Frequently Asked Questions: Health Care Ethics

The terms “morals” and “ethics” are frequently used interchangeably; however, many others make a distinction between them. The “moral thing to do” is based on our traditions, customs, laws, and personal faith-based beliefs that an individual calls upon for regular guidance. The “ethical thing to do” means a course of action that has been reflected upon and the reasoning directs that something seems like the right thing to do.

Ethics connotes deliberation and explicit arguments based on ethical theories and principles to justify particular actions. Therefore, ethical reasoning can lead to the ethical thing to do. The ethical thing to do can become part of common morality.

Ethics conflicts occur when there is uncertainty, a question, or a conflict regarding competing ethical principles, personal values (morals), or professional and organizational standards of practice (group morality) or, when one considers violating an ethical principle, personal value, or ethical standard of practice.

Common features of ethics conflicts include:

• Uncertainty about what is the right action or decision
• Patient, family, and staff stress
• Determination of who is decision-maker

Law and compliance is not the same as ethics. Ethics is the foundation for law. The law sets minimally acceptable conduct and rarely provides conclusive guidance to ethics conflicts. Compliance programs and law informs and monitors staff adherence to a specific set of established laws and/or regulations. Despite the differences, ethics decision-making in health care should work closely with compliance and legal counsel offices.

by William Nelson, Rural Ethics Program, Dartmouth Medical School

Ethics and quality care are common drivers for healthcare organizations. Both are based on common values that serve as the foundation for healthcare – respect for the patient, and acting in the patient’s best interest. The push for ethics and quality is commonly captured in organizations’ mission, value and vision statements.

Although clinicians, ethicists and health care leaders do not often conceptualize quality in this manner, when organizational quality is compromised, ethics standards of practice are frequently violated or eroded.

When healthcare professionals provide ineffective or futile care, they erode the organization’s quality aims of providing only effective, patient-centered care, as well as its ethics standards of promoting beneficial patient care and avoiding actions that can cause harm. Similarly, when ethics issues occur, quality of care can be diminished.

by William Nelson, Rural Ethics Program, Dartmouth Medical School

Clarify the ethical conflict or question:

• What is the specific ethics question or conflict?
• What if the question or conflict is not an ethical question?

Identify all the affected stakeholders and their values:

• Who are the individuals or programs affected by the ethics question?
• What are the values and perspectives of all the affected stakeholders?

Understand the circumstances surrounding the ethical conflict:

• Why has the ethical conflict arisen?
• What are the facts surrounding and related to the ethics conflict or question?

Identify the ethical perspectives relevant to the conflict:

• What are the ethics concepts or principles related to the conflict or question?
• Does the organization’s mission, value statement, and/or policies address the conflict?
• Are there ethical guidelines concerning the ethical conflict, such as American Medical Association (AMA) or American College of Healthcare Executives (ACHE) guidelines?

Identify different options for action:

• What are the possible options for responding to the ethics conflict?
• What are the potential benefits or outcomes, as well as the potential harms of each option?
• What is the ethics basis for each option?

Select among the options:

• Have you systematically and quantitatively evaluated each option?
• Is the option practical? Does it have a clear ethical foundation?
• Does one ethical concept or stakeholder value appear to be stronger than the others?
• Is there an assessment plan to evaluate for the decision?

Share and implement the decision:

• What method will be used to share and implement the decision?
• Was the assessment plan implemented?

Review the decision to ensure it achieved the desired goal:

• What was the outcome of the decision?
• Do you need to revise the decision?

Once the case has been resolved – address what can be done to prevent the same ethical conflict from recurring in the future.

Nelson, W. An Organizational Ethics Decision-Making Process. 2005, Healthcare Executive, 20(4):9-14.

• Respect the patient’s decisions and values. Every adult patient of sound mind has the right to decide what is to be done to his or her own body. This includes the right to have the information needed to make an informed decision and an absolute right to refuse unwanted treatment. (Autonomy)
• Do good. Help the patient advance his or her own good. (Beneficence)
• Do no harm to a patient, either intentionally or indirectly. (Nonmaleficence)
• Be fair. Treat like cases alike and work for fair distribution of medical benefits and burdens among all people. (Justice)