Ethics in Healthcare

Editor’s note: This text-based course is an edited transcript of the one-hour webinar, Ethics in Healthcare, presented by Lori Taylor, PhD, RRT.

Learning Outcomes

After this course, participants will be able to:

• Explain the meaning of ethics and its importance in the practice of healthcare
• State the purpose of professional codes of conduct
• Identify the eight major ethical principles that apply to healthcare and identify the laws that support each

Define Ethics

For centuries, humans have struggled with answering questions about the meaning of life and how to properly conduct themselves. Ethics is a system of principles a society develops to guide decisions about what is right or wrong. Ethical principles are influenced by religion, history, and the collective experiences of the people in a group. People are often guided by a variety of ethical principles and beliefs about what is right or wrong.

Ethical Dilemmas

However, even within a single ethical system, decisions arise when there is no clear answer that will satisfy everyone. In this instance, we have an ethical dilemma. Right behavior for some people often results in wrong effects for others. An example of this is capital punishment. One group may decide that criminals should be punished for their crimes. While on the other hand, some may believe that capital punishment is wrong and the society should not determine or justify killing anyone.

The Purpose of Ethics in Healthcare

The importance of ethics in healthcare has been recognized for thousands of years. Because of the diverse populations composed of hundreds of cultures, healthcare providers have a significant impact on human life. In addition, we are often making life and death decisions. Healthcare providers are guided by a variety of ethical principles and beliefs about what is right and wrong.

The Hippocratic Oath

The important role of healthcare professionals has existed since ancient times. The Greek physician Hippocrates was also concerned with medical ethics. The Hippocratic oath taken by physicians over centuries contains issues and ideas that are still being debated today. Some of those issues include mercy killing, abortion, and even sexual harassment. Healthcare professionals today are confronted with more ethical problems than ever before. Technology has progressed beyond society's readiness to deal with the ethical and legal issues that it presents. We are able to prevent conception, prolong life, transplant organs, and perform life-saving procedures that extend beyond our imagination.

Professional Code of Ethics

The code of ethics is an important part of any professional organization. Healthcare professionals are guided by principles that are outlined in their occupation-specific code of ethics. Codes of ethics seek to establish perimeters of behavior for its members in a chosen profession. While they may vary in detail they share the same purpose, which is to set standards of professional conduct that promote the welfare of patients and ensure a high quality of care.

American Association for Respiratory Care (AARC) Statement of Ethics and Professional Conduct

The American Association for Respiratory Care (AARC) is a living, breathing organization dedicated to improving all aspects of the science of respiratory care. The AARC has adopted a statement of ethics and professional conduct for those in the respiratory therapy profession. This code represents a set of general principles and rules that have been developed to help ensure that the health needs of the public are provided in a safe, effective, and caring manner. You can take a look at your code of ethics by logging on to aarc.org and review your code of ethics for the respiratory care profession.

As we review these codes of ethical codes of conduct, we will see how they apply to our current practice in our healthcare institution, as well as state licensure. Later, you will also see how they align with the eight guiding principles of ethics.

1.    The AARC code of ethics says that every respiratory therapist shall demonstrate behavior that reflects integrity, supports objectivity, and fosters trust in the profession and its professionals. They shall actively maintain and continually improve their professional competence and represent it accurately.

2.    The respiratory therapist shall perform only those procedures and functions in which they are individually competent and which are within their scope of accepted and reasonable practice.

3.    As respiratory therapists, we are bound to respect and protect the legal and personal rights of patients that we treat, including the right to informed consent and the refusal of treatment. We know that there are times when some patients refuse to be treated, and we have to respect that right because that we know that patients have a right to autonomy.

4.    The respiratory therapist is bound to divulge no confidential information regarding any patient or family unless disclosure is required for responsible performance of duty or required by law.

5.    The respiratory therapist shall provide care without discrimination on any basis, with respect to the rights and dignity of all individuals.

6.    As respiratory therapists, we shall promote disease prevention and wellness.

7.    The AARC statement of ethics says that the respiratory therapist shall refuse to participate in illegal or unethical acts, and shall refuse to conceal illegal, unethical, or incompetent acts of others. We should report such unethical acts of others to our superiors or to management to ensure that our profession is performing in ethical conduct.

8.    The respiratory therapist should follow sound scientific procedures and ethical principles regarding research. The advancement of technology has grown and we should be on the cutting edge of the technology as it pertains to respiratory care.

9.    We should comply with state or federal laws that govern and relate to our practice, including maintaining educational credits to maintain our licensure.

Here is a deeper look at what respiratory therapists must do. In addition to keeping professional conduct, the respiratory therapist must keep and maintain accurate records of patient contact and treatment. We should report suspected cases of spousal, elderly, and child abuse. We should communicate honestly and effectively with other members of the healthcare team. As respiratory therapists, we act as patient advocates in all situations involving respiratory care. We always want to advocate and be a voice for our patients.

The respiratory therapist should uphold the integrity of the Respiratory Therapy Licensure Act, as it pertains to their state. We do so with integrity to the NBRC examination system and the integrity of the profession by reporting actions and activities detrimental to the proper function and administration of these processes.

Now that we know what we, as respiratory therapists should do, let's look at some things a respiratory therapist may not do. We may not prescribe medicines, therapeutic activities, or treatments other than those that are permitted under the approved protocols or formal agreements with our particular physicians. Keep in mind, every hospital in each state may operate differently. Respiratory therapists may not falsely hold themselves out to be physicians, nurses, or other types of healthcare practitioners. We should not practice at a level or in a manner beyond our legal level of competence unless enrolled in a formal training program aimed at learning those advanced skills. For example, if you are not trained to intubate, that is not a practice that you want to do.

10. The AARC ethical code of ethics for professional conduct also says that the respiratory therapist should avoid any form of conduct that creates a conflict of interest and shall follow the principles of ethical business behavior.

11. The respiratory therapist should promote healthcare delivery through the improvement of access, efficacy, and cost to patient care.

Ethics and the Law

Ethics provide the general principles on which laws are based. In other words, laws are the means of enforcing ethical principles. For example, if society agrees that life is precious, its members pass laws that make murder a crime. Laws, however, can conflict with individual ethics for some members. For example, the use of medical marijuana can pose an ethical problem. Although it is proven to help treat patients with chemotherapy, its use for this purpose is illegal in most states because many people believe that it encourages inappropriate drug use or unethical behavior.

Some well-intended laws do not succeed in bringing about justice. Others have harmful consequences that are not recognized until after the laws are in effect. For example, legislation has been passed requiring hospital emergency rooms to accept all patients who require care regardless of their ability to pay. Many hospitals cannot afford this financial lass of treating every patient who comes to care. This has resulted in many emergency rooms closing down and thus denying the entire community important healthcare resources.

Guiding Principles of Healthcare Ethics

Next are the guiding principles of ethics that we use in the healthcare setting. There are eight guiding principles.

• Preserve Life
• Do Good
• Respect Autonomy
• Uphold Justice
• Be Honest
• Be Discreet
• Keep Promises
• Do No Harm

We will look at these guiding principles and the laws that support them, as well as how the healthcare professional provides these educational principles on the job.

Preserve Life

We will start with preserve life. This basic guiding principle says that life is precious and that all possible means should be taken to preserve it. How was this principle applied in our healthcare institution? We provide all patients, including the terminally ill, with caring attention. Difficulties may arise when we do not have a clear definition of the meaning of life. Advancement in technology has made it possible to maintain life by artificial means through mechanical ventilation or feeding tubes.

The argument has been made that patients suffering from terminal diseases or injuries are being forced to exist under cruel and unnatural conditions. Some suggest that a better description would take the quality of life into consideration. In other words, is it worth prolonging life when a patient is in severe pain and cannot be relieved? Is it worth prolonging life if a patient is suffering from a terminal condition? What if a patient is in a coma with no reasonable hope of regaining consciousness? Is it worth preserving the life of a patient without any brain function? These are some of the ethical dilemmas that we are facing.

Even withholding artificial means of support of life can become widely accepted, as long as this is the desire of the patient or those who are authorized to make decisions. Withholding life support can be justified, some argued because it simply allows the existing fatal condition to take its natural course. Artificial support merely delays a death that cannot be avoided.

We look at other dilemmas facing preserving life, such as organ transplants. Organ transplants are the ability to successfully transplant organs to save the lives of people who otherwise would not survive. While organ transplants can save lives, it creates an ethical dilemma because not everyone agrees to have their organs or their family's organs donated at the time of their death. While the organs from one person can save the lives of as many as eight others, it is illegal to take the organs without prior permission of a patient or following the death of a family member.

Another dilemma under preserving life is the controversy over stem cell research. Stem cells hold promise for replacing patient's cells that have been damaged by disease or injuries. According to scientists, some of the most effective stem cells for these purposes are those taken from human embryos or aborted fetuses. Taking cells from embryos results in its death and some individuals believe this is a form of murder. This use of fetal tissue presents problems for opponents of abortion. These disagreements have prevented the use of federal funding in the past to support research that uses newly-harvested embryonic or fetal stem cells.

When it comes to preserving life, some suggest that a better description would take the quality of life into consideration. Is it worth prolonging life when the patient is:

• In severe pain that cannot be relieved?
• Suffering from a terminal condition?
• In a coma with no reasonable hope of regaining consciousness?
• Without brain function?
• Requesting that treatment be discontinued?
• Asking that life be terminated?

Avoiding terminally ill patients or hurrying through their care is unethical. Many terminally ill patients report that they believe they received less attention than those for whom “there is hope.”

Do Good

The next guiding principle is to do good. This is helping and promoting the welfare of others. It is the basic duty of the healthcare provider. The reasonable needs of the patient must be considered before the needs of self. How do we apply this ethical principle in our healthcare setting? Helping to promote the welfare of others is the guiding principle for healthcare workers.

We apply this principle in our jobs by practicing good communication. Treating every patient with respect and courtesy is another way of applying this ethical principle. Personal conveniences are always secondary to your patient's welfare. The reasonable needs of your patient must be considered before the needs of self.

• Working in the best interest of the patient requires the following:
• Listening carefully to what they say
• Making an effort to understand their ethnic and cultural backgrounds
• Carefully assessing their needs
• Being aware of their ethnical beliefs
• Explaining what you are doing as you perform tests, treatments, and other procedures
• Providing appropriate instruction
• Allowing the patient to feel comfortable enough to ask questions
• Answering all patient questions, or finding the answers if necessary

Respect Autonomy

Our next guiding principle is autonomy. Autonomy means self-determination. Remember that the patient should be involved in their own care pending their age, mental, and physical capabilities. Patients have the right to make decisions about their healthcare, including whether or not they choose to receive treatment.

How do we apply this practice in our institution? We have to be sure that our patients have consented to all treatments and procedures. We become familiar with our state laws and healthcare industry policies that deal with advanced directives. We respect the beliefs and values of various cultural groups.

From this principle, the rules of informed consent are derived. Medical treatment cannot be carried out unless the patient gives consent or permission. When a procedure has been explained, including the possible consequences, the patient's permission is known as informed consent. There are two types of consent. One is implied consent, which is indicated by the patient's actions, such as showing up for an appointment or participating in an exercise or an exam. The other is express consent. That is something that a patient gives in writing and is required for many procedures.

Touching a patient or performing a procedure without his or her permission can result in being charged with a crime of battery, which refers to unwanted touching of another person. If a patient feels threatened about receiving unwanted treatment, even if it is not performed, it can result in a crime of assault. It does not matter if the patient benefits from the treatment.

The only difference between proper medical treatment and crimes of assault and battery is whether the patient gives permission. An exception is emergency care administration when the patient is physically unable to give consent. Battery can also be charged if a patient is handled too roughly, is spanked, or hit. A patient's full consent must be obtained before performing any procedure.

A resisted action that is done for the patient's own good may be illegal and result in criminal charges or lawsuits. An example of this is using any type of restraints, especially with an uncooperative patient. The healthcare professional must always use proper techniques when moving patients to prevent pulling on their limbs or other unintended roughness.

Excessive persuasion is also a form of assault. A patient who feels that they are being talked into a procedure may charge assault and battery. For example, a woman who believes that she was persuaded into being sterilized or having a tubal ligation may successfully sue. Patients who are worried about health problems or financial matters often feel afraid and confused. They may accept the advice of a healthcare provider only to change their minds later.

For patients who become unable to make decisions about their own care, self-determination is possible through an advanced directive. An advanced directive is written instructions that outline the individual's desires regarding their care. Again, this is set in place by patients who become unable to make decisions.

There are two major forms of advanced directives. One is the designation of a healthcare surrogate or representative, also called a healthcare power of attorney, which occurs when an individual designates a specific representative to act on their behalf if they become unable to make healthcare decisions. An individual can select anyone to be a surrogate. It is not necessary for the surrogate to be related. Each state has specific requirements and designation forms. Check your state laws to see what they say about advanced directives.

A living will, or healthcare instructions is another form of advance directives. This document outlines an individual's wishes regarding the type and extent of care to be given. Some living wills allow the inclusion of specific directions about whether the individual consents to certain procedures, such as cardiac resuscitation, mechanical ventilation, or feeding tubes. A Do-Not-Resuscitate (DNR) or Do-Not-Intubate(DNI) request can be included in the living will.

The Patient Self-Determination Act of 1991 says healthcare facilities must provide adult patients with information about advanced directives. Family members and physicians may disagree about the proper course of action, but in these cases, the courts are called on to make the final decision.

Uphold Justice

The next guiding principle is to uphold justice. Justice refers to fairness. How do we apply this ethical principle to our jobs? We treat all patients equally regardless of their economic or social background. We learn the state laws and institution policies and procedures on handling and reporting suspected abuse. Justice requires that all patients, regardless of their race, economic status, religion, nationality, and personal characteristics, receive the same level of care and consideration. The equitable distribution of healthcare resources has been an issue of great concern for all Americans. The high cost of healthcare has resulted in restrictions being set by managed care organizations.

Upholding justice also refers to the use of the authority of power to uphold what is right and lawful. It requires healthcare professionals to report suspected abuse. All states have laws and reporting systems for abuse. It is very important that you learn your state laws regarding reporting and abuse.

Be Honest

Good healthcare relies on honesty. How do we use and apply this ethical principle on the job? We have to admit mistakes promptly and offer to do what is necessary to correct them. Refuse to participate in any form of fraud. Document all procedures accurately. A patient’s trust is important in their well-being and trust is built on honesty.

One of the dilemmas that arise with this ethical principle is how much do we tell our patients about their condition? It can be argued that telling a patient the truth may not always be in his or her best interests. For example, should a clinically depressed patient be told that he has a terminal illness if it is believed that this might lead him to attempt suicide?

Truth-telling is also critical among coworkers and with supervisors. It is not always easy. For example, if you make a mistake in performing a lab test it is tempting to forget to mention it. Mistakes, however, can have serious consequences and must be admitted and corrected as quickly as possible. Fraud is a form of dishonesty and involves cheating or trickery. Healthcare examples of fraud can be insurance claims for services not performed, selling ineffective treatments, or claiming education or credentials that one has not earned.

Be Discreet

Being discreet means being careful about what you say, preserving confidentiality, and respecting privacy. In healthcare, this is not only one of the most important ethical principles, it is the law. Patients have a legal right to privacy concerning their medical affairs. Patients’ information cannot be released without their written consent and violating that right, even if well-intended, can result in lawsuits.

In 1996, Congress passed the Health Insurance Portability and Accountability Act, commonly referred to as HIPAA. This was implemented in 2003. It is an important part of the law that promotes the creation of the national standard to protect patient's privacy and personal health information which many people believe could be compromised by the use of electronic medical records. Healthcare facilities have formulated policies to comply with the HIPAA requirements.

Being discreet also means not disclosing unauthorized information that can harm the reputation of others. This is known as defamation of character. When disclosed in writing form it is called libel. In spoken form, it is called slander. These are serious offenses that can result from innocent but careless behavior. For example, reporting a patient's HIV status within the hearing range of others could result in charges of slander.

Maintaining patient privacy is very important. Maintain individual rights when seeing your patient by closing the doors and curtains and draping your patient appropriately if you find them exposed. Being discreet also means you do not discuss the patients in public areas, including the hallways, elevators, the cafeteria, or any other public area. Being discreet means discussing your patients only with other authorized personnel.

One dilemma that can occur surrounding this ethical principle is public safety. If your patient has a contagious disease should the public be aware? Another dilemma is patients who desire to hurt themselves. You have to keep in mind patient confidentiality, but there is also the dilemma that should this information be disclosed.

A recent dilemma involving confidentiality is the controversial issue of genetic testing. This relatively simple test is used to identify many potential hereditary diseases and conditions. Knowing in advance about the possibility of a genetic disorder can help couples with family planning and can assist individuals in choosing lifestyle changes and treatment plans to prevent or minimize the effects of a disorder. However, disclosing the results for the insurance coverage might be a concern.

Equitable distribution of healthcare resources is another dilemma around being discreet. The high cost of healthcare has resulted in the restrictions being set by insurance companies and organizations. This may lead to limits on the length of hospital stays or the number of therapy sessions a patient may receive.

Keep Promises

In everyday life, promises are an important part of relationships with others. How do we use this guiding principle in our workplace? We have to be sure that necessary contracts have been completed. Be very careful about what you say to your patients. They may only hear the good news.

Contracts are formal promises that are enforced by law. They contain agreements of people to do specific things. Contracts contain three components.

1. Offer – the action that starts the process of forming a contract such as making an appointment to see a dentist or a doctor
2. Acceptance – the agreement by both parties, you and your provider, such as agreeing to treat the patient
3. Consideration – providing the service and getting paid for that service

In order for a contract to be enforceable, people who enter into the contract must be competent. The law defines competency by age and mental condition as it does with consent. State laws govern who may legally enter into a contract.

There are two types of contracts, implied and express. Most contracts between healthcare providers and patients are implied contracts. This means that the actions of the parties create a contract. An express contract is created when the parties discuss and agree to a specific term and conditions. The contract can either be written or oral. It is important that the healthcare provider avoid making statements that might be interpreted as a contract. Although it is natural to want to reassure and encourage patients, this should never be confused with giving what might be understood as a guarantee or false hope.

A breach of contract is when one party fails to carry out part of the agreement. Damages may include money to compensate for the injury or loss. An agent is may also be involved in a contract.  An agent is someone who represents another person when making a contract, such as an attorney.

Respondeat superior is a Latin phrase that means let the master answer. It is a legal doctrine holding the employer responsible for the actions of the employee. The following examples illustrate this concept. A physician could be held liable for the consequences of a medical assistant administering the wrong medication. A patient suffering injuries from a fall caused by the incompetence of a physical therapist assistant could be awarded damages or money to compensate for their injuries.

Do No Harm

Do no harm is our last guiding principle. An essential responsibility of the healthcare worker is to do no harm. They must work within their scope of practice and perform only those duties that they have been trained to do. It is critical that safety rules be followed and that medical advice never is given by a person who is not qualified to do so. Harm can result from negligence, which is the failure to meet the responsible standard of care reasonably expected from a person with certain training and expertise. This could result from actions being performed incorrectly or failure to take necessary action when needed.

When we do harm we run the risk of malpractice, which is professional negligence filed by patients who believe they have received improper care. It may result in a lawsuit against healthcare providers and/or that facility. Patients who perceive a lack of attention, care, and respect, are much more likely to sue than those who feel positive about their care.

The Good Samaritan laws protect individuals who give care in emergency situations. These laws have been passed by states to protect those individuals. Check to see what your individual state says about Good Samaritan laws. Good Samaritan laws say that it is best to stay within your scope of training. Even in an emergency is important for healthcare providers not to offer aid beyond their scope of training.

Handling Ethical Dilemmas

The first consideration of the ethical healthcare professional is making the wellbeing of patients a priority. Accept responsibility for making difficult decisions and know that sometimes there are no right or wrong answers. Remember to honor and value the ethical beliefs and values of others.

Report any illegal behavior in the healthcare setting. Illegal and unethical behavior can endanger a patient’s welfare and cannot be tolerated. Observations of this behavior in others must not be ignored. Although it is difficult to confront the wrongdoer or tell on your coworker, doing the right thing must override the short-term discomfort. If the behavior observed in a coworker is illegal, it should be reported to the supervisor. If the behavior involves legal but ethically questionable behavior, such as bad-mouthing an employer, it may be best to speak directly to your coworker.

Case Studies

Complying with State and Federal Laws which Govern and Relate to Their Practice

Our first case study is about complying with state and federal laws that govern and relate to their practice. Tara Z. Someliynski has been practicing as a registered respiratory therapist for seven years. Prior to that, she practiced for three years in an adjacent state. Licensure became a requirement in her state this year.

As a condition for licensure, each practitioner must submit a copy of their current driver's license, her NBRC registration card, and an application containing among other information, a notarized statement attesting that all the information submitted to the board is true. Upon submission to the board and during the application process, J.H., MS, RRT an appointed member of the board, became curious. He stated to other board members, "You know, this is very strange. I went to respiratory care school with Tara, but about eight years ago, she was killed in an automobile accident three days after passing her RRT exam. What are the chances that someone with that exact same name would also be an RRT from my home state?" The rest of the board agreed that it was an exceptionally strange circumstance and was referred to the investigative branch. There are cases in which falsifying information may raise concerns to the board before issuing a state license.

Upon examination, it was discovered that Tara Someliynski was actually Billie Sue Renfrew, a former roommate, and coworker of Tara’s. Billie Sue had been dismissed near the end of training for attitude problems and poor grades from the same school. It was discovered that Billie Sue had intercepted the NBRC card from the mail and had altered her driver's license by switching photos. When these actions were successful, Billie Sue moved to her current state under the newly switched identity.

What legal issue arose from this case? How could this situation have been avoided by the employer, the NBRC, or by the state or federal government? Is Billie Sue the only one at fault here? What sanctions should be leveled?

Promoting Healthcare Delivery through Improvement of the Access, Efficacy, and Cost of Patient Care

The next case study is about H.M., a 43-year-old HIV-positive patient who has an admitting diagnosis of bronchial pneumonia and pneumothorax. He is hepatitis A, B, and C negative. His body temperature is 98.6 degrees Fahrenheit with respiration at 24 breaths per minute and shallow. He is cyanotic and tachycardic with normal blood pressure. His oxygen saturation is 89% and he has a PaO2 of 65 milliliters of mercury on a 40% Venturi mask. The patient has a 25% pneumothorax seen on chest X-ray. His CD4 T-cell count is very low and he has a positive sputum culture or pneumocystis carinii. He has been HIV positive for 11 years and he reports that he has lost 40 pounds over the last three months.

This patient was admitted to the ICU where a chest tube was inserted which resulted in a slight improvement of his oxygenation. He is awake and lightly sedated but is able to answer questions appropriately. The patient declines intubation should he proceed to full respiratory failure. This statement is well-documented on the medical records. Previous medical records indicate the presence of a durable power of attorney, which excludes “heroic efforts” and the use of “life support equipment.” The patient's life partner of eight years states he has seen the document and affirms that in the course of such decision the patient has said he does not want any life-support and all that goes with it.

The patient's family, who has been out of contact with him for 10 years, cannot be located for confirmation. One week later, the patient has clinically deteriorated to a degree that he is comatose and near death. His mother suddenly appears and is devastated to learn of her son’s illness and demands that he be immediately intubated and fully resuscitated. The mother insists that he should not be allowed to die, regardless of the durable power attorney, which has not been found among the patient's records at home. However, the patient's will is found which leaves a large sum of money to his life partner.

The case is immediately referred to the hospital's ethical committee. They rule that the patient’s statements, as documented on the charge before he became mentally incompetent from his acute illness, have precedence and he is not to be aggressively treated, as demanded by his mother. Soon thereafter, the patient dies.

Because of the large sums of money and his estate, his mother brings a lawsuit for wrongful death against the hospital, the physicians, and his life partner. The court subsequently dismisses the hospital and the physicians as defendants due to their use of the hospital's ethical committee for consultation and careful documentation of the patient's statements. The mother and the life partner settle out of court. Think about all of the ethical and legal issues that arose from this case.

Resources

You can seek out these resources to get a better understanding of how to handle ethical dilemmas in your healthcare facility.

• American Medical Association Council on Ethical and Judicial Affairs
• Ethics committee at your healthcare facility
• Clergy and counselors
• Lawyers and risk management specialists

References

AARC Statement of Ethics and Professional Conduct (Revised 2015). American Association for Respiratory Care (AARC). https://www.aarc.org/wp-content/uploads/2017/03/statement-of-ethics.pdf

Mitchell, D., & Haroun, L. (2016). Introduction to Health Care (4th ed.). Cengage Learning.

Heuer, A., Kacmarek, R., Stoller, J. (2016). Egan’s Fundamentals of Respiratory Care (11th ed.). Mosby.