Basic Ethical Principles

Clinicians practicing in post-acute and long-term care often must confront and resolve ethical conflicts, problems, and dilemmas. Although federal, state, and local regulations may support the rights of PALTC residents and patients, ethical conflicts may require a broader perspective, which requires the delineation of clinical ethical principles.

The field of ethics studies morality and the rightness and wrongness of human acts.  In health care, moral questions may arise in the care of patients and residents, requiring a structured ethical approach to understand, analyze, and resolve moral issues.

Moral dilemmas arise when the rights or wishes of patients and residents conflict with the obligations of care team members or when there are competing rights and obligations among the care team. When such issues arise, PALTC organizations and facilities should have policies, procedures, and mechanisms to address these often-challenging conflicts.

Although there are many principles which support biomedical ethics, there are four prima facie principles that are most often cited as the bedrock of clinical ethics: autonomy, beneficence, nonmaleficence, and justice. 

Autonomy

The principle of autonomy is derived from the notion that all persons have intrinsic worth, according to Justice Cardozo in the 1914 judicial ruling, Schloendorff vs. Society of New York Hospital (NY 1914), “Every human being of adult years and of sound mind has a right to determine what shall be done with his body.”    

In PALTC, clinicians often care for persons unable to make decisions due to cognitive impairment caused by dementia and/or delirium.  Autonomy and respect for persons also includes respect for previously expressed wishes, so-called advance directives. Furthermore, respect for autonomy includes the recognition that individuals have the right to delegate decision-making to others. Known as substituted judgment, decisions made on behalf of the individual may be provided by an authorized family member or representative, who knows the individual’s values and preferences. This individual is known as the agent or surrogate. 

In practice, autonomy is operationalized by the concept of informed consent. This is the process by which an individual is provided sufficient information about a treatment or procedure, including its benefits and risks, to allow for autonomous decision-making.  

Autonomy, as is true with other ethical principles such as beneficence, nonmaleficence, and justice, may need to be weighed against one another depending on the situation.

Beneficence

Beneficence refers to the clinician’s responsibility to provide benefit or help the individual, i.e. “to do good.” It is the essence of the clinician-patient relationship and includes promotion of health, relief of suffering, and curing of disease. Beneficence may conflict with autonomy when a patient declines interventions intended to promote healing or requests treatments that are futile or even harmful.  

Nonmaleficence

The principle of nonmaleficence finds its root in the Hippocratic credo, “at the least, do no harm.” It describes the responsibility of the clinician to avoid harm and to minimize risk. Nonmaleficence may conflict with autonomy when a patient requests treatment known to cause harm. It may also conflict with beneficence when the risks and benefits of treatments are weighed against each other. 

Justice

Justice is the duty to treat patients fairly. It may be viewed in two dimensions, access and allocation. Distributive justice is defined as the fair and equitable distribution of healthcare resources determined by moral norms. Justice may conflict with other ethical principles when resources are scarce and choices must be made to govern the distribution of treatments. 

Other Principles

In addition to these four prima facie ethical principles, there are other principles often invoked in the PALTC environment. The principle of authenticity refers to the ability to choose a lifestyle consistent with one’s own values and beliefs. The principle of community refers to the impact that biomedical ethical practices and decisions have on those with whom the individual resides. The principle of fidelity is the responsibility of the clinician to tell the truth and to avoid lying. Respect for the dignity of patients is a component of respect for persons. Still, in addition to respecting self-determination, respect for dignity recognizes the integrity, worth, and cultural values of the individual. 

In nursing facilities, resident rights, as enumerated in the United States Code of Federal Regulations (CFR), CFR §483.10(a) Resident Rights, include requirements derived from ethical principles, including the right to dignity, self-determination, respect and equal access to quality care. (See first section of this toolkit on Legal and Regulatory Background.)

Ethical dilemmas and other issues arise when ethical principles come into conflict with each other. To methodically analyze, deliberate, and resolve these ethical conflicts, the PALTC clinician will need to ask relevant ethical questions and identify the ethical principles that are in conflict with one another.   

Other Models

While the Principlist Model is the most commonly applied lens through which bioethical dilemmas are viewed, other models may also be relevant and helpful in the context of PALTC. The Narrative Ethics model goes beyond rights and obligations, focusing on what matters most to the individual patient. Virtue Ethics takes the perspective of a virtuous clinician, emphasizing characteristics such as compassion and integrity. Ethics of Care focuses on relationships and responsibilities rather than rights and obligations, by examining, for instance, the actions and decisions of a surrogate decision-maker. Casuistry is a methodology that analyzes a case  by comparing its key features to those of a similar or paradigm case.

 

FURTHER READING