Introduction
Healthcare professionals sometimes face difficult decisions in their line of work. These difficult decisions may sometimes involve a conflict with the patient’s family’s morals and beliefs, and the set healthcare guidelines. Healthcare ethics are based on the healthcare professional acting in the best interest of the patient and his or her family. It also involves making the right choices after a thorough consideration of beliefs and values about health, suffering, life, and death (Aveyard, Edward & West, 2005, p. 45).
Healthcare professionals are usually guided by professional ethics in doing their job. However, they regularly encounter difficult patients or family members who pressurize them to do anything possible to help the patient, even if it doing that would create an ethical dilemma for the healthcare professionals. For the healthcare professional in such a situation, there are also personal ethics at play in addition to the professional ethics expected of them (Beauchamp & Childress, 2001).
Regardless of the disrespectful treatment that the healthcare professional might get from the patient and the patient’s family, he or she is expected to stick to professional ethics and make decisions in the best interest of the patient and the family. This paper will provide critical analysis of ethical issues that arose when a physiotherapist encountered a difficult family member when attending to one of his patients.
Critical Analysis of Ethical Issues
I picked on this story because it touches on several issues related to medical ethics. It also touches on the physiotherapist as a person, and how his personal feelings and attitudes can affect his decision-making in relation to how he attends to the patient. I have decided to analyze the ethical issues arising from this story using the “four principles plus scope” method (Gillon, 1994, p. 6950).
This approach provides a neutral way of analyzing the various ethical issues that arise in healthcare. It entails four basic moral commitments and the extent of their application. The four principles are respect for autonomy, beneficence for the patient and others, non-malfeasance on the part of the health worker and justice for all parties (Bergman, 1990, p. 81).
This approach acts as a moral analytical guide that can be applied in any situation in which the healthcare worker is faced with an ethical dilemma. These principles override our personal attitudes, beliefs and moral standing, and give the healthcare worker a chance to approach every issue in a professional and ethical manner without fear or prejudice (Carpenter, 2010, p. 72). These principles do not provide a method for making the final decision; they merely act as a moral and ethical guide. The ultimate decision lies with the healthcare worker after a careful analysis of all the factors at play.
Respect for Autonomy
In the medical world, healthcare workers are called upon to respect other people’s autonomy in many situations. They are usually required to obtain the consent of patients and their families before proceeding with any medical intervention procedures. The patient Mr. H had a traumatic brain injury so his father was exercising this right of consent. When the neurologist attending to Mr. H recommended further hospital stay for extensive rehabilitation, the father had to agree to it first.
From the previous encounter, the father had expressed his reservations about the role of the physiotherapist and categorically stated that the physiotherapy was not helping his son. However, much of his anger arose out of frustration because his son did not seem to make any progress. After cooling down, the next day he was able to be rational and allowed the physiotherapy to continue for another month. In the end, the son made good progress and was later discharged to continue with physiotherapy at home.
If he had let his anger and frustrations get the better of him, perhaps he could have demanded that his son be released immediately. This could have had serious health implications for the patient, but there is nothing much that I, the physiotherapist, or the neurologist could do to stop him.
In such a situation, the health workers usually know what is best for the patient, but because of respect for autonomy, they can only advise and make recommendations, then wait for the patient or family members to make the final decision on the next course of treatment (Delany, 2008, p. 3). However, it is the obligation of health workers to create conditions that will enable the patient the right autonomous choice. Patients and their family members require the guidance of health workers in making their decisions since they lack the necessary medical background to make informed choices.
It is the work of the health workers to educate the patients so that they have a good understanding of what is at hand. The health workers are supposed to cool down emotions and address any fears that may cloud the patient’s judgment in making the decision. They are also supposed to advise the patients if their decisions seem to be harmful to their health and well-being. Respect for autonomy also requires health workers to practice confidentiality and maintain the privacy of the patient.
As a physiotherapist, it was not upon me to decide whether the patient could continue staying in the ward even after the father asked me to facilitate that. I had to ask the discharge planner if the bed was still available. The attending physician also had to agree to an extension of the patient’s stay. It was critical to respect the autonomy of the discharge planner in assigning beds in the ward, and any move without his consent would have been grounds for conflict (Donchin, 2001, p. 372).
In such a case, it did not really matter whether a prolonged stay in our wards was going to benefit Mr. H or not, it all depended on the availability of bed space as allocated by the discharge planner and I had to respect that.
Beneficence and Non-Malfeasance
The principles of beneficence and non-malfeasance are at the heart of my story. As health workers, it is our duty to help others, even though in doing so we also risk harming them (Ells, 2001, p. 604). Every health worker must therefore weigh the two principles carefully and produce the net benefit for the patient and his family. Even in situations in which we have no obligation of beneficence to others, we still have a duty not to harm them (Khan & Stirling, 2002, p. 208).
The aim of medical practice is to promote the well-being of the patients. The relationship between the patient and the health worker makes it an obligation of the health worker to prevent and remove anything that would harm the patient. The health worker is also obligated to weigh the possible benefits against any perceived risks of any act towards the patient. Beneficence also covers the protection of other people and defending their rights, saving people who are in danger and assisting disabled individuals.
When the colonel described my physiotherapy sessions on his son as “poor and useless”, it was very demoralizing. Not only was I very angry, I felt unappreciated. In such a situation, the normal human reaction would be to stop and abandon the whole thing. However, as a healthcare worker, it is expected of me not to cause harm to my patients. Abandoning Mr. H would have caused him harm, and this is against the medical ethics.
Since we are required to benefit the patient always, I continued with Mr. H’s physiotherapy sessions despite the insults from his father. In continuing with the physiotherapy, I had to do the best for Mr. H as I had been doing even before his father insulted me. I could not go through the motions of physiotherapy just to be seen to be doing my work. I still had to work on Mr. H in the best way possible in order to help his quick recovery.
In the end, the patient managed to register impressive improvement and was eventually discharged. At the end of it all, I had put the medical ethics above my personal feelings, and that is what enabled me to contribute to the patient’s recovery. If I had not put the patient’s beneficence first, I would have compromised his path to recovery, and this would have been highly unethical in medical circles.
Patience beneficence also goes hand in hand with non-malfeasance. This means that we are also not supposed to do things that would harm the patient, or cause harm to the patient by avoiding doing certain things (Macklin, 2003, p. 279). This means that health workers must avoid giving ineffective treatments or acting in a malicious way towards their patients. In healthcare, many beneficial treatments usually come with serious risks, so the ethical issue is to determine whether the benefits outweigh the risks.
When the Colonel told me to arrange for extended stay for his son, I had the opportunity to ensure that does not happen. Based on my personal feelings, I could have taken this opportunity to get rid of the disrespectful colonel and his son. I could have chosen not to write to the attending physician to request an extension. I could have also told the father that the bed had already been assigned to another patient by the discharge planner so he had to get his son out of there.
All these could have resulted in malfeasance on my part, since I would have done things that would have hurt the patient in the end. This is highly unethical in the medical fraternity. At no point are healthcare workers allowed to intentionally do things that would harm the patients, or avoid doing certain things and end up harming the patients (Macklin, 2003, p. 278). In the case of MR. H, moving him in his state of comma would have posed serious health risks.
The best thing would have been to let his stay in hospital until his CGS improved. While staying in our hospital, he would need to continue getting physiotherapy, which was provided by me. Eventually, after the extended stay, his CGS improved and he could be moved. He was taken home where a home physiotherapist was to continue attending to him. In the end, I followed the principles of beneficence and non-malfeasance in handling the whole situation.
The patient benefitted from his extended hospital stay, which I had arranged, and from my physiotherapy. If my anger towards the father had clouded my reasoning and judgment, I would have acted unethically and put the patient in danger. Sometimes the frustrations and insults can come from the patients themselves. Even in such situations, the health worker must always be guided by the principles of beneficence and non-malfeasance in dealing with the difficult patient.
Justice
This moral principle requires health workers to act with fairness to all parties in any situation. Justice also espouses equality, even though equality alone does not amount to justice. As Aristotle argued, people can be treated equally while still being treated unjustly (Kerridge, Lowe &Stewart, 2009). There is a lot of debate about how justice should be delivered in the workplace and even in the broader society. For health workers, we cannot impose our personal or professional opinions regarding justice on others.
However, we need to acknowledge and consider all the competing moral concerns raised by different parties. In the healthcare environment, there are three general categories of justice that the healthcare worker will be obligated to administer at one point or another. First, there is distributive justice that concerns the fair distribution of hospital resources, especially when they are scarce.
In relation to my case, what if the discharge planner had somebody waiting to be allocated the bed Mr. H was occupying? As much as I was acting in good faith to help Mr. H by extending his stay, would it have been fair to the other patient who was waiting? In such a situation, the hospital guidelines can help. The other patient also deserves proper healthcare just like Mr. H. Since Mr. H had already stayed his designated days, the only option would have been to move him even if it meant putting him at risk.
This would have been fair for all since we would be following preset hospital guidelines. Alternatively, I could have looked for another bed for the waiting patient and let Mr. H stay put. This would have also been fair to all parties, as long as the other patient and his family members were in agreement. Situations calling for distributive justice are many in the medical field, and are usually very volatile in most cases. Healthcare workers have to proceed carefully and follow policy guidelines in making their decisions (Skene & Smallwood, 2002, p. 40).
There is also rights-based justice, which is concerned with respect for other people’s rights (Beauchamp & Childress, 2001). It is Mr. H’s right to get the best medical care possible from our hospital, and the attitude or behavior of his father should not compromise that in any way. The third category refers to legal justice, which is based on the laws of the land. For example, the law requires that all gun shot wounds be reported to the police whenever the victim comes to hospital.
The healthcare worker has no choice but to follow the law on this matter, even if it seems unfair to the patient who might end up being arrested. Justice in the healthcare environment is a sensitive issue that generates a lot of debate. Healthcare workers should not take it upon themselves to administer justice based on their personal interpretation of things, but rather should be guided by policy guidelines for the hospital and the state or country as a whole.
Ethical Decision-Making
It is essential for health employees to ensure that they have compassion while taking care of patient. At the same time, they are also expected to be kind to the family members and friends of the patients whom they are handling. While doing this, they need to maintain a high level of professionalism and avoid treating patients, their families or any other individual associated with them with automated emotions and acts. Health professionals are required to follow a code of ethics that has been crafted from values based in professional theory, culture, social and legal norms (Kerridge, Lowe &Stewart, 2009).
In the hospital set up, the well-being of the patient demands that the health workers help patients and family members in making decisions that may sometimes be difficult. For example, the colonel felt that the physiotherapy that his son was undergoing at our hospital was not helping at all. His comma situation seemed to be getting worse as indicated by the GCS readings. The colonel must have been thinking of taking his son home, or at least to another hospital.
However, after a serious chat with the neurologist, he decided to extend his son’s stay. The neurologist helped him make the right decision because moving his son at that time could have put his life at more risk. The value of the physiotherapy could also not be underestimated, even if the colonel could not see tangible benefits. In the end he agreed to have his son stay longer, and I continued with the physiotherapy. After a month, his son’s condition improved greatly and he could be taken home.
It was also organized for him to continue getting physiotherapy at home. In the end, the patient benefitted because the neurologist guided the father into making the right decision despite his misgivings. This is what is expected of healthcare workers when it comes to decision-making, even if the final decision rests with the patient or family members (Beauchamp & Childress, 2001).
I also had a big decision to make since I was the one to request and facilitate the extended stay of the patient. After my run in with the colonel, I still had to do what was in the best interest of the patient. Here was the colonel asking for my help yet he had insulted me just a day before. I still had to apply professionalism in my decision-making.
Emotions in health care
In the hospital setting, the health care worker is expected to have the ability to manage his emotions and express them in an appropriate manner (Carpenter, 2010, p. 74). In a normal setting outside the hospital, the colonel’s insults could have elicited a strong backlash from me. I could have reacted angrily and maybe thrown some insults back at him. However, my position as a health worker, and being in the hospital setting meant that I had to check my emotional reaction.
Emotional intelligence is very important in the healthcare environment. As health care workers, we need self awareness to help us recognize our emotions as we go about our work in the hospital setting (Beauchamp & Childress, 2001). This awareness should go hand in hand with self regulation so that we are able to control our impulses and emotions in any situation. Losing my cool in front of my supervisor, the colonel, Mr. H and any other person in the vicinity would not have augured well for my position as a health worker.
As health workers we are supposed to remain cool under all circumstances, as the patients and their families, consciously and unconsciously, rely on our emotional strength to get them through their ordeal. Losing control of our emotions is a sign of weakness that would not inspire any confidence in us from the patients. A health worker must have the ability to manage his emotions if he is to attain his goals (Kerridge, Lowe &Stewart, 2009).
In my case, my goals were to provide physiotherapy treatment to Mr. H. Even when the colonel described my efforts as “poor and useless”, I had to remain focused on my goals, and this required me to manage my emotions properly despite the verbal attacks from the colonel. A big part of emotional intelligence also requires empathy. Health workers must be aware about the feelings and the needs of others. The colonel was under a lot of pressure.
His son was in a comma and was not showing signs of recovery, and this must have stressed him a lot. Being a colonel, with all his rank and ability, there was nothing much he could do to help his patient. This took an emotional toll on him, and he reacted by lashing out at me. However, despite his emotional outburst, my supervisor still talked to him calmly and politely. I also had a duty to be polite to him despite the insults. Health care workers are required to empathize with patients and their families in such situations.
It is only when we understand the emotional turmoil that they are going through that we will be able to tolerate all the annoying things they might say or do to us. Being in control of our emotions is not just about suppressing our reactions in public. It should also be reflected in the decisions we make afterwards. After insulting me, the colonel still needed my help the following day. I could not let my feelings get in the way and may be deny his request or sabotage him in any way.
Being in control of our emotions means not letting those emotions cloud your judgment even if you don’t express them publicly. Despite the colonel’s insults, I had to remain focused on my work. This means I had to continue with the physiotherapy sessions, and when I was asked to facilitate the continued stay of the patient, I had to do that. That is what my job entails as a physiotherapist. At the end of the day, health care workers are supposed to put the welfare of the patient first, and doing that requires high emotional intelligence.
Conclusion
The incident that prompted me to write the narrative and the subsequent reflection may seem commonplace in the healthcare set up but it touched a few ethical issues that health workers face on a daily basis. Healthcare is a very sensitive field, and healthcare workers are usually faced with many ethical considerations especially when it comes to making decisions on the course of action to take for their patients. Health workers are expected to respect the autonomy of patients and their families.
This is why they have to consult and get consent before proceeding with certain procedures. They are also expected to respect their colleagues and their designated areas of jurisdiction. Perhaps the biggest ethical principle that guides health workers is beneficence. It goes hand in hand with non-malfeasance, and requires health workers to act in the best interests of their patients at all times. The health workers are supposed to do things that will benefit the patients, and avoid doing things that would harm them. When faced with an ethical dilemma, the health worker should consider the net benefits of their course of action.
Health workers are also expected to deliver justice to all concerned parties if the need arises in the hospital setting. However, most of these decisions on justice should not be based on personal assessment or attitudes, but should be guided by professional ethics and the laid down policies by which the hospital operates. By following the guidelines of the “four principles and scope”, health workers should not find it hard arriving at the appropriate ethical decisions that are expected of them.
This is because these principles are neutral, and try to keep off any political, religious, or personal biases that may interfere with proper judgment. After reflecting on my case, I have come to the conclusion that medical ethics are very important, and should always guide the decisions of the health workers in the hospital set up.
References
Aveyard, H., Edwards, S., & West, S. (2005). Core Topics of Health Care Ethics: The Identification of Core Topics for Interprofessional Education. Journal of Interprofessional Care, 19 (1), 37-56.
Beauchamp, T., & Childress, J. (2001). Principles of Biomedical Ethics (5th ed.). Oxford: Oxford University Press.
Bergman, B. (1990). Professional Role and Autonomy in Physiotherapy: A Study of Swedish Physiotherapists. Scandinavian Journal of Rehabilitation Medicine, 22(2), 79-84.
Carpenter, C. (2010). Moral Distress in Physical Therapy Practice. Physiotherapy Theory and Practice, 26 (2), 69-78.
Delany, C. (2008). Making a Difference: Incorporating Theories of Autonomy into Models of Informed Consent. Journal of Medical Ethics, 34 (3), 1-5.
Donchin, A. (2001). Understanding Autonomy Relationally: Toward a Reconfiguration of Bioethical Principles. Journal of Medical Philosophy, 26 (1), 365-386.
Ells, C. (2001). Lessons about Autonomy From The Experience Of Disability. Social Theory and Practice, 27 (4), 599-615.
Gillon, R. (1994). Medical Ethics: Four Principles plus Attention to Scope. British Medical Journal, 909 (1), 6948-6951.
Kerridge, I., Lowe, M., & Stewart, C. (2009). Ethics and Law for The Health Professions (3rd Ed.). Annandale, NSW: Federation Press.
Khan, Y. & Stirling, R. J. (2002): Ethical Implications of Consent And Confidentiality. Journal of Medical Ethics, 28 (2), 207–208.
Macklin, R. (2003). Applying the Four Principles. Journal of Medical Ethics, 29 (5), 275-280.
Skene, L., & Smallwood, R. (2002). Informed Consent: Lessons from Australia. British Medical Journal, 324 (2), 39-41.