The Most Current and Controversial Issues Surrounding Healthcare Ethics - Literature review Example

Healthcare Ethics Introduction Healthcare ethics are a key component to the medical decision making process and have evolved alongside medical science since Hippocrates first implored medical practitioners to 'do no harm' almost 25 centuries ago. Since then, medical science has continually faced new dilemmas that brought into question patient safety, morality, research standards, and the protection of the rights of all the stakeholders. Today, medical ethics is evolving in the face of new technologies, greater knowledge of medicine and its limits, and the impact of culture and the individual's view of personal ethics. Volumes have been written in an attempt to clarify professional ethical standards, while trying to anticipate the next ethical question created by modernity. Often, these standards are the subject of rigorous debate as religion or social agendas come to bear on the question of morality. This paper will examine some of the most recent professional literature in an effort to codify the existing standards, as well as reporting on the prevailing trends in regards to new technologies, the impact of culture, and the evolving morality surrounding life and the end of life care. Healthcare is an extremely broad field comprised on numerous disciplines, and myriad roles for healthcare workers within each discipline. This paper will not address a specific discipline, but instead will examine healthcare ethics from a broad lens while focusing on the commonalities found throughout the different fields. Numerous professional organizations have their own codes of ethics and may have specific guidelines that deal with their clinical specialty. As an example, this may be seen in addiction services, mental health, or gender transformation. However, this paper will report with a broader brush and a major portion will be spent focusing on recent developments in ethics and the challenges that all healthcare workers face in the light of technology, changing demographics, and evolving social standards. Literature Review End of Life Care One of the critical aspects of healthcare ethics is providing palliative care for the terminally ill, and the numerous issues facing end of life care. One of these important ethical issues is 'medical futility', and the application of medical treatment that has little hope of being beneficial. There can be significant disagreements among the patient, family, physician, and insurance providers that all have different treatment goals, as well as their own personal interpretation of medical futility (Bagheri 46). A hospital ethical review board, at the initiation of a physician or the patient, often mediates this dilemma. In a recent comprehensive study conducted at the Mayo Clinic, Rochester Minnesota, the most frequently cited reasons for an ethics review were "the permissibility of withholding and withdrawing life sustaining treatments, resuscitation issues, [and the] appropriateness of treatment (ie, futility vs. nonfutility" (Swetz et al. 690). However, this issue is steeped in controversy, and according to Bagheri, "Some argue that physicians should be given sole authority to make decisions to withhold or withdraw treatment" (47). Indeed, multiple studies have indicated that in the US, as well as in Europe, physicians unilaterally withhold treatment that they deem futile without consulting either the patient or their family (Bagheri 47). This approach demeans the patient's mental well-being and disregards the ethical component of autonomy. If a patient is mentally capable, they should be apprised of the lack of potential benefit (futility) of a treatment. Eliminating the patient from being informed, or a part of the decision making process, is at best a questionable ethical practice. Still, "physicians cannot be forced (or even expected) to give 'futile' treatment to their patients" (Loewy 299). One question that should routinely be asked when making an ethical decision regarding futility is 'are there any better alternatives'. Professional medical organizations have attempted to define futility and offer some guidelines for patient participation. Bagheri reports that "The American Medical Association's Council on Ethical and Judicial Affairs emphasizes providing a set of procedural guidelines to help direct physician-patient (or surrogate) conversations and decisions" (Bagheri 50). The general result of these guidelines and standards is that ethical decisions must be made on a case-by-case basis and evaluated for each individual's unique situation. Still, the ethical process is daunting. According to Crawford and Way, "There are no predetermined scripts to be followed and it would be foolish to imagine that a protocol could ever be developed for the range of scenarios that might occur" (24). The result of the tensions that are expressed in regards to end of life care and medical futility are viewed through the dimensions of utility and deontology. Deontology exerts an ethical force due to the duty to legalities, common law, or professional regulation, while utility imposes duties that "require healthcare professionals to consider the impact of their work on the individuals in receipt of care" (Cooke and Hurley 1373). As with many other situations that require an ethical decision making process, the competing interests need to be considered in context with the individual patient's needs. Abortion Almost no issue in healthcare has raised more controversy and initiated more conflict than the legal, social, and political status of abortion. The issue is compounded by the reality that almost no one favors abortion, but preserves it as the least unfavorable alternative to an unwanted pregnancy. In addition, the legal aspect of abortion has never confronted the issue of life and death, but has found it to be constitutional on the basis of the right to privacy. Although the US Constitution does not explicitly address privacy, the US Supreme Court in Roe v. Wade (1973) stated that, "the right of privacy, however based, is broad enough to cover the abortion decision; that the right, nonetheless, is not absolute and is subject to some limitations; and that at some point the state interests as to protection of health, medical standards, and prenatal life, become dominant" (Roe v. Wade VIII). Individual ethics will dictate a person's individual view on abortion, and though it is a legal procedure, physicians cannot be required to perform it. Personal viewpoints will be either absolutist, that finds abortion to be unethical in all situations, or the alternative of occasionally permitting abortion as the lesser of two evils (Loewy 224). If abortion is allowed in the case where it saves the mother's life, the absolutist position has already been abandoned. People will make rational choices based on the individual context of the situation. Here again, the tension between deontological duty ethics and utilitarian realities compete to satisfy the stockholder's needs and desires. Abortion ethics, to a large degree, are a social construct based on individual religious beliefs, special interest politics, and organizational influence. Ethical issues that have a strong religious component are often influenced by external forces, as the individual surrenders their decision making autonomy to a group hierarchy. Religious organizations place the law of the church above the right of the individual to decide. Clearly, ethics and legality do not always go hand in hand, and what is legal does not always define it as ethical. The Woolf Committee (2008), a UK group formed to investigate and make recommendation in regards to business and corporate ethics, suggested that two questions be asked whenever an ethical decision is made. These two questions are; "If this action were to be widely known, would it damage my reputation" and "Can I publicly defend this action to others" (Cornock 64). In the case of abortion, church members would find these questions problematic if their personal views were not exactly in line with those of the church. In this way, ethical standards evolve to become community values, without regards for individual morality. They remain unquestioned, and are sustained by the external forces applied by the traditions of the church. Access to Healthcare Healthcare ethics, sufficient treatment, reasonable procedures, and the concern for the individual's health have little implication if the patient does not have adequate access to the healthcare system. This access can be limited by a lack of insurance, geography, transportation problems, cultural obstacles, or discriminatory practices. There are over 40 million people who are under-insured in the US, and this greatly inhibits their ability to participate in the healthcare system. Cost is cited as the number one reason for a lack of insurance and they are "more likely to be younger, Hispanic, nonwhite, unmarried (widowed, divorced, or never married), poor, and foreign-born. They were less likely to hold U.S. citizenship. Despite relatively high rates of chronic medical conditions, they were unlikely to receive outpatient or home healthcare services" (Mold, Fryer and Thomas 601). Clearly, in regards to the uninsured there is a de facto discriminatory factor that targets this socio-economic class. If these actions took place in the workplace, they would be illegal. However, in healthcare it is merely unethical. It largely affects immigrant populations, the poor, and the under educated. At the foundation of the poor ethical standards is the lack of good communication. In addition to the problems that the language barrier presents in being able to communicate symptoms and treatments, "a number of studies show that misunderstandings that stem from cultural differences and language barriers have resulted in poor patient-provider relationships [and ...] decreased patient compliance with physician directives and follow-up care" (Whitman and Davis 27). Whether the limitation to access is physical or psychological, the ethical considerations do not change. These patients are still being denied adequate healthcare. Generally, the US is divided into two camps in regards to healthcare. One camp believes that healthcare is a market commodity that is available to those that can afford it at the cost that the market dictates. A second group that has gained increasing popularity in recent years, believes that healthcare is a human right that everyone is entitled to, without regards to economics. This is a global problem where the world is confronted with the morality of sick children in a developing nation, where an immunization could have saved their life for a few dollars. In the US, the morality becomes obvious in the emergency room, where patients end up with a terminal condition because they had nowhere to receive adequate early intervention. This lack of morality is self-sustaining and perpetuates its own lack of ethical standards. For example, "Researchers tend to purposely avoid recruiting marginalized populations (such as members of minority groups, substance abusers, or homeless persons) to clinical trials because they believe that poor compliance is common in these groups" (Clark 123). Discriminatory practices increase poor compliance, and poor compliance results in a bias against the group. However, it is the duty of the healthcare system to rectify the poor communication that is at the foundation of these moral lapses. Geography The ability to receive adequate healthcare is often simply a matter of where you are located. Rural America presents an entirely new set of ethical dilemmas as compared to the larger urban settings. While we would like to believe that ethical decisions are transparent, fair, and logical, the rural decisions regarding healthcare are more likely to be "colored and shaded by values, beliefs, competencies, and resources" rather than a universal set of ethical principles (Bolin et al. 63). Physicians may have several roles, often in conflict, which they must serve. A physician in a small town may be a principle member of the review board that reviews his lifelong associates, leaving them struggling with the conflict of "competing interests of organizational loyalty versus patient rights" (Bolin et al. 63). The last thing a local physician wants to do is offend the pillars of the community if their opinion differs from theirs. In addition, there is additional pressure put on the small town physician by a demanding public. "A person in a professional role will experience additional moral demands beyond what is normally expected, or demanded, by the broad-based ethical requirements of everyday life" (Crowden 65). In this environment, "the discussion of ethical issues can be viewed as risky, unwise, and possibly disloyal to the person, the profession, and the organization. In this environment, silence can seem the wisest course of action" (Cook and Hoas w3). Ethics is an area that demands full disclosure, honesty, open debate, and transparency. When silence is seen as the best course of action, ethics has entered a dangerous area where medical decisions are at risk of becoming unethical and unjustifiable. Organ Transplants and the Marketing of Organs Organ transplantation offers another set of ethical standards that often conflict based on deeply held religious convictions that both advocate and discourage the transplant process. Most religions are somewhat ambiguous in regards to the morality of transplanting an organ. The Eastern Orthodox Christian Church, which is one of the strictest religions in regards to the modification of the sanctity of the body, even after death, only allows for the use of blood products (Reardon 211). Islamic law allows "organ donation and transplantation in cases of necessity, provided organ donation would not cause a risk to the donor's life" (Khalili 13). In 1995, the National Conference of Catholic Bishops issued a statement that said organ transplanting would be allowed only if it does not, "seriously impair any essential bodily functions" and "the freedom of the prospective donor must be respected, and economic advantages should not accrue to the donor" (Stempsey 198). Religions often discourage transplanting based on the sanctity of the whole and complete body, as well as the belief that removing an organ destroys the "integrated union of body, mind, will, and spirit" (Meilaender 15). While organ donation has a legal status, the major churches and the law have a strong tradition of forbidding the selling of organs. Medical ethicists occasionally cite the ban on the selling of organs, primarily kidneys, as unfair and unnecessary. There is the fear that the lower classes and poor would be taken advantage of and used as organ farms. However, this also eliminates one opportunity that the poor may have to earn money. It is argued that, "In typical cases of organ donation, the wrongness of violating bodily integrity is overridden by a combination of extremely good consequences (for example the saving of another's life) and the pure altruism involved in the giving" (Wilkinson and Garrard 338). These religious beliefs are placed upon the poor, which may have a different set of ethical standards in regards to religion and altruism. They may find it more important and altruistic to sacrifice and give to their family and children. However, the long tradition of the Christian religion in the US, and the uneasiness most people have with the issue of selling organs, makes it unlikely that there will be any change in public policy in the foreseeable future. Genetics The issue of genetics is a challenge for medical ethicists due to the pace at which the science is advancing and the poorly understood ramifications of the application of genetic research. Science has the capability of identifying traits, diseases, pre-dispositions for behavior, gender, and talents, shortly after conception while the baby is still in the womb. There is a growing fear that this information will be used to select children, or society will begin to design babies for the most desirable traits. Currently there are over 35 companies doing genome testing on the Internet. Marietta and McGuire contend that, "personal genome testing blurs the boundaries of when the performance of a genetic test constitutes the practice of medicine" (Marietta and McGuire 369). Proponents of the testing claim that it "will empower consumers to take more personal responsibility for their health by providing them risk-assessment information and allowing them to proactively search for specific genetic variants of interest" (Marietta and McGuire 370). However, opponents point out the great potential for abuse by potential employers, health insurance companies, or other interested parties that have little regard for medical privacy. No matter where the individual falls on the ethics spectrum in regards to this issue, there must be a call for moral restraint in our ability to categorize the individual based on a genetic profile. Drugs Drugs and pharmaceutical research is integrally linked to the ethics of genetics. Clearly the advances made in the human genome hold great promise for the future of medical science and disease prevention. It may be possible to cure diseases that are only now being identified. However, research efficiency dictates that the research data will need to be shared with a significant number of stakeholders. Maintaining privacy, and respecting individual rights, may be more problematic in this environment than previously disclosed. On the one hand, drug companies have a vested interest to "maximize the benefits from the information that donors provide and to speed the development of beneficial drugs and other biomedical applications" (Foster and Sharp 634). However, the privacy and anonymity of the data may not be able to be controlled adequately, and kept in line with current ethical standards regarding medical privacy. It has been reported that "even a minimal list of stakeholders can generate a large number of actual and potential interactions and intersections of interests, most of which have not been analysed or extensively investigated in the bioethics literature or in discussions about new policies" (Foster and Sharp 636). Once again, ethicists need to call for restraint until the industry can assure the rights of the patients are protected against abuse and exploitation. Patient's Rights In all these cases of challenging ethical dilemmas and moral scenarios, there is a priority to protect the patient's rights. Patients have the expectation of quality care, treatment that works, and the hope of healing. They also have the right to culturally appropriate care and individually acceptable treatment methods. Translators should be available if possible, and healthcare workers need to become more culturally sensitive. In addition, they have the right to be a participant in their own medical decisions. A top priority in patient's rights is protecting their personal information. Electronic patient records have the potential to be a cost effective measure that will improve the efficiency of the healthcare system dramatically. However, they are not without their ethical detractors that highlight the potential for misuse. Angst and Agarwal argue that "With respect to personal medical information, the privacy debate has escalated considerably. With the advent of the Health Insurance Portability and Accountability Act (HIPAA) and increased awareness about personal information breaches, privacy and security of health information has been elevated to the forefront of medical informatics research" (Angst & Agarwal 342). However, there is still considerable anxiety about the ability of the healthcare system to protect the patient's privacy. The patient should have an expectation of compliance, rather than a fear of misuse. In many other fields there has been the "negative consequences such as breaches of security, fraud, or theft of information" (Angst & Agarwal 360). There is little assurance that the medical system will not be breached and this sensitive data sold across the globe. Conclusion and Recommendations While this paper has attempted to highlight some of the most current and controversial issues surrounding healthcare ethics, the rate of evolution and the broad scope of issues necessitated that some important issues would need to be omitted. Future research and reporting should be prepared to cover the important issue of medical science being used to execute prisoners of the state. In addition, there needs to be a section that covers the expanding use of prisoners being used in medical research. Prisoners have an unrealistic view of the value of material incentives in this setting. It may be unethical to tempt a prisoner to risk his health for a small material gain. Additionally, the literature needs to be examined for cases that involve the unethical use of the homeless in research and development of drugs. This strategy is often employed by the pharmaceutical companies as a way to acquire inexpensive test subjects, with little liability. The speed and pace of medical advancements make the application of ethical standards difficult at best, and non-existent in the worst-case scenarios. The technology to prolong life with the aid of artificial means has surpassed the public's ability to plan for this ultimate situation. Doctors are placed in the position of making uneasy medical decisions that should involve the patient and the family. In other cases, such as abortion, public policy has not been able to keep pace with the political and social agendas that drive the issues. With the looming advent of universal healthcare, there will still be untold people who have little access to healthcare due to transportation, awareness, and geography. Still, the greatest challenge that healthcare ethics faces in the 21st century is showing the restraint necessary in the face of the rapidly advancing science of genetics. It is difficult to be conservative when the opportunities hold so much potential for progress. However, restraint and deliberation are the two most critical components needed by the healthcare ethics system as we are mindlessly pulled into the future, while dragging our proverbial rational mind behind us. Works Cited Angst, Corey M and Rigu Agarwal. "Adoption of Electronic Health Records in the Presence of Privacy Concerns: The Elaboration Likelihood Model and Individual Persuasion." MIS Quarterly 33.2 (2009): 339-70. Bagheri, Alireza. "Regulating Medical Futility: Neither Excessive Patient's Autonomy Nor Physician's Paternalism." European Journal of Health Law 15.1 (2008): 45-53. Bolin, Jane N et al. "An Alternative Strategy for Resolving Ethical Dilemmas in Rural Healthcare." The American Journal of Bioethics 8.4 (2008): 63-65. Clark, Peter A. "Prejudice and the Medical Profession: A Five-Year Update." The Journal of Law, Medicine & Ethics 37.1 (2009): 118-33. Cook, Ann F, and Helena Hoas. "Revisiting Ethics and Rural Healthcare: What Really Happens What Might Help" The American Journal of Bioethics 8.4 (2008): W3-W4. Cooke, Mary, and Ciaran Hurley. "A Case Study Exploring the Ethical and Policy Dimensions of Allocating Acute Care Resources to a Dying Patient." Journal of Clinical Nursing 17.10 (2008): 1371-79. Cornock, Marc. "Aim For the Higher Ground." Nursing Standard 22.48 (2008): 64-64. Crawford, Doreen, and Colin Way. "Just Because We Can, Should We A Discussion of Treatment Withdrawal." Pediatric Nursing 21.1 (2009): 22-25. Crowden, Andrew. "Distinct Rural Ethics." The American Journal of Bioethics 8.48 (2008): 65-67. Foster, MW, and RR Sharp. "Share and Share Alike: Deciding How to Distribute the Scientific and Social Benefits of Genomic Data." Nature Reviews Genetics 8.8 (2007): 632-39. Khalili, MI. "Organ Trading in Jordan." Politics and Life Sciences 26.1 (2007): 12-14. Loewy, Roberta S. Textbook of Healthcare Ethics. Norwell, MA: Kluwer Academic Publishers, 2004. Marietta, C, and AL McGuire. "Currents in Contemporary Ethics." Journal of Law, Medicine, and Ethics 37.2 (2009): 369-74. Meilaender, G. "The Giving and Taking of Organs." First Things: A Monthly Journal of Religion and Public Life 181.1 (2008): 14-15. Mold, JW, Fryer, George E, and Cynthia H Thomas. "Who Are the Uninsured Elderly in the United States" Journal of the American Geriatrics Society 52.4 (2004): 601-06. Reardon, PH. "'The Commerce of Human Body Parts: An Eastern Orthodox Response." Christian Bioethics 6.2 (2000): 205-13. "Roe v. Wade," US Supreme Court, No. 70-18, 1973. Stempsy, SJ. "'Organ Markets and Human Dignity: On Selling Your Body and Soul." Christian Bioethics 6.2 (2000): 195-204. Swetz, Keith M et al. "Report of 255 Clinical Ethics Consultations and Review of the Literature." Mayo Clinic Proceedings 82.6 (2007): 686-91. Whitman, Marilyn V, and Jullett A Davis. "Cultural and Linguistic Competence in Healthcare: The Case of Alabama General Hospitals." Journal of Healthcare Management 53.1 (2008): 26-40. Wilkinson, S, and E Garrard. "'Bodily Integrity and the Sale of Human Organs." Journal of Medical Ethics 22.6 (1996): 334-39. Read More