You have come a long way already and are prepared to take a giant stride towards becoming skilled in the art of ethical decision making. The first part of this chapter guides you through an inquiry regarding how you know when you are faced with an ethical question instead of (or in addition to) a clinical or legal question. Then comes the further question: How do you know if 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 features of any ethical problem and be introduced to three prototypes of ethical problems. To help you get started, we offer the story of Beulah Watson and Tiffany Bryant.

The Story of Beulah Watson and Tiffany Bryant

Beulah Watson is a 46-year-old environmental services employee in a large hotel in town. She has been employed for 18 years in this position and by and large says she has enjoyed her work. In recent years, however, she has increasingly suffered from shoulder and neck pain that the physician employed by the hotel’s health plan accredits to her many years of tugging and hauling heavy linens and cleaning equipment on the job.

Tiffany Bryant is the occupational therapist who has been treating Ms. Watson for the pain and stiffness in her upper body, which has caused her much discomfort and has increased her absenteeism. Beulah Watson originally was prompt in keeping her appointments, but recently she has missed almost all of her sessions. Tiffany is concerned about whether Beulah is taking the time off to do other things while telling her workplace that she has a therapy appointment. This idea starts to work on Tiffany, and she gets more and more annoyed with Beulah.

Finally, Tiffany calls the hotel looking for Beulah but instead she gets her supervisor, the environmental services manager. Tiffany tells her about Beulah’s regularly missed appointments (five in the last 6 weeks). She also tells the manager that the hotel is being charged for the missed visits because Beulah has not called to cancel, which is the billing policy of the institution where Tiffany is employed.

The manager responds that Beulah does not qualify for release time from work for the visits, and because the clinic hours correspond with her work hours, she may not keep all her appointments for that reason. She adds that Beulah probably is worried about the salary loss, even though the treatments are paid for, because she is the sole breadwinner for herself, her disabled husband, and two small grandchildren. The manager says she will talk to Beulah about the unacceptability of her failing to let the occupational therapy department know when she decides not to keep her appointment. In fact, if Beulah keeps that up, the manager continues, she will find herself paying for the missed appointments because the hotel cannot be expected to pay for her lack of responsibility. Tiffany responds that maybe Beulah did not know about the policy. The manager replies, “It doesn’t matter. She knows better than that. By the way, she has been here all the times you mentioned except one, when she did call in sick, so at least she wasn’t off on shopping trips or anything like that.”

A week goes by. At the scheduled time for Beulah’s appointment, she again does not appear. Tiffany 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 Tiffany’s feelings that something is not right? If yes, what do you think the problem is? You can 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 their clinical practice. Some are ethical questions, but others are not. Many times what might appear to be an ethical question is in fact something else, such as a miscommunication or a question about a strictly clinical fact or a legal issue. Often complex questions present with clinical, legal, and ethical problems.

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? Yes or no:

Can a person with early stage dementia drive?

If you answered “no,” you are right. It 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 Beulah Watson, Tiffany Bryant, and the hotel manager, what additional clinical information would help you better evaluate the situation?

Now consider the following question. Is it a clinical, legal, or ethical question?

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

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 assure 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 it is not always up to an individual patient to ignore clinical recommendations.

Now, go to the specific legal implications of Beulah Watson’s situation. When the physician employed by the hotel referred Beulah for therapy, she had assessed that the patient’s discomfort was from years of labor at the hotel. The time may come when Beulah wants to recover workman’s compensation for her condition or apply for disability benefits. Workman’s compensation and disability benefits are legally enforced national programs in the United States to help protect employees from financial duress when injured on the job. 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 Beulah missed so many treatments may compromise her case. The hotel management may choose to fight her claim for disability benefits now that Tiffany has contacted them with this information.

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

Should people with dementia who refuse to take a recommended on-road 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. Tiffany’s reflection on whether she should have talked with Beulah’s supervisor 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, all of which 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.

To continue your learning, we invite you to familiarize yourself with prototypes of ethical problems into which many different everyday ethical questions can 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, and situations.1 Prototypes of ethical problems are recognizable as a group by three features they have in common. Each of the prototypes you will learn about in this chapter appears different from the others, and 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 you find in all the prototypes of ethical problems:

A: A moral agent (or agents)

C: A course of action

O: An outcome

Each feature will be 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, 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 her or his actions 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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A moral agent intends the morally right course of action. You can probably see that the idea of responsibility that you learned about in Chapter 2 is in fact the description of what an agent does; with an ethical challenge in the health professions, the actor is assuming the role of a moral agent. Professional responsibility is exercised through moral agency. Tiffany, the physician employed by the hotel, and the hotel manager all are agents whose actions influence the outcome of Tiffany’s efforts and affect Beulah’s health. As a health professional, Tiffany is clearly in the role of being a moral agent.

Agents and emotion

Both your reason and emotion operate as part of your internal website where you can go and search to find the appropriate tools to exercise your professional responsibility. Much will be said about ethical reasoning and problem solving in this book. Over the years, considerable debate about the significance of emotion in an agent’s activity has taken place. Strict rationalists view emotion as too subjective and unpredictable to serve as a reliable guide. However, a burgeoning body of current professional and lay literature lends new knowledge about the role of emotion in decision making more generally to support the essential role of emotion in ethical decision making. Such well-regarded bodies as the Harvard Decision-making Science Laboratory conduct research on the mechanisms through which emotion and social factors influence judgment and decision making. From their work and the work of others, we find convincing arguments for assigning emotion at least two roles in ethics.

First, emotion is an “alert” system that warns that you may be veering off the road of a caring response. When you encounter a morally perplexing situation, you, who will be accountable, feel discomfort, anxiety, anger, or some other disturbing emotion. Nancy Sherman, a contemporary philosopher working on the place of emotion in morality, proposes that emotions are “modes of sensitivity that record what is morally salient and . . . communicate those concerns to self and others.”3 Sometimes, an emotional response to wrongdoing or tragedy or a heroic act stirs a person out of lethargy and into moral action on someone else’s behalf.⁴ In other words, your emotions help grab your attention and motivate you to “do something.”

Second, according to current research, emotion kicks in again at the point of decision making to complete the human picture of what is happening.⁵ Even if you have been logical in your assessment of the ethical problem, emotion puts the last strokes on the canvas, bringing this decision into focus as one example of how humans actually conduct their lives all around. In the end, each of us can be ethical only about what we see, feel, loathe, or love. In short, ethical responsibility devoid of life infused into it by emotional responsiveness in specific situations is vacuous and can deter you from your best intent to be an effective moral agent.

Summary

An agent has responsibility for an action. A moral agent has responsibility to act in a way that protects moral values and other aspects of morality. An ethical problem requires attention to both reasoning and emotion in the process of decision making. Emotion alerts, focuses attention, motivates, and increases one’s knowledge about complex situations.

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