Morality and ethics: what are they and why do they matter?

Objectives

• Define morality and ethics and distinguish between the two.

• Describe the differences among and relationship of personal, group, and societal moralities that health professionals must integrate into their own moral life.

• Describe the function of a health professions code of ethics in terms of professional morality.

• List three ways in which ethics is useful in everyday professional practice.

• Compare the basic function of law and ethics in professional practice.

• Identify some laws and policies that protect the personal moral convictions of health professionals while upholding ethical standards of the profession.

• Delineate a basic distinction between theories of action and virtue and between approaches that emphasize individuals or communities as the primary moral concern of ethics.

New terms and ideas you will encounter in this chapter

plateau

morality

moral judgment

values

moral value

moral duty

moral character/virtue

personal morality

integrity

societal morality

group morality

professional morality

code of ethics

Hippocratic Oath

ethics

ethicists

ethics committees

Constitutional law

statutory law

administrative law

common law

state interests

licensing laws

moral repugnance

Introduction

Your adventure into the world of health care ethics begins with a story. Throughout this textbook you will meet patients, health professionals, families, and others who face challenges posed by their situations and the health care environment. Their stories illustrate the types of ethical issues you yourself may face as a caregiver, a patient, or a family member. The underlying ethical themes in the stories are woven into the very fabric of health care. This book attempts to pull out the threads, examine them for their unique or interesting characteristics, and assess the role each plays in the overall scheme of good professional practice.

The following story concerns the Harvey family and the health care system into which they are catapulted after the tragic events of a beautiful late spring day.

The Story of the Harvey Family and the Health Care Team

Drew Harvey was undoubtedly one of the most popular students at Mountmore College. Now in his senior year, he was captain of the college basketball team, which had had its best season ever, going to regional competition, and he had his own band that played every Saturday night at the most popular local pub, the Mole Hole. He had played more than studied during his first 2 years of college, never having to “crack the books” in high school. But after his sophomore year, he worked as an assistant in a local law firm. When he returned in his junior year, he announced that he was going to become a lawyer. He buckled down, gaining an almost straight “A” record, without having to give up basketball or the band.

May 20

The violent incident that occurred the weekend before commencement rocked the entire community. Drew’s band was playing at the Mole Hole at an event reserved for the college seniors and their friends. At the end of the first set, just as Drew was acknowledging the band members to the applause and howls of the audience, he suddenly staggered backward; blood appeared on his forehead as he fell forward off the platform. After a moment of stunned silence, someone screamed, “He’s been shot!” Pandemonium broke out. Someone called 911. Drew mumbled, a confused and frightened look on his face, “What’s going on?” Then he lost consciousness. He was taken to the emergency department of a hospital, where a bullet was determined to have lodged in his skull, penetrating it above his left temple.

The physician assistant and nurses on duty administered first aid trauma measures. By now his parents had arrived. The physician on call asked Drew’s mother, Alice, to sign informed consent, insurance, and other forms and began to prepare Drew for immediate surgery to remove the bullet and for subsequent admission to the hospital.

Mrs. Harvey wept. When a nurse put an arm across Alice’s shoulder and said, “I’m sorry,” Alice began to cry inconsolably. Alfonso Harvey, Drew’s father, stood off to one side, staring straight ahead as if in shock. The nurse offered to get Alice a drink of water and guided them to a private waiting room while explaining what would happen next. Police were everywhere.

June 11

After 2 weeks in the intensive care unit, Drew regained consciousness. The shunt that had been placed in his skull to relieve the swelling of his brain was working well. He was beginning to focus his gaze, and the nurses believed he was trying to say something, although no one else saw this gesture yet. On the 18th day, the physician reported that Drew would be transferred to the medical unit. This morning, 22 days after the shooting, the physician told Alice that Drew’s condition was stabilized and he would be going home soon. “Home!” Alice gasped. “How can we possibly manage at home? He can barely talk, can’t walk, can’t go to the bathroom alone!” The social worker who was standing at the foot of the bed explained that the Harveys would be visited by a home care nurse and for some time (depending on his progress) by an occupational therapist, physical therapist, speech therapist, and others. The physician reminded the Harveys that Drew’s progress exceeded their expectations, likely a reflection of the excellent physical shape he was in before his trauma. The social worker added that a home health aide also would visit periodically. The physician did caution that although Drew’s condition was improving, how much it would finally improve was impossible to predict. However, she said the entire team was hopeful.

July 11

At home, Drew’s right arm and hand regained function so that he could almost dress himself. He could not walk because of spasticity of the right leg, although the spasticity seemed at times to be subsiding. He suffered from a limited vocabulary but increasingly caught himself when he used a wrong word. Because of this progress, the case manager authorized another 6 weeks of physical therapy, speech therapy, and occupational therapy.

Mr. and Mrs. Harvey were understandably anxious but very supportive throughout the entire ordeal, encouraging their son toward as much independence as possible and offering support when needed. Drew’s older brother made some adjustments in the Harveys’ home to accommodate Drew’s impaired functional status.

Today (august 1)

The several health professionals working with Drew have grown attached to him and his family. They have rejoiced with every sign of progress and have struggled with him through the frustration and depression that accompany such a catastrophe. But the health professionals are now faced with a difficult situation. Another treatment review is due. Understandably, when no further progress can be shown, authorization for his treatments (and therefore, the reimbursements for them) will be discontinued. At the moment, his progress seems to have stopped.

The story of the harvey family (continued)

Drew’s speech and progress in performing activities of daily living have reached a plateau. Yet the health professionals have not reached an agreement regarding whether more improvement may be on the way if his condition is not allowed to slip back. Maybe he will be able to avoid lifelong use of a wheelchair if his treatment is not discontinued at this critical juncture. But his university’s health plan insurers use success (“outcomes”) measures that make it unlikely he will continue to be reimbursed for therapy costs. The health professionals know that continued payments for treatment depend on their report of his progress. What should they do?

• Should they “bend the truth a little,” reporting that Drew continues to make daily progress, so that he is less likely to lose an opportunity for possible further progress?

• Should they tell the truth, knowing that Drew will be discontinued from treatment at this time?

• What other alternatives to an either/or solution to this perplexing problem should they pursue?

• Should they get involved in trying to change the insurance company policies that put them in this difficult situation in the first place?

Anyone who works with patients who experience brain trauma knows that the team faces a critical and delicate situation. The rate of “progress” is not always constant. It may be marked by periods of rapid improvement interspersed with other periods of almost no perceptible change (plateaus). If the patient ceases to receive maintenance treatments during these plateau periods, a dramatic loss in functioning may occur. Yet many insurance plans or other reimbursement mechanisms make little or no allowance for these plateau periods, and treatment usually is discontinued. A patient must have a symptom that becomes acute again before treatment can be reinstituted. In summary, although progress eventually does end, the failure to allow for a plateau period often results in the patient’s premature discontinuation from treatment altogether. This is precisely the ambiguity facing the health professionals who have been treating Drew Harvey.

Reflection

Suppose you are treating Drew and believe you are the one who has to be an advocate for him and his family. What, if anything, should you do to figure out some way to report on his condition that gives him a chance at a few more treatment sessions? Questions with a broader outlook might occur as well. For instance, is it fair to continue treating him if you are not prepared to make a similar defense for all patients in a comparable situation? Or an even broader scope may be encompassed: Are you as a health professional responsible for trying to change the insurance system or hospital policies so that such situations do not occur and you can more easily give patients what you think they need?

Take a minute to jot down what you think are the most important challenges facing health professionals involved with Drew Harvey’s situation, regardless of whether they are suggested in the text:

1.________________________________________________________________

2.________________________________________________________________

3.________________________________________________________________

4.________________________________________________________________

Responses to these challenges are not found in the textbooks that deal with the technical skills of your chosen field. You are beginning to use your understanding of morality and how ethics figures into your professional life if you are concerned with what would be right or wrong conduct for you in this situation and why; what your duties are to everyone involved and what your (and everyone else’s) rights are; also if you are thinking about the type of character traits you want to preserve; or what constitutes fairness for all patients in similar situations. In a word, what is involved in showing Drew and his family that you care?

Summary

Facing difficult human questions about right and wrong conduct, duties, rights, character traits, and fair treatment is part and parcel of your professional ethical life.

These considerations may even make you think about what type of society you want to help build in your professional career. In all of these areas of your professional life, you are dealing with morality and moral values.

Morality and moral values

When morality is mentioned, you might think of what you were told to do or not to do as a child. You are right. That is a part of morality. But morality is a much richer set of ideas than that. From the earliest societies onward, people have established guidelines designed to preserve the very fabric of their society. The guidelines become a natural language and behavior that describe the way things ought to be and what types of things we should value. Most members of society accept these guidelines, allowing the assumptions on which morality is based to prescribe decisions about many aspects of daily life.

Morality is not simply an intellectual exercise. Individuals and groups feel strongly about what is right and wrong, good or bad. A part of moral development is to instill these assumptions into children at a deep emotional level so that acting on the guidelines is not only habitual but makes them feel as if the right decision was taken. Viewed collectively, these guidelines constitute a society’s morality.

First and foremost, morality is relational. It is concerned with relationships between people and how, ultimately, they can best live in peace and harmony. The goal of morality is to protect a high quality of life for an individual or for the community as a whole. Ethicists Tom Beauchamp and James Childress summarize it this way: “certain things ought or ought not to be done because of their deep social importance in the ways they affect the interests of other people.”¹ It follows that morality is context dependent. A moral judgment is needed when the particulars of a specific situation arise. When you are faced with being an advocate for Drew, you are forced into thinking of him in very specific terms as a human in relationship to his family, to the health professionals, and to society.

Values is the language that has evolved to identify intrinsic things a person, group, or society holds dear. Not all values are moral values of course. For instance, some things are cherished for their beauty, novelty, or efficiency they bring to our lives. Things that uphold our ideas of what is needed for morality to survive and thrive are viewed as moral values. Many moral values describe qualities that support individuals in their desire to live full lives, allowing them to pursue their own basic interests and providing help for others to do so. We ascribe moral value to character traits of persons or societies, too, making a moral judgment of their being praiseworthy or blameworthy traits. A compassionate person is judged as praiseworthy and a cruel one as blameworthy; a just society is praiseworthy and one that holds its citizens in a grip of terror is blameworthy.

Moral duty and moral character also are associated with morality. Duty is a language that has evolved to describe actions in response to claims placed on a person or society. Not all duty is moral duty, just as not all we value is of moral value. Moral duty describes certain actions required of you if you are to play your part in preventing harm and building a society in which individuals can thrive. Specific duties and the ethical theories based on this aspect of morality are described in Chapter 4. Moral character or virtue is a language used to describe traits and dispositions or attitudes that are needed to be able to trust each other and to provide for human flourishing in times of stress, such as compassion, courage, honesty, faithfulness, respectfulness, humility, and other ways of being in the world that we want to be able to count on. These traits taken together and exercised regularly make up what we mean when we say a person is “of high moral character.” These, too, are addressed more fully in later chapters of this book.

As a child, you acquired parts of your morality from parents, family, and friends; reading and television; your religious teaching; and experiences in school. Behavior was modified when knowingly or unknowingly you did something outside of what you had been taught is right and you were punished or shamed by others for what you did (or failed to do).

Reflection

Consider some sources that have informed your own moral beliefs. Your answers can be personal reference points as you read on about morality.

1. Who or what have been five important influences on your understanding of right and wrong?

a. _______________________________________________________________

b. _______________________________________________________________

c. _______________________________________________________________

d._______________________________________________________________

e._____________________________________________________________

2. Name three people who you admire for living exemplary moral lives. They may be people you know personally or only by reputation. What makes them admirable?

a._____________________________________________________________

b._____________________________________________________________

c._____________________________________________________________

Morality informs many decisions in your everyday experience, but you are so accustomed to moving through your life in accordance with your moral values and actions associated with moral duty that you have little conscious awareness of it. In short, it is safe to say that morality is habitual, shaping the character of individuals and communities, most of the time without them even realizing it.

As a student entering the health professions, you must reckon with at least three subgroups of morality: your personal morality, societal morality, and the morality of the health professions and its institutions. Fortunately, there are large areas of overlap. Whether as an individual among family members or friends, as a citizen, or as a professional, the sources of moral belief usually derive from similar understandings of value, of right and wrong, and of desirable character traits.

Personal morality

Personal morality is a collage of values, duties, actions, and character traits each person adopts as relevant for his or her life. It is “who you are” as a unique moral being among others; you named some of the influences on you in the previous reflection. Everyone has a personal morality, and you must become intimately familiar with the particulars of your own. Doing so enhances the self-understanding that is essential to you as you begin to take on the responsibilities and tasks of your professional role. It is also a foundation stone from which you can step out to try to understand and respect the personal morality of patients, colleagues, and others with whom you come into professional contact. To illustrate, the health professionals treating Drew Harvey will not be successful if they are not aware of their own moral values and beliefs as they encounter the moral values and beliefs of the Harvey family. Without deep self-awareness, it is impossible to discern why you respond to another with the feelings, emotions, and judgments that arise in the course of your communications and decisions.