Chapter 2- Values and Ethics
Learning Objectives
- Summarize the importance of maintaining high values and ethics in healthcare settings.
- Assess the components of IPEC’s values and ethics competency.
- Analyze how ethical challenges may arise in healthcare settings.
Introduction
People strive to be “good,” to do the “right” thing, and to lead a “good life,” but where do such basic, familiar moral values as good and right originate? Throughout history, religious people have explained these ideas as revelations of divine command. Anthropologists, however, view morals as customs that govern social interactions, and because all cultures display such customs, interpret moral practices in terms of a survival function rooted in human nature. By contrast, many social and political thinkers emphasize that moral concepts result from social conventions or agreements that are subject to deliberation and change. Governments today often consult social scientists and health experts who empirically investigate what fosters or improves human life, health, and happiness. Where science informs law and policy, it helps define in a conventional sense what we mean by good and right. In particular, health science helps establish what is considered good for the health of populations and communities. Further below we will examine how ethics, the law, and the health profession interact and intersect. We will also explore some of the major sources of ethical challenges in healthcare.
Values and Ethics for Interprofessional Practice
The first IPEC competency is related to values and ethics and it states, “Work with team members to maintain a climate of shared values, ethical conduct, and mutual respect” (Interprofessional Education Collaborative, 2023). See the table below for the components related to this competency.
Components of IPEC’s Values and Ethics Competency
- Promote the values and interests of persons and populations in health care delivery, One Health, and population health initiatives.
- Advocate for social justice and health equity of persons and populations across the life span.
- Uphold the dignity, privacy, identity, and autonomy of persons while maintaining confidentiality in the delivery of team-based care.
- Value diversity, identities, cultures, and differences.
- Value the expertise of health professionals and its impacts on team functions and health outcomes.
- Collaborate with honesty and integrity while striving for health equity and improvements in health outcomes.
- Practice trust, empathy, respect, and compassion with persons, caregivers, health professionals, and populations.
- Apply high standards of ethical conduct and quality in contributions to team-based care.
- Maintain competence in one’s own profession in order to contribute to interprofessional care.
- Contribute to a just culture that fosters self-fulfillment, collegiality, and civility across the team.
- Support a workplace where differences are respected, career satisfaction is supported, and well-being is prioritized.
Source: Core Competencies for Interprofessional Collaborative Practice: Version 3 from the Interprofessional Education Collaborative.
Ethics and why they matter in healthcare
Media 2.1. World Health Organization. (2018). Ethics matters in health [Online video]. YouTube. https://www.youtube.com/watch?v=VJ_s51QGbg8
Ethics are a set of standards that govern the conduct of a person, especially a member of a profession. While ethical beliefs are held by individuals, they can also be reflected in the values, practices, and policies that shape the choices made by decision-makers on behalf of their organizations.
Principles are general categories, rules, or guidelines that form the basis of a discipline. In ethics, there are various kinds of principles and many examples of each kind. The kinds include basic ethical categories (e.g., virtues, values, or rights), ethical commands or rules of conduct (e.g., not stealing, not harming, or treating others with respect ), and guidelines for weighing outcomes (e.g., achieving the greatest good for the greatest number, distributing burdens and benefits fairly, or properly proportioning benefit to harm).
Many people who study medical ethics say that the basics of healthcare ethics can be captured by four principles: respect for autonomy, beneficence, non-maleficence, and justice. Some experts are critical of this approach as each of the broad principles is open to a variety of interpretations. However, the concept of these four basic principles is widely used and serves as the starting point for many discussions of healthcare ethics.
Ethics can assist in:
- Recognizing ethical issues and distinguishing them from factual issues
- Providing a vocabulary to systematically discuss ethics
- Identifying appropriate ethical principles to guide action in a particular context
- Using these principles to analyze actions in regard to their ethical acceptability
- Understanding the competing moral claims and values of stakeholders
- Designing alternative courses of action that incorporate these claims and values
- Evaluating which alternative best fits a given context, all things considered
- Establishing a procedurally just, transparent process for decision-making
- Justifying decisions regarding recommendations, policies, or interventions
Ethical principles like justice or respect for autonomy are simultaneously values, ideals, and the basis for deriving rules of conduct. When addressing complex or controversial issues or issues involving numerous stakeholders, many different principles can come into play. However, because ethical decision-making depends on context (e.g., on local circumstances, community stakeholders, and decision-makers), no formula can determine the most relevant ethical principles.
Healthcare professionals have an obligation to consider difficult questions about how far and wide their ethical duties extend. It is not reasonable to think that every individual healthcare professional is responsible for caring for every individual in the world. But is each healthcare professional responsible to everyone in their community? How about everyone in the country? Furthermore, does the healthcare profession as a whole have a duty to society as a whole? Do healthcare professionals have to respect the rights of laboratory animals or the whole natural environment? These are difficult questions, and well-meaning people can have fundamentally different beliefs about the answers.
Ethics, The Law, and The Healthcare Profession
People in the medical profession are required to meet both ethical standards and legal standards. Sometimes these standards are one and the same. For example, it would be both an ethical violation and a crime to perform disabling surgery on a healthy person. Sometimes, ethical standards and legal standards overlap or interact, and they are subject to interpretation by both legal authorities and professional oversight committees. In other cases, ethical and legal standards may conflict. For example, even though a physician has an ethical duty to maintain patient confidentiality, a court may order the release of a patient’s medical records for use in a lawsuit.
The relationship between professionalism and law is a two-way street. The law sets standards for professionalism, and standards set by a profession can provide a basis for legal responsibility. State medical practice laws are a primary source of legal standards of professionalism, but other state and federal laws also apply. Courts sometimes decide that a healthcare professional did not meet the bottom-line standard for professionalism. In other words, healthcare professionals are sometimes found legally liable for actions that are not specifically prohibited by law.
Another way in which law, ethics, and professionalism intersect is in the self-regulation of the healthcare profession. On one hand, the healthcare profession holds itself to lofty ethical goals. On the other hand, the severity of the potential consequences can make it difficult for the profession to police itself.
Sources of Ethical Challenges in Healthcare
It is beyond the scope of this textbook to review all the ways in which ethics intersect with healthcare. However, we will review a few of the major areas in which ethics pertain to interprofessional practice in the healthcare environment.
Informed Consent
Informed consent is based on the duty to respect patient autonomy. Healthcare professionals are required to obtain informed consent from patients before administering treatment (or from participants before conducting research), as both a legal and ethical duty. Before giving informed consent, a patient needs to know the nature of the proposed treatment. This includes the purpose of the treatment and a description of how the treatment will be administered or performed. In order to give informed consent, a person also needs to know about the alternatives to the proposed treatment and the risks and benefits of each option.
One of the basic tenets of informed consent is that the patient must be capable of making medical decisions. An adult who is capable of making their own medical decisions must be given all the relevant information necessary to give valid informed consent. The information must be provided in a way that is understandable to the person being asked to consent, and they must voluntarily communicate a decision to accept the treatment or participate in the research study.
If an adult does not have the ability to make informed decisions, that person is said to lack the mental capacity to give informed consent. Typically, in these cases, another person is designated to make decisions for the patient. Alternatively, a child might have the mental ability and understanding to make their own decisions, but the law may deny them that right. In that case, the child is said to lack the legal capacity to give informed consent.
Sometimes an emergency situation is an exception to the rule of getting informed consent before treatment. For example, if a patient is unconscious and a surrogate decision-maker is not available in a life-threatening situation, it may be determined that the patient has given implied consent to treatment. Furthermore, some experts say that the principle of beneficence requires that treatment be provided under these circumstances.
Health Information Privacy
In the United States, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), is a federal law that requires most doctors, nurses, hospitals, nursing homes, and other healthcare providers to protect the privacy of a patient’s health information. However, if the patient doesn’t object, a healthcare provider or health plan may share relevant information with family members or friends involved in the patient’s healthcare or payment for their healthcare in certain circumstances. The law also permits, but does not require, healthcare providers or entities to use and disclose protected health information, without an individual’s authorization, in specific situations, such as for use in a public health dataset. Healthcare professionals should rely on professional ethics and best judgment when considering requests for these permissive uses and disclosures.
Conflicts of Interest
A conflict of interest is a situation in which a person has a private or personal interest sufficient to appear to influence the objective exercise of their official duties as, say, a public official, an employee, or a professional.
Conflict of interest is ethically important for two reasons. First, a person who is in a conflict of interest may not be able to exercise their duties in an objective, professional manner. In spite of their best intentions, their judgment may be biased in a way that leads to giving bad advice or making a bad decision. Just as importantly, if a conflict of interest is not dealt with properly, it can lead to a loss of faith in an entire decision-making process, and ultimately to a loss of faith in an entire organization.
It is important to see that conflict of interest is not an accusation, but rather a situation in which an individual may find him or herself. Many people get this wrong, especially when discussing conflict of interest in the public sphere. It is common, for example, for politicians to accuse each other of conflict of interest. However, there is nothing unethical about being in a conflict of interest. Being in a conflict of interest can happen to you through no fault of your own. The crucial question, ethically, is how an individual handles being in a conflict of interest. To be in a conflict of interest is not unethical; but failure to do the right thing when in a conflict of interest can be.
Ethical dilemmas
A conflict between ethical principles is called an ethical dilemma. People working in the healthcare field are often faced with ethical dilemmas, and although the four principles are a guide, they do not always provide an answer.
Sometimes, ethical issues are divided into those that are professional obligations and those that are aspirational:
- An obligation is a standard that must be met, the minimum of care that must be provided. Some examples of ethical obligations are to provide competent healthcare to individual patients and to make sure patients understand the risks and benefits of treatment.
- In contrast, an aspirational goal is a standard that would be met in an ideal world but is not currently achievable in the real world. Some examples of aspirational goals are providing equal worldwide access to care and finding cures for diseases that are currently incurable.
Barriers to Disclosing Unethical Behavior
Most healthcare professionals behave ethically, but sometimes, unethical acts or practices occur. General attributes of the culture of healthcare can make it difficult for people to report unethical behavior to their bosses or outside authorities.
A study into well-known cases in which institutions refused to acknowledge ethical lapses by doctors or researchers, even after extensive investigations, revealed that organizational culture can make it difficult to report ethical gaps.
Three general types of barriers to disclosing unethical behavior were identified:
- Personal motivations (e.g., loyalty to the profession)
- Institutional motivations (e.g., fear of negative publicity associated with a scandal)
- Shared understandings of how to behave (e.g., be confident and exercise independent judgment, or do not raise concerns with others).
This leads to another area in which law, ethics, and professionalism intertwine: whistleblowing. The term whistleblower refers to someone who reports illegal or unethical behavior to their superiors at work, or to outside authorities. A wide range of activities have been described as healthcare whistleblowing, from telling a patient about an error to disclosing violations of professional conduct that are occurring throughout an entire institution.
Deciding to “blow the whistle” can be a difficult choice, especially if a person fears that their reputation or career will be negatively affected by bringing unethical behavior to light.
Resolving Ethical Conflicts
A common way for healthcare professionals to resolve ethical dilemmas is to consult with others, including co-workers. In some cases, they might even consult a medical ethicist, a person who is specially trained to deal with ethical questions. This can be accomplished by having an ethics committee that is consulted to make ethical decisions. In the United States, all accredited hospitals must have a process for resolving ethical questions, and this usually takes the form of an ethics committee. Many long-term-care facilities and home healthcare organizations also have ethics committees. The members of the ethics committee usually represent the many kinds of people who have a stake in resolving ethical questions. This can include doctors, nurses, social workers, lawyers, members of the clergy, and people from the community who are not healthcare professionals.
Another way in which healthcare professionals may get guidance about a difficult ethical situation is to consult a code of ethics created by an organization related to their specific profession. A code of ethics may also be called an ethical statement, statement of professional conduct, or something similar. They can be statements of current professional standards, or they can be aspirational, seeking to raise the standards of the profession. Some codes of ethics contain both obligatory and aspirational statements. Review the following pages and take note of similarities and differences in expectations of ethical behavior:
- American College of Healthcare Executives – Code of Ethics
- American Medical Association – Principles of Medical Ethics
- American Psychologist Association – Ethical Principles of Psychologists and Code of Conduct
- American Society for Clinical Laboratory Science – Code of Ethics
- National Commission for Health Education Credentialing – Health Education Code of Ethics
Ethical Scenarios in Interprofessional Practice: What Would You Do?
Ethical Scenarios in Interprofessional Practice: What Would You Do?
Patient Safety versus Team Dynamics
Alex, a new nurse, observes that a seasoned nurse, Lisa, occasionally skips crucial steps during patient handovers, leaving out essential information that could impact care quality and patient safety. Lisa is well-respected and liked by her colleagues. When Alex mentioned his concerns to someone else on the team, he was told, “We don’t focus on negativity around here.” He wonders whether it’s worth rocking the boat.
What should Alex do?
Confronting the Ethics of Gossip
Pharmacist Sarah has a close bond with Physician Assistant Tom. Over lunch, Tom reveals sensitive information about a colleague they both work closely with, casting the coworker in a negative light. Sarah feels uncomfortable. She’s concerned this knowledge might strain her professional relationship with the coworker, but confronting Tom may hurt their rapport.
Faced with this dilemma, what is the most ethical approach for Sarah?
Collaboration or Competition?
The endocrinology and cardiology teams have been working separately on a shared research project related to diabetes and heart health. After months of collaboration, they make a significant discovery. When it’s time to present the findings at a major conference, the cardiology team, led by Dr. Mitchell, unexpectedly presents the entire project as their own, barely mentioning the crucial contributions of the endocrinology team. Dr. Gupta, from the endocrinology team, believes his team’s efforts are being overshadowed.
How should Dr. Gupta address the situation to ensure proper recognition for his team without escalating tensions?
Addressing Concerning Behavior
Evelyn has worked alongside Henry for several years in the Emergency Department. Lately, she’s noticed that Henry often appears fatigued, his hands occasionally shake, and he’s been taking more frequent and unexplained breaks. She overhears whispered conversations among other staff about missing medications. Evelyn is torn between her duty to ensure patient safety and her concern for a colleague’s well-being.
How should Evelyn handle this sensitive situation?
- Ethical principles underpin the healthcare field. They guide individual conduct and inform the standards healthcare professionals are expected to meet.
- Some of the most significant sources of ethical challenges in healthcare are the duty to obtain informed consent, complying with the Health Insurance Portability and Accountability Act of 1996, and managing conflicts of interest.
- Healthcare professionals caught in an ethical dilemma must understand how best to resolve it.
- Conflict of Interest – A situation in which a person has a private or personal interest sufficient to appear to influence the objective exercise of their official duties.
- Ethical Dilemma – A conflict between ethical principles.
- Ethics – A set of standards that govern the conduct of a person, especially a member of a profession.
- Health Insurance Portability and Accountability Act of 1996 – A federal law that requires most doctors, nurses, hospitals, nursing homes, and other healthcare providers to protect the privacy of a patient’s health information.
- Informed Consent – A process in which a healthcare provider explains the nature of the treatment, alternatives to the treatment, and the risks and benefits of the treatment.
- Principles – General categories, rules, or guidelines that form the basis of a discipline.
- Whistleblower – Someone who reports illegal or unethical behavior to their superiors at work, or to outside authorities.
References and attributions
Introduction
“Public Health Ethics: Global Cases, Practice, and Context” by Leonard W. Ortmann, Drue H. Barrett, Carla Saenz, Ruth Gaare Bernheim, Angus Dawson, Jo A. Valentine, and Andreas Reisin. Published by Springer Nature in Public Health Ethics: Cases Spanning the Globe under a CC BY-NC 2.5 license. Lightly edited for brevity and consistency with its new context.
Values and Ethics for Interprofessional Practice
Interprofessional Education Collaborative Expert Panel. (2023). Core competencies for interprofessional collaborative practice: Version 3. https://www.ipecollaborative.org/assets/core-competencies/IPEC_Core_Competencies_Version_3_2023.pdf
Ethics and Why They Matter in Healthcare
World Health Organization. (2018). Ethics matters in health [Online video]. YouTube. https://www.youtube.com/watch?v=VJ_s51QGbg8
“Ethical and Legal Behavior” in Introduction to Business by Lumen Learning. Content authored by Robert Carroll and revised/adapted by Linda Williams and Lumen Learning. Published by Lumen Learning under a CC BY 4.0 license.
“Public Health Ethics: Global Cases, Practice, and Context” by Leonard W. Ortmann, Drue H. Barrett, Carla Saenz, Ruth Gaare Bernheim, Angus Dawson, Jo A. Valentine, and Andreas Reisin. Published by Springer Nature in Public Health Ethics: Cases Spanning the Globe under a CC BY-NC 2.5 license. Lightly edited for brevity.
“Ethics and Professionalism: Lecture A” from The Culture of Healthcare as part of the Health IT Workforce Curriculum. Developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. Published under a CC BY-NC-SA 3.0 license. Lightly edited for brevity.
Ethics, The Law, and The Healthcare Profession
“Ethics and Professionalism: Lecture B” from The Culture of Healthcare as part of the Health IT Workforce Curriculum. Developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. Published under a CC BY-NC-SA 3.0 license. Lightly edited for brevity.
Sources of Ethical Challenges in Healthcare
Informed Consent
“Ethics and Professionalism: Lecture C” from The Culture of Healthcare as part of the Health IT Workforce Curriculum. Developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. Published under a CC BY-NC-SA 3.0 license. Lightly edited for brevity, consistency with its new context, and flow.
Health Information Privacy
The following sources were combined:
- “Sharing Health Information with Family Members and Friends” from the Office for Civil Rights (OCR). Published by the U.S. Department of Health and Human Services under public domain. Lightly edited for tone and reformatted for consistency with its new context.
- “Health Insurance Portability and Accountability Act of 1996 (HIPAA)” from the Centers for Disease Control and Prevention. Published under public domain. Lightly edited and reorganized for flow and brevity.
Conflicts of Interest
“Conflict of Interest” in The Concise Encyclopedia of Business Ethics by Chris MacDonald and Alexei Marcoux. Published by Journal Review Foundation of the Americas under a CC BY 4.0 license. Lightly edited for tone.
Image adapted from “Ethics and Professionalism: Lecture C” from The Culture of Healthcare as part of the Health IT Workforce Curriculum. Developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. Published under a CC BY-NC-SA 3.0 license.
Ethical Dilemmas
“Ethics and Professionalism: Lecture A” from The Culture of Healthcare as part of the Health IT Workforce Curriculum. Developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. Published under a CC BY-NC-SA 3.0 license. Lightly edited for brevity.
Barriers to Disclosing Unethical Behavior
“Ethics and Professionalism: Lecture B” from The Culture of Healthcare as part of the Health IT Workforce Curriculum. Developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. Published under a CC BY-NC-SA 3.0 license. Lightly edited for brevity, clarity, and reorganized for flow.
Resolving Ethical Dilemmas
“Ethics and Professionalism: Lecture A” from The Culture of Healthcare as part of the Health IT Workforce Curriculum. Developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. Published under a CC BY-NC-SA 3.0 license. Lightly edited for brevity and reorganized for flow. Additional content added to provide examples of codes of ethics.
Image Descriptions
Image 2.1: A photo. A patient sitting at a table and reading a document on a clipboard is in the foreground, and a doctor is sitting across the table. [Return to Image 2.1].
Image 2.2: Infographic. An icon representing a healthcare professional is in the center. This icon is surrounded by interests related to healthcare obligations (patient welfare, medical education quality, and medical research integrity) and interests related to personal benefits (financial gain, favors to others, professional advancement, and recognition). [Return to Image 2.2].
Image 2.3: A photo. Healthcare professionals talking to each other at a meeting. [Return to Image 2.3].
