ETHICS IN HEALTHCARE

Learning Objectives:

At the end of the session, the participants

should be able to:

1. Know Ethics in Healthcare and its principles

2. Know Ethics in Rehabilitation and its
principles
 What is Ethics?
• A system of moral principles or standards
governing conduct.
• a system of principles by which human
actions and proposals may be judged good
or bad, right or wrong;
• Any set of moral principles or values
recognized by a particular religion, belief or
philosophy;
• The principles of right conduct of an
individual. (UNESCO/IUBS/Eubios Living Bioethics Dictionary version 1.4)
What is “ethics”?

• Ethics: “the rules

of conduct
recognized in
respect to a
particular class of
human actions or
a particular group,
culture”
 Ethical/Moral Reasoning

• It is the process we need to go through to reach a

decision about an ethical issue.
• It helps us to differentiate:
• Facts: description of the way the world
is; an actual state of affairs (“is”)
• Values: judgment about the way things
should be (“ought”).
• Ethical principles: they are meant to
guide actions. (e.g., principle of respect
for autonomy)
 What is an “ethical issue”
or a “moral problem”?
• There is an ethical issue when:
• …we encounter conflicting values,
beliefs, goals, or responsibilities
• …we are concerned that persons or
their rights are not being respected
• …we are concerned about fairness
and justice
• …we are unsure what we should do or
why we should do it, morally speaking
 What is Bioethics?

• It is derived from Greek bio- life

and ethicos moral.
• The science/art that aims at

identification, analysis, and

resolution of the ethical issues in
almost any field that is related to
human life and health.
What is “bioethics”?
• Bioethics: “a field of
study concerned with
the ethics and
philosophical
implications of certain
biological and medical
procedures,
technologies, and
treatments, such as
organ transplants,
genetic engineering,
and care of the
terminally ill”
Questions answered by Bioethics

 deciding what we should do (what

decisions are morally right or acceptable);
 Example: Should patient A or B have the ICU
bed?
 explaining why we should do it (how do
we justify our decision in moral terms); and
 Why did we decide to admit A & not B?
 describing how we should do it (the
method or manner of our response when we
act on our decision).
 What are we going to do for patient B?
 What is Clinical/Medical Ethics?

• It is a branch of bioethics that is

related to the identification,
analysis, and resolution of moral
problems that arise in the
healthcare of individual patients.
 What is Medical Ethics?
• Medical ethics refers to...
• chiefly to the rules of etiquette
adopted by the medical
profession to regulate
professional conduct with each
other.
• and includes considerations of
motives behind that conduct.
 Medical Ethics
• Medical ethics does not only concern doctors
but also patients and society.
• The central question of medical ethics is the
doctor-patient relationship.
The Problems of Health System :

• Who will live?

• Who will die?
• Who will get what treatment?
• Who will decide?
• And how?
 Utility of Medical Ethics
• Medical ethics principles provide a
framework for discussing ethical
issues and for medical decision
making.
 World Views:
• In a world of health
care… economics,
consumers, clients
and service
providers, health
care has to be based
on sound ethical
principles that reflect
the reality and needs
of contemporary
society.
 The Philosophical Underpinnings
of Medical Ethics:
ETHICAL THEORIES
• DEONTOLOGY (Deon = duty)
• Duty or principle based theory

• Springs from moral obligations

• Actions determined by
rightness or wrongness ( virtue
ethics)
• The outcome of action is not
important
• RULE / PRINCIPLE / DUTY
 Ethical Theories
• TELEOLOGY (Telos =
goal)
• Actions determined
by their
consequences
• Motives less
important than the
outcome
• Greatest good for the
greatest number
• Actions will vary
depending on the
situation (situational
ethics)
SUMMARY
 RECONCILING THE TWO:
• CONSEQUENTIAL MODEL
• What is the right thing to do in this
instance?
• What would be the consequences?
• Additional ethical principles
 Consequentialism
• Actions are right or
wrong according to
the balance of their
good and bad
consequences
• the right act is the
one that produces
the best overall
result
•  "the ends justify
the means".
• Utilitarianism
(what action has
the greatest utility -
use/benefit/positive
outcome) is a type
of
consequentialism
ETHICAL PRINCIPLES
A Classic Bioethical Decision
• One heart available  who should get it?
40-year-old school
17-year old girl principal 70-year-old woman
 A Classic Bioethical Decision
• One heart available  who should get it?
17-year old girl 40-year-old school 70-year-old woman
principal
 Principles… are guides
• There is considerable
room for judgement in
specific cases
• The ethical
framework is relevant
to multicultural,
pluralist societies
• They work by
providing action
guides in specific
circumstances
 The Ethical Duties of a Doctor
Cause no harm Non-maleficence

Effect a cure or provide Beneficence

palliative treatment
Respect a patient’s Autonomy
autonomy
Treat patient’s fairly Justice

Non-maleficence and Beneficence are mainly

utilitarian
Autonomy and Justice are mainly deontological
Non-maleficence and Beneficence are... two
aspects of well-being
 Four Ethical Rules
• Veracity – truth telling, informed consent, respect
for autonomy

• Privacy – a persons right to remain private, not to

disclose information

• Confidentiality – only sharing private information

on a ‘need to know basis’

• Fidelity – loyalty, maintaining the duty to care for

all no matter who they are or what they may have
done
 Two Methodologies for the Moral
Evaluation of Action:

• Weighing of • Principle of Double

Goods Effects
 Principle of Double Effect

• An action that is good in itself that

has two effects--an intended and
otherwise not reasonably attainable
good effect, and an unintended yet
foreseen evil effect--is licit,
provided there is a due proportion
between the intended good and the
permitted evil.
• Source: Mangan, Joseph. (1949). “An Historical Analysis of the Principle of
Double Effect”. Theological Studies 10, 41-61; Quoted in Alison McIntyre,
“Doctrine of the Double Effect,” Stanford Encyclopedia of Philosophy
 Dilemma….
• When there is a clash between the two
universal norms of "do good" and "avoid
evil," the question arises as to whether
the obligation to avoid evil requires one
to abstain from a good action in order to
prevent a foreseen but merely permitted
concomitant evil effect.
• The answer is… one need not always
abstain from a good action that has
foreseen bad effects, depending on
certain moral criteria.
The Five Moral Criteria that Bring
in the Principle of Double
Effects…
1. The action in itself from its very
object be good or at least indifferent

• The action cannot be something that is

evil in itself.

• Performing surgery to remove a life-

threatening uterine cancer from a pregnant
woman may be permitted, since the action
is not evil in itself, even though it may
incidentally cause an abortion.
 2. The good effect and not the evil
effect be intended;
• The intention of the action must always be
to bring about the good effect.

• Example: Giving increasingly high doses of

morphine at the end of life to relieve
suffering, even though this might bring about
end of life.
3. The good effect be not produced by
means of the evil effect;

• The evil effect (e.g., abortion) can only be

an incidental by-product of the act, not the
means to the good effect.
 4. There be a proportionately grave
reason for permitting the evil effect

• Cannot be used in trivial cases.

• Example: can justify bringing about

an abortion in the case of someone
with life-threatening cancer, but not
in the case of someone who simply
needs minor surgery.
5. There must be no other way to
accomplish the end…
• If there is a way of accomplishing the
same end that does not cause the bad
effect, then that way must be used.

• For example, if the pain can be eliminated

through other means than morphine
without running the risk of death, then the
other means must be used
 Ethical vs. Legal Obligations
• Medical ethics and the law are not the same,
but often help define each other
• “Breach of ethical obligation may not necessarily
mean breach of law”
• Breach of ethical obligation may be used to prove
medical malpractice or medical negligence
Let us also remember that….
• Medicine is about : “Can we?”
• Ethics is about: “Should we?”
 Professionalism in Healthcare:

• What is professionalism?

• How can it be implemented?

• How is it taught?

• How is it assessed?
What does
professionalism
mean to you?
• Professionalism is a term which
embodies numerous qualities of
physicians as public servants.
 Definition
• It is not easy to define a
professional healthcare
provider, but it is likely to have
all or some of the following
characteristics:
• It is a vocation or calling and implies
service to others
• It has a distinctive knowledge base
which is kept up to date
• It determines its own standards and
sets its own examinations
• It has a special relationship with those
whom it serves – patients.
• It has particular ethical principles
• “Constituting those attitudes and
behaviors that serve to maintain
patient interest above physician
self- interest”
“A commitment to the highest
standards of excellence in the practice
of medicine and in the generation and
dissemination of knowledge”.
• A commitment to sustain the interests
and welfare of patients (and the
community).
• A commitment to be responsive to the
health needs of society.
 Professionalism aspires to:

• altruism
• accountability
• excellence
• duty
• honor
• integrity
• respect for other 
 Main Characteristics of
Professional Conduct
• Altruism is the essence of professionalism.
• The best interest of the patients, not self-
interest, is the rule.
 TRIVIA…..
• Healthcare System of Thailand…
• Success… in creating healthcare system
• “ COMBINING ITS OWN INHERENT SENSE
OF WARMTH AND HOSPITALITY plus WELL-
EDUCATED MEDICAL COMMUNITY USING
MODERN MEDICAL TECHNOLOGY”
• Accountability is required at many
levels: individual patients, society and
the profession
• Excellence entails a conscientious
effort to exceed normal expectations
and make a commitment to life-long
learning.
• Duty is the free acceptance of a
commitment to service.
• Honor and integrity are the consistent
regard for the highest standards of behavior
and refusal to violate one’s personal and
professional codes.
• Respect for others like patients and their
families, other physician and professional
colleagues such as nurses, medical
students, residents, subspecialty fellows.
 Patient’s Rights

• Right to Treatment
• Right to Refuse Treatment
• Right to Informed Consent
• Rights regarding Restraint and Seclusion
Ethical Skills of a Mental Health Worker

•The ability to identify ethical features of a

patient’s care.
•The ability to see how a mental health
professional’s life experience, knowledge
and attitude may influence the care of a
patient
•The ability to identify one’s area of
expertise and to work within these
boundaries (scope of clinical competence)
• Ability to anticipate ethically risky or
problematic situations.
• The ability to gather additional information
and to seek consultation and additional
expertise in order to clarify and ideally to
resolve conflict.
• The ability to build additional ethical
safeguards into the patient care situation

• American PsychiatricAssociation,2009
• Rehabilitation counselors are committed to
facilitating the personal, social, and
economic independence of individuals with
disabilities.

• Rehabilitation counselors recognize diversity

and embrace a cultural approach in support
of the worth, dignity, potential, and
uniqueness of individuals with disabilities
within their social and cultural context.
Commitment

• Respecting human rights and dignity

• Ensuring the integrity of all professional
relationships
• Acting to alleviate personal distress and
suffering
•Enhancing the quality of professional
knowledge and its application to increase
professional and personal effectiveness
•Appreciating the diversity of human
experience and culture
•Advocating for the fair and adequate
provision of services
 ETHICS IN REHABILITATION

CODE OF ETHICS OF REHABILITATION WORKERS

GENERAL ETHICAL PRINCIPLES

RELATIONSHIP WITH CO-WORKERS

RELATIONSHIP WITH CLIENTS
RELATIONSHIP WITH THE COMMUNITY
 CODE OF ETHICS OF
REHABILITATION WORKERS
GENERAL ETHICAL PRINCIPLES

1. The rehabilitation worker shall abide by the ethical

principles laid down by the profession.

2. The rehabilitation worker shall exert effort and/or avail of

opportunities to maintain professional growth through
continuing educational learning, keeping well informed with
the current trends, and through affiliation with reputable
national and international associations or societies.
3. The rehabilitation worker shall render services well
within his/her competence and shall not assume more
than his professional qualifications.

4. The rehabilitation worker shall have unreserved

commitment bound to the principles of his profession
for the welfare of his clients but not to the detriment of
his physical and mental health.
5. The rehabilitation worker shall not misuse his
relationship with his client for profit, power, prestige,
personal gratification and any motive not consonant
with the welfare of the client.

6. The rehabilitation worker shall accept with respect

and understanding clients, colleagues, and all those who
come within his sphere or professional activity with
regards to their values, customs and spiritual beliefs.
 RELATIONSHIP WITH
CO-WORKERS

1. The rehabilitation worker shall not only give due

regard to the competence of his colleagues but also
share his expertise in the process of treatment and
rehabilitation of clients.

2. The rehabilitation worker shall always uphold

professionalism in all his dealings and relationships
with others.
3. The rehabilitation worker shall keep mutual respect
and confidence with fellow workers even when they
follow different schools of thought.

4. The rehabilitation worker shall consult colleagues,

experts or proper authorities on matters of national
interest involving the treatment and rehabilitation of
drug dependents.
5. The rehabilitation worker shall refer cases beyond
his competence to an appropriate specialist.

6. The rehabilitation worker shall guard professional

confidence as a trust and reveal such confidence
only after most careful deliberation and when there
is clear and eminent danger to an individual or to
society.
 RELATIONSHIP WITH CLIENTS

1. The rehabilitation worker shall maintain a

professional relationship with the client avoiding any
emotional involvement that will be detrimental to
his/her physical and mental health.

2. The rehabilitation worker shall be flexible in

dealing with client as each individual has his/her
own distinct personality with needs.
3. The rehabilitation worker shall be discreet in
giving information to those persons whom he/she
thinks could be of help to the former with the
approval of the client and his parents or guardian.
Then, however, when this information will endanger
the client or the community, the rehabilitation worker
must take precautionary measures of reporting to the
proper authorities.
4. The rehabilitation worker shall discontinue the
helping relationship when the client does not respond
nor benefit from the counseling. However, the
counselor should refer and assist the client to other
agencies which he believes could be of more help to
the client.
 RELATIONSHIP WITH THE
COMMUNITY

1. The rehabilitation worker shall establish a

relationship between the rehabilitation and the
community in a way that is beneficial to both.

2. The rehabilitation worker shall show deference and

consideration for the social codes and moral
expectations of the community in which he works.
 Code of Professional Ethics for
Rehabilitation Workers, 2011
• Boundary Maintenance The mental health
professional need to stay in the therapeutic role,
avoiding role reversals, extra therapeutic
interventions and multiple relationships with the
patients
• Informed consent and adherence to a contract are
foundations of effective clinical treatment and ethical
treatment
• Secure boundaries of time and place give the
therapeutic frame structure, stability, security,
regularity, consistency and predictability.
Conclusion

• Boundary violations is best prevented by maintaining

an awareness of the clinical dynamics and being
sensitive to the boundary challenges that may arise.

• A spot check for actual or potential boundary

violations is the question: FOR WHOSE BENEFIT?

• Documentation and consultation are pillars of

responsible clinical and ethical care but also insures
liability prevention.
• Consultation is called for when sexual feelings
enter into the relationship.

• Timely recognition of potential boundary

violations
• A mental health professional should receive
explicit guidance in the ethical, clinical, legal
Issues surrounding boundary violations and
sexual misconduct.

• Good health, a balanced satisfying life and

personal psychotherapy are protective factors
against vulnerability to violating clinical
boundaries. (Guthiel & Brodsky, 2008)
Learning Objectives:

At the end of the session, the participants

should be able to:

1. know ethics in healthcare and its principles

2. know ethics in rehabilitation and its
principles
 Even the most rational
approach to ethics is
defenseless if there isn't the will
to do what is right - Alexander
Solzhenitsyn