Chapter 2

Health Care Ethics:

The refinement of ethical beliefs and principles is a dynamic process changing as society beliefs change. Medical ethics has grown to become a separate arena within the realm of ethics and moral decision-making. Thus, the rest of this course will concentrate on medical ethics and the impact such understanding has on the field of rehabilitation.


Medical ethics is generally divided into four principles. The four principles are:

  1. Beneficence – the obligation of health care providers to help people in need.
  2. Nonmaleficence – the duty of health care providers to do no harm.
  3. Autonomy – the right of patients to make choices regarding their health care.
  4. Justice – the concept of treating everyone in a fair manner.

Almost every facet of rehabilitation practice is impacted by ethics and moral dilemmas. The next course section will highlight the application of ethics to clinical practice. Consider the following case study:

Case Study:

RB is a physical therapist working in an SNF. Routinely, RB is asked to fill-in Section G of the MDS form for new admits to the facility. RB does as told as that is the facility policy. Another physical therapist, TL, joins the staff of the facility. TL objects to completing Section G. TL points out that the MDS is a nursing assessment and not an interdisciplinary tool to be shared among staff. Further, most of the patients do not have physician’s orders and are not on the physical therapy case load. This disagreement came to the attention of the Facility Director when RB was requested to fill-in Section G for a patient who was admitted on Friday evening to the hospice program. The patient died on Sunday. RB had never seen the patient nor were there therapy orders. RB stated that the MDS Nurse demands that this section be filled in and that he is to use the nurses’ documentation to complete “his section.” RB has previously been reprimanded for refusing in similar situations. He values his employment and has learned to be compliant.

This case represents a complex situation of issues and ethical dilemmas. Through this document, a schematic for decision-making is outlined to assist therapists with making the most ethical decision.

Beneficence:
The first ethical principle, beneficence, refers to the obligation of health care providers to help people in need. The following scenario helps to highlight this principle.

JT, DPT is a diligent physical therapist in a sports medicine clinic. JT shows concern for patients and takes his practice seriously. However, on one occasion, the exercise protocol prescribed by an orthopedist for all anterior cruciate ligament (ACL) surgical patients was too intense for a small female athlete who was 2 weeks post ACL repair. JT recognized that the patient did need to rigorously follow an exercise protocol, however in this case, the protocol must be modified.

Taken to an extreme, this patient outcome could be quite different. Accurately following the physician’s protocol may have resulted in damage to the surgical site. This patient in need would have had an undesirable outcome. However, even with a poor outcome, beneficence may also come into play if JT recognized his failure to apply appropriate clinical judgment for this patient and learned from the incident. If JT learned that he should change or modify the protocol as required by patients and his intent in learning is to continue to help people in need, JT will be embracing beneficence. However, if JT focused the unfortunate outcome on the orthopedist or the protocol, he would be violating this basic ethical principle. Beneficence infers that medical practitioners simply do their best in each situation. It doesn’t mean that all help needs to perfect!

Beneficence may be the trump card played in many activities that seek physical therapist intervention. For example, local community organizations may call upon a PT to provide oversight of a local exercise program; or the local physical therapy chapter may request donations for the “Toys for Tots” holiday toy give-away for needy youngsters; or the hospital CEO may request that physical therapists help with transferring patients who come by personal vehicle to the emergency room. All of these examples play upon the ethical principle of helping people in need. Taken to extreme lengths, health care providers may become weary from the obligation to “help people in need.” Thus, with every ethical principle, the physical therapist must balance the individual’s ability to live the ethical principle while retaining a balanced life. Saying, “No,” in such situations does not mean the principle is violated. Altruism has its limits for everyone.

Nonmaleficence:
The second principle generally recognized in medical ethics is nonmaleficence; the duty of health care providers to do no harm. The following scenario illustrates this principle.

GK accompanies her father to an occupational therapy evaluation for a rotator cuff injury he sustained painting the porch steps. GK takes the therapist aside and confidentially requests that the therapist recommend that her father no longer drive. She feels that he is too old to drive. The therapist, LN, evaluates the patient and initiates treatment. Through the evaluation process, LN determines that the patient is cognitively intact, has visual acuity to see well for at least 20 feet aided by his glasses, his muscle strength is 4+ or better for all measured muscles; and he is functionally independent with no assistive devices. LN sees no impairment that might impact driving for this client. LN does not honor the daughter’s request.

Nonmaleficence is the ethical principle that LN employed in her view of this patient interaction. Driving is considered an Independent Activity of Daily Living (IADL) for many people. Taking away mobility for arbitrary reasons (such as a daughter’s request) could cause harm to this patient.

The idea of “harm” may be difficult to define in therapy settings. In a broader sense, harm may be defined as physical or psychological or emotional damage or injury to a person, animal, or other entity. Harm may be viewed as an infliction of pain onto another person. However, in the realm of physical therapy, often exercises or stretching regimes may cause pain. Inflicting pain in the therapy realm is not causing “harm.” A therapist that fails to adequately treat a patient in order to avoid causing pain MAY be causing harm. For example, treating patients in a burn unit may call for some painful sessions. Not following through on adequate contracture reduction will result in lifelong disablement for such a patient.

Autonomy:
Autonomy is the third principle defined in medical ethics. Autonomy means that patients have the right make their own choices in health care. This principle is based in the overall desire of most people wishing to control their own life and decisions. Autonomy does recognize that this principle relies on competent adults agreeing to care through an informed consent process. The health care provider does have the obligation to respect the patient’s wishes while continuing to provide education and recommendations according to the best medical practices of the time. For children or adults with cognitive issues, autonomy to make medical decisions rests with a parent, guardian, other family member, or surrogate decision maker named in a legal document.

The next vignette outlines a common practice and an unfortunate outcome where the autonomy of the patient was not respected.

RZ is an older adult with severe rheumatoid arthritis. She was referred to physical therapy for evaluation and treatment to improve functional mobility. On her first visit she was assigned a senior physical therapist who is a Board Certified Clinical Specialists in Geriatrics (GCS). Upon arriving for her second appointment, RZ is welcomed by a physical therapist assistant. RZ is incensed. She would like to be treated by the evaluating therapist. RZ was informed that the physical therapists only do the evaluations while the physical therapist assistants provide ongoing treatment. RZ leaves the physical therapy clinic in a huff without receiving treatment.

The patient in this situation does have the right to be treated by the provider she desires to receive treatment from; or, at the very least she should have been told what to expect and who is available to work with her during her next appointment. Clinic systems or practices may be based on efficiency or methods that make perfect management sense. However, patients such as RZ do have the right, based on autonomy, to choose who they will receive treatment from. As with any principle, this idea may be taken to greater lengths. A patient hospitalized as inpatient must exercise reasonable expectations in care – requesting the same nurse for 24 hours would not be reasonable. However, expecting the same nurse throughout an 8 hour shift is reasonable.

This principle has become increasingly important in health care. Patients’ Bills of Rights are required in virtually any area of health care that a clinician may practice. Patients have the right to determine what health care they will access; what they will or won’t do; and who they will or will not see. In previous generations, many health care providers were viewed as paternalistic. Health care providers would make decisions for their patients and did not expect or accept input from their patients. The ethical principle of autonomy changes that practice.

Justice:
The fourth medical ethics principle is justice. Justice is the ethical concept of treating everyone in a fair manner. Though each of the first three principles is complex, justice is the most controversial and the hardest to define of the four. In a general view, people are treated justly when they receive the care they deserve. Even broader, justice refers to universal rights such as the right to have enough to eat; the right to shelter; and the opportunity to have access to basic medical care and education along with the right to speak freely. If any of these rights are denied, then justice has been violated. Justice if the principle that equal opportunity is derived from. All people should have equal opportunity to realize their own potential. Of all of the ethical principles, justice is the principle most linked to the golden rule: “Treat others as you would want others to treat you.” Consider the following vignette.

PP is a newly hired physical therapist for a home care agency that is the only home care provider for 40 miles. PP has orders for three new clients. Each client was discharged from the local acute hospital the day before following total hip arthroplasty 6 to 8 days previous. PP receives general guidance from the coordinating office manager who informs her that Patient A is a Medicaid client who should be evaluated and discharged from care immediately; Patient B has a managed Medicare health plan that provides up to six visits for this diagnosis before requiring authorizations for ongoing therapy; and Patient C is covered by a standard Medicare policy with no specified limits and care dependent on the evaluation of the physical therapist.

All things being equal in the above situation, PP finds that therapy provision is being determined based solely on the payer. The principle of justice (along with nonmaleficence and beneficence) certainly plays into this conversation. The world of pay and equal treatment is a controversial topic in health care. One could say that justice is served in that all three patients were offered the opportunity for “basic” physical therapy. Conversely, justice may not really be served if Patient A is de-conditioned, unable to functionally manage in her home, or be at risk for falls and then only be offered a single home-based appointment based solely on her inability to have funding for more premier services.

Distributive Justice:
Dissecting justice and the idea of payment for services rendered, the issue of distributive justice arises. The justice vignette pointed out ongoing concerns about the allocation of health care dollars and the resulting burdens on society for that care. Distributive justice addresses concerns about who receives how much money, education, or medical care. Ideas such as who pays what amount of taxes or percentage of individual health care costs are linked to distributive justice. Consider the following situation:

HP, a 68 year-old male with coronary artery disease was told by his primary care physician that he may need further diagnostic testing including an angiogram with the possibility of stent placement or the need for open-heart surgery. HP was a retired farmer with no health insurance. He had never paid into the federal government for Medicare taxes and therefore did not have Medicare. Further, he still had large assets as he owned the farm land that his son now farmed. HP’s son investigated the procedure on the internet and found that many Americans were traveling to India to receive medical care. These travelers reported that they received the same health care they would expect in the United States but, at a fraction of the cost. These travelers considered the care a “medical vacation.” In the internet search, the son noted several companies in the United States that specialized in arranging for this type of service. He called one company and arranged for his father to fly to India.

Scenario’s such as HP’s have become a topic for many major news stories. The idea that the same care is provided in foreign lands for a fraction of the costs has caused many Americans to seek such care. In considering these possibilities, multiple concerns and issues arise. Thoughts such as what if complications arise? What if the care is not “the same”? If Americans routinely travel elsewhere for elective care, what about those who cannot afford such an option? Is this fair? Is distributing care world wide really a free-market at play? And then, should health care even be considered part of a free market enterprise? These are topics that scholars will continue to debate and an area that clinicians need to pay attention to in the future.

In the areas of distributive there is no uniform agreement or formula on how society should allocate benefits and costs fairly. On could ask, should each person get an equal share? Should those who work harder receive more? Should the proper formula be that each person pay according to their ability to pay or should payment be based on a free-market principle? Still further, should each pay according to need? These are difficult questions for societies to ponder. Rehabilitation is a subset of these societies. Decisions and answers are controversial and fraught with consequences.

From a historical perspective, health care is viewed as a privilege that should be allocated according to ability to pay. More socialistic societies believe that health care is a right and should be distributed according to need. This debate will rage on in the United States and worldwide. Failure to have universal coverage guidelines and the ability for the wealthiest to pay for more than others, makes distributive justice a hot political topic. Therefore, clinicians will continue to be challenged on how to provide the best care to all clients while remaining cognizant that someone must pay the bill. Simply providing services without considering the financial reality of that care is callus. It is the responsibility of clinicians to act in an ethical manner, provide the best care possible, and ecognize that distributive justice requires ongoing consideration.

  Next: Chapter 3