Theory of Healthcare Ethics

Theory of Healthcare Ethics

 

 

HEALTH CARE ETHICS

Critical Issues for the 21st Century

FOURTH 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 Emerita, Center for Health

Policy and Ethics Creighton University Omaha, Nebraska

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Library of Congress Cataloging-in-Publication Data Names: Morrison, Eileen E., editor. | Furlong, Elizabeth, editor. Title: Health care ethics: critical issues for the 21st century / edited by Eileen Morrison, Beth Furlong. Other titles: Health care ethics (Morrison) Description: Fourth edition. | Burlington, Massachusetts: Jones & Bartlett Learning, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2017043204 | ISBN 9781284124910 (pbk.: alk. paper) Subjects: | MESH: Bioethical Issues | Delivery of Health Care—ethics | Ethics, Clinical Classification: LCC R724 | NLM WB 60 | DDC 174.2— dc23 LC record available at https://lccn.loc.gov/2017043204

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Writing is always a collaboration. While writers have unique ways of seeing the world, they are influenced by their experiences, research,

and education. Therefore, I dedicate this edition of Health Care Ethics: Critical Issues for the 21st Century to all those who contributed to

chapters in this work and those who supported me through its creation. First, there is my immediate family, Grant, Kate, Emery Aidan, and

Morrigan Leigh, who listened and encouraged. There are also colleagues, relatives, and friends who provided feedback and a lift of spirit when I needed it. Finally, there is my publisher, Michael Brown; my coeditor, Beth Furlong; and my Jones & Bartlett Learning editor,

Danielle Bessette. They each added much to the quality and integrity of this work.

–Eileen E. Morrison

 

 

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 ethics education of others with this book is possible because of the collegiality and support of my coeditor, Dr.

Eileen Morrison. It has been a professional pleasure to work with her.

–Beth Furlong

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© f11photo/Shutterstock

Contents

Contributors About the Editors Preface

PART I Foundations in Theory

Chapter 1 Theory of Healthcare Ethics Introduction

Ethics and Health Care

Ethical Relativism

Ethics Theories

Ethics Theories and Their Value to Healthcare Professionals

Summary

Questions for Discussion

Notes

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Chapter 2 Principles of Healthcare Ethics Introduction

Nonmaleficence

Beneficence

Autonomy

Theories of Justice

Reflective Equilibrium as a Decision-Making Model

Summary

Questions for Discussion

Notes

PART II Critical Issues for Individuals

Chapter 3 The Moral Status of Gametes and Embryos: Storage and Surrogacy Introduction

The Moral Community

Making Decisions

Surrogacy

Storage

Summary

Questions for Discussion

Additional Readings

Notes

Chapter 4 The Ethical Challenges of the New Reproductive Technologies

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Introduction

Two Inadequate Approaches to Evaluating Alternative Reproductive Technology

A Basis for Developing an Ethical Position

A Proposed Ethical Standard

The Family

Donors and the Cultural Ethos

Summary

Questions for Discussion

Notes

Chapter 5 Ethics and Aging in America Introduction

The Growing Population Needing Care

Issues of Access

Forces for Improving Access

What Are the Prospects for Improved Access?

Update from a Practitioner’s View

Summary

Questions for Discussion

Additional Resources

Notes

PART III Critical Issues for Healthcare Organizations

Chapter 6 Healthcare Ethics Committees: Roles, Memberships, Structure, and Difficulties

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Introduction

Why an Ethics Committee?

The Function and Roles of Ethics Committees

Ethics Committee Membership

The Healthcare Ethics Committee’s Background and Education

Institutional Commitment

Challenges for Healthcare Ethics Committees

Update from a Practitioner’s View

Summary

Questions for Discussion

Notes

Chapter 7 Ethics in the Management of Health Information Systems Introduction

Operational Definitions

Ethical Dilemmas Involving Data on HISs

Smartphone Network of Healthcare Awareness—Good Idea or Violation of Privacy?

Is Health Care a Right or a Benefit? What Data Protection Should Be Provided to PHI?

Ethical Decision-Making Models for the Management of HIM

Acknowledgment

Questions for Discussion

Notes

Chapter 8 Technological Advances in Health Care: Blessing or Ethics Nightmare?

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Introduction

Medical and HIT Defined

The Ethical Obligation

Science and Technology Innovations and Ethics Concerns

Recent Innovations Involving Technology and Their Ethics Concerns

HIT and the Medical Group Practice

Summary

Questions for Review

Notes

Chapter 9 Ethics and Safe Patient Handling and Mobility Introduction

Extent of the Problem

Problem-Solving

Ethics Concerns

Summary

Questions for Discussion

Notes

Chapter 10 Spirituality and Healthcare Organizations Introduction

Evidence-Based Practice: The Answer and the Challenge

This Thing Called Spirituality

Is There a Place for Spirituality in the Healthcare Workplace?

Spirituality in the Business of Health Care

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Integration of Spirituality into Healthcare Workplaces

Ethics Theories and Spirituality

Ethics Principles and Spirituality

Summary

Questions for Review

Notes

Chapter 11 A New Era of Health Care: The Ethics of Healthcare Reform Introduction

Healthcare Reform in the United States

Health System Reform in the 20th Century

Key Provisions of the Healthcare Reform Legislation of 2010 (ACA)

How Well Have the Reforms Met the Expectations of a Just Healthcare System?

Ethics Considerations Underlying Healthcare Reform

Summary

Questions for Discussion

Notes

PART IV Critical Issues for Society’s Health

Chapter 12 Health Inequalities and Health Inequities Introduction

What Are Health Inequalities?

Why Are Some Health Inequalities also Health Inequities?

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How Can We Measure Health Inequalities?

What Is the Best Way to Reduce or Eliminate Health Inequalities?

Conclusion

Summary

Questions for Discussion

Notes

Chapter 13 The Ethics of Epidemics Introduction

Epidemics, Ethics, and Public Health

Modern Epidemics

Determination of the Decision-Making Responsibility: Individual Autonomy Versus Paternalism

International Perspectives and the Bioethics Model

Summary

Questions for Discussion

Acknowledgment

Notes

Chapter 14 Ethics of Disasters: Planning and Response Introduction

Disasters in U.S. History

Disaster Planning and Response by the Federal Government

Disaster Preparedness and Response for Healthcare Institutions

Professional Readiness for Disasters

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Individual Response to Disasters

Update from a Practitioner’s Point of View

Summary

Questions for Discussion

Notes

Chapter 15 Domestic Violence: Changing Theory, Changing Practice Introduction

Personal and Social Barriers

Systemic Barriers

Impact of Theory on Clinical Practice

Structural Constraints

Implications for Training and Practice

Conclusion

Summary

Questions for Discussion

Notes

Chapter 16 Looking Toward the Future Introduction

New Considerations in Ethics Theory

Summary

Questions for Discussion

Notes

Glossary

Index

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Contributors

Omolola Adepoju, PhD, MPH Assistant Professor School of Health Administration College of Health Professions Texas State University San Marcos, TX

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

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Kimberly A. Contreraz, BSN, MSN, FNP, ACHPN Director of Palliative Care St. Vincent Anderson Regional Hospital Anderson, IN

Dexter R. Freeman, DSW, LCSW Director Master of Social Work Program Army Medical Department Center & School Army-Fayetteville State University Houston, TX

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

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

Nicholas King, PhD Assistant Professor Biomedical Ethics Unit McGill University Faculty of Medicine Montreal, QC, Canada

Scott Kruse, MBA, MSIT, MHA, PhD, FACHE, CPHIMS, CSSGB, Security+, MCSE

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Assistant Professor and Graduate Programs Director School of Health Administration College of Health Professions Texas State University San Marcos, TX

Christian Lieneck, PhD, FACMPE, FACHE, FAHM Associate Professor School of Health Administration College of Health Professions Texas State University San Marcos, TX

Richard L. O’Brien, MD University Professor Emeritus Creighton University Omaha, NB

Robert W. Sandstrom, PT, PhD Professor and Faculty Associate School of Pharmacy and Health Professions Creighton University Omaha, NB

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

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Carole Warshaw, MD Director National Center on Domestic Violence, Trauma & Mental Health Chicago, IL

Michael P. West, EdD, FACHE Executive Director University of Texas Arlington-Fort Worth Campus Fort Worth, TX

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About the Editors

Eileen E. Morrison is a professor in the School of Health Administration at Texas State University, San Marcos, Texas, USA. Her educational background includes a doctorate from Vanderbilt University, Nashville, Tennessee, USA, and a master of public health degree from the University of Tennessee, Knoxville, Tennessee, USA. In addition, she holds an associate degree in logotherapy and a clinical degree in dental hygiene.

Dr. Morrison has taught graduate and undergraduate courses in ethics and provided workshops to professionals, including those in medicine, nursing, clinical laboratory services, health information, and dentistry. She has also 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 (3rd ed.), published by Jones & Bartlett

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Learning, and a children’s book called The Adventures of Emery the Candy Man.

Beth Furlong is an associate professor emerita and adjunct faculty in the Center for Health Policy and Ethics at Creighton University, Omaha, Nebraska, USA. Her academic background includes a diploma, BSN, and MS in nursing, an MA and PhD in political science, and a JD. Dr. Furlong has taught graduate ethics courses and provided continuing education unit (CEU) workshops for nurses on ethics issues. Her publications are in the areas of health policy, vulnerable populations, and ethics.

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T

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Preface

he history of health care is filled with change. For example, providers and systems have embraced changes that lead to cures for disease, new ways to

care for patients, regulation, and funding. However, during the creation of this fourth edition of Health Care Ethics: Critical Issues for the 21st Century, the healthcare system has been in change overload. It must address changes from technology, the emphasis on patient-centered care, and fiscal challenges. It is also trying to address the truly unknown. For example, legislators continue to consider the appeal of the Patient Protection and Affordable Care Act of 2010, while others are debating its repair. Since healthcare funding, programs, and regulations are linked to this legislation, the healthcare system will continue to engage in multilayers of contingency planning for survival and service.

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Readers will also notice changes in this edition as its authors consider the implications of change with respect to their content areas. However, the fourth edition still reflects the organizational model that was used in previous editions. Therefore, the Greek temple image remains its organizational framework as a model for addressing ethics issues in health care (see Figure FM.1).

Like all buildings, this temple needs a firm foundation and ethics theory and principles serve this purpose. It also makes sense if one is going to be able to analyze the ethical implications of an issue. An appropriate analogy would be that a surgeon cannot be successful unless he or she understands human anatomy. Likewise, a student who wishes to analyze the ethics of a particular issue in health care must have knowledge of theories and principles of ethics. Dr. Summers provides a strong foundation for applying ethics in the chapters “Theory of Healthcare Ethics” and “Principles of Healthcare Ethics” of this edition.

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FIGURE FM.1 Healthcare Ethics Organizational Model.

The three main pillars of the temple model illustrate sections to organize the ethics issues faced in healthcare situations. Note that the center pillar represents individuals who are called patients in the healthcare system. This is because the healthcare system would not function unless there are patients who need care. The remaining two pillars represent issues relevant to healthcare organizations and society and reflect challenges to the future of healthcare organizations and their ability to care for patients.

Given the current environment in the healthcare system, the potential for chapters and their content was extensive. The challenge for the writers was to select example of topics that represent ethics challenges for the future and avoid a non-readable tome. While it was not possible to address each potential issue, topics were updated and

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expanded within a 16-chapter format. For example, under the “Critical Issues for Individuals” section, attention was given to the most vulnerable patients. Therefore, there are chapters related to the moral status of embryos and infants and reproductive technology. To address patients at the other end of the life continuum, major revisions were made to the discussion of aging patients and the ethics of their care. The other pillars of healthcare organizations and society also include major revisions of existing chapters. New chapters that reflect current ethics issues in today’s environment have also been added. For example, there are chapters on the ethics of health information management and the ethics of epidemics.

Health care is truly in the epoch of change, but ethics will always matter. Even experts in ethics and health care cannot predict the future of health care with absolute certainty. However, this does not mean that ethics should not be part of making decisions amid a challenging environment. In fact, the ethics of what we do maybe even more important because health care is always held to a higher standard, even when it must meet unknown challenges.

However, Morrison and Furlong are optimistic that students will continue to ask themselves, “Is this the best ethical decision to make?” and “How do I know that this it is the best?” as they progress through their careers. Patients, healthcare organizations, and the community rely on their answers so that health care can be patient-

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centered, cost-effective, and fiscally responsible. What a challenging combination to face in the epoch of change!

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PART I Foundations in Theory

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Change is not new, but it appears to be the theme of the current era of health care. The Patient Protection and Affordable Care Act (ACA 2010) became a law in 2010 and created major changes in the health care system. Regardless of the outcome of its status, healthcare organizations will be expected to provide patient-centered care that complies with legislation, uses qualified and compassionate professionals, and is conducted with fiscal responsibility. In addition, the foundation of health care must also be centered in ethical policies and action.

To address necessary ethics-based decisions amid an environment of consistent change, you must have a foundation in ethics theory and principles. While some think that ethics is just about “doing the right thing,” in an epoch of change, one must justify decisions. In addition, the professionals employed in healthcare settings have ethics guidelines and duties encoded in their practices. Of course, patients expect healthcare providers and facilities to be concerned about their best interests, which include ethical behavior and practices. How can you justify your decisions in the practice or administration with an ethics rationale? The first section of this new edition of Health Care Ethics: Critical Issues for the 21st Century begins with two chapters that will provide this foundation.

The foundation in ethics theory and principles provided in the chapters “Theory of Healthcare Ethics” and “Principles of Healthcare Ethics” give you practical tools for analyzing ethics-related issues. In the chapter “Theory of Healthcare Ethics,” Dr. Summers presents a well-researched

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overview of the theories commonly used in healthcare ethics. He includes a model that illustrates the position of ethics in philosophy. Following that, he discusses theories that indirectly relate to healthcare, such as authority-based ethics, egoism, and ethical relativism. Then, he provides a thorough analysis of theories that are most commonly applied in healthcare practice. These include natural law, deontology, utilitarianism, and virtue ethics. In his discussions, he uses several examples to improve understanding concerning the application of these theories in professional practice.

In the chapter “Principles of Healthcare Ethics,” Summers continues his scholarly discussion of ethics by presenting the most commonly used ethics principles in health care. These principles are nonmaleficence, beneficence, autonomy, and justice. Because justice is the most complex of the four, he provides additional definitions of types of justice and includes information for making decisions about justice in healthcare practice. At the end of the chapter, Summers also presents a decision-making model called the reflective equilibrium model. This model demonstrates the application of ethics theory and principles in the practice of making clinical and business decisions.

You can apply the information given in these two chapters to your understanding of the remaining chapters in this edition. You will find that having a solid grounding in theory and principles will allow you to have greater clarity in making ethics-based decisions in your own area of

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health care. Certainly, as Summers suggests, principles and theory should be an important part of your ethical decision-making throughout your practice of health care.

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CHAPTER 1 Theory of Healthcare Ethics Jim Summers

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I ▶ Introduction

n this chapter, Dr. Summers provides a scholarly review of the main theories that apply to the ethics of healthcare situations. Why is knowledge of theory

important to busy healthcare professionals? In this time of great change and challenge within the healthcare system, there is a need to apply ethics in all types of decision- making. To make this application successfully, one needs a foundation in ethics, in addition to data and evidence- based management tools, including those offered by advanced technologies. An understanding of ethics theory gives you the ability to make and defend ethics-based decisions that support both fiscal responsibilities and patient-centered care. While these kinds of decisions are difficult, without a foundation in ethics theory, they might prove impossible. Therefore, this chapter and the one that follows, on the principles of ethics, will serve as your ethics theory toolbox.

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▶ 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 situation 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 will provide challenges that will necessitate reasoning about the right course of action. In addition, healthcare resource allocations will become more vexing as new diseases threaten, global climate change continues apace, and ever more people around the world find their lives increasingly desperate. In the Patient Protection and Affordable Care Act of 2010 (ACA 2010) era, managers of healthcare organizations will find the resources to carry out their charge increasingly constrained by multiple levels of change, differences in payment structures, and labor shortages. A foundation in ethics theory and ethical decision-making tools can assist healthcare leaders in assessing the choices that they must make in these vexing circumstances.

With the current emphasis on patient-centered care, knowledge of ethics can also be valuable when working with healthcare professionals, patients and their families, and policy makers. In this sense, ethical understanding, particularly of alternative views, becomes a form of cultural competence. However, this chapter is limited to a1

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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 ethics 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.

As one might suspect, when normative ethics seeks to determine the moral views or rules that are appropriate or correct and to explain why they are correct, major disagreements in interpretation often result. These 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 ethics theories to be considered in this chapter. Although no single theory has generated consensus in the ethics community, there is no cause for despair.

FIGURE 1-1 Normative ethics theories.

The best way to interpret these various ethics theories, some of which overlap, is to use the analogy of a toolbox.

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Each of these theories 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 ethics theory over another for all situations. You can choose the best theory for a task, according to the requirements of your role and the circumstances. Trained philosophers will find flaws with this approach, but 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. For example, I can 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.

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