Prototypes of Ethical Problems
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. Prototypes of 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? 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? Prototypes of Ethical Problems
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. Prototypes of Ethical Problems
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. Prototypes of Ethical Problems
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. Prototypes of Ethical Problems
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). Prototypes of Ethical Problems
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
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 Prototypes of Ethical Problems