UNIT I

Professional ethics concerns the moral issues that arise because of the specialist
knowledge that professionals attain, and how the use of this knowledge should be
governed when providing a service to the public.[1]

Contents
• 1 Professional responsibility
• 2 Codes of practice
o 2.1 Problems with internal regulation
o 2.2 Separatism

Professional responsibility
The professional carries additional moral responsibilities to those held by the population
in general. This is because professionals are capable of making and acting on an informed
decision in situations that the general public cannot, because they have not received the
relevant training.[2] For example, a layman member of the public could not be held
responsible for failing to act to save a car crash victim because they could not give an
emergency tracheotomy. This is because they do not have the relevant knowledge. In
contrast, a fully trained doctor (with the correct equipment) would be capable of making
the correct diagnosis and carrying out the procedure and we would think it wrong if they
stood by and failed to help in this situation. You cannot be held accountable for failing to
do something that you do not have the ability to do. Ethics are rules and values used in a
professional setting (Changing Minds, n.d.). In the workplace managers and supervisors
should set the standard for using ethics by showing respect, being honest, and promoting
trust. If the management team uses unethical forms of communication, the team and
business can fail. Ethics are used world-wide in large companies and small businesses.
Promoting ethics in the workplace gives employees a sense of worth and trust that can
help the business and employees succeed (Joseph, Joshua, 2000). This additional
knowledge also comes with authority and power. The client places trust in the
professional on the basis that the service provided will be of benefit to them. It would be
quite possible for the professional to use his authority to exploit the client.[3] An obvious
example is that of the dentist who carries out unneeded dental work on his patients in
order to gain more money. It is likely that the patient will not have sufficient knowledge
to question what is being done, and so will undergo and pay for the treatments.

Codes of practice
Questions arise as to the ethical limits of the professional’s responsibility and how power
and authority should be used in service to the client and society. Most professions have
internally enforced codes of practice that members of the profession must follow, to
prevent exploitation of the client and preserve the integrity of the profession. This is not
only to the benefit of the client but to the benefit of those belonging to the profession. For
example, an American business may approach an engineer to certify the safety of a
project which is not safe. Whilst one engineer may refuse to certify the project on moral
grounds, the business may find a less scrupulous engineer who will be prepared to certify
the project for a bribe, thus saving the business the expense of redesigning.[4] Disciplinary
codes allow the profession to draw a standard of conduct and ensure that individual
practitioners meet this standard, by disciplining them from the professional body if they
do not practice accordingly. This allows those professionals who act with conscience to
practice in the knowledge that they will not be undermined commercially by those who
have less ethical qualms. It also maintains the public’s trust in the profession, meaning
that the public will continue to seek their services.

Problems with internal regulation

There are questions surrounding the validity of professional codes of ethics. On a

practical level it is very difficult for those independent of the profession to monitor
practice, leaving the possibility that a code of practice may be self serving. This is
because the nature of professions is that they have almost a complete monopoly on a
particular area of knowledge. For example, until recently, the English courts deferred to
the professional consensus on matters relating to their practice that lay outside case law
and legislation.[5]

Separatism

On a theoretical level, there is debate as to whether an ethical code for a profession

should be consistent with the requirements of morality governing the public. Separatists
argue that professions should be allowed to go beyond such confines when they judge it
necessary. This is because they are trained to produce certain outcomes which may take
moral precedence over other functions of society.[6] For example, it could be argued that a
doctor may lie to a patient about the severity of/mm their condition, if there is reason to
think that telling the patient could cause them so much distress that it would be
detrimental to their health. This would be a disrespect of the patient’s autonomy, as it
denies them information on something that could have a great impact on their life. This
would generally be seen as morally wrong. However, if the end of improving and
maintaining health is given a moral priority in society, then it may be justifiable to
contravene other moral demands in order to meet this goal.[7] Separatism is based on a
relativist conception of morality that there can be different, equally valid moral codes that
apply to different sections of society and differences in codes between societies (see
moral relativism). If moral universalism is ascribed to, then this would be inconsistent
with the view that professions can have a different moral code, as the universalist holds
that there is only one valid moral code for all.[8]
UNIT II
Ethical code
From Wikipedia, the free encyclopedia

An ethical code is adopted by an organization in an attempt to assist those in the

organization called upon to make a decision (usually most, if not all) understand the
difference between 'right' and 'wrong' and to apply this understanding to their decision.
The ethical code therefore generally implies documents at three levels:

Contents
• 1 Code of ethics (corporate or business ethics)
• 2 Code of conduct (employee ethics)
• 3 Code of practice (professional ethics)
• 4 General notes
• 5 Examples of Ethical Codes
• 6 See also
• 7 References

• 8 External links

Code of ethics (corporate or business ethics)

A code of ethics: A code of ethics often focuses on social issues. It may set out general
principles about an organization's beliefs on matters such as mission, quality, privacy or
the environment. It may delineate proper procedures to determine whether a violation of
the code of ethics has occurred and, if so, what remedies should be imposed. The
effectiveness of such codes of ethics depends on the extent to which management
supports them with sanctions and rewards. Violations of a private organization's code of
ethics usually can subject the violator to the organization's remedies (such as restraint of
trade based on moral principles). The code of ethics links to and gives rise to a code of
conduct for employees.

Code of conduct (employee ethics)

A code of conduct is a document designed to influence the behavior of employees: They
set out the procedures to be used in specific ethical situations - such as conflicts of
interest or the acceptance of gifts, and delineate the procedures to determine whether a
violation of the code of ethics occurred and, if so, what remedies should be imposed. The
effectiveness of such codes of ethics depends on the extent to which management
supports them with sanctions and rewards. Violations of a code of conduct may subject
the violator to the organization's remedies which can under particular circumstances
result in the termination of employment.

Code of practice (professional ethics)

A code of practice is adopted by a profession or by a governmental or non-governmental
organization to regulate that profession, a code of practice may be styled as a code of
professional responsibility, which will discuss difficult issues, difficult decisions that will
often be need to made and provide clear account of what behavior is considered "ethical"
or "correct" or "right" in the circumstances. In a membership context, failure to comply
with a code of practice can result in expulsion from the professional organization. In its
2007 International Good Practice Guidance, Defining and Developing an Effective Code
of Conduct for Organizations, the International Federation of Accountants [1] provided
the following working definition: "Principles, values, standards, or rules of behavior that
guide the decisions, procedures and systems of an organization in a way that (a)
contributes to the welfare of its key stakeholders, and (b) respects the rights of all
constituents affected by its operations."

General notes
Ethical Codes are often not adopted by management because of some over-riding
corporate mission to promote a particular moral theory but accepted by management as
pragmatic necessities in running an organization in a complex society in which moral
concepts inevitably play an important part.

They are distinct from moral codes that may apply to the culture, education, and religion
of a whole society.

Of course, certain acts that constitute a violation of ethical codes may also violate a law
or regulation and can be punishable at law or by government agency remedies.

Even organizations and communities that may be considered criminal may have their
own ethical code of conduct, be it official or unofficial. Examples could be hackers,
thieves, or even street gangs.

Examples of Ethical Codes

• Code of Conduct for the International Red Cross and Red Crescent Movement
and NGOs in Disaster Relief
• Code of the U.S. Fighting Force
• Declaration of Geneva
• Eight Precepts
• Ethic of reciprocity (Golden Rule)
• Five Precepts
• Hippocratic Oath
 • ICC Cricket Code of Conduct
• International Code of Conduct against Ballistic Missile Proliferation (ICOC or
Hague Code of Conduct)
• Journalist's Creed
• Moral Code of the Builder of Communism
• Patimokkha
• Pirate code of the Brethren
• Israel Defense Forces - Code of Conduct
• Rule of St. Benedict
• Silver Rule
• Thomas Percival
• Ten Commandments
• Ten Indian commandments
• Ten Precepts (Buddhism)
• Ten Precepts (Taoism)
• Warrior code
• Bushidō
• Uniform Code of Military Justice
• [Members' Code of Conduct]http://www.standardsboard.gov.uk/CodeofConduct/
• Aviators Model Code of Conduct

UNIT III
Professional Ethics

Ethical considerations and responsibilities to patrons

are part of reference service.
Review

Reference Service (Module 1) is one way libraries meet the information needs of the
community. Discovering the real need behind a patron's first question is an ongoing
process of outreach, determining needs, filling needs, and follow-up.

The reference interview (Module 2), using open questions, paraphrasing, clarifying
and verifying, determines information needs. Model behaviors (approachability, comfort,
interest, listening, inquiring, searching, informing, and follow-up) increase the chances
for a successful interview and make patrons comfortable in the library (Module 3). Filling
needs determined by the reference interview calls for effective search strategies (Module
4) to locate the resources (Module 5) in your library that answer the basic question of
what the patron really wants to know.
 Module 6 provides information about professional ethics and your responsibilities to
patrons throughout the entire reference process.

A Context for the Reference Process

Library work has a set of ethics that all library employees should understand. This set
of ethics helps us to preserve our users' right to privacy, to fair and equitable treatment,
and helps ensure that people who need information have access to it.

These are guidelines only. Many of the issues are very complex, and there are not
always easy answers to every situation. Please check with your supervisor if you are not
sure how to handle a situation. You should also be familiar with your own library's
policies and procedures.

While the term "librarian" is used frequently in the following guidelines, everyone
who works in a library should be working to apply these guidelines in transactions with
the public.

UNIT IV

Professional Ethics
Purpose To provide you with the necessary attitudes, motivation, and
knowledge to apply ethical conduct to HIV rapid testing.
Content Outline What is ethics?
Why is ethics important?
Who is responsible for ethics?
How is ethics applied to HIV rapid testing?
Maintaining confidentiality
Code of conduct
Handouts Guidelines for Ethical Behavior (ASCP)
Code of Ethics (IFBLS)
Notes on
Customization
Provide national policy on ethics or code of conduct.
Module 16: Professional Ethics 2 Participant Manual
2005
Consequences of
a False Positive or
False Negative
Result
A false positive HIV result can lead to considerable personal
stress and family and marital problems. A false negative result
can lead to increased transmission.
Each result you report is connected to a patient/client. A lot is at
stake – people’s health, lives, mental health. The emotional
costs of a wrong result can be huge. Also the health
consequences can be enormous. Considerable personal stress
also includes depression, fear and even suicidal tendencies.
You must strive to do the right things right.
What Is Ethics?
Ethics is “A set of principles of right conduct.”
Why is Ethics
Important?
Decisions about diagnosis, prognosis and treatment are
frequently based on results and interpretations of laboratory
tests. Irreversible harm may be caused by erroneous tests.
In other words if we do not apply a code of ethics the patient or
someone else will suffer.

Maintaining
Confidentiality
It is important to:
• Keep all client/patient information private
• Secure all records / logbooks
• Restrict access to testing areas
Remember…prior to testing, clients should be informed about
the purpose, advantages, and disadvantages of testing. This
process ensures understanding of the Counseling-Testing
process. Keeping information confidential means that it is kept a
secret from everyone.
People often violate ethics not because they mean to, but
because they are careless. Therefore, we must be extra vigilant
about ethical conduct.
Module 16: Professional Ethics 7 Participant Manual
2005

Who is
Responsible for
Ethics?
Everyone at a testing site plays a part. Anyone who plays a part
in testing or has access to the test results must adhere to ethical
conduct. This includes medical laboratory technicians, nurse
counselors, clerks, secretary, general hand, and driver.
Incidents may happen where specimens are damaged, results
are falsified, or confidentiality is broken. Equally they can decide
to ensure that specimens are delivered, recorded, stored and
reported with high quality.

How Do We Apply
Ethics To HIV
Rapid Testing?
Ethics is applied in the work that we do at the test site. This
includes:
_ Using only kits approved for use in country
_ Ensuring quality outputs – Following SOPs as written. If
a test procedure calls for 20 minutes incubation or wait
time, DON’T take shortcuts. Wait the full time before
recording and reporting test results
_ Keeping supplies and kits in safekeeping. Unauthorized
use of test kits outside of the testing site is prohibited.
_ If you have questions, ASK.
_ DO NOT falsify results.
Ethics is also applied in your behavior. Always conduct yourself
in a professional manner. Examples of professionalism include:
Dressing appropriately. If lab coat of apron is soiled,
change to a clean one
Turning cell phones off. It is disruptive and not
considerate of clients to talk on the phone during the
course of testing.
Not discussing results of interaction with clients with
others. Maintaining patient confidentiality is a MUST.
Behavior of management – Management sets the example or
expectations of how staff should conduct themselves.

What is a Code of
Ethics?
A Code of Ethics is an expression of basic values - the
principles and standards by which you should conduct yourself
A number of laboratory professional organizations have code of
ethics, with common principles of conduct.
Module 16: Professional Ethics 9 Participant Manual
2005

Code of Ethics
(IFBLS)
Excerpts from International Federation of Biomedical
Laboratory Science (IFBLS)
Maintain strict confidentiality of patient information and
test results
Safeguard the dignity and privacy of patients
Be accountable for the quality and integrity of clinical
laboratory services. You must take personal
responsibility for everything you do and be able to
answer for your conduct and moral obligations to
choose to do right over wrong.

Code of Ethics
(ASCP)
Excerpts from American Society for Clinical Pathology
(ASCP)
_ Treat patients and colleagues with respect, care and
thoughtfulness
_ Perform duties in an accurate, precise, timely and
responsible manner
_ Safeguard patient information as confidential, within the
limits of the law
_ Prudently use laboratory resources

Key message
• Maintain strict confidentiality of patient information and
test results
• Ethical issues are important. We must constantly remind
ourselves of the code of conducts and ensure we do the
right thing.
• Ethical issues are often hard to deal with because they
create dilemmas.
• People often violate ethics not because they mean to,
but because they are careless. As a matter of fact, they
sometimes act with good intentions.
Module 16: Professional Ethics 10 Participant Manual
2005

Module Review
Find out how much you have learned by answering these questions.
In your own words, what is ethics?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Why is ethics important?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Give examples of actions you can take to maintain client
confidentiality.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Give an example of a code of ethics to which you are willing to
personally
commit.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

BOARD OF REGISTRY
Guidelines for Ethical Behavior
American Society of Clinical Pathology (ASCP) Registrants and
Associate
Members
Recognizing that my integrity and that of my profession must be pledged to the best
possible care of patients lased on the reliability of my work, I will:
1. Treat patients and colleagues with respect, care and thoughtfulness
2. Perform my duties in an accurate, precise, timely and responsible manner
3. Safeguard patient information as confidential, within the limits of the law
4. Prudently use laboratory resources
5. Advocate the delivery of quality laboratory services in a cost effective manner
6. Work within the boundaries of laws and regulations and strive to disclose
illegal or improper behavior to the appropriate authorities
7. Continue to study, apply and advance medical laboratory knowledge and
skills and share such with my colleagues, other members of the health care
community and the public.
Reprinted by permission of ASCP
Module 16: Professional Ethics 12 Participant Manual
2005

International Federation of Biomedical Laboratory Science (IFBLS)

Code of Ethics
Medical laboratory technologists shall:
_ Be dedicated to the use of clinical laboratory science to benefit mankind
_ Actively seek to establish cooperative and specific working relationships with
other health professionals
_ Provide expertise to advise and counsel other health professionals
_ Maintain strict confidentiality of patient information and test results
_ Safeguard the dignity and privacy of patients
_ Be responsible for the logical process from the acquisition of the specimen to
the production of data and the final report of the test results
_ Be accountable for the quality and integrity of clinical laboratory services
_ Exercise professional judgment, skill and care while meeting established
standards
_ Uphold and maintain the dignity and respect of the profession and strive to
maintain a reputation of honesty, integrity and reliability
_ Strive to improve professional skills and knowledge, and adopt scientific
advances that benefit the patient and improve the delivery of test results.
Reprinted by permission of I

http://faculty.weber.edu/lburton/4400/Professional%20Ethics.ppt#13 - powerpoint
presentation of ethics

UNIT V
Description
In the wake of recent major corporate collapses, business ethics have
gained popularity and new regulation has been enacted to restore
trust, integrity, and a level playing field in the marketplace. There is so
much buzz about ethics that we might take it for granted or greet the
subject with cynicism.

Everyone is required to follow the law. That is the minimum standard

of behaviour. However, the law does not cover all contingencies of life
and some choose to go beyond compliance with the law and set a
higher standard of performance in their activities. As we shall see,
compliance with legal and professional standards may be a legally
sound strategy but it may not be sufficient for acting professionally.
Ethics deals with those many free zones of moral choice and judgment
about what is “right” or “best” to do. As a result, ethics covers decision
making where the law does not prescribe a minimum standard or
where we seek to act in a manner that is above the minimum
prescribed legal standard, such as in a Code of Ethics.

While most people naturally think of themselves as ethical and may

consider this subject to be soft common sense, everyone, and every
organization, will be tested by actual events. Professionalism, ethics
policies, and Codes might not prevent certain losses, embarrassments,
and other unfortunate incidents from occurring. However, they may
reduce some problems and abate the severity of others. And, most of
all, professionalism and ethics will provide a long-term management
framework.

Addressing complex ethical questions must consider:

• State, federal, and local laws and regulations

• Organizational policy and procedure
• Organizational principles and values
• Professional and individual values of the decision maker
• Expectations and demands of the local community and a broader society

Guidance from Law and Regulation

• Externally imposed rules

• Addressing both
• Practice of medicine
• Business
• Extends beyond the institution and individual to relationships with:
– Suppliers
– Agents
– Patients and
– Third party payers
Guidance from Policy and Procedure

• Internally imposed
– Institutional equivalent of of law and regulation
• Specific expectations and requirements for those doing the work of the
organization

Guidance from Organizational Principles and Values

• Self-descriptive statements that define actual or aspirational standards of:
– Personal
– Professional
– Organizational conduct
• Business terms
– “customer service/customer satisfaction”
• Ethical terms
– Integrity, honesty, and compassion

Guidance from Personal/Professional Values

• A set of principles and values that describe standards of conduct

• Professionally focused
– Patient well-being and privacy
• Integrity
• Honesty
• Compassion

Guidance from Society and Community

• Some expectations of society are codified and others are not.

– Respect for the patients and their family
– Bedside manner
– Responsiveness to unusual circumstances

The ethics spectrum

Guidance from
Law and Regulation
Guidance from
Policy and Procedure
Guidance from
Organizational Principles
And Values
Guidance from
Personal/Professional Values
Guidance from Society and Community
Generic decision-making
process

Define the situation

2. Identify the options
3. Evaluate the options
4. Select the optimal option
5. Implement the decision
6. Evaluate the outcome

Ethical decision-making process

Define the situation using the 5points of the ethics spectrum

• P = Policy and procedures
– Are there policies and procedures that I should consider in this
situation?
• L = Law and regulation
– Are there laws and regulations that I should consider in this
situation?
• U = Universal organizational values
– What organizational values apply to all situations and decision
makers?
• S = Self
– What guidance do my personal values provide in this case?
• S = Society
– How do community/society values and expectations apply to this
situation?

Ethical Decision-making Process

2. Identify the options:

• Typically characterized as a creative step
• Encumbered and degraded by premature evaluation

Ethical Decision-making Process

3. Evaluate the options

– Use the five PLUSS questions for each.
4. Select the optimal option
5. Implement the decision
– Until the decision is implemented nothing happens
6. Evaluate the outcome
 – Examine the consequences (intended and unintended) of the decision.
– Once again apply the 5 PLUSS questions.

Chinese Saying:

“He whose virtues exceed his talents is a superior man; he whose talent exceeds his
virtues is a dangerous man.”

Source: Porter-O’Grady & Wilson

HCA Corporate Strategy

…..put the patient first in all of our decision-making.

….the core value of the company lies in the inherent worth of our individual
facilities and groups of facilities in local communities. It follows that this value is
created by locally-generated visions, strategies, and market initiatives…

…simultaneous need for both standardization and decentralization….

THOMAS F. FRIST, JR., M.D.
CHAIRMAN & CHIEF EXECUTIVE OFFICER
JACK O. BOVENDER, JR.
PRESIDENT & CHIEF OPERATING OFFICER

Therefore I say:
One who knows the enemy and knows himself will not be in danger in a hundred battles.

One who does not know the enemy but knows himself will sometimes win, sometimes
lose.

One who does not know the enemy and does not know himself will be in danger in every
battle.
Sun Tzu

Sample Organizational Values

People are important

Learning is essential
Timing is critical
Integrity is paramount
Ethical dilemma

The support of your board chairman is crucial for a new project that is not popular
with your hospital's doctors. You want to spend $10 million on a needed renovation
in the intensive care unit, while a good number of the doctors want that money
spent on new equipment. The board chairman, who has a lot of influence with the
doctors, has told you that his friend’s son would like to do the bond work for the
renovation.You fear he won’t get behind the renovation if the hospital doesn't use
the firm he wants.
-TERESE HUDSON THRALL

KEITH PRYOR
Governance consultant and former system CEO, Bryn Mawr, Pa.

There are often more valid requests for resources than there is funding. I may
improve my position by following a disciplined process for spending money that
incorporates physician input. I'm not looking to build doctor support, but to use a
process that produces an objective answer. Maybe the ICU renovation isn’t the best
thing to do. If that process shows that the renovation should go forward, I'd follow a
similar process for selection of legal counsel. Companies should disclose
relationships to those in leadership positions at the hospital. If the friends son is
recommended via this process, any conflict should be disclosed to the board. In the
meantime, I'd give my board reports outlining conflict-of-- interest questions posed
by the attorney general of Pennsylvania to the leadership of the Allegheny Health
System Board.

WILLIAM GONZALEZ
Health care adviser and former system CEO, Chicago

I would erode my relationship with the doctors if they discover that the chairs
favored firm did the bond work for a project they don't support. It would look as
though I were trying to improve my position with the chair at their expense.
Instead, I would reopen the discussion of the ICU renovation, involving physicians
and the board's construction committee. Even if I'm not able to get doctor support,
I've made an attempt to justify it. I'd also talk with the chair about conflict of
interest. He should inform the board about his ties to the law firm, which should be
considered along with others based on best terms and interest costs. The chair
shouldn't participate in voting or discussion. A trustee should never use his or her
position to influence the choice of a vendor, even if that vendor does quality work.
Fraud and Abuse

• False Claims
Gov’t purchasing services vs. goods
Services provided to beneficiaries of programs rather than gov’t agents
Services provides at thousands of remote sites
Complexity of prof services make it difficult to question quality and appropriateness
Personal and confidential nature prevents direct observation by the gov’t at time of
service

Problem = Gov’t must rely on the word of the provider or written documentation.

• Kickbacks

Kickbacks
(Medicare Anti-kickback Act)
• It is unlawful to knowingly and willingly give or receive anything of value to
induce someone to refer a Medicare/Medicaid patient
• Or induce someone to purchase something from which payment may be made
under these programs.
• Felony: <$25,000 fine, 5 years imprisonment, exclusion from government
payment programs..

Types of fraud

• Claims for services never rendered

• “Upcoding”
– Some providers see nothing wrong with false statements to justify service
to patients need service and cannot afford it.
Examples of Fraud
(False Claims)

• One physician billed $350,000 over a 2 year period for comprehensive physical
exams of residents without ever seeing a single resident. Falsified medical
records to indicate nonexistent services were rendered.

Theories of Moral Obligation

• Utilitarian and Other Teleological Theories

– Choosing the alternative that produces the greatest balance of good over
evil for members of a moral reference group.
• Deontological Theories
 – A duty-based theory

Utilitarianism
• Three questions are left unanswered:
– Who is to be included in the moral reference group?
– What is to count as good or bad?
– What sort of alternative is to be considered?

Moral Reference Group

• Egoism
• Racism
• Sexism
• Nationalism
• One’s patients
• Utilitarianism “all sentient beings” (human?)

Theories of Value

• Subjective Preference
– Maximize satisfaction of preferences and minimize frustration.
• Hedonism
– Pleasure is good, pain is bad.
• Pluralism
– Four fundamental intrinsic goods
• Pleasure
• Knowledge
• Virtue
• Justice

Act versus Rule

• Should a standard be applied to individual concrete actions or more generally in

formulating policies for action in all situations of a certain type?

Making ethical decisions

Edmund Erde

• A methodology
1. Characterize the dilemma as fully as possible
2. Keeping the nature of morality in mind, discard those constituents that arise as a result
of inclinations and prejudices.
3. If step 2 does not suffice to solve the problem, consider fully the characterized case in
the light of the available moral theories.
 Common Rationalizations
• “It’s not really illegal or immoral.”
• “It’s in my (or the organization’s) best interest.”
• “No one will find out.”
• “Since it helps the organization, the organization will condone it and protect
me.”

Ethical questions
Does it provide
the greatest good
for the greatest
number
Does it respect
the rights of the
individual
affected?

Is it fair
and equitable?

A guide for ethical behavior.

Questions to ask yourself.

1. How did this problem occur in the first place?

2. Would you define the problem differently if you stood on the other side of the
fence?
3. To whom and to what do you give your loyalty as a person and as a member of
your organization/
4. What is your intention in making this decision?
5. What is the potential for your intentions to be misunderstood by others in the
organization?
6. How does your intention compare with the probable result?
7. Whom could your decision injure?
8. Can you discuss the problem with affected parties before you make the decision?
9. Are you confident that your position will be as valid over a long period of time as
it seems now.
10. Could you disclose your decision to your boss or your immediate family?
11. How would you feel if your decision was described, in detail, on the front page of
your local newspaper?
 Group Decision-making

Advantages
more information
more alternatives
solution acceptance
legitimacy

vs.

Disadvantages
time consuming
minority domination
conformity
ambiguous responsibility

Ethics
• Morality
• Conscience
• Legality
• Trust
• Values
• Responsibility
• Integrity

Blanchard and Peale’s Three Questions

1. Is it legal?
2. Is it balanced?
3. How will it make me feel about myself?

Tests of Ethical Behavior

• Morning-after Test
 – How will you feel about this tomorrow morning?
• Front-Page Test
– How would you like to see this behavior written up on the front page
of your hometown newspaper?
• Mirror Test
– How will you feel about this behavior when you look in the mirror?
• Role Reversal Test
– How would you feel about being on the receiving end of this behavior?
• Common Sense Test
– What does every common sense say about this behavior?

Approaches to Ethics

Best-Ratio
Approach

Black & White

Approach - Pragmatic,
Situational Ethics

Full Potential
Approach
Guidelines for Handling Ethical Dilemmas:
Before taking any action in situations involving ethical dilemmas,
answer the following questions:
– What solution is most likely to build trust among those involved?
– What solution fits best into the company’s value system?
– What solution will pass the morning-after, front-page, mirror, role
reversal, and common sense tests?
– What solution is most likely to enhance the organization’s integrity?
– What solution is the most responsible option?

“There’s a tendency today to absolve individuals of moral responsibility and treat them as
victims of social circumstance. You buy that and you pay with your soul. What limits
people is a lack of character.”
Tom Robbins

Character
 • What sort person should you strive to become?
• What are your core virtues?

UNIT VI
Introduction

The purpose of this module is to help you to use ethics terms as guides to action. They
describe the moral dynamics that surround you all the time in your work environment.
Being a responsible moral agent in the nurse practitioner's work environment requires a
knowledge of ethical terms and a set of skills. Module 3 will expand on the tools of
ethical analysis.

Managed care came to the forefront very quickly in the late 1970's and early 1980's. It
took a longer period of time for ethics to constructively react. The prominent issues in
bioethics at that time were end-of-life and HIV issues. John LaPuma, physician-ethicist,
writes:

While ethics was trying to figure out whether to be a committee or a consultant, to

work inside or outside of medicine, to be part of the academy or part of active practice,
to talk to itself or to talk to others, it missed the ways that [provider] -patient"
relationships were changing, and the fact that the payer was now calling the shots.
(LaPuma, 1999)

Therefore, it is critically important that the nurse practitioner understand the moral
tensions within a managed care environment that focuses on the "bottom line" and the
methods that can be used to resolve, or reduce, those tensions through ethical decision-
making.

Ethics as Guide to Action

Ethics is a guide to action. Ethics involves deciding about a response to whatever is the
situation through a careful discernment about which values are important and a reasoned
deliberation about the consequences of a decision. Remember that some make a real
distinction between morals and ethics: morals being the values that form our beliefs and
preferences, and ethics being the systematic analysis of those values, beliefs, and
preferences. From a more practical perspective, morals and ethics mean the same: "the
customs of the people."

Ethical deliberation is a complex of reason and emotion. Reason and emotion are
cooperating partners in ethical deliberation. Our "reasons" that guide decisions that guide
actions are not always based on a strong logic or critical thinking. Rationality is not a
strong characteristic of human beings. Some reasons are casts as intuitions, hunches,
"gut" feelings, moral distress, or a vague disquiet. Emotion is a strong influence in human
motivation and decision making. Sometimes emotion and reason work together and other
times in conflict. Finding the balance of reason and emotion is the task of critical
thinking.

Aristotle called ethical deliberation practical reasoning. Practical is a word that points
toward action. Anything practical is about human action or behavior. This is the formula
of practical reasoning: values inform reasons that shape decisions that drive action that
results in consequences. Ethics is about action.

Two questions can form the framework of ethical deliberation:

1. What is going on here?

2. What is the fitting response to what is going on here?

Answering these two questions requires critical thinking, openness to diverse points of
view, and moral imagination. The answer that a moral agent gives to the first question
can be called a belief: an interpretation of the situation or a belief about the situation. The
answer to the second question can be called a preference: a conclusion about what the
person wants to do about the situation. Beliefs and preferences are central to ethical
deliberation.

The three main theories are organized around rules, goals, and roles.

The rules theory of morality places abstract principles at the center of ethical analysis. If
one knows the principles and how they apply then the rules of behavior to follow become
clear. In bioethics four principles have been widely accepted for the past twenty-five
years to guide ethical action: autonomy, nonmalificence, beneficence, and justice.

Respect for the autonomy of an individual is a cornerstone for bioethics in the United
States. In our society the individual is given strong protection for the right to determine
what is allowed and what is not allowed. In healthcare the right of self determination is
expressed in advance directives, informed consent, shared decision making,
confidentiality, and privacy.
Nonmalificence means: do no harm. Patients are always vulnerable to risks in the medical
interventions to which they are exposed. The obligation of healthcare provideers is to do
their best to minimize the risk and to prevent harm from occurring.

Beneficence, or doing good for patients, is a noble goal of medicine. It is possible to be

misguided as to what the good is. Determining the "good" has always been a problem for
the philosophy of bioethics. What is considered good by the patient may not be what the
physician thinks is good. Conflict can develop between points of view of what is the
correct good for the patient.

Justice has many aspects to be considered. Distributive justice, or how fairly every
member of society is treated, is the main concern of justice in healthcare. Allocation of
medical resources, access to medical care, and applying medical intervention evenly
among racial, ethnic, or other social groups are examples of justice in healthcare. (Return
to the triangle)

The goals theory of morality focuses attention on the good that can be done, or the
consequences of an action. The goals of bioethics are also the goals of healthcare: to
maximize human flourishing, and to minimize human suffering. These abstract goals can
be turned in a variety of good actions that are directed twoard maximizing benefits to a
patient. To maximize human flourishing for a teenager with severe acne is to clear up the
pimples. To maximize human flourishing for a 50 year old woman with hypothyroidism
is to adjust the thyroid medical to optimize her metabolism. To minimize human
suffering for a 75 year old diabetic with end stage heart failure is to provide oxygen
through the night. To minimize human suffering for a 80 year old man with terminal
colon cancer is to refer him to hospice for palliative care. The many goals of medicine is
between the two poles of maximizing flourishing and minimizing suffering. (Return to
the triangle)

The roles theory of morality features the virtues of a person's character. Virtues have a
long history in philosophical analysis starting with the great Greek thinkers. In the past,
25 years virtue ethics has made a comeback. Among the many virtues that have been
identified, healthcare favors such virtues as integrity, respect, and compassion. Integrity
includes truth telling, being honest, and taking responsibility for your actions. Respect
means to consider the other person's values and to not insist on your own way of doing
things. Compassion refers to the willingness and the sensitivity to understand the
suffering of another person. These virtues belong to the kind of persons who are patient-
oriented in their thinking. The ethic of care describes this patient-centered thinking. It can
be of special interest to nurse practitioners because it is based on the primacy of
relationships, mutual regard, and the goal of meeting the needs of vulnerable persons.
These interests tend to be characteristic of nurse practitioners who value relationships.
(Return to the triangle)

As the nurse practitioner acts out the rules, goals, and roles, conflicts become apparent
among the various elements of the standards of morality. What the autonomous patient
wants done may be in direct conflict with what the provider believes is the most
beneficial action to take. A 69 year old man with severe diabetes and renal failure may
not agree to taking insulin therapy even though it may be medically necessary. Conflicts
of this kind are difficult to resolve without violating some value held by someone.

Conflict tends to cause moral distress because some value held by someone is going to be
violated. A nurse practitioner who is self-reflective, patient-centered and alert to events in
the social environment will likely experience moral distress because some value held by
someone will have to be given up.

The Moral Formula.

Every person is a center of values. Values become structured into beliefs and preferences:
beliefs about what is happening, and preferences about what kind of response to make to
what is happening. Patients bring their beliefs about what is happening to them and their
preferences about what ought to be done about their problem, and providers bring their
own beliefs and preferences into the relationship. Both sets of beliefs and preferences
desire respect. The moral concept of mutual regard demands that both persons respect
one another. When the beliefs and preferences of the patient and the provider are in
agreement, mutual regard is preserved and cooperation in the medical intervention moves
forward smoothly. When the beliefs and preferences are not in full agreement, conflict
occurs and must be negotiated. The stronger the conflict of beliefs and preferences
(values), the greater the demand for negotiation and compromise to reach an agreed to
middle ground.

The Moral Formula

Mutual regard for beliefs and preferences.

Ethical Deliberation
Negotiation to reach agreement on action.

Values Clarification
In order to understand the values of oneself and the values of the other person, a values
clarification method is necessary. Values clarification is not a formal process, but a
natural, mostly unconscious, moral exercise that each person performs continuously as
decisions have to be made in all kinds of life situations. We are constantly sorting out our
values in order to decide which program to watch on TV, what to have for dinner, where
to go out or which class to take in school. When the value choice just affects us, we are
not as aware of its moral weight and we are likely to call it a non-moral choice. When the
value choice affects another person we are more aware of the moral significance of the
choice. The more effect it has on the other person the more likely we are to call it a moral
choice. Some values that we hold have important effects on other persons. Being aware
of those values and how they effect other persons is the ethical task of values
clarification.
This list contains values that are often associated with being a healthcare provider. Think
about your set of personal values in relationship to this list.

Empathic---being caring, compassionate, benevolent---being deeply interested in the

perspective of the other person

Integrity--having self-knowledge and being willing to act from the most authentic and
best ideals that guide behavior

Truthtelling-always willing to tell as much truth as one knows and that the other person
can constructively accept

Being respectful-taking care to guard human dignity in general and to treat the
individual person with cultural sensitivity and regard for personal values

Responsibility-being willing to follow through on commitments, to accept blame and

praise, and to relate to every life situation in a way fitting to the character of the person,
the goals adopted, and the rules that have been agreed to-synonym is trustworthy

Competence-being able to do well what you claim to do

Practical-to be able to apply knowledge and skills to solve real problems

Prudence-wisdom is a prize that many achieve by being calm, reflective, experienced,

and focused on being about the most good in every situation

Effacement of self-interest-the willingness to set aside the goals that serve one's own
interest for the preference of serving the well-being of another person

Courage-it is often necessary to accept risk in order to act well and do what is right

Justice-to act fairly toward all persons and expecting everyone acting through social
structures to treat all persons fairly with a special preference for vulnerable persons

Values and virtues are closely related. "Virtues are those values that, when inculcated
into an individual, create a habitual disposition to act well." [Aristotle]

The ETHICS Project Case Studies

These are working examples of applied ethical problems used in teaching to highlight
relevant ethical principles. They are all:

• Defined in relation to stated learning and teaching objectives.

• Of proven effectiveness in meeting those learning and teaching objectives.
• Drawn from a wide range of disciplines but presented so as to facilitate translation
into other subject areas.
Click on the links below to view the individual case studies available:

Advanced Statements Contextualised Scenario

Lindsey Dow

This case has been developed for common learning for nurses and medical students and
uses reflection and problem solving to enable students to explore ethical and legal issues
concerning advanced statements, withholding and withdrawing treatment.

Asbestos Contextualised Scenario

Nick Johnson

This scenario is intended for use with second or third year undergraduate law students. It
is appropriate to any module or course that includes the study of lawyers? roles and
responsibilities and may be particularly well suited to a clinical module or professional
ethics class. It exemplifies the problems of advising a client where the client's instruction
or preferred course of action may conflict with the legitimate interests of third parties, the
wider society or the solicitor's own moral stance. This case study is based on a scenario
developed as part of the Professional Conduct course on the Legal Practice Course (LPC)
at the Oxford Institute of Legal Practice.

Beginning of Life Contextualised Scenario

Janet Holt

This case concerns Diane Blood who requested to use her dead husband's sperm to
conceive a child- offering the opportunity to look at consent, rights, advocacy & moral vs
legal judgments.

Best Interests Contextualised Scenario

Jennifer Jackson

This scenario examines some of the ethical issues that may arise concerning parental
proxy decision making regarding surgery on children. It uses two cases, each of which
raises issues concerning children's competence to be involved in decisions; the notions of
best interests and best health interests; how interests are related to wishes and welfare the
role of parents in assessing best interests and parental rights in deciding for their children.

Burglar Contextualised Scenario

Nick Johnson

This scenario is intended for use with second or third year undergraduate law students. It
is appropriate to any module or course that includes the study of lawyers? roles and
responsibilities and may be particularly well suited to a clinical module or professional
ethics class. It exemplifies the problems of advising a client where the client's instruction
or preferred course of action may conflict with the legitimate interests of third parties, the
wider society or the solicitor's own moral stance. This case study is based on a scenario
developed as part of the Professional Conduct course on the Legal Practice Course (LPC)
at the Oxford Institute of Legal Practice.

Conjoined Twins Contextualised Scenario

Jan Wood-Harper

In 2000, the case of conjoined twins, Jodie and Mary, provoked a unique and widely
publicised debate, involving not only the medical team and the parents, but also lawyers,
religious leaders and ethicists, as to whether or not surgery to separate them should
proceed. Complex legal and moral issues focussed on parental rights in relation to
welfare of children, duties of medical professionals, the sanctity and value of human life,
and the rights and interests of the twins.

Defective Cot Contextualised Scenario

Nick Johnson

This scenario is intended for use with second or third year undergraduate law students. It
is appropriate to any module or course that includes the study of lawyers? roles and
responsibilities and may be particularly well suited to a clinical module or professional
ethics class. It exemplifies the problems of advising a client where the client's instruction
or preferred course of action may conflict with the legitimate interests of third parties, the
wider society or the solicitor's own moral stance.
Diane Pretty Contextualised Scenario

N. Athanassoulis

This scenario examines some of the ethical issues surrounding euthanasia. It compares a
case in which a patient requests the withdrawal of life-sustaining treatment (artificial
ventilation) with a case in which the patient requested assistance in the termination of her
own life. Both cases concern euthanasia in mentally competent patients.

Dothiepin Contextualised Scenario

Bryan Vernon

This scenario gives medical students a chance to think about a patient who is refusing
treatment when there is a serious risk of death. The woman, a patient with MS, has been
found after attempting suicide and brought to the hospital by her husband where she
refuses treatment. Her wish to die can be understood, but her competence may be
compromised. Having considered defensible reasons for treating and not treating,
students have to decide which course they would follow.

Edward Bilton Contextualised Scenario

Lindsey Dow

This case has been developed for common learning for nurses and medical students and
uses reflection and problem solving to enable students to explore ethical and legal issues
concerning advanced statements, withholding and withdrawing treatment. Main ethical
issue: the legal, ethical and clinical issues surrounding a young persons advanced
statement that he did not want to be kept alive in the face of severe disability.

Ethical Research Contextualised Scenario

Alison Wearden

On week one, students have a 2 hour introductory session, in a mixed lecture/discussion

format, on research ethics and ethical theories (primarily distinguishing deontological and
teleological theories) and ethical codes (with particular emphasis on the BPS ethical
guidelines). Students are then given an anonymised version of a real-life research
protocol and ethics application. The following week, in group discussion, they 1) identify
the ethical dilemmas involved in the study from the viewpoint of the two theoretical
perspectives taught in the previous week, and 2) consider how the application might be
dealt with by an ethics committee operating to BPS guidelines.

Gamete Donation Contextualised Scenario

John Bryant

This is a series of four mini case studies that may be used as discussion starters. The
topics range from embryo selection to use of natural resources.

Genetics Contextualised Scenario

Jan Deckers

The case uses an imaginary couple, Katie and Mark, who experience a range of medical
problems involving the need to make difficult decisions about genetics. The students are
invited to identify the ethical issues involved, and stimulated to work through the options
that are available. Ethical justification is required to choose from the variety of courses of
action that are available to Katie and Mark.

Hydration and Nutrition Contextualised Scenario

Bristol University, UWE and North Bristol NHS Trust

This case has been developed for common learning for nurses and medical students and
uses reflection and problem solving to enable students to explore ethical and legal issues
concerning hydration and nutrition in severe illness. .

Myotonic Dystrophy Contextualised Scenario

John Bryant

The case study deals with the ethical dilemmas that arise following a positive diagnosis
of myotonic dystrophy and asks in particular who should have access to the genetic
information that relates to a specific individual. The question is asked in relation to
family members, employer and insurance companies. It also raises questions about the
genetic testing of children.
Parent Contextualised Scenario

Nick Johnson

This scenario is intended for use with second or third year undergraduate law students. It
is appropriate to any module or course that includes the study of lawyers? roles and
responsibilities and may be particularly well suited to a clinical module or professional
ethics class. It exemplifies the problems of advising a client where the client's instruction
or preferred course of action may conflict with the legitimate interests of third parties, the
wider society or the solicitor's own moral stance.

Renal Transplant in Cats Contextualised Scenario

Carol Gray

The morality of using healthy cats as donors for renal transplant surgery is considered.
This case is complicated by the circumstances of the recipient cat's owner. The ethical
dilemma of carrying out transplant surgery in animals is explored from three perspectives
- that of the transplant surgeon, the general practitioner and the recipient animal's owner.
The involvement of an ethics committee widens the scope of the discussion.

Thalassaemia Contextualised Scenario

John Bryant

This case study presents the problems faced by a young couple who discover that they are
both carriers of a serious genetic condition. In particular it looks at the dilemmas to be
dealt with in relation to starting a family and impact of their genetic carrier status on
reproductive decisions.

Withholding and Withdrawing Treatment Contextualised Scenario

Lindsey Dow

This case has been developed for common learning for nurses and medical students and
uses reflection and problem solving to enable students to explore ethical and legal issues
concerning advanced statements, withholding and withdrawing treatment.
UNIT VI References:

Medical Ethics

• Horn, P. (2002) Clinical Ethics Casebook, Wadsworth.

• Kushner, T.K. & Thomasma, D. C. (eds.) (2001) Ward Ethics: Dilemmas for
Medical Students and Doctors in Training, Cambridge University Press.
• Parker, M. & Dickenson D. (2001) The Cambridge Medical Ethics Workbook:
Case Studies, Commentaries and Activities, Cambridge University Press.
• Pence, G. (1999) Classic Cases in Medical Ethics: Accounts of Cases That Have
Shaped Medical Ethics, McGraw-Hill Education.

Healthcare Ethics

• Council of European Publishing Staff, (1998) The Human Rights, Ethical and
Moral Dimensions of Health Care: 120 Practical Cases Studies, Council of
Europe.
• Fulford, K.W.M., Dickenson, Donna L. (2002) Healthcare Ethics and Human
Values: An Introductory Text with Readings and Case Studies, Blackwell.
• Greenberg J.S. (2001), Code of Ethics for the Health Education Profession , Jones
and Bartlett Publishers International.
• Holm S. (1998) Ethical Problems in Clinical Practice: the Ethical Reasoning of
Health Care Professionals, Manchester: Manchester University Press.

Nursing

• Fry S.T. Veatch R.M. (2000) Case Studies in Nursing Ethics, Jones and Bartlett
Publishers International.
• Thompson JE, Thompson J. (1992) Bioethical Decision Making for Nurses,
London: University Press of America.

Midwifery

• Jones S.R. (2000) Ethics in Midwifery, Mosby.

Pharmacy

• Appelbe, G.E. & Wingfield J. (2001) Dale and Appelbe&apos;s Pharmacy, Law
and Ethics, Pharmaceutical Press.
• Veatch R.M., Haddad A.N. Case Studies in Pharmacy Ethics, Oxford University
Press Inc, USA.
Others areas of applied/professional ethics:

Research

• Penslar, Robyn L. (Ed.) 1995. Research Ethics: A Case-Based Approach

(Bloomington, IN: Indiana University Press).

Engineering

• Harris, C.E, Pritchard, M.S. & Rabins M.J. (1999), Engineering Ethics: Concepts
and Cases, Wadsworth.

Business

• Ferrell, O.C, Fraedrich J. (2001) Business Ethics: Ethical Decision Making and
Cases, Houghton Mifflin (Academic).
• Beauchamp T.L. (1998) Case Studies in Business, Society and Ethics, Prentice
Hall.

Media Ethics

• Patterson P. & Wilkins L.C. (2001) Media Ethics: Issues & Cases, McGraw-Hill
Higher Education

Environmental

• Newton L.H, Dillingham C.K., (2001) Watersheds: Ten Cases in Environmental

Ethics, Wadsworth.