous situations, health care practitioners may want to ask the advice of a medical ethicist or members of an institutional ethics committee.

Medical ethicists or bioethicists are specialists who consult with physicians, researchers, and others to help them make difficult deci- sions, such as whether to resuscitate brain-damaged premature infants or what ethics should govern privacy in genetic testing. Hospital or medical center ethics committees usually consist of physicians, nurses, social workers, clergy, a patient's family, members of the community, and other individuals involved with the patient's medical care. A medical ethicist may also sit on the ethics committee if such a specialist is available. When difficult decisions must be made, any one of the indi- viduals involved in a patient's medical care can ask for a consultation with the ethics committee. Larger hospitals have standing ethics com- mittees, while smaller facilities may form ethics committees as needed.

14 Part One I The Foundations of Law and Ethics

When a case is referred to the ethics committee, the members meet and review the case. The committee does not make binding decisions, but helps the physician, nurse, patient, patient's family, and others clarify the issue and understand the medical facts of the case and the alternatives available to resolve the situation. Ethics committees may also help with conflict resolution among parties involved with a case. They do not, however, function as institutional review boards or morals police looking for health care workers who have committed unethical acts.

See Chapter 2 for a more detailed discussion of the processes involved in making ethical decisions.

ETIQUETTE

While professional codes of ethics focus on the protection of the patient and his or her right to appropriate, competent, and humane treatment, etiquette refers to standards of behavior that are considered good manners. Every culture has its own ideas of common courtesy. Behav- ior considered good manners in one culture may be bad manners in another. For example, in some Middle Eastern countries, it is extremely discourteous for one male acquaintance to ask another, "How is your wife?" In Western culture, such a question is well received. Similarly, within nearly every profession, there are recognized practices consid- ered to be good manners for members.

Most health care facilities have their own policies concerning pro- fessional etiquette that staff members are expected to follow. Policy manuals written especially for the facility can serve as permanent records and as guidelines for employees in these matters.

By the same token, health care practitioners are expected to know protocol, standard rules of etiquette applicable specifically to their place of employment. For example, when another physician telephones, does the receptionist put the call through without delay? What is the protocol in the diagnostic testing office when the technicians get behind because of a late patient or a repair to an X-ray machine?

Within the health care environment, all health care practitioners are, of course, expected to treat patients with the same respect and cour- tesy afforded others in the course of day-to-day living. Politeness and appropriate dress are mandatory.

Qualities of Successful Health Care Practitioners Successful health care practitioners have a knowledge of techniques and principles that includes an understanding of legal and ethical issues. They must also acquire a working knowledge of and tolerance for human nature and individual characteristics, since daily con- tact with a wide variety of individuals with a host of problems and concerns is a significant part of the work. Courtesy, compassion, and common sense are often cited as the "three Cs" most vital to the professional success of health care practitioners.

etiquette Standards of behavior considered to be good manners among members of a profession as t hey function as individua ls in society.

protocol A code prescribing correct behavior in a specific situation, such as a situation ari sing in a medical office.

LO 1.4 Discuss the characteristics and ski lls most likely to lead to a successful career in one of the health care professions.

Chapter I !Introduction to Law and Ethics 15

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courtesy The practice of good manners.

compassion The identification with and understanding of another's situation, feelings, and mot ives.

common sense Sound practical judgment.

COURTESY

The simplest definition of courtesy is the practice of good manners. Most of us know how to practice good manners, but sometimes circumstances make us forget. Maybe we're having a rotten day-we overslept and dressed in a hurry but were still late to work; the car didn't start so we had to walk, making us even more late; we were rebuked at work for coming in late . .. and on and on. Perhaps we're burned out, stressed out, or simply too busy to think. Regardless of a health care practitioner's personal situation, however, patients have the right to expect courtesy and respect, including self-introduction. ("Hi, I'm Maggie and I'll be taking care of you," is one nursing assis- tant's way of introducing herself to new patients in the nursing home where she works.)

Think back to experiences you have had with health care practi- tioners. Did the receptionist in a medical office greet you pleasantly, or did he or she make you feel as though you were an unwelcome intruder? (Remember Elaine in the chapter's opening scenario?) Did the laboratory technician or phlebotomist who drew your blood for testing put you at ease or make you more anxious than you already were? If you were hospitalized, did health care practitioners carefully explain procedures and treatments before performing them, or were you left wondering what was happening to you? Chances are that you know from your own experiences how important common courtesy can be to a patient.

COMPASSION

Compassion is empathy-the identification with and understanding of another's situation, feelings, and motives. In other words, compas- sion is temporarily putting oneself in another's shoes. It should not be confused with sympathy, which is feeling sorry for another person's plight- typically a less deeply felt emotion than compassion. While "I know how you feel" is not usually the best phrase to utter to a patient (it too often earns the retort, "No, you don't"), compassion means that you are sincerely attempting to know how the patient feels.

COMMON SENSE

Common sense is simply sound practical judgment. It is somewhat difficult to define, because it can have different meanings for different people, but it generally means that you can see which solution or action makes good sense in a given situation. For example, if you were a nursing assistant and a gasping, panicked patient told you he was having trouble breathing, common sense would tell you to immedi- ately seek help. You wouldn't simply enter the patient's complaint in his medical chart and wait for a physician or a nurse to see the nota- tion. Likewise, if a patient spilled something on the floor, common sense would tell you to wipe it up (even if you were not a member of the housekeeping staff) before someone stepped in it and possibly slipped and fell. While it's not always immediately obvious that some- one has common sense, it usually doesn't take long to recognize its absence in an individual.

16 Part One I The Foundations of Law and Ethics

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Additional capabilities that are helpful to those who choose to work in the health care field include those that are listed in the following sections "People Skills" and "Technical Skills."

PEOPLE SKILLS

People skills are those traits and capabilities that allow you to get along well with others and to relate well to patients or clients in a health care setting. They include such attributes as the following:

• A relaxed attitude when meeting new people.

• An understanding of and empathy for others.

• Good communication skills, including writing, speaking, and listening.

• Patience in dealing with others and the ability to work as a member of a health care team.

• Tact

• The ability to impart information clearly and accurately.

• The ability to keep information confidential.

• The ability to leave private concerns at home.

• Trustworthiness and a sense of responsibility.

TECHNICAL SKILLS

Technical skills include those abilities you have acquired in your course of study, including but not limited to the following:

• Computer literacy

• Proficiency in English, science, and mathematics.

• A willingness to learn new skills and techniques.

• An aptitude for working with the hands.

• Ability to document well.

• Ability to think critically.

CRITICAL THINKING SKILLS

When faced with a problem, most of us worry a lot before we finally begin working through the problem effectively, which means using fewer emotions and more rational thinking skills. As a health care practitioner, you will be expected to approach a problem at work in a manner that lets you act as ethically, legally, and helpfully as possible. Sometimes solutions to problems must also be found as quickly as possible, but solutions must always be within the scope of your training, licensure, and capabilities. This problem-solving process is called critical thinking. Here is a five-step aid for approaching a problem using critical thinking:

1. Identify and clarify the problem. It's impossible to solve a prob- lem unless you know the exact nature of the problem. For example, imagine that patients in a medical office have frequently complained that the wait to see physicians is too long, and several have protested

critical thinking The abil ity to thi nk analytica lly, us ing fewer emotions and more rational ity.

Chapter I !Introduction to Law and Ethics 17

loudly and angrily that their time "is valuable too." Rhea is the wait- ing room receptionist and the person who faces angry patients first, so she would like to solve this problem as quickly as possible. Rhea has recognized that a problem exists, of course, but her apologies to patients have been temporary fixes, and the situation continues.

2. Gather information. In the previous situation, Rhea begins to gather information. She first checks to see exactly why patients have been kept waiting, and considers the following questions: Are all the phy- sicians simply oversleeping and beginning the day behind schedule? (Not likely, but an easy solution if this were the case would be to buy the physicians new alarm clocks.) Are the physicians often delayed in surgery or because of hospital rounds? Is the clinic understaffed? How long, on average, has each patient who has complained been left waiting beyond his or her appointment time?

3. Evaluate the evidence. Rhea evaluates the answers she has gath- ered to the earlier questions and determines that too many patients are, indeed, waiting too long beyond appointment times to see their physicians. The next step in the critical thinking process is to consider all possible ways to solve the problem.

4. Consider alternatives and implications. Rhea has determined that the evidence supports the fact that a problem exists and begins to formulate alternatives by asking herself these questions: Could the waiting room be better supplied with current reading material or perhaps television sets and a children's corner, so that patients both with and without children are less likely to complain about waiting? Is the waiting room cheery and comfortable, so waiting does not seem interminable? What solution would best serve the goals of physicians, other medical office personnel, and patients? Rhea must consider costs of, objections to, and all others' opinions of each alternative she considers.

5. Choose and implement the best alternative. Rhea selects an alter- native and implements it. As a medical office receptionist, she cannot act alone, but she has brought the problem to the atten- tion of those who can help, and her suggestions have been heard. As a result of Rhea's research, acceptable solutions to patients' complaints that they are forced to wait too long to see physicians might include the following:

• Patients are asked to remind receptionists when they have been waiting over 15 minutes so receptionists can check to see what is causing the delay.

• Additional personnel are hired to see patients.

• The waiting room is stocked with current news publications, television sets, and/or a child play center for patient comfort while waiting.

Critical thinking is not easy, but, like any skill, it improves with practice.

DETERMINING IF A DECISION IS ETHICAL

While considering the legality of a certain act, health care practitioners must also consider ethical implications. According to many ethics

18 Part One I The Foundations of Law and Ethics

Check Your Progress

8. Tell how each of the following characteristics relates to law and ethics in the health care professions:

The ability to be a good communicator and listener.

The ability to keep information confidential.

The ability to impart information clearly and accurately.

The ability to think critically.

9. List and discuss each of the steps helpful to developing critical thinking skills.

I 0. Explain how you, as a health care practitioner, would use the critical thinking steps listed previously to reach a solution to the following problem: A patient from a different culture believes he has been cursed with a "liver demon" and will die unless the organ is surgically removed.

experts, the following questions can help you determine if an act you have decided on via critical thinking skills is ethical:

• If you perform this act, have you followed relevant laws, and kept within your employing company's policy?

• Will this act promote a win-win situation for as many of the involved individuals as possible?

• How would you feel if this act were to be publicized in the news- papers or other media?

• Would you want your family members to know?

• If you perform this act, can you look at yourself in a mirror?

The health care practitioner who demonstrates these qualities and skills, coupled with a working knowledge of law and ethics, is most likely to find success and job satisfaction in his or her chosen profession.

Chapter I !Introduction to Law and Ethics 19

FIGURE 1-4 Assessing Your Strengths and Wea kn esses Exercise:

Think carefully about each of the following statements; then put a check mark next to the statement that most accurately describes you. This is not a test, and there are no correct or incorrect answers; it is intended solely to help you evaluate those areas where you excel or need improvement.

20

D

D

D

D

D

D

D

D

D

D

D

D

D

D

D

D D

D

D

D

D

D

I like meeting new people and willingly place myself in situations where I can interact with someone new.

I often make excuses in order to decline social invitations that would require me to meet and interact with new people.

I can visit with anyone, and I enjoy listening to the opinions and experiences of others.

I often have trouble initiating a conversation, and if forced to listen too long, my mind wanders or I find myself concentrating on my response, rather than on the conversation.

If someone complains to me and I am in a position to help, I willingly explore solutions with the person who complains.

I go out of my way to avoid people who chronically complain.

I can tactfully tell a person the truth when necessary, without hurting feelings or fostering anger.

I believe it's best to always tell others the truth, even if it risks making them angry or hurting their feelings.

I know correct grammar, and always use it when writing reports or conversing with others.

I can get my meaning across without always using good grammar.

On the job I can listen to another person's complaints or criticism without becoming angry.

Complaining about or criticizing my work always makes me angry.

I can always keep private information about others to myself.

One of my most endearing qualities is my inability to keep a secret.

In stressful situations I keep my composure and think about the best way to proceed.

I avoid stressful situations, because I tend to panic and would rather rely on someone else to tell me what to do.

I am familiar with computers and enjoy learning new applications.

I don't like using computers.

I like science and math, and get good grades in those subjects.

Science and math turn me off, and I avoid those courses whenever possible.

Using my own words, both orally and in writing, I can explain technical or complicated material in a way others can easily understand.

I don't like explaining complicated material to others, either orally or in writing.

Part One I The Foundat ions of Law and Ethics

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•

I~

Chapter Summary

Learning Outcome Summary

LO 1.1 Explain why knowledge of law and ethics is important to health care practitioners.

LO 1.2 & LO 1.3 Distinguish among law, ethics, bioethics, etiquette, and protocol; Define mora/ values and explain how they relate to law, ethics, and etiquette.

LO 1.4 Discuss the characteristics and skills most likely to lead to a success- ful career in one of the health care professions.

Why study law and ethics?

• Health care practitioners who function at the highest possible levels have a working knowledge of law and ethics.

• Knowing the law relevant to your profession can help you avoid legal entangle- ments that threaten your ability to earn a living. Court cases illustrate how health care practitioners, hea lth care facilities, and drug and medical device manufacturers can be held accountable in a court of law.

• A knowledge of law and ethics will also help familiarize you with the following areas:

• The rights, responsibilities, and concerns of health care consumers.

• The legal and ethical issues facing society, patients, and health care practi- tioners as the world changes.

• The impact of rising costs on the laws and ethics of hea lth care delivery.

What are the basic aspects of law and ethics, and how do they compare?

Laws are considered the minimum standard necessary to keep society func- tioning. Many laws govern the health care professions, including criminal and civil statutes and medical practice acts.

Ethics are principles and standards that govern behavior. Most health care pro- fessions have a code of ethics members are expected to follow.

Bioethics is the discipline dealing with the ethical impl ications of biological research methods and results, especially in medicine.

• Moral values define one's persona l concept of right and wrong.

Etiquette refers to manners and courtesy.

Protocol is a code prescribing correct behavior in a specific situation, such as in a medical office.

What characteristics and skills will most likely help a health care practitioner achieve success?

People skills, such as listening to others and commu nicating well, are an asset to health ca re practitioners.

• Technica l skills, including a basic knowledge of computers, and a foundation in science and math are necessary to achieve an education in the health care sciences.

• Critical thinking skil ls are required for you to correctly assess a situation and provide the proper response. Solving problems through critical thinking involves:

1. Identifying and clarifying the problem.

2. Gathering information.

3. Evaluating the eviden ce.

4. Considering alternatives and impl ications.

5. Choosing and implementing the best alternative.

What questions can help you decide if a decision is ethical?

1. If you perform this act , have you fol lowed relevant laws and kept w ithin your employing company's policy?

2. Will this act promote a wi n-win situation for as many of the involved indi- viduals as possible?

3. How wou ld you feel if this act were to be publicized in the newspapers or other media?

4. Would you want your family members to know?

5. If you perform this act, can you look at yourself in a mirror?

Chapter I I Introduction to Law and Ethics 21

Ethics Issues Introduction to End-of-Chapter Ethics Discussions

Learning Outcomes for the Ethics Issues Feature at the End of Each Chapter After studying the material in each chapter's Ethics Issues feature, you should be able to:

1. Discuss current ethical issues of concern to health care practitioners.

2. Compare ethical guidelines to the law as discussed in each chapter of the text.

3. Practice critical thinking skills as you consider medical, legal, and ethical issues for each situation presented.

4. Relate the ethical issues presented in the text to the health care profession you intend to practice.

Health care practitioners are bound by state and federal laws, but they are also bound by certain ethical standards-both personal standards and those set forth by professional codes of ethics and ethical guidelines, and by bioethicists. Many professional organizations for health care practitioners employ an ethics consultant who is available to speak with organization members who need help with an ethical dilemma. "We serve as a third party who can stand outside a situation and facilitate communication," says Dr. Carmen Paradis, an ethics consultant with the Cleveland Clinic's Department of Bioethics. At the Cleveland Clinic, ethics consul- tations are available to health care practitioners, patients, family members, and others involved with patient decisions.

Medical facility ethics committees can also serve as consultants. In larger health care facilities such commit- tees usually deal with institutional matters, but in smaller communities where ethics consultants may not be available, members of an ethics committee may also function as ethics consultants.

Keep in mind as you read the Ethics Issues feature for each chapter that ethical guidelines are not law, but deal solely with ethical conduct for health care practitioners. Most guidelines published for professional health care practitioner organizations emphasize this difference. For example, as stated in Guidelines for Ethical Conduct for the Physician Assistant Profession, "Generally, the law delineates the minimum standard of accept- able behavior in our society. Acceptable ethical behavior is usually less clearly defined than law and often places greater demands on an individual. .. .

"Ethical guidelines for health care practitioners are not meant to be used in courts of law as legal standards to which practitioners will be held. Ethical guidelines are, rather, meant to guide health care practitioners and to encourage them to think about their individual actions in certain situations."

The ethical guidelines for various health care professions have several points in common, but first and foremost is that health care practitioners are obligated to provide the best care possible for every patient, and to protect the safety and welfare of every patient.

State and federal law may differ somewhat from an ethical principle. For example, a state's law may not require physicians to routinely inquire about physical, sexual, and psychological abuse as part of a patient's medical history, but the physician may feel an ethical duty to his or her patients to do so.

Furthermore, the fact that a health care practitioner who has been charged with illegal conduct is acquitted or exonerated does not necessarily mean that the health care practitioner acted ethically.

The term ethical as used here refers to matters involving the following:

1. Moral principles or practices.

2. Matters of social policy involving issues of morality in the practice of medicine.

The term unethical refers to professional conduct that fails to conform to these moral standards or policies. The ethical issues raised are from the real-life experiences of a variety of health care practitioners and are

recounted throughout the text to raise awareness of the ethical dilemmas many practitioners face daily, and to stimulate discussion.

22 Part One I The Foundations of Law and Ethics

Ethics Issues Introduction to Law and Ethics

Ethics ISSUE 1: A physician assistant in a medical practice with several physicians contacts his professional association, the American Academy of Physician Assistants (AAPA), to report that one of his employing physicians often recommends chiropractic treatment for patients with persistent back pain issues that have resisted medical solutions. The PA knows it is legal to refer a patient for chiropractic treatments, but he adamantly opposes the practice, considering it "bogus medicine." The physician declines to discuss the matter.

Discussion Questions

1. In your opinion, how might the situation be resolved?

2. Is it ethical for the PA to continue working for the physician when their opinions differ so widely on this issue?

Ethics ISSUE 2: A registered nurse calls her professional organization's ethics consultant to ask for resources she can present to her employing medical clinic to support her intention to quit working with a physician she feels is provid- ing sloppy and possibly dangerous care.

Discussion Questions

1. What is the most important principle for the nurse to consider here?

2. In your opinion, are there legal issues inherent in this situation, as well as ethical issues? Explain your answer.

Ethics ISSUE 3: A physician assistant (PA) has been helping treat a patient awaiting a heart transplant. The patient is depressed, and says he no longer wants to live. The PAis doubtful that the patient will cooperate in the demanding regi- men required for posttransplantation patients.

Discussion Question

1. Is it ethical for the PA to say nothing to the patient's attending physician, or should he chart the patient's remarks and discuss the matter with the patient's physician?

Ethics ISSUE 4: Family members of a certified medical assistant (CMA) (AAMA) employed by a medical clinic in a small community often ask the CMA for medical advice. Two of her family members have asked her to bring antibiotic samples home for them.

Chapter I !Introduction to Law and Ethics 23

Discussion Question

1. In your opinion, would it be ethical for the CMA to give medical advice to her own family members? To bring drug samples home for them? Explain your answers.

Ethics ISSUE 5: A radiology technician practicing in a small community is interested in dating a person he has seen as a patient.

Discussion Question

1. In your opinion, would it be ethical for the radiology technician to date one of his patients? Would it be ethical for him to date a coworker? Explain your answers.

Chapter 1 Review

Enhance your learning by completing these exercises and more at http:/ /connect.mheducation.com!

Applying Knowledge

LO 1.1

mconnect®

1. List three areas where health care practitioners can gain insight through studying law and ethics.

2. Define summary judgment.

LO 1.2

3. Define bioethics.

24 Part One I The Foundations of Law and Ethics

4. Define law.

5. Define ethics.

6. How is unethical behavior punished?

7. Define etiquette.

8. How are violations of etiquette handled?

9. What is the purpose of a professional code of ethics?

10. Name five bioethical issues of concern in today's society.

11. What duties might a medical ethicist perform?

12. Decisions made by judges in the various courts and used as a guide for future decisions are called what?

13. Written codes of ethics for health care practitioners

a. Evolved primarily to serve as moral guidelines for those who provided care to the sick

b. Are legally binding

c. Did not exist in ancient times

d . None of these

Chapter I !Introduction to Law and Ethics 25

14. What Greek physician is known as the Father of Medicine?

a. Hippocrates

b. Percival

c. Hammurabi

d. Socrates

15. Name the pledge for physicians that remains influential today.

a. Code of Hammurabi

b. Babylonian Ethics Code

c. Hippocratic oath

d. None of these

16. What ethics code superseded earlier codes to become the definitive guide for a physician's professional conduct?

a. Code of Hammurabi

b . Percival's Medical Ethics

c. Hippocratic oath

d. Babylonian Ethics Code

17. Unethical behavior is always

a. Illegal

b. Punishable by legal means

c. Unacceptable

d. None of these

18. Unlawful acts are always

a. Unacceptable

b. Unethical

c. Punishable by legal means

d. All of these

19. Violation of a professional organization's formalized code of ethics

a. Always leads to prosecution in a court of law

b. Is ignored if one's membership dues in the organization are paid

c. Can lead to expulsion from the organization

d. None of these

20. Law is

a. The minimum standard necessary to keep society functioning smoothly

b. Ignored if transgressions are ethical, rather than legal

c. Seldom enforced by controlling authorities

d. None of these

26 Part One I The Foundations of Law and Ethics

21. Conviction of a crime

a. Cannot result in loss of license unless ethical violations also exist

b . Is always punishable by imprisonment

c. Always results in expulsion from a professional organization

d . Can result in loss of license

22. Sellers and manufacturers can be held legally responsible for defective medical devices and products through what charges?

a. Fraud

b. Breach of warranty

c. Misrepresentation of the product through untrue statements made by the manufacturer or seller

d. All of these

23. The basis for ethical conduct includes

a. One's morals

b . One's culture

c. One's family

d. All of these

LO 1.2 & LO 1.3

24. What is bioethics concerned with?

a. Health care law

b. Etiquette in medical facilities

c. The ethical implications of biological research methods and results

d. None of these

LO 1.4

25. Critical thinking skills include

a. Assessing the ethics of a situation

b. First clearly defining a problem

c. Determining the legal implications of a situation

d. None of these

Case Studies

LO 1.2 & LO 1.3

Use your critical thinking skills to answer the questions that follow each case study. Indicate whether each situation is a question of law, ethics, protocol, or etiquette.

You are employed as an assistant in an ophthalmologist's office. Your neighbor asks you to find out for him how much another patient was charged for an eye examination at the eye clinic that employs you. Your neigh- bor also asks you how much the patient was charged for his prescription eyeglasses (the eye clinic also sells lenses and frames).

Chapter I !Introduction to Law and Ethics 27

26. Can you answer either of your neighbor's questions? Explain your answer.

A physician employs you as a medical assistant. Another physician comes into the medical office where you work and asks to speak with your physician/employer.

27. Should you seat the physician in the waiting room, or show her to your employer's private office? Why?

You are employed as a licensed practical nurse (LPN) in a small town. (In California and Texas, the term for this profession is "licensed vocational nurse"-abbreviated as LVN.) A woman visits the clinic where you work, complaining of a rash on her body. She says she recently came in contact with a child who had the same symptoms, and she asks, "What did this child see the doctor for, and what was the diagnosis?" She explains that she needs to know, so that she can be immunized if necessary. You explain that you cannot give out this information, but another LPN overhears, pulls the child's chart, and gives the woman the information she requested.

28. Did both LPNs in this scenario act ethically and responsibly? Explain your answer.

LO 1.4

A physician admitted an elderly patient to the hospital, where she was treated for an irregular heartbeat and chest pain. The patient was competent to make her own decisions about a course of treatment, but her opin- ionated and outspoken daughter repeatedly second-guessed the physician's recommendations with medical information she had obtained from the Internet.

29. In your opinion, what responsibilities, if any, does a physician or other health care practitioner have toward difficult family members or other third parties who interfere with a patient's medical care?

30. What might the physician in this situation have said to her patient's daughter to help resolve the situation?

Internet Activities LO 1.1 and LO 1.2

Complete the activities and answer the questions that follow.

31. Use a search engine to conduct a search for Web sites on the Internet concerned with bioethics. Name two of those sites you think are reliable sources of information. Explain your choices. How does each site define the term bioethics?

28 Part One I The Foundations of Law and Ethics

32. Locate the Web site for the organization that represents the health care profession you intend to practice. Does the site provide guidance on ethics? If so, how? Does the site link to other sites concerning ethics? If so, list three ethics links; then explore these links.

33. Visit the Web site sponsored by the National Institutes of Health called Bioethics Resources (http:// bioethics.od.nih.gov/casestudies.html). Click on the "Case Studies" link, and pick a case study and review it. Do you agree or disagree with the conclusions reached about the issue? Explain your answer.