For A-Plus Writer Only

Part I Tetra Images/SuperStock Foundations of Health Care Ethics Chapter 1 The Evolution of Health Care Ethics: Overview, Theories, and Methods Chapter 2 The Health Care Profession and the Virtuous Professional Chapter 3 Moral Identities and Organizations The aim of Part I of Understanding Health Care Ethics and Medical Law is to introduce and explain the foun- dations of contemporary health care ethics, particularly in industrialized nations. Ethical conduct is a require- ment for all health care professionals, including physicians, nurses, social workers, and administrators. It also applies to patients and their families; indeed, to everyone who interacts in a system. Health care is provided in an intimate, urgent, critical, and turbulent environment. Actions are thus continually challenged by ethical demands and by some ethical quandaries. Chapter 1 attempts to clarify the meanings and use of the term ethics , and it briefly summarizes the rise of modern health care ethics as well as that of the theories and methods for approaching ethical questions.

Chapter 2 explores the meaning, duties, and responsibilities of health care professionals. It also examines the corollary importance of virtue, which emphasizes the ability to nimbly, deliberatively, and reflectively assess the relative weights of competing values and norms and choose prudently from among them. We will also explore the concept of fiduciary duty and its relevance to health administration and health care. In Chapter 3 the importance of reflecting on and purposely crafting and articulating the moral identity of the health care organization is highlighted. You will be asked to reflect on your own values and perspectives, and through exercises and questions, you will be guided to articulate a personal moral vision or statement. 3 Travel Pictures Ltd./SuperStock The Evolution of Health Care Ethics: Overview, Theories, and Methods 1 Learning Objectives 1. Summarize major factors that contributed to the interest and importance of medical ethics in the mid-20th century. 2. Identify the major ethical theories that attempt to explain and guide right action. 3. Discuss principlism, along with its strengths and weaknesses, as a prime method for addressing ethical problems. 4. Identify the major factors associated with the rise of bioethics committees, as well as with their primary functions. 4 CHAPTER 1 Section 1.1 The Rise of Contemporary Health Care Ethics Ethics is a word that is frequently used, heard, and seen in the media. It generally refers to what people should do and how they ought to act. However, the meaning of the term is often unclear, and people do not always share a common understanding of its meaning. It is not always evident whose ethics are being invoked, and individuals may not agree about what constitutes an ethical problem.

The term ethics refers to an academic study; as such, it is a systematic analysis of the rightness and wrongness of actions, along with the theoretical basis and methods used in deciding which course to take. Ethics also encompasses a very practical application: It seeks to provide a guide to behav - iors. In viewing an action or alternative actions, the goal of applied ethics is to identify and resolve problems. How people behave toward one another is based on their personal morals as well as on societal ethics. There is some universal agreement about what is right and wrong; for example, murder and incest are almost always considered wrong. However, there is much variability in what an individual or particular society considers ethical behavior, depending on its laws and norms.

This is in part due to the fact that different peoples regard different situations as posing an ethical dilemma, or situation in which they are uncertain about the correct course of action.

Given that Western societies, particularly the United States, comprise many communities, cul- tures, and languages, it is not surprising that there is difficulty formulating concise and coherent language to describe a comprehensive set of moral standards that can be applied to society at large. Similar challenges arise within organizations. These challenges are particularly pronounced in health care organizations, where communities, cultures, and languages intersect on a daily basis, sometimes under critical and urgent circumstances. Therefore, the major question we will explore in the chapters that follow is, can health care professionals and organizational decision makers identify a core set of fundamental precepts and principles that should be considered regardless of location, religion, and law? We will consider which principles are to be prioritized, as well as how to address ethical questions systematically. First, we will explore the ways in which health care and ethics have intersected throughout history.

1.1 The Rise of Contempor ary Health Care Ethics M edicine has been preoccupied with doing the right thing since healers were shamans and priests. The Hippocratic oath is believed to have been written in the 5th century BCE.

Though other philosophers commented on the code and ethical duties over the centu- ries, and some have recently written contemporary versions, the oath remains foundational to medical practice. Graduating physicians still swear to uphold the tenets of the oath, which include the promise of fidelity (faithfulness), the promise to observe patients’ confidentiality, and the promise to have respect for those under their care. See Figure 1.1 for a timeline of the history of ethical principles in health care. 5 CHAPTER 1 Section 1.1 The Rise of Contemporary Health Care Ethics Figure 1.1: The bumpy road of the ethical principles of health care Ethical principles in health care have evolved over the course of history. 6 CHAPTER 1 Section 1.1 The Rise of Contemporary Health Care Ethics For a very long time (until the mid-20th century), health care was delivered without significant technology or capability other than simple procedures and a great deal of compassion. For exam- ple, sterile techniques and anesthesia were unknown until the beginning of the 20th century, and antibiotics were not developed until World War II. When medicine was less effective, the belief that the doctor knew best (paternalism) was not significantly challenged; without effective treat - ments, kindness and caring were indeed the best medicine.

With the development of modern medicine and the invention of life-supporting technology begin - ning around the 1950s and 1960s, choices and costs increased, which complicated medical decisions. In the 1960s, the invention of dialysis, ventilators, and intensive care units vastly improved patient health; the advent of dialysis, for example, meant that patients could now be maintained on machines that cleaned their kidneys and oxygenated their blood. The rise of technology coincided with political demands for increased civil liberties and feminist rights. Individuals and interest groups who represented those factions agitated for their rights to make health care decisions and to advance their own particular position. On occa- sion, patients, their families, and their physicians dis - agreed about whether to continue treatment. In those cases it was not clear what to do, who should decide, and what basis to use for decisions. Given the plural - istic society of the United States and the fact that the nation lacks a common ethos, these decisions fell to the courts to decide. New technology also required capital-intensive hospitals, specialization, and new financing mechanisms. Specialists who often did not have any relationship with the patient or the family replaced the old family doctor who had the luxury of knowing his or her patients. This affected the physician-patient relationship, and new forms of health care delivery developed.

In addition to court decisions that influence practice, heightened public expectations sometimes result in malpractice suits. In turn, many physicians practice defensively. Practice is also regulated by third-party payers, including the state and federal governments and insurance companies. The medical and hospital associations further regulate practitioners through accreditation and peer review.

Organizations and Physicians The relationships of individual physicians to health care organizations have become increasingly important and complex. These relationships also vary by the particular characteristics of the orga - nization, which may be integrated vertically with facilities that offer either a lower or higher level of care, such as nursing homes or tertiary care hospitals, or horizontally with similar institutions at the same level of care, or both. Hospitals also differ in their characteristics and feature a wide array of options and potential arrangements: health care organizations might be religious, pri - vate, government, for profit, urban, or community. The structural differences among the organiza - tions do not predict the ethical challenges; they simply change some of the contextual details of the cases. Individuals and organizations have somewhat different roles and functions, but they all share the primary goals of quality patient care. However, they also may compete for limited Exactostock/SuperStock Advancements in medical technology, especially in life-support systems, have given rise to new ethical dilemmas for doctors, patients, and family members. 7 CHAPTER 1 Section 1.1 The Rise of Contemporary Health Care Ethics resources and power, and there is the potential for a conflict of interest. Thus, duties and respon- sibilities of the board of directors, the CEO, and the administrative team and their relationships to individual physicians and medical groups all present potential ethical pitfalls. The following are examples of structural differences that could potentially pose a conflict of interest: • Physicians may work independently of the organization in their own office, but they will usually also be a member of the medical staff, which has its own bylaws. They are thus constrained by rules with which they may not agree or which they might not respect. • Administrators may have loyalty to their institution, but as part of a corporation, they are also required to comply with financial and managerial demands. Potential financial and clinical conflicts are part of their daily lives. • The board of directors has differing power, authority, and functions, depending on whether the facility is independent or part of a corporation. Its philosophy of care may diverge from the corporation or from administration. In addition, the boundaries of the board’s authority may not be clear. Human Subjects Research Another historical stream that influenced the rise of bioethics was the realization, which began around World War II, that persons all over the world had been forced to become subjects in clini - cal research; in other cases, research subjects were mistreated or abused. Perhaps the best known example in the United States of grievous research misconduct was the Tuskegee syphilis study conducted by the U.S. Public Health Service from the late 1930s until the early 1970s. In that trial, individuals afflicted with the disease were not given antibiotics, despite availability and efficacy.

Table 1.1 shows the number of participants who were not treated for syphilis for research pur - poses. Many research abuses have been reported worldwide, and in response, the international community has developed codes and regulations that foster ethical practice.

Table 1.1: Participants in the Tuskegee syphilis study Results of the Tuskegee syphilis study conducted from 1932 to 1972. In 1932 poor Black sharecroppers from Macon County, Alabama, were recruited to participate in the study so researchers could follow the progression of untreated syphilis over time. The men all believed they were receiving free health care and did not know they had the disease. The controversial study led to tight federal regulations that require informed consent to protect human research subjects. Control participants Syphilitic participants Total Classification at initial examination 200.0 411.0 611.0 Cases added in 1938–1939 2 14.0 14.0 Total—original classification 200.0 425.0 625.0 Controls infected during observation 29.0 19.02 Controls reclassified as syphilitic on basis of additional history 21.0 11.0 2 Controls reclassified as syphilitic on basis of treponemal tests 28.0 18.0 2 Total—final classification 182.0 443.0 625.0 Known dead—number 97.0 276.0 373.0 Known dead—percentage 53.3 62.3 59.7 Remainder; examined in 1968—number 36.0 53.0 89.0 Remainder; examined in 1968—percentage 42.4 31.7 35.3 Source: Records of the Centers for Disease Control and Prevention 8 CHAPTER 1 Section 1.1 The Rise of Contemporary Health Care Ethics Indeed, ethics committees in many countries remain concerned with research rather than clinical or organizational issues. Clinical trials are heavily regulated to protect quality and human safety.

The ethics of who has the right and authority to make decisions, the propriety of those choices, and access to care, as well as those surrounding research, have assumed increasing importance.

This soft paternalistic approach has been justified by the long and widespread international his- tory of abuse of human subjects and by the complexity of proposed trials that require highly regu - lated review by institutional review boards (IRBs) . In the United States the IRB is separate from the bioethics committee, which deals with clinical and organizational ethical issues. In other parts of the world, the bioethics committee functions similar to the IRB. Some major ethical issues sur - rounding the protection of human subjects—including informed consent, confidentiality, conflict of interest, and justice—are similar to the clinical concerns. However, there are essential differ - ences between the clinic—where patients’ rights to refuse recommended treatments are well established—and in research, where the primary ethical goals surround protection of human sub - jects’ safety and assurance that informed consent was obtained. The true differences between clinical care and research, however, are in the goals of clinical care, which is to heal and care for, and research, which is to discover and increase knowledge.

Particular research ethics questions include selection of research subjects, access to studies, use of placebos, the ethics of international trials, and compliance and relationships with outside ven- dors. A particular continuing dilemma is the confusion patients feel when enrolled in clinical trials by their personal physician. Both parties may be wary of the potential conflict when the investi - gator and the clinician are the same person. Is the physician acting as an investigator or as the treating doctor who places the patient’s interests above all? Many of these issues are not easily addressed by regulation, but require professional and organizational diligence. As more research is conducted by private pharmaceutical companies and in developing nations, the ethical dilem - mas persist.

Bioethics Committees Bioethics committees (BECs) have grown in response to issues raised by exploding medical tech- nology, diversity among the population, and directives from the courts and health care systems attempting to address ethical conflicts in health care organizations. Technology has increased choices and thus raised questions about what medical decisions to make, who should make them, and when they are appropriate. Ideally, BECs can prevent some of the many ethical dilemmas posed by these developments. Preventive ethics implies that the best resolution to a dilemma is to prevent it from arising in the first place.

Society’s diversity means that people of different cultures and beliefs bring an array of perspec - tives and values to the table when they make critical health care decisions. On the other hand, in nations with a dominant theocracy, religion has often provided direction or resolution to ethical dilemmas through consistent moral authority. Examples include the Catholic Church’s prohibition of elective abortions and the Islamic prohibition on male physicians touching female patients.

Most countries lack a single authority, however, and many developed nations have various multi - cultural communities. Thus, particularly in pluralistic regions that lack a unified religion, language, or culture, there is confusion over how to universally address or resolve ethical dilemmas.

In an effort to prevent such confusion, most hospitals have established a mechanism for address - ing bioethical problems such as who has the authority to give informed consent, whether to con - tinue life support, and how to resolve disagreements between or among caregivers and families 9 CHAPTER 1 Section 1.2 Theories and Methods of Contemporary Bioethics when patients can no longer represent themselves. Some larger institutions and university medi- cal centers employ clinical ethicists. In the United States and other Western nations, the com - mittees are predominantly a part of the medical staff, although some are part of administrative departments. In other countries ethics committees serve as the review board for proposed clini - cal trials and other institutional research. As recently noted by the UNESCO Committee on Bio - ethics, there is increasing, widespread interest in the Western model, which features a BEC that deals with clinical concerns and an IRB that manages ethical concerns in research. The function of bioethics committees and institutional review boards will be discussed in greater detail in Chap - ter 3.

Prior to the mid-20th century, theology and philosophy provided the foundation for bioethics scholarship. However, it was soon clear that the questions generated by new technology, which included life-sustaining equipment and complex organizational structures, required ethical study and explicit practice standards. Thus, in the United States the 1960s and 1970s saw the birth of freestanding and university-affiliated entities devoted to the study and reflection of bioethics.

Early prominent examples are the Hastings Center, which is freestanding, and the Kennedy Insti- tute of Ethics, which is affiliated with Georgetown University. Several professional organizations (now largely subsumed under the American Society for Bioethics and Humanities) also developed within philosophy, law, and medicine. The field is still very new, and it continues to struggle with identity, its own code, and structural requirements, as well as with a unified theory and method, as well as with whether such a multi-disciplinary field should have a unified theory or method.

1.2 Theories and Methods of Cont emporary Bioethics B efore turning to the specific ethical issues health care practitioners face, an introduction to ethical theory is helpful. This introduction is an overview of several major views put forward by ethical theorists. While none of the views presented here will be treated in sufficient depth to judge their relative merits, the goal of this section is to discuss several ways to think about the rightness or wrongness of actions that have been historically important. These views underlie the principles and methods used by practitioners to resolve bioethical problems. There- fore, a basic understanding of ethical theory is a necessary foundation for developing competency in the use of bioethical methods. Ethical Theory Traditionally, ethical theory has been the purview of philosophers, including Immanuel Kant, John Rawls, and John Stuart Mill. Today, ethics, or moral philosophy, is a major branch of academic philosophy. Moral philosophers ask questions such as “What features of an action or event make it right or good?” “What are the sources of our moral obligations?” and “Do outcomes matter when determining the rightness of an action? If so, are they all that matter or, at least, the most impor - tant factor?” Philosophers then attempt to systematize their answers to arrive at an explanation of the rightness or goodness of actions and events in general. These explanations are ethical theo - ries. In essence, an ethical theory is a view about what makes actions or events right or good; an ethical theory gives general criteria for rightness and identifies the right-making features of actions and events—i.e., what sorts of things we should take into account when judging whether an act is right or wrong. To see what philosophers mean by “right-making features” consider the case study. 10 CHAPTER 1 Section 1.2 Theories and Methods of Contemporary Bioethics The answer probably seems clear. Of course, the antidote should be divided among the five patients who require a smaller dose. Given that the hospital has a choice between saving one life or sav- ing five lives, the hospital should save the greater number. This requires the assumption that there are no other factors that should influence the decision about whom to save. If, to give an extreme example, the five patients were violent criminals who escaped from prison and the one patient was the president of the United States, some might think the hospital should act differently. The antidote case study is, of course, imaginative and unrealistic. However, it highlights an important moral intu - ition that many people share. Indeed, in 1960 when dialysis units were first developed in Seattle, Washington, there were not enough for everyone who needed them. The question of how to distrib - ute them was real, and a process for deciding had to be developed prior to selecting patients.

Consequentialism and Utilitarianism When faced with an ethical decision, the right choice is the choice that has the best outcome or consequences; individuals should act so as to increase the good in the world. This intuition is the basis for one family of ethical theories, fittingly called consequentialist theories. Generally speak - ing, consequentialism is the view that whether an act is right or wrong depends only on results.

An act is right insofar as it produces good consequences. This seems simple enough. However, the consequentialist viewpoint requires some further explanation. If actions are right insofar as they produce good consequences, the theory has to identify both the “good” and the “consequences” in “good consequences.” The model and best known version of consequentialism is utilitarianism, which includes the attempt to spell out what are good and bad outcomes. The best known proponents of utilitarian - ism are the 19th-century British philosophers Jeremy Bentham and John Stuart Mill. According to utilitarianism, in any given circumstance, the right action is the action that will result in the best overall consequences of all the possible alternatives. This thesis is actually a conjunction of several major claims about rightness. First, utilitarianism claims that we determine whether an action is right by its net consequences. In other words, in a given situation the overall consequences of each possible action are computed by adding together all the good consequences of that act and subtracting all the bad. The alternative with the highest overall consequences “score” is the right action. Second, utilitarianism is concerned with the total amount of good produced by an action. It is not the case, according to utilitarianism, that all the possible actions with positive net consequences are good, albeit some better than others. Rather, the only right action is the one that maximizes net consequences. Third, utilitarianism assigns equal weight to all persons and Case Study: Rationing the Antidote You are a hospital administrator. One afternoon, the director of your emergency department notifies you that six patients have been brought to your emergency room, all of whom are dying after ingesting a rare poison. Unfortunately, your facility does not have a large enough supply of the antidote on hand to save the lives of all six patients. There is also no way to acquire more antidote in time to save all the patients. The patients must be treated within one hour of ingestion of the poison for the antidote to be effective, and time is already running out. The director informs you that one of the patients has ingested a much larger dose of the poison than the others. If the antidote on hand is divided five ways, there will be enough antidote to save the five who ingested a small dose. In order to save the patient who ingested the large dose, however, all the antidote on hand would have to be administered. How should the emergency department staff distribute the antidote? 11 CHAPTER 1 Section 1.2 Theories and Methods of Contemporary Bioethics perspectives when determining whether actions are right. Utilitarianism is concerned with maximizing the good in the world. Fourth, all good consequences are measured by a single standard: utility or well-being. If consequences are good, they are so only because they increase utility.

That last point requires some elaboration. Bentham, for example, held that the only intrinsic good is plea- sure and the only intrinsic bad is pain. This view is known as hedonism, which has been misunderstood in popular usage. Bentham thought that anything we might call good is good only instrumentally; things are good insofar as they increase pleasure. In his Introduction to the Principles of Morals and Legisla - tion , Bentham (1823) stated the point this way:

Nature has placed mankind under the gov - ernance of two sovereign masters, pain and pleasure. It is for them alone to point out what we ought to do, as well as to determine what we shall do. On the one hand the standard of right and wrong, on the other the chain of causes and effects, are fastened to their throne. They govern us in all we do, in all we say, in all we think: every effort we can make to throw off our subjection, will serve but to demonstrate and confirm it. (p. 1) For Bentham then, utility is the measure of total pleasure minus total pain. An act is said to have positive net consequences only if that act results in an increase in net pleasure in the world. This increase in net pleasure is an increase in utility, and what is right is what maximizes total utility.

The claim that all goods can be reduced to a single intrinsic good enables utilitarianism to explain what might otherwise be a potential problem for the theory. Suppose I have five dollars that I can spend on a new T-shirt for myself or give to some kids to buy candy. How should I decide whether a new shirt for me or candy for kids is the better outcome? These are two very different things.

According to the hedonist utilitarian view, the answer is straightforward—whichever outcome produces the most pleasure is the better outcome, and it does not matter whether it is pleasure for me or pleasure for the kids. What matters is only the net well-being of all of us.

Simple pleasure, however, is not the only candidate for utility. Mill, while a follower of Bentham, disagreed with him on the nature of pleasure. Mill held that although pleasure is the intrinsic good, we can differentiate between pleasures not only quantitatively, but also qualitatively. Thus, the pleasure one gets from experiencing an artistic masterpiece is a higher pleasure than that of tasting something sweet and therefore carries greater weight in a utility calculation. Later utilitar - ians rejected pleasure as the only intrinsic good and argued that there exists a plurality of intrinsic goods—including, for example, beauty. Others contend that pleasure is not an intrinsic good at all. Classic Vision/age fotostock/SuperStock John Stuart Mill was a proponent of utilitarianism, which aims to select the action that will do the greatest amount of good for the greatest number of people. In utilitarianism, an action is determined to be right or wrong based on its consequences, not on the action itself. 12 CHAPTER 1 Section 1.2 Theories and Methods of Contemporary Bioethics In sum, utilitarianism is the classic consequentialist ethical theory. According to utilitarianism, an action is right only if it maximizes utility. That is, among all possible actions in a given situation, only one will lead to the best overall outcome measured in terms of gains in utility. In the words of Mill (1863/1998):The happiness which forms the utilitarian standard of what is right in conduct is not the agent’s own happiness but that of all concerned. As between his own hap- piness and that of others, utilitarianism requires him to be as strictly impartial as a disinterested and benevolent spectator. In the golden rule of Jesus of Nazareth, we read the complete spirit of ethics of utility. “To do as you would be done by,” and “to love your neighbor as yourself,” constitute the ideal perfection of utilitar - ian morality. (chap. 2, para. 18) In addition to utilitarianism, there are other consequentialist ethical theories. These theories dif - fer from utilitarianism because they reject one or more of its claims about rightness. All con - sequentialist theories share the basic tenet that the only right-making features of actions are consequences. However, they reject hedonism, the claim that we should measure only net con- sequences, and the claim that morality is agent neutral. (Figure 1.2 compares ethical theories.) Figure 1.2: Ethical theories compared This chart provides a visual image of the different ethical theories and their main focal points.

Source: Reprinted by permission of Lawrence Hinman. 13 CHAPTER 1 Section 1.2 Theories and Methods of Contemporary Bioethics As seen in the antidote case study, consequentialism, particularly the utilitarian variety, is an attractive ethical view because it coincides with our intuition that outcomes matter. This intuition is especially salient in health care settings. Health care professionals believe it is their duty to do the most good for the most patients. Another appealing feature of utilitarianism is the fact that it requires that people take the consequences for everyone into account when determining whether an act is right or wrong. The act with the best consequences is not the act with the best conse- quences for the individual; it is the act with the best consequences overall. Moral intuitions are an important measure that philosophers use to judge the merit of an ethical theory.

However, if an ethical theory cannot explain intuitive judgments regarding ethical cases— especially like the one presented in the antidote case study, where there is widespread agreement—that is a major strike against the theory. The following case study highlights just such a case in which utilitarianism runs counter to intuitive judgments. Case Study: Transplant In the following excerpt, first printed in 1985 in the Yale Law Journal , philosopher Judith Jarvis Thom- son highlights a case in which utilitarianism has trouble explaining which choice is the right one to make.

Imagine yourself to be a surgeon, a truly great surgeon. Among other things you do, you transplant organs, and you are such a great surgeon that the organs you trans - plant always take. At the moment you have five patients who need organs. Two need one lung each, two need a kidney each, and the fifth needs a heart. If they do not get those organs today, they will all die; if you find organs for them today, you can transplant the organs and they will all live. But where to find the lungs, the kidneys, and the heart? The time is almost up when a report is brought to you that a young man who has just come into your clinic for his yearly check-up has exactly the right blood-type, and is in excellent health. Lo, you have a possible donor. All you need do is cut him up and distribute his parts among the five who need them. You ask, but he says, “Sorry. I deeply sympathize, but no.” Would it be morally permissible for you to operate anyway? (Thomson, 1985, p. 1396) As in the antidote case study, the answer in this case should seem clear. Of course it is wrong for you to operate! But that is exactly what utilitarianism would seem to tell you to do. After all, if you oper - ate you save five lives at the cost of only one. Like the antidote case, the transplant case requires that we assume that no other factors affect the doctor’s decision. We must assume, for example, that the doctor will not face legal consequences and that the young man’s family will not find out about the transplant. But suppose that we make such assumptions and that there are no additional reasons to value any one of the six lives over another; i.e., none of the six patients is the president.

In that scenario, utilitarianism says that we should go ahead with the operation. Performing the transplant would result in better overall consequences than not performing the transplant.

This may be the case, but nonetheless most are appalled at the thought of someone performing such an act. Society views killing one person to save others as a prime case of immoral action— not to mention that it is illegal. Why does society think this? One explanation put forward by philosophers is that killing one person to save another violates the rights of the individual killed. 14 CHAPTER 1 Section 1.2 Theories and Methods of Contemporary Bioethics Individuals have certain rights, including the right to decide what can or cannot be done to their bodies, and rights have a moral importance that trumps, or places limits on, the importance of ensuring the best outcomes. Rights are also of great importance in contemporary bioethics.

Deontology Given the difficulty utilitarianism has in explaining human intuition about rights, many moral phi- losophers defend nonconsequentialist ethical theories. There are many types of nonconsequen - tialist ethical theories, but what all these theories have in common is they hold that outcomes are not (or are not the only) right-making features of actions and events. We cannot judge an action simply based on the states of affairs that action brings about. Two families of nonconsequentialist ethical theories that play a large role in bioethics are deontological ethics and virtue ethics. Con - sequentialism is best contrasted with deontological ethics, so we will focus on those views here.

Virtue ethics will be discussed in the next chapter.

Deontology is often thought of as consequentialism’s foil because the most familiar versions of deon - tological ethics hold that there are some actions that are wrong no matter how good their conse - quences. The word deontological comes from the Greek word deon, meaning “duty.” According to deontological views, an action is right not because of any consequences it results in, but rather because it conforms with a moral norm; it is right in and of itself, and the action’s conformance with a moral norm is the right-making feature. A deontological theory then must explain what moral norms exist.

In most deontological theories, there are two kinds of moral norms—norms of obligations and norms of permission. Norms of obligation indicate actions or duties that people ought to perform or fulfill; these norms express our moral obligations. Norms of permission indicate actions that are permissible but not necessary to perform; they help define which actions are morally allowable. For example, one might think individuals should not kill innocents. This is a norm of obligation. How - ever, one might also think it is permissible for individuals to kill in self-defense. Individuals need not kill in self-defense, but they are not acting immorally if they do. This is a norm of permission.

For the purposes of health care ethics, deontological theories can be roughly divided into agent- centered and patient-centered theories. Agent-centered theories focus on individual human beings as loci, or originators of moral actions. Such theories hold that, in addition to the moral norms that apply generally, there are some moral obligations and permissions that only one per - son has. For example, parents’ obligation to care for their own children does not obligate them or give them reason to care for someone else’s children. Agent-centered deontological theories may include norms that govern intentions as well as actions, but they share the emphasis on individual agents. Morality in agent-centered deontology is not about the total good in the world, as it is for utilitarianism. Rather, morality is about the duties of individual agents, or persons.

Patient-centered theories, on the other hand, focus on the recipients of our actions. In patient- centered deontological theories, morality is about rights. According to such theories, our moral obligations are rights-based. People have rights (for example, not to be killed), and we are morally obligated to respect those rights. Morally permissible action is that which does not violate any - one’s rights. Patient-centered theories explain our intuition in the transplant case study by saying yes, it is true that harvesting the young man’s organs is wrong because it violates the patient’s rights. The doctor would be using him as a means to achieve his or her own end. The imper - missibility of using another as a means to one’s own ends is central to most patient-centered 15 CHAPTER 1 Section 1.3 Principlist Ethics deontological theories, which hold that persons have a right not to be used by others without their consent. This idea is credited to the German philosopher Immanuel Kant (1785/1993), whose famous formula of humanity reads: “So act that you use humanity, whether in your own person or in the person of any other, always at the same time as an end, never merely as a means” (p. 429). Though Kant’s moral philosophy includes far more than the formula of humanity, it is important to understand that this Kantian idea undergirds much of contemporary bioethics.

To sum up, we have briefly introduced two major families of ethical theories—consequentialism and deontological ethics. Consequentialist theories hold that the right-making features of actions are the outcomes. Deontological theories, on the other hand, hold that we cannot judge the right - ness of actions by the state of affairs they bring about. The right-making feature of an action is its conformance with some moral norm. A right action fulfills a moral duty or respects a moral right.

A shorthand way of remembering the contrast between consequentialism and deontological eth - ics has to do with the relationship between the good and the right in each. In consequentialism the good has priority over, and in effect determines, the right; in deontological ethics, the right often has priority over the good. If an action is in conflict with a moral norm, no amount of good consequences can make that action right. To see how this works, let us return one more time to the transplant case study. Remember that the good in this case study is that if the doctor oper - ates, five additional lives are saved. According to deontological ethics, this good should not factor into our determination of the right action. The action of harvesting the organs from the young man violates his rights and the doctor’s duty not to harm the patient. No amount of additional lives saved would justify this action. Thus, the right—what is in accordance with moral norms— takes priority over the good. Consequentialism, on the other hand, says this good is the crucial factor in deciding whether it is right for the doctor to operate. Whichever action will result in the most good consequences is the right action. Thus, the good—positive outcomes—determines and therefore takes priority over the right.

One more point about the function of ethical theory is in order before concluding this brief intro - duction. The beginning of this section stated that an ethical theory is a view about what makes actions right or good. An ethical theory gives criteria by which we can judge the rightness of an action. Notice that nothing has been said about offering a procedure for ethical decision making.

This is not what ethical theories purport to do. Ethical theories provide an explanation of what makes actions right or wrong and criteria for judging the morality of actions. Bioethics needs these explanations to provide a basis for its resolutions of ethical problems. However, bioethics also needs something more. It needs procedures or methods for solving the problems when they arise.

1.3 Principlist Ethics T here are several methods for “doing bioethics.” Whatever methods or combination of meth - ods applies to the individual case or problem, it is helpful to remember that basically, ethics is about respect for persons, truthfulness, and fidelity. Primarily in the 1970s and 1980s, courts and philosophers emphasized principlist ethics, which stresses the application of general principles, in a top-down fashion, to serve as the basis for rules or guides to action. This approach has mainly been associated with Tom Beauchamp and James Childress (2009), the authors of the canonical text on principlism. Figure 1.3 provides a diagram to help visualize the four principles, which are autonomy, nonmaleficence, beneficence, and justice. 16 CHAPTER 1 Section 1.3 Principlist Ethics Figure 1.3: Venn diagram of ethical principles in health care A useful way to imagine the four principles is as a Venn diagram, or a group of overlapping areas of concepts. These areas overlap because often the concerns and questions promoted by the principles occupy more than one area. For example, respecting a patient’s autonomous choices falls under “respect for persons,” but it can also fairly be described as observing the principle of nonmaleficence, since disrespecting a person is a form of harm. It might also be described as falling under the aegis of beneficence if respecting a patient’s wishes fosters autonomy or a sense of control that may itself be therapeutic or beneficial.

Autonomy Autonomy has been the dominant principle as a result of court decisions in landmark cases. It grants the right to be left alone and not be touched without permission, and it forms the basis for our laws against battery. Autonomy literally means “self-determination,” but the term is con - fusing. Clearly, no one is entirely self-determining. Everyone has aspirations and dreams, and yet everyone encounters reality. In health care, for example, providing what the patient wants must be contrasted with what he or she gets; this is limited by the physician, who is responsible for clini - cal judgment and determining medical necessity. 17 CHAPTER 1 Section 1.3 Principlist Ethics The autonomy maxim “Do not do unto others that which they would not have you do, and keep your promises” has been such a misunderstood concept that Englehardt (1996) renamed it the principle of permission. Autonomy forms the rationale for informed consent. If one may not touch another without permission, informed consent provides a mechanism to obtain the permission by declaring risks, potential benefits, and alternatives. Note that the maxim includes the mandate to keep promises. Autonomy is particularly confusing to providers and patients in that the principle grants the right to accept or reject recommended treatments, but decisions about appropriateness and effectiveness are the domain of the physician. Many cultures value community over individual choice, and autonomy may not be the most important value for such communities. It may not even be considered. In all cases practitioners need to discuss decisions with the patient to discern the relative value he or she places on autonomous choice. Does the patient want information? Does the patient want to be involved in decisions, or does he or she delegate to family? Those are autono- mous choices; health care practitioners have a duty to assure they are stable and authentic.

As noted above, informed consent derives from the principle of autonomy, and it is discussed in detail in Chapter 4. However, note that informed consent requires a conversation between the physician and the patient or surrogate engaged in shared decision making. Informed consent requires that the patient be an active participant in the process, necessitating well-documented notes in the medical records. It is much more than a signature on a form.

Although Western courts have generally found in favor of patient autonomy, the repeated lack of a clear mechanism to resolve conflicts between and among the principals at the bedside dem- onstrates weakness in the principlist approach. For example, consider a case in which, based on medical necessity and the physician’s clinical judgment, surgery is recommended for a particular patient. However, the patient refuses, based on his or her own complex reasons, preferences, and values. This collision between the patient’s choices or refusals causes dilemmas at the bed - side and in setting policy. Before life-sustaining technology, such dilemmas were precluded by old paternalistic methods in which the physician decided. Critics ask how principles help resolve conflicts in a given case. Beauchamp and Childress address the question in their later editions by recommending specifying and balancing approaches in specific cases.

Nonmaleficence The ethical principle of nonmaleficence is based on the age-old medical precept “first, do no harm,” or the Latin primum non nocere. Nonmaleficence is the general duty to avoid causing harm to others, either directly or indirectly. It sometimes is necessary to risk harm in order to achieve a greater good or prevent a worse harm. For example, performing a difficult gastric sur - gery on a patient with heart or organ failure jeopardizes the weak organ, but it may be necessary to save the life. The decision about what to do is not primarily a medical one; there is a choice and values are at stake. Life-saving technology has sometimes made it difficult to know what is a harm and what is a benefit. For example, consider a dying patient who is on a ventilator. Is con - tinuing aggressive support saving the life or prolonging the dying? These questions require more information and much greater understanding of the case. 18 CHAPTER 1 Section 1.3 Principlist Ethics In clinical health care it is easy to think of the myriad ways in which a patient can be harmed through incompetence, error, or systems failure, or ways in which a physician can inadvertently cause pain, disability, or even death. Prevent- ing harm to patients is the responsibil - ity of the administrator, in collaboration with the medical staff. In addition to the physical, psychological, and economic ways that health care managers can affect patients or staff, those in leader - ship roles also have the ability to affect the culture of the organization in criti- cal ways. The duty of nonmaleficence not only involves not causing harm, but actively choosing the least harmful alter - natives. Nonmaleficence requires that managers actively minimize or eliminate workplace hazards and risks that could harm employees as well as patients. It is prudential as well as practical for administrators to regu - larly review relevant policies, make rounds, meet with practitioners and employees, and attend meetings in which the topic is preventing or responding to error and other harms.

Beneficence Beneficence is the principle that guides health care professionals to do good. It provides the grounding for charitable duty to others. At the bedside, patients define their own good; this may present a conflict with a health care provider’s recommendations, which are based on the physi - cian’s clinical judgment about the best medical good. Problems may occur when patients refuse recommended treatments. Conversely, they may occur when patients or their surrogates demand care that physicians deem inappropriate or nonbeneficial. Misunderstandings about patient and provider rights lead to many of the requests for bioethics consultation. In the case of refusal, autonomy usually trumps. However, it is critical to evaluate the patient’s capacity to make rational and authentic decisions. Capacity goes beyond being oriented to time, person, and place. It is the ability to understand the context, meaning, and implications of choices. If the patient is incapable of making his or her own decisions, it is necessary to evaluate whether the surrogate is acting in a way that is consistent with the patients’ directives and interests.

Health care professionals are not obligated to participate in acts about which they have a con- scientious objection. Organizations are also protected. For example, Catholic hospitals are not required to perform elective abortions or participate in assisted reproductive technologies that compromise their ethical and religious doctrine. The positive duty imposed by the principle of beneficence requires that health care managers do everything they can to reasonably care for and benefit patients, employees, and others for whom the organization is or may be responsible.

How this duty is put into practice depends upon the nature of the organization and its mission.

For example, if a practitioner’s organization has an explicit mission to serve the health needs of a iStockphoto/Thinkstock Health care providers have an ethical obligation to bring no harm to their patients. However, sometimes harm must be risked in order to prevent a greater detriment. 19 CHAPTER 1 Section 1.3 Principlist Ethics particular population or community, then those commitments should give shape and substance to the practitioner’s duty of beneficence.

Justice The justice principle can be broadly defined as “fairness.” It is exemplified by the Aristotelian ideal that people in similar situations ought to be treated similarly, and people in different situations should be treated differently. A distinction is sometimes made between distributive justice, which refers to the allocation of resources, and procedural justice, or the fairness and transparency of processes by which decisions are made. The Belmont Report, prepared by the National Commis- sion for the Protection of Human Subjects of Biomedical and Behavioral Research (1979), offers guidelines on ethical principles; it states that “an injustice occurs when some benefit to which a person is entitled is denied without good reason or when some burden is imposed unduly.” This may occur in the clinic or in research. For example, there is some evidence that persons who are poor and thus have less access to care and information about options may also have less access to clinical trials. They also have less access to the benefits of findings and to drugs that are approved as a result of such studies. Charges of injustice in access to research among women have also been made in the literature (Mastroianni, 1998); women have proportionately been less often repre- sented as research subjects. The data indicate that persons belonging to some racial groups are treated differently when they appear at an emergency department (James et al., 2005; Selassie et al., 2003). Statistics have consistently shown differences in life expectancy by socioeconomic status (National Center for Health Statistics, 2012).

The leading American political philosopher of the 20th century, John Rawls (1921–2002), wrote the highly influential book A Theory of Justice in 1971 that advances the idea that the best prin - ciples of justice are those that we would all agree to if we were all impartially situated as equals.

This he arrives at through his famous thought experiment “the veil of ignorance,” in which we are asked to imagine an “original position” from which no one was better situated than anyone else (or at least that we’d be ignorant of any inequalities in such a utopian state-of-affairs).

Justice is a fundamental principle for health care administrators and practitioners—particularly in their responsibilities to make resource allocation decisions—and among those who work toward eliminating health inequities. The justice principle impacts many other day-to-day decisions that health care managers make. Examples include policies regarding unionization, working conditions, and staffing patterns for employees; hiring and promoting staff; decisions about where and to whom the institution should be marketed; and determining whether promotion should be by merit, seniority, or favoritism. In addition, hospitals that undergo purchase or mergers often have to make choices about their mission and values.

Procedural Justice A Rawlsian approach to distributive justice and health care ethics is one based on fairness. There - fore, even in cases where not everyone will have access to a certain good because it is scarce, there needs to be fair opportunity of access to the benefit. For Rawls, fair access was ensured by formal procedures that were themselves required to be fair. This leads us to the concept of pro - cedural justice. 20 CHAPTER 1 Section 1.3 Principlist Ethics In order for the justice principle’s requirements to be met, any formal procedures or mechanisms by which people attempt to decide dilemmas must be fair and just, or equitable. Procedural justice requires that policy makers craft regulations, laws, and formal procedures that are free from bias that would render them inaccessible to some or that would unduly restrict the chances of fair treatment for others. For example, a policy that recognizes employees’ rights to opt out of procedures when they have a strong conscientious objection states that employees must pro- vide documentation in writing to the supervisor at least 2 weeks prior to the event. But given the nature of acute care, in which the unexpected happens routinely, how can a nurse know in advance that something will be demanded of her that strongly violates her conscience? When this issue came up in a local hospital, human resources had the policy rewritten to accommodate real- ity. Hospitals and nursing homes have to be clear about nurses’ rights and duties. For example, a policy might state that a nurse who has a strong moral objection to terminal extubations could be transferred to a unit where this procedure will not likely occur. Other policies might call for less supportive measures such as unpaid leave; such options could trigger a union dispute.

Strengths and Weaknesses of Principlism Scholars continue to refine the principlist approach; with each new edition, Beauchamp and Chil - dress refine the text to accommodate legitimate criticism. Some bioethicist academics turn to casuistry, a case-based mechanism to resolve dilemmas. Other important methods are informed by the growth of feminist ethics, which focuses on the patient’s narrative and an ethic of car - ing. Most practitioners use a combined approach from different methods, depending somewhat on the particulars of the case. The several methods reflect the necessity of an interdisciplinary approach; no single method has been successful in addressing the varied and complex dilem - mas that arise in the clinic, the institution, or the community. Indeed, the diversity of settings, issues, and options are not readily amenable to simple strategies. Principles provide fundamental guidelines, but when they conflict with one another, there is a lack of clear instructions on how to prioritize. The courts have consistently favored autonomy, but that does not always seem cor - rect in an acute health care setting. It is also not always clear whether a choice is consistent and authentic, i.e., will the decision be the same later today or tomorrow? Is it an accurate reflection of the person’s narrative and the other choices he or she has made?

Some argue that principlism fails to consider the complexities of real-world situations or that it is too rigid in following prescribed formulas for making ethical decisions (Pellegrino & Thomasma, 1993). Other critics posit that principlism pays too little attention to the character of the agent, opting instead to focus on actions that typify the principle in question; for example, asking if the decision was autonomous rather than also looking at precedent or important context (Bulger & Reiser, 1990). Does the way the four principles are selected, prioritized, and applied to ethical dilemmas depend on who gets to do the selecting, prioritizing, and applying? Given that along with their great strengths, principles have weaknesses in application, leading proponents of prin - ciplism—especially Beauchamp and Childress—continue to refine their text to include the neces- sity to specify and balance in individual cases. Whether in management, at the bedside, or in the community, it has become clear that principles are important, but they are not to serve as a blind mantra. They work when they are aptly applied, usually along with other methods, and always in conjunction with good judgment.

Casuistry Casuistry is a method of reasoning for solving particular cases. It has come to describe a general case-based approach to solving ethical problems, somewhat similar to the process of using legal 21 CHAPTER 1 Section 1.4 Practical, Ethical Decision Making in Health Care Administration precedent. Particular cases are explored with reference to prior, paradigm cases. However, in ethi- cal analysis, norms as well as precedent are important. In practice, principles usually form the nor - mative backdrop for the case analysis. Jonsen and Toulmin (1988) argue on behalf of casuistry as a way of “avoiding the tyranny of principles” (p. 5). They argue that while rules are foundational, they can only take us part of the way. “Surely the issue is rather one for the exercise of wisdom, discretion and discernment in enforcing the rules we already have. . . . [Casuistry] redresses the excessive emphasis placed on universal rules and invariant principles by moral philosophers and political preachers alike” (Jonsen & Toulmin, 1988, pp. 9, 13). The normative limits in the casuist method are still cited as a primary weakness. In practice, however, principles form the foundation for ethical discernment in the case approach, and the two methods are used together. Casuistry has become a valuable tool in resolving specific problems. For example, in a conflict between the family’s decision to withdraw life support and the physician’s contention that the patient’s con - dition might improve, there is a conflict between the principles of autonomy and beneficence.

Examining the specifics of the case in a deliberate manner and with reference to similar cases is necessary to resolve the dilemma.

The major difficulty in arriving at a unified method for addressing ethical dilemmas has been the challenge of applying such a method in a culturally diverse and plural society.

1.4 Practical, Ethical Decision Making in Health Care Administration T he complicated nature of the work of modern health care administrators and leaders often means that they have to take into consideration a multitude of factors and facts when making a well-reasoned, ethical decision. Issues involving mergers with institu - tions at the same level of care or above or below the acuity level, changes in financing, relationships with the community, and profit status are only a few of the ethical challenges. Without an organiza- tion’s clearly defined moral identity, often through mission and vision statements, or without a well- articulated moral identity statement of his or her own (see Chapter 3), the modern health care leader may lack direction and base decisions on ill-defined or undeveloped personal ethics. These types of decisions run the risk of being unfair, inconsistent over time, or easily swayed by factors that seem the most urgent, instead of those that are most important to the pri - mary goals of the institution or practice. It is crucial that institutions develop and use vision and mission statements to guide the facility.

The bulk of this textbook is devoted to helping culti - vate in the student the characteristics of a moral leader capable of leading a moral organization. In this section we will consider the value of a flowchart method of resolving ethical dilemmas. Creatas/Thinkstock Administrators routinely face ethical dilemmas at the institutional level. 22 CHAPTER 1 Section 1.4 Practical, Ethical Decision Making in Health Care Administration Introduction to the Sample Framework Flowcharts, or decision-tree diagrams, such as the one seen in Figure 1.4, help demonstrate some of the important factors and norms that should be a part of any thoughtful ethical decision. How- ever, it is also important to remember that these guides, when misused or relied on too strictly, can serve as a crutch for bureaucrats and can impede the kind of rigorous and nuanced analysis that usually needs to happen in modern health care ethics. Once you become confident in apply - ing the rules and norms covered in this text and become adept at identifying the most important stakeholders and factors that need to be addressed, then you can use the diagram as a reference.

It can be stored in a file cabinet or on a computer to access when you need to make sure nothing important has been overlooked. It can also be used as a reminder of important questions to raise in an ethics committee meeting.

The Process First, progress through the diagram in a stepwise fashion, from top to bottom, answering the questions along the way and thinking of all the factors that should be considered at each step. The chart itself is meant only as a guide. It is helpful to take copious notes on a different sheet of paper or on a note-taking app on your computer.

If all goes well, you should have a small set of alternatives at the end of the process from which to choose the final decision. However, it is also important to note that in many cases the final decisions of good ethical managers are not truly “final.” Ideally, they are tentative and provisional rather than a once-and-for-all solution. If the decision fails to solve the problem, or if the negative consequences of the decision turn out to be greater than expected, the expert health care man - ager should be amenable to refining or replacing the decision with a better one. Therefore, the review and feedback loop that goes from the bottom of the diagram back to the top is an essential part of the ongoing ethical decision-making process. You can practice using the flowchart in the St. Louis Apothecary case study in the end of chapter content. 23 CHAPTER 1 Section 1.4 Practical, Ethical Decision Making in Health Care Administration Figure 1.4: Ethical decision-making flowchart The process of ethical decision making is illustrated in the infographic below. 24 CHAPTER 1 Section 1.5 Chapter Highlights 1.5 Chapter Highlights • As the discipline concerned with doing the right thing , ethics and ethical behavior have been of critical importance in health care in general and medicine in particular since the beginning of recorded time. • The major factor s associated with the rise in contemporary bioethics have been: 1. Changes in the health care delivery system a. insurance b. financing c. costs d. structure to accommodate inventions 2. Developments in technology that a. increased the cost of care b. offered life-supporting machines, including dialysis and ventilators c. provided choices in treatments for physicians to offer and patients to accept or reject 3. Discovery of research misconduct, which led to regulation and the development of ethical codes. 4. Cultural diversity under which there were differences in societal values and understandings of the right thing to do. 5. Religious pluralism, which meant there was no consistent authority for deter - mining right action. 6. The civil libertarian movements, which demanded that private individuals make their own choices about what to accept and reject. • Ethics committees have been mandated by the courts and accrediting agencies as a mechanism to address ethical dilemmas. • Ethics committees are organized by medical staff or administration, but they need the support of both. Their functions are case consultation, education, and policy develop- ment and updating. • Two major theories in ethics include deontology and consequentialism, which attempt to identify and justify what is right action along very different paths. 1. Deontology looks at duty and obligation; it is heavily rule-based. 2. Consequentialism considers the outcomes of actions; its major branch is utilitarianism. • Methods provide guidance for how to address problems. The two major methods are principlism and casuistry. 1. Principlism has served as the major method in bioethics; the four primary prin- ciples are autonomy, nonmaleficence, beneficence, and justice. Principles serve as fundamental guides; they provide the foundation for rules. However, they require specifying and balancing, and the lack of ranking when principles com- pete has been a problem with the method. 25 CHAPTER 1 Section 1.5 Chapter Highlights 2. Casuistry uses a case-based approach to explore the context of a particular prob- lem in light of similar cases. Principles underpin the method to provide a norma- tive guide. • The chapter ended with a discussion of the import ance of implementing a well-planned and reflexive procedure when organizing and making an ethical decision. Case Study: St. Louis Apothecary Using the ethical decision-making flowchart, consider the following dilemma and come up with a plan for responding to it.

The Problem You are a human resources administrator for St. Louis Apothecary, a company that owns and runs 23 full- service pharmacies in Missouri and eastern Illinois. Your company prides itself on providing exceptional customer experience and exceptional job satisfaction and has always offered among the highest pay and benefits in the field. One of the fringe benefits that has attracted excellent pharmaceutical staff is the tenure system at St. Louis Apothecary. A pharmacist who remains with the company for 5 years gains tenure and cannot be terminated unless it is for cause (basically, only for theft or revocation of license).

This means that your pharmacies have had the best job retention and job satisfaction of any pharmacy in the region, a fact that has made your job of handling human resources easy—that is, until recently.

Although yours is a private company, it just so happens that a large percentage of your full-time phar - macists are Roman Catholic. Some of these pharmacists have decided to conscientiously object to filling prescriptions for any abortifacient or contraception drug or device. Until recently, this was not much of a problem, since there were usually other pharmacists at the location who would fill the pre- scription (Catholic or not). Recently, however, you have had to cut back your nontenured pharmacist work hours because of the recession and declining profits. With new “morning-after” pills and a rise in other contraception, the conscientious refusal by tenured pharmacists has become a dilemma at St.

Louis Apothecary, since it has become increasingly difficult for customers to have these prescriptions filled at your pharmacies.

Usually, there is another pharmacy within a mile or two of a location if the only pharmacist on duty refuses to fill a prescription or sell contraception. But customers who have been turned away have begun complaining not only about the inconvenience but also the fact that some of the objecting phar - macists have become judgmental and rude. In addition, for several of your company’s rural locations, it is more than merely an inconvenience, since the St. Louis Apothecary store is sometimes the only option for dozens of miles around. For some customers, this imposes a real obstacle to health care.

Sales are down now that quite a few customers have taken not only their birth control prescriptions but all of their business elsewhere. Your remaining customers have also started to show lower cus - tomer satisfaction on a recent questionnaire you instituted after becoming aware of the complaints.

Answer the Following Question What would you do in your role as administrator for St. Louis Apothecary and why? Here are some helpful hints: • Remember to justify any ethical decision made by appealing to what you have learned so far in this chapter as well as by using any other resources you care to incorporate. You may find it helpful to review the “Ethical Decision-Making Flowchart” in this chapter and its accompanying video walk-through when organizing your decision. (continued) 26 CHAPTER 1 Section 1.5 Chapter Highlights Critical Thinking and Discussion Questions 1. Provide a utilitarian argument for each of the following:

a. mandated vaccinations b. lying about a patient ’s diagnosis in order to get coverage for necessary care the patient could not otherwise afford c. giving priority to patien ts for whom immediate care might result in a better out - come over those who may have a more severe condition but for whom care may be futile 2. The four principles of ethics all generate general duties and responsibilities for ethi - cal health care. Describe an example of when the four principles might generate competing, or even contradictory, duties for a health care manager. 3. Give an example of when a health care administrator might have to cause harm, despite the nonmaleficence principle. 4. Discuss, explain, and provide an example of informed consent in health care. 5. Give an example (either from personal experience or that you have read about) of a health care administrator or professional acting in a way that had ethical implica- tions. This can be an example of acting on a specific ethical problem or acting in a way that might result in ethical problems. Critique the administrator’s actions or decisions (use this chapter’s flowchart if needed) and judge whether you believe the administrator acted or decided with appropriate regard for the four principles of health care ethics, and explain why you think so. Case Study: St. Louis Apothecary (continued ) • Who are the primary stakeholders in this case? Are there secondary stakeholders? How would you attempt to balance the relative interests of all of the stakeholders? Would the primary stakeholders’ interests always trump those of secondary stakeholders, or would an interest’s relative importance be the deciding factor? How would you decide the relative importance of rights versus privileges? • Assume that you will face legal liability for breach of contract if you fire any tenured pharmacist for anything other than theft, revocation of license, or the elimination of his or her position (the last of which would only happen if you were to close a store permanently, since you cannot replace a licensed pharmacist with anything other than another licensed pharmacist). 27 CHAPTER 1 Section 1.5 Chapter Highlights Key Terms autonomy The concept that rational adult decision makers have the ability and should be given the opportunity to self-govern, or make decisions for themselves. In the context of health care, it is the right to accept or reject recommended treatments, procedures, and clinical trials. beneficence The ethical principle and require- ment to benefit and care (do good) for others; it is especially relevant to health care because its goals are to care and benefit patients or clients. bioethics committee (BEC) A body that deals with clinical and organizational ethical issues, including ethical conflicts in health care organizations. casuistry The method of reasoning for solv - ing particular cases. It has come to describe a general case-based approach to solving ethical problems, somewhat similar to the process of using legal precedent. consequentialism A major moral philosophy in which the morality of actions are deter - mined solely by the reasonably foreseeable consequences of those actions. deontology The ethical theory that says that the moral value of an action can be found by looking at the nature of the act itself. Ethical behavior is therefore that which is in accord with rules, principles, or duties, irrespective of any consequences of the behavior. dilemma Individuals experience a dilemma when they are uncertain about what the right or best decision might be when faced with difficult problems. It may also be a dilemma when people know what the right or optimal decision is, but for whatever reason it is not one of the available options. distributive justice The just allocation of resources or goods in a society or group. It relies on a definition of justice as “fairness” or what is deserved. equitable The state of affairs that is fair or just. Achieving equity requires impartiality.

It may not require that everyone be treated exactly equally; sometimes it requires that dif - ferently situated people be treated differently. ethical theory A view about what makes actions or events right or good; an ethical theory gives general criteria for rightness and identifies the right-making features of actions and events; i.e., what sorts of things should be taken into account when judging whether an act is right or wrong. ethics The systematic study and the practi- cal application of the process for determining right action, or what the individual or organiza- tion ought to do in a given situation. feminist ethics An outgrowth of the feminist movement that focuses on the patient’s narra- tive and an ethic of caring. fidelity The virtue of faithfulness; keeping one’s word and making decisions that align with the integrity and ethics of the profes- sional is a form of fidelity. It is also evidenced when a health care administrator makes dif - ficult or unpopular decisions that are required by a duty. general duty A duty to act in particular ways toward everyone in general. For example, the duty of nonmaleficence is a general one in that it requires people to refrain from harming all others. 28 CHAPTER 1 Section 1.5 Chapter Highlights institutional review boards (IRBs) Commit- tees made up of diverse organizations and community members that review the ethics of research. Highly regulated and subject to significant governmental oversight. nonmaleficence The ethical principle that requires people to avoid causing needless harm to others or to minimize the harmful but necessary consequences of their actions. It has been termed the primary duty of physicians:

“Above all else, do no harm.” paternalism The belief that the doctor knows best. preventive ethics The concept that the best resolution to an ethical dilemma is to prevent it from happening in the first place. Preventive ethics requires proactive leaders in health care to identify potentially problematic areas and act on them to prevent moral dilemmas. principlist ethics Fundamental guides or truths. An approach to ethics that emphasizes the application of general principles, in a top- down fashion, to serve as the basis for rules or guides to action. procedural justice The fairness and trans- parency of processes by which decisions are made. utilitarianism The form of consequentialism originated by Bentham and Mill that is char - acterized by the rule “always act so that you maximize the pleasure and minimize the pain of all those affected by your actions.” Some - times described by the phrase “the greatest good for the greatest number.”