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Prototypes of Ethical Problems

Objectives

The reader should be able to:

• Recognize an ethical question and distinguish it from a strictly clinical or legal one.

• Identify three component parts of any ethical problem.

• Describe what an agent is and, more importantly, what it is to be a moral agent.

• Name two prototypical ethical problems.

• Distinguish between two varieties of moral distress.

• Compare the fundamental difference between moral distress and an ethical dilemma.

• Describe the role of emotions in moral distress and ethical dilemmas.

• Describe a type of ethical dilemma that challenges a professional’s desire (and duty) to treat everyone fairly and equitably.

• Discuss the role of locus of authority considerations in ethical problem solving.

• Identify four criteria to assist in deciding who should assume authority for a specific ethical decision to achieve a caring response.

• Describe how shared agency functions in ethical problem solving.

NEW TERMS AND IDEAS YOU WILL ENCOUNTER IN THIS CHAPTER

legal question

disability benefits

ethical question

prototype

clinical question

agent

moral agent

locus of authority

shared agency

moral distress

moral residue

ethical dilemma

Topics in this chapter introduced in earlier chapters

Topic

Introduced in chapter

Ethical problem

1

Integrity

1

Interprofessional care team

1

Professional responsibility

2

A caring response

2

Accountability

2

Social determinants of care

2

Justice

2

Introduction

You have come a long way already and are prepared to take the next steps toward becoming skilled in the art of ethical decision making. The first part of this chapter guides you through an inquiry regarding how to know when you are faced with an ethical question instead of (or in addition to) a clinical or legal question. A further question is raised: How do you know whether the situation that raised the question is a problem that requires your involvement? This chapter helps you prepare to answer that question too. You will learn the basic components of an ethical problem and be introduced to two prototypes of ethical problems. We start with the story of Bill Boyd and Kate Lindy.

 The Story of Bill Boyd and Kate Lindy

Bill Boyd is a 25-year-old soldier who lives in a large city. Bill served in the U.S. Army for more than 6 years and was deployed to both Iraq and Afghanistan for multiple military missions in the past 4 years. During his final deployment, Bill suffered a blast injury in which he sustained significant shoulder and neck trauma and a mild traumatic brain injury (TBI) and posttraumatic stress. He was treated in an inpatient military hospital and transitioned back to his hometown, where he moved into his childhood home with his mother.

Kate Lindy is the outpatient psychologist who has been treating Bill for pain and posttraumatic stress. Bill is in a structured civilian reentry program. This competitive program is administered by a government subcontractor; its goal is to help injured veterans find meaningful careers or employment on return from the front lines. Bill reports that he is struggling with the transition to civilian life. He originally was prompt in keeping his appointments but recently has missed almost all of his sessions. Twice Bill has arrived for his appointment more than 30 minutes late and smelling of alcohol. Kate informed Bill that she could not treat him in this condition and that if he continued to arrive in this state, she would need to discontinue therapy. Bill responded to Kate and said “You have no idea what all of this is like. And don’t even go there on the alcohol; like you have never had a drink on a bad day.”

Kate is concerned about Bill. She calls his home and gets no answer. She then calls the case manager listed on his intake form. Kate tells the case manager about Bill’s regularly missed appointments (three in the last 4 weeks). She also tells the case manager that Bill has been charged for the missed visits because he has not called to cancel, which is the billing policy of the institution where Kate is employed.

The manager responds that Bill does not qualify for transitional career/employment services unless he is compliant with all outpatient care. She adds that in her experience patients like Bill have a hard time adjusting to the fact that they are no longer eligible for active duty.

The case manager says she will talk to Bill about the unacceptability of his failing to let the therapist know when he decides not to keep his appointment. In fact, if Bill keeps that up, the case manager continues, he will be kicked out of the civilian reentry program because the government cannot be expected to pay for his lack of responsibility. Kate responds that maybe Bill was unclear about the policy. The manager replies, “It doesn’t matter. He’s an army man; he knows better than that.”

A week goes by. At the scheduled time for Bill’s appointment, he again does not appear. Kate has been uneasy about the conversation with the manager, and when the time comes for her to fill out the billing slip for another missed appointment, she feels positively terrible.

 Reflection

Do you share Kate’s feelings that something is not right? If yes, what do you think the problem is? Jot down a few thoughts here and refer back to them as the chapter progresses.

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Recognizing an Ethical Question

Health professionals face all types of questions in clinical practice. Some are ethical questions, but others are not. Many times, what may appear to be an ethical question is in fact something else, such as a miscommunication or a question about a clinical fact or a legal issue. Often, complex clinical situations include clinical, legal, and ethical questions; part of your challenge is to distinguish them and sort them out for their relevance to the patient and the delivery of care.

The following exercise is designed to walk you through one example of an issue that includes clinical, legal, and ethical dimensions, with a description of why the last is an ethical question.

Is this an ethical question? Answer Yes or No:

Can a person status post TBI drive?

If you answered “no,” you are correct. This is a clinical question because clinical tests and procedures can help answer it. Patients who pass various cognitive assessments and an on-road driving evaluation have the clinical ability to drive, and those who fail do not. Refer back to the story at the beginning of this chapter. In the narrative about Bill Boyd, Kate Lindy, and the case manager, what additional clinical information can help you better evaluate the situation?

Now consider the following question:

Must patients with TBI comply with medical advice in this type of situation if they want to continue to drive?

Is this a clinical, legal, or ethical question? If you said “a legal question,” you are on the right track. A tip-off is the word “must.” As you learned in Chapter 1, the laws of the state and other laws are designed to monitor public well-being and enforce practices that protect the public good. Almost all states include procedures to help ensure road safety. Relevant information about people who are dangerous behind the wheel is found in part through clinical examinations. Clinical and legal systems are interdependent in that and other situations, so the decision to ignore clinical recommendations is not always up to an individual patient.

Now, go to the specific legal implications of Bill Boyd’s situation. When the physician referred Bill for therapy, she assessed that the patient’s discomfort was from a combat-related injury. The time may come when Bill wants to apply for disability benefits for his condition. Veterans disability benefits are legally enforced governmental programs in the United States to help protect members of the military from financial duress when injured during service duty. And so, a related legal question relevant to this situation is: Do patients have the right to benefits provided by the government if for any reason they miss prescribed treatment and the professional reports this?

Eligibility usually requires that a patient comply with treatments that are prescribed; the fact that Bill missed multiple treatments may compromise his case. The case manager may choose to fight Bill’s claim for disability benefits now that Kate has contacted the manager with this information.

Finally, consider this question, which is an ethical question. As you read it, think about why it is an ethical question.

Should people with TBIs who refuse to take a recommended onroad driving assessment be allowed to continue driving? If so, under what circumstances?

The word “should” is the tip-off here. It points to something in society all have agreed to support and each individual has a responsibility to help do so. Kate’s reflection on whether she should have talked with Bill’s case manager and her ambivalence about having to charge for treatments that she did not administer are examples of ethical questions about the wrongdoing or rightness of her actions that she was pondering.

 Summary

Ethical questions can be distinguished from strictly clinical or legal questions, although all of these questions often arise in health professional and patient situations. An ethical question places the focus on one’s role as a moral agent and those aspects of the situation that involve moral values, duties, and quality-of-life concerns in an effort to arrive at a caring response.

For your continued learning, we now introduce several prototypes of ethical problems, into which many different everyday ethical questions will fit.

Prototypes of Ethical Problems: Common Features

What is a prototype? Prototypes are a society’s attempt to name a basic category of something. Prototypes can be objects, concepts, ideas, or situations.1 Prototypes of ethical problems are recognizable as a group by three features they have in common. Each of the prototypes in this chapter appears different from the others; in fact, each has a different role to play when ethical questions have arisen. That said, the first step into this venture is to become familiar with the same basic structural features found in all the prototypes of ethical problems:

A: A moral agent (or agents)

C: A course of action

O: An outcome

Each feature is discussed in turn.

The Moral Agent: A

Which of the following best describes your idea of a health professional as an agent?

A. A person with more than one basic loyalty; a deeply divided loyalty (e.g., a double agent).

B. A person who has the moral or legal capacity to make decisions and be held responsible for them (e.g., a signee on a contract).

C. A person who plans schedules or events (e.g., a booking agent).

If you answered “B,” you are most clearly focused on the meaning of agency in the health professions roles you will assume. In ethics or law, an agent is anyone responsible for the course of action chosen and the outcome of that action in a specific situation. Obviously, being an agent requires that a person be able to understand the situation and be free to act voluntarily. Acting as an agent also implies intention: The person wants something specific to happen as a result of that action. A moral agent is a person who “acts for him or herself, or in the place of another by the authority of that person, and does so by conforming to a standard of right behavior.”2

 Reflection

This book emphasizes your role as a moral agent in the health profession setting because as a professional, you must answer for your own actions and attitudes. If you have observed a situation in which someone in your chosen field has had to act courageously, then you have observed a moral agent at work. Briefly describe what you observed and why you feel the responsibility fell to that person to be on the front line of the decision.

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