These sections examine a real-world link to ethical behavior in the healthcare sector. It presents an example of how we apply ethical behaviors to our fellow human beings, a concept which contrasts to how we treat the environment in which we live.
This extract considers what it means to practise ethically; why ethics is so central to the healthcare relationship; and the responsibilities of practitioners, professional bodies, users and those making healthcare decisions for other people (for example, parents and carers of users who are unable to make their own decisions). This extract also explores the unique ethical issues raised by complementary and alternative medicine (CAM) and the extent to which ethical obligations and legal requirements overlap.
To understand the main ethical concepts in delivering healthcare.
To demonstrate a sound understanding of the roles of professional bodies in regulating CAM practitioners.
Write down a few sentences about what you think "acting ethically" means.
Most people understand "being ethical" as having something to do with people acting in "the right way." Acting ethically embraces ideas about what people ought to do or what they should do, which presupposes there are rules of conduct or behaviour by which people expressly or implicitly agree to be bound.
In this sense, acting ethically is similar to acting legally: following a set of rules that determine how people ought to behave. However, whereas the law lays down hard-and-fast rules, ethics presumes that people have a degree of choice about the decisions they make: they can choose to act either ethically or unethically.
The notion of choosing to do the right thing is important because society largely holds people accountable for the actions they take. So when a person's actions are judged, the pertinent questions are why did they act in the way they did, what were their motivations, and what did they hope the consequences of their actions would be?
To be held accountable, people have to understand what they are doing. So, a child would not necessarily be called to account for doing something wrong, on the basis that they are considered to lack the capacity to understand the fundamental difference between right and wrong.
The term ethics is often used interchangeably with morality, although people sometimes draw a distinction between them on the basis that morality is personal to each individual or to a particular group, for example Christian morality. There is probably a more relevant distinction between individual ethics and professional ethics. Each profession has a set of rules and obligations that are central to how professionals acting within that sphere of practice must behave. Many of the requirements of professional practice reflect the expected obligations of the ordinary citizen, including:
Another way of thinking about ethics is to concentrate on people's rights, both in everyday life and specifically as health service users. As individuals, people have a right:
The obligations of a health professional embrace all of these rights. Ethics is important in healthcare for several reasons, but primarily because failing to act ethically can harm someone. Also, the unique vulnerability associated with being a patient leads people to trust that health practitioners will act ethically, by putting their best interests first. This includes taking their wishes into account, and not doing anything without their express permission (for example, by obtaining informed consent).
Healthcare ethics concerns both professionals’ duties and users' rights. Ethics in healthcare tends to concentrate on the following four key principles (Beauchamp and Childress, 1994).
The principle of respect for autonomy – giving competent adults the information they need to make their own decisions, based on their own values and their personal assessment of risk factors, free from coercion or undue influence.
The principle of beneficence – benefiting or acting in the patient's best interests.
The principle of non-maleficence – not deliberately causing the patient harm, or making sure that the benefits outweigh the harm if harm is unavoidable.
The principle of respect for justice – treating all patients equally and providing mechanisms for when care goes wrong.
While these four principles underpin the range of duties that health professionals owe their patients, they do not provide an exact blueprint for how a practitioner ought to act in every given situation. However, they do provide a good starting point for making decisions, so that a practitioner faced with an ethically contentious choice does not make a decision solely on personal preference (for example, a doctor refusing to agree to a woman's abortion because of their personal opposition to it).
Sometimes these four ethical principles clash. For example, a doctor might be reluctant to tell patients they are dying, believing this will cause distress. In the past, doctors could override patients’ autonomy by withholding that information from them in what they perceived were the patients’ best interests. These might include keeping hope alive and encouraging the dying person to take the prescribed medication. Nowadays, such an action would be regarded as unacceptably ‘paternalistic’.
Paternalism has a distinct meaning in healthcare ethics. It describes the actions of a healthcare practitioner who overrides or does not seek the wishes of a competent person (that is, someone who has sufficient autonomy to make their own decisions), believing that they are better able to decide what is in the patient's best interests. A paternalistic action is always well intentioned but is ethically unacceptable because it usurps people's rights to make their own decisions, based on their own values and beliefs.
Since the 1970s, there has been a cultural shift towards respecting rights and promoting self-determination. This means it is now considered more preferable for people to make their own choices on the basis of all the relevant facts than for other people to make decisions for them.
This example also demonstrates that ethics is not static but reflects what is considered ethically appropriate by a society at different points in time, and that different cultures may have differing views on what is ethical. This explains why euthanasia can be lawful in the Netherlands but not in the UK: in the Netherlands, the emphasis is on respecting people's autonomy, whereas in the UK, the emphasis is on not causing harm.
Historically, healthcare ethics tended to concentrate on the responsibilities owed by the practitioner to an individual person. However, the true scope of healthcare ethics is considerably wider. Practitioners have duties not just to the individual in front of them but to all of their clients. They may even have duties to the public in general.
For example, a practitioner who treats someone for a sexually transmitted disease has a duty to act in that person's best interests, but may also have a duty to that person's sexual partner, who could be a client. The practitioner may have a duty to warn third parties, who may not be clients, that they are at risk. Practitioners have ethical duties not just to service users but also to their profession and their employers.
Users have ethical responsibilities as well as rights. These include doing what they can to maintain their own health; not drawing inappropriately on health services (for example going to the accident and emergency department with a routine or trivial complaint); and providing all necessary relevant information to a practitioner to facilitate an accurate diagnosis.
In the next activity you will reflect on your experiences as a user of health services and consider some of the ethical issues that arise in everyday health encounters.
Reflect on your last healthcare consultation (for example, a routine check-up with your GP or practice nurse, a visit to the dentist, a hospital appointment or a consultation with a CAM practitioner).
Did any aspects of the encounter give rise to ethical issues? Focus on the positive as well as the negative aspects.
Try to consider as broadly as possible, for example, whether the receptionist was polite to you, whether you felt confident to discuss personal information, whether the practitioner seemed genuinely interested in your problem or whether your appointment was on time.
Ethics permeates every aspect of the healthcare encounter. Healing relationships are, at their heart, based on trust. When people are ill, they need to believe that everyone involved in providing their healthcare is acting appropriately and treating them in their best interests (for example, giving them the treatment that is best for their condition, not simply the cheapest or the quickest to administer).
Acting ethically involves healthcarers respecting users' rights and supporting their choices (for example, giving them as much information as they want about the range of treatments available and the alternatives to treatment); being good at what they do (keeping up to date with and undertaking continuing professional development); refraining from actively harming users (by following approved and appropriate practices); and treating people in a fair and consistent manner (for example, not having favourite users with whom they spend twice as long as they do with difficult users).
In Activity 9, it was probably easier to think about instances of unethical practice than examples of ethical practice. The following list identifies some of the areas you may have considered as giving rise to ethical issues.
When you made your appointment did you feel that the initial contact with the receptionist or the professional was handled sensitively? Was the information you provided managed in a sensitive way, with respect for your privacy?
When you arrived for your appointment did the receptionist (if one was present) give you the chance to say why you were there (if relevant) and privacy in which to give your personal details?
Did the practitioner respect your autonomy, by asking you what you think is wrong and what you want to do about it, by gaining your consent to treatment, by respecting your personal health information as being confidential, by not discussing your details with anyone who does not need to know (other than to benefit your health), and by ensuring that written notes or computer records about you are kept safely?
Did the practitioner act in your best interests, by obtaining an adequate history from which to form a diagnosis and consider the right treatment plan, by providing treatment that should bring about the desired outcome with a minimum of side effects, and by keeping up to date with professional developments?
Did the practitioner act detrimentally towards you in any way: for example, being rude or dismissive, suggesting an inappropriate treatment, or charging you excessively for their services?
As far as you could tell, did the practitioner treat you fairly: for example, was the appointment on time, or were you or other people kept waiting? If your appointment was much later than the arranged time, were you given an explanation or apology? Did you feel that you could complain if there was anything you were unhappy about?
The above list shows that most interactions in health and social care have ethical dimensions, even if you did not necessarily consider them as ‘ethical’ issues. Most ethical issues concern the ordinary, everyday relationships between practitioners and users, although the media tend to focus on the more dramatic life-and-death issues, often presenting them in a highly polarised way.
Almost all interactions have an ethical aspect, which spans encounters from what might appear to be simple questionnaires sent to people at home, through all the interactions they have with the service providers, including the treatment. There are ethics about how people are referred to a practitioner, and the treatment prescribed to them.
As previously mentioned, users also have ethical responsibilities, for example telling their doctor they are also receiving treatment from a CAM practitioner, which might have a bearing on the doctor's recommended treatment and vice versa.
The healthcare relationship is basically a relationship of trust. This implies that practitioners are motivated by the users' best interests; will not exploit the therapeutic relationship to satisfy their own ends; will behave in an appropriate manner that is conducive to the healing process; and will refrain from behaviour that could harm users, including being physically or psychologically unfit to treat them. The examples in Box 2 give a clearer idea of what this means.
A patient may reveal extremely personal information to a practice nurse during a family planning consultation, even though the patient knows little about the practitioner.
A dental patient who is paying for private dental treatment needs to trust that they will not be subjected to unnecessary and painful procedures simply to increase the dentist's earnings.
An osteopathic patient needs to feel confident that she has been asked to undress down to her underwear only for the purposes of her treatment, and not for the practitioner's personal gratification.
A surgical patient takes it on trust that the surgeon's skills are up to date, and that they know about all the available options that might obviate the need for surgery.
All of these examples demonstrate that people would be uncomfortable in trusting or confiding in a practitioner unless they can believe the practitioner is worthy of respect and can be relied on not to abuse their trust.
Ethical behaviour is central to the healthcare relationship because of the inherent power disequilibrium between user and practitioner. This is based largely on the relative disparity in knowledge between healthcarers and the people they treat. Health professionals are consulted precisely because they have skills that lay people do not have.
People increasingly expect to be informed and involved in all aspects of decision making about their medical treatment, which is acknowledged in the development of the ‘expert patient’ (Department of Health, 2001). At the same time, many people are much more knowledgeable about health-related matters than in the past. This is hardly surprising given the attention health issues receive in the media. The internet has also helped to narrow the knowledge gap between doctors and users.
In addition, television series such as Casualty, ER, Holby City and Peak Practice have made people more familiar with medical terminology and seeing healthcarers working through fictionalised ethical dilemmas. They also see documentaries about, for example, the ethics of assisted reproduction, separating conjoined twins and end-of-life decisions.
In contrast, many people know relatively little about CAM unless they have had personal experience. When people consult a complementary practitioner for the first time, they may not know what the therapy involves or what outcomes to expect realistically.
For example, although people are increasingly aware of being asked to give their consent to conventional medical procedures, they would not necessarily expect a chiropractor to ask them to sign a consent form. They might also be unaware of the level of information they need before they can give valid consent to their first acupuncture session.
In these situations, and from an ethical standpoint, it is even more important for the practitioner to openly discuss the form of treatment being offered, what it entails, and what it could achieve in the given situation, as well as to discuss alternative treatment strategies.
Another obvious inequality between practitioners and users is that most people who are ‘ill’ (loosely defined) may be frightened, in pain and vulnerable, and need to be able to rely on the practitioner. Health providers, in contrast, should be in robust psychological and physical health and in no sense reliant or dependent on the user. When people are ill, they usually look for a health practitioner who has the skill and expertise to make them better, and who may, conceivably, impose their own professional judgement when appropriate.
The autonomy of people who are ill is already compromised. They may be unable to work, or their mobility may be restricted, limiting their ability to get about as they would like. They may be in too much pain or discomfort to continue with their normal business.
Depending on the severity of the diagnosis, they could be anxious and possibly depressed. All of these factors compromise autonomy. To regain their health and full autonomy, many people are prepared to depend on advice and allow themselves to be cared for by others.
People who are used to managing their own affairs can feel uncomfortable being dependent on others. The loss of health interferes with people's ability to enjoy their lives. They invest significant trust and hope in the belief that the person they depend on can restore them to good health. While respecting autonomy is a very important part of healthcare, so is the ability to care and be dependable.