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Chapter 2 Ethical Decision-Making Guidelines and Tools CHAPTER 2 Ethical Decision-Making Guidelines and Tools Jacqueline J. Glover, PhD © kentoh/Shutterstock © kentoh/Shutterstock Learning Objectives Scenario 2-A Decision Making After completing this chapter, the reader should for an Adolescent be able to: ■■ Define ethics. MT is a 16-year-old young man with terminal ■■ Identify the importance of studying ethics brain cancer. At the age of 10 he was diag- for the health information management nosed with acute leukemia. After three years (HIM) professional. of intense treatment, MT was in remission. ■■ Identify ethical concepts, including rele- After two years of remission, during which vant values, principles, virtues, approaches, he was doing very well in school and loved and theories. playing soccer, MT began having severe headaches. Unfortunately, his magnetic reso- ■■ Apply a process of ethical decision making nance imaging (MRI) scan showed a large to HIM scenarios. mass requiring immediate workup. The tis- sue biopsy of the intracranial mass showed a uniformly fatal tumor, likely related to his previous leukemia treatment. No additional Introduction intervention was recommended by the team, Ethics is the formal process of intentionally and and they wanted to refer him to hospice. critically analyzing, with clarity and consistency, MT’s parents had heard stories in the basis for one’s moral judgments. It is impor- the media about unprecedented recov- tant for HIM professionals to engage in this ery of children with terminal diagnoses. process, because they are accountable for their A national search of experimental proto- actions as professionals, not just personally as cols for brain tumors revealed two centers individuals. Ethical reasoning is necessary to that were considering starting aggressive surgical approaches to this devastating resolve the potential tensions between personal diagnosis, but no active studies were open values and professional values and among pro- at this time. MT’s parents were thinking fessional values. This chapter presents a model about moving him to a different cancer for ethical decision making and outlines ethi- center for another experimental treatment. cal theories and approaches that can help HIM A close friend of theirs had been success- professionals identify ethical issues, work with fully treated there after everyone else said other members of the team to identify and ana- nothing more could be done. lyze choices, decide on a course of action, and justify that choice. (continued ) 51 9781284053708_CH02_Pass03.indd 51 13/11/15 12:17 PM 52 Chapter 2 Ethical Decision-Making Guidelines and Tools MT’s parents did not want him to know Why Do Ethical Issues Need he was dying. They insisted on full code status. They forbid the nurses and resident to Be Addressed? physicians to tell him anything unless the Many people may want to answer questions parents were in the room, and they did not of professional ethics according to their own allow any conversation about his terminal personal morality. They may believe that the condition and their recommendations. issue in Scenario 2-A can be easily resolved When asked by staff, MT seemed to according to their own personal upbringing agree with his parents’ decisions in the past. Recently, however, he began to initi- and beliefs. They think, “My parents taught me ate conversations with the night nurse on the to always tell the truth,” or “My parents taught rare occasions when his parents were not me that family is important and you should lis- in his room. One night MT was particularly ten to your parents.” But is that type of think- agitated and asked to speak to a favorite ing really sufficient? Notice that the two belief resident physician who happened to be on systems are in tension. How do you resolve the call and his nurse, and without his parents tension? present. This was a surprising request from Resolving the tensions among values depends MT; his parents were very upset, but they on the more formal mechanism of ethics. Per- complied and left the room. MT shared with sonal morality and ethics differ. Most of the the resident physician and the nurse that he time, people do not distinguish between moral- just accessed his health information from the patient portal that he and his parents signed ity and ethics; they just use the words inter- up for a long time ago, and was upset to changeably. But when a distinction is made, it learn the name of his new diagnosis, glio- is often as follows: Morality refers to your own blastoma multiforme (GBM). Through an personal moral choices based on your upbring- online search he discovered the extremely ing, faith traditions, and experiences; ethics poor prognosis. He asked the resident phy- refers to the formal process of intentionally sician directly, “Am I dying?” The nurse and and critically analyzing the basis for your moral resident physician had grown close to MT judgments for clarity and consistency. Because and wondered what they should do. of the potential tension between personal val- ues and professional values, and because of the potential for tensions among professional val- A completed ethical decision-making matrix for ues, we need ethics to help resolve such tensions. the scenario is provided at the end of the chapter. Ethics provides a formal way to step back from the tension, search for reasons to support one choice over another, and apply this reasoning in What Is an Ethical Issue? future situations. An ethical issue is one that involves the core val- This process of stepping back to formally ues of practice. The case set forth in Scenario 2-A analyze values is important, because you are raises ethical issues in that the core values of accountable for your actions as a professional, respect for patient autonomy, truth telling, ben- not just personally. Patients, other profession- efiting, not harming, and integrity are in conflict als, and the general public do not know about with the values of respect for family decision mak- your personal moral values. But they do have ing and a different interpretation of what counts expectations for your professional conduct. as a benefit or a harm. You know you have an ethi- Standards arise from the trust that the public cal issue when such core values are at stake. Often, places in you. They expect you to be able to act your emotions are the first to alert you that some- professionally—even, or perhaps especially, when thing may be wrong. Many people become upset difficult ethical issues are involved. You have to when faced with the potential for not disclosing uphold that trust, and, at the heart of it, that is the truth or going against patient or family wishes. why you must study ethics. 9781284053708_CH02_Pass03.indd 52 13/11/15 12:17 PM The Process of Ethical Decision Making 53 But You Can’t Teach Ethics, The Process of Ethical Can You? Decision Making Two major objections are commonly given Various models for ethical decision making are to the study of ethics. First, many people available in the literature, but all share some claim that their character is already formed, and basic components or steps (Purtilo, 2005; Lo, that the study of ethics is not going to change 2000; Benjamin & Curtis, 2010; Davis, Fowler, & their behavior if they are inclined not to do the Aroskar, 2010; Jonsen, Siegler, & Winslade, right thing. Second, many people argue that 2006). You should use an ethical decision- there is no ethical content to teach. There is no making process to ensure that you make reliable knowledge of right and wrong that everyone moral judgments in your professional practice. accepts. Ethics is a matter of opinion, and every- We will demonstrate the decision-making pro- one is entitled to his or her own opinion. cess by applying it to Scenario 2-A. See the end Regarding the first objection, the goal of a of the chapter for the complete matrix. course in ethics is not to make you a good per- The first step of the ethical decision-making son. Rather, it is to enable you to make reliable process is to ask, “What is the ethical question?” moral judgments as a professional. Regard- In Scenario 2-A, the ethical question is, “Should ing the second argument, as professionals, we the nurse and the resident physician disclose expect not just opinions, but judgments backed MT’s prognosis?” There is a second ethical ques- up by good reasoning. When making clinical tion that will be discussed as Scenario 2-B fur- judgments, healthcare professionals must offer ther in this chapter, “What EMR access should support for their choices and be able to apply be given to adolescents?” In identifying the ethi- that reasoning in similar situations. The same is cal questions, the HIM professional needs to true when making moral judgments. look for the “shoulds.” These “shoulds” are the An ethics curriculum has three parts: normative questions (i.e., what should or ought to happen according to norms or standards), as 1. Knowledge. The HIM professional needs opposed to descriptive questions (i.e., what actu- to be aware of standards of ethical conduct ally does happen). as expressed in the American Health Infor- However, the HIM professional needs to be mation Management Association (AHIMA) aware of different kinds of “shoulds.” For exam- Code of Ethics and have knowledge of ethi- ple, there are the clinical “shoulds”: in this case, cal principles and concepts. what treatments should be available to MT for 2. Development. The moral maturity of the his GBM according to evidence-based practice HIM professional needs to be modeled and guidelines and the knowledge and judgment nurtured. Even if someone’s character is of clinicians? In Scenario 2-B, what flexibility formed, it needs reinforcement and appli- should the current EMR platform have for dif- cation in professional settings.
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