Ethical Considerations in Health Care - Essay Example

How far decision making influences Ethical Considerations in Health care Introduction This paper analyses the scope of ethical decision making and its justification in the light of principles and theories. Decisions in NHS division of health care are explored along with taking into account problems and goals of reinforcement. Principles underlying ethical concerns are discussed. It also explores what critics claim about NHS access, whether they see it as the possibility of justice model in health care that seems appropriate to adopt along with the challenges of health care reform. Crucially, the paper seeks challenges underlying decision making process that often treat patients as autonomous agents who are expected to freely enter into a relationship with health care providers. Practitioners today, suggest that the patient may be understood as always already embedded within a particular community, and further as a member of a system of state health care provision, with at best limited scope for a partial withdrawal from that service (Parker, 1999, p. 15). Healthcare settings identify appropriate decision making where the scope of decision is applicable, but not limited to treatment or modification in treatment, usually provided in stages (GMC, 2008, p. 18). Furthermore, decision making involves the role of healthcare professionals, assigned to a variety of investigative treatments like anesthesia, surgery etc. Management and supervision processes portray indirect leadership activities which influence practitioners personally or by being delegated responsibilities. Even practitioners often feel helpless when they feel bounded by the relationship deployed between clinicians and managers or by such issues that reflect that the system managed by the primary care nurse is much smaller in actual size that of the nursing administrator. Such issues on one hand analyses the lack of developing a model of justice in health care, on the other hand illustrates the concern about appropriate decision making. Though there has been many changes in the NHS in recent years including the impact of clinical governance on the day-to-day work and professional development of everyone employed by the service. Even there is a positive response by the government to react to notorious cases of malpractice by establishing the National Institute for Clinical Excellence (NICE), which sets standards of service through the NHS Frameworks. But still there is a room for betterment of the clinical supervision that focuses on the accountability to patients. It is through effective clinical governance that organisations are confident on their managerial framework to focus on clinical case-works and professional development by making individuals accountable for setting and monitoring performance standards (Fleming & Steen, 2003, p. 15). Justification of Ethical Principles Ethical decision making requires four main principles that national health organisations and practices including NHS have adopted, namely principle of beneficence, autonomy, non-maleficence and principle of justice. The principle of autonomy is applicable to the extent where the right to be told one's true medical condition appears to be an area over which an individual has a right to be self-governing. This knowledge might affect how the individual who is suffering from a chronic disease like cancer likes to conduct the last few months of his life. For example, there might be certain issues in his personal life which he chooses to discuss to those who have been close to him. There could also be an issue over how he might chooses to spend the last few months at home, if this is possible, rather than in hospital. On the other hand, it might be argued that application of the principles of beneficence and non-maleficence favor, not telling this individual the true condition of his diagnosis. This concept has taken place due to the fact that many managers assume that harm would be indirectly done to the individual if he knows, since then he will be thwarted by depression. Since the principle of non-maleficence states that a practitioner must not perform any action or advice to do harm, application of this principle would appear to favor non disclosure. Let it consider in a positive way that the principle of beneficence is applicable since the duty to benefit here might be assumed to be accomplished by not telling the individual the truth. Therefore, in this case it seems that application of the principle of autonomy favors a different action to that which would result from applying the principles of beneficence and non-maleficence (Singleton & McLaren, 1995, p. 12). The dilemma is that instead of having a clear understanding of the nature of principles and policies adopted by health care departments, we have not been able to determine which course of action the practitioner should take. Consequentialist Ethical Theories There are different ways in which NHS seeks to answer the question of what will produce the best outcome in ethical dilemmas. The 'cancer example' is a direct query of inquiring the right action for the nurse to perform without making any reference to the three principles mentioned above. Health care management in this case should only consider the consequences on the individual, relatives and other members of the health-care team of the nurse's action of telling or not. The consequentialist view would help the management team to decide in the light of consequences of what action would be the most feasible by setting priorities, so that an action that is chosen produces the best possible outcome. In order to avoid a lengthy examination in context with yielding the best outcomes, NHS policies suggest that certain principles or rules could be justified on consequentialist grounds. If this really happens, then when a principle with a consequentialist justification is applicable in a particular case, health care leaders know that adoption of this principle is likely to lead to good outcomes and instead of applying the consequentialist justification directly to acts, the staff should be using it to justify certain rules or principles. This way is adopted in NHS, and as mentioned by the GMC by Savulensu (2007) that the clinical framework of NHS is not concerned with the outcome of the treatment, but what it considers is the success of the treatment proposed (Savulescu, Oct 2007). This suggests that though applying the consequentialist doctrine is indirect, it is still not adopted as opposed to the direct application considered in the act consequentialist approach. NHS in this case does not consider the consequences of an individual action but evaluating an action on the basis of proposing a treatment because it falls under a rule that has a consequentialist justification. Utilitarianism Utilitarianism approach is followed by the NHS that agrees on the fundamental point that what values is the happiness of an outcome, because good outcomes are those that yield a certain initial plausibility that makes it worth examining. NHS while adopting consequentialist perspective, identifies that a primary modern health care system is determined by the consequences of an action and the consequences that are taken to be good are those that produce contention. Humphreys (2007) points out that the developed body of secondary care committees perform intentional actions on matters having an ethical dimension (Humphreys, 2007). However, such intentions remain unheard in primary care despite the fact that medical ethics is not an inappropriate consideration for primary care practitioners. Thus, there are ethical frameworks that are designed to equip a modern basis for primary care ethics, the problem is in stirring such frameworks into motion in the primary care setting (ibid). The Critical Aspects Ethical issues are witnessed at every stage of health care, whether it is beginning or end of life or information exchange that concerns confidentiality and informed consent or, to be brief, truth telling. From both moral and legal perspectives, the rationales for maintaining the confidentiality of information relating to individuals, both verbal and in records, are extremely powerful and compelling (Singleton & McLaren, 1995, p. 103). NHS no doubt, as a utilitarianism follows strong justifications that allow breaking a duty in exceptional situations. But such duties are implied under the contract of employment, which for medical practitioners and nurses are delineated in codes of professional conduct. Although the BMA (British Medical Association) acknowledges that identifying exceptions to the duty of confidentiality can arise, the World Medical Association maintains that it is an absolute duty of professional conduct which continues to apply after the death of a patient. UKCC (2009) mentions "In the context of health care nursing, midwifery and health visiting, Clause 9 of the UKCC Code of Professional Conduct requires that practitioners while maintaining their professional accountability, shall by all means are obliged to retain confidential information" (UKCC, 2009). The nature, components and virtues inherent in the caring relationship which exists between health professionals and recipients of care, lies at the heart of the duty to respect the confidentiality of information as patient-practitioner relationships are built on trust, worth, dignity and endowed with compassion and positive mutual regard. Unequal distribution of Health Outcomes Macroeconomic decisions regarding health care are concerned with partition of the health care budget amongst different types of treatments, where priorities must be considered in relation to resources. Decision making and changes result in the transfer of decision making on some of these crucial issues to managers and accountants. To what extent the interpretation of clinical issues is essential, depends upon the informed decision making that questions the involvement of individuals without the appropriate skills or professional judgment. Decisions in NHS are governed by the effects of a given distribution model mainly concerned by mediating social determinants with which it is packaged. This on one hand produces the possibility of trade-offs where one person's relative disadvantage with respect to a distribution of health care, may be offset by a relative advantage with respect to a complementary distribution of the social determinants. While on the other it is relative advantage that at issue such offsetting can be achieved either by changing the person's own absolute position or by changing the absolute position of others (Sreenivasan, 2007). Critics suggest that such distributions in the context of health care can result in determining social determinants of the same final distribution of health outcomes. NHS reasoning claims that the best final distribution that NHS makes, results from a distribution of health care that makes at least some health care available to every citizen. A common principle for utilising limited resources is to maximise the health benefits, but since there are various ethical objections for the prioritisation for health , no comprehensive account guarantees incorporation of justice (Dawson & Verweij, 2007, p.112). Every package that NHS decides, grants some universal access to health care and has very little effect on the social gradient in mortality, which for long is discouraging health practitioners and policy makers. This provides the decision makers with a good reason to suppose that certain groups could be excluded from health care altogether, that may involve the elite class and this without adverse effects on the final distribution of health outcomes. If in some manner, the management is able to save the resources by excluding some people from health care, they not only put an effective use in promoting health by various other means, but also would be able to best utilise this package by distributing health outcomes in a better manner. Another empirical objection regarding NHS that might raise with the new package is that Britain's Health Service does not really provide universal access to health care in the relevant sense, and because NHS does not actually provide everyone with comparable access to health care, the persisting social gradient in mortality with the reference to the remaining inequalities is there (Sreenivasan, 2007). Political Uncertainty Besides concern over inequalities, NHS being a world-renowned model of successful health care, confronts an uncertain political future. This uncertainty according to Luna (2006) is for the reason that despite the best defenses of the Labour government, the Conservative opposition has outlined a number of inherent failures in the NHS which includes the lack of a family doctor service, inefficient long-term care services, and diminished priority for cancer patients (Luna, 2006). Similarly, critics blame the Labour government for failure to meet adequate resources on elderly care, waiting times, and patient choices. Britain's health services are being blamed for inefficiently dealing with burgeoning demand for increasingly scarce health services, which must not be overlooked by NHS management . NHS Projects NHS management identified the need for adequate training on resources such as accommodation and clerical support along with the need for general managers to find ways for supervisors to accommodate the additional workload of trainee supervision within their work plans. This, where aimed to consider reduction in the clinical caseloads of supervisors taking trainees on placement, on other hand NHS projects highlighted the need to formalise the procedures for planning and utilising the placement resource. Decision making was done with an aim to include service level agreements so that a better co-ordination standard is implemented by having confederation-wide placement planning in order to avoid competition for placements between programmes. Local training co-coordinators were employed within NHS trusts with more use of part-time staff not currently used by having one main supervisor working alongside other supplementary supervisors to provide a component of the experience (Fleming & Steen, 2003, p. 62). Difficulties have been witnessed in NHS management like clinicians working with people with a learning disability and with older adults provide, on average, a greater number of placements than those working in adult mental health and child and family services. Traditionally, posts in learning disability and older adult services have been harder to fill and with vacant posts, these clinical psychology departments use their funding creatively, employing assistant supervisors who factor in to the ongoing service provision. Health care benefits in terms of QALY (Quality Adjusted Life Years) provides how an organisation can make the most of medical ethics in context with policy making and management (Williams, 1998, p. 20). Triggle (2005) points out that NHS declares it as a complex system which though possesses the ability to give each individual treatment a score for the benefit it gives in quality and length of life, but when compared to cost, is expensive (Triggle, 2005). Conclusion NHS management and the changing trends has not been able to change the conventional perception according to which the relationship between individual doctors and their patients reflects as an institution and its patients. It made no difference which way one looked at it, because despite ethical considerations, doctors enjoyed the respect of patients and health service managers and had the lion's share of power within the system. Therefore, it was said, that clinical priorities prevailed and patients considered themselves to be in safe hands. Unfortunately, this perception may never have been entirely accurate, and it seems unlikely that all patients always received all the treatment they needed, but it offered a degree of reassurance that the service was doing all it could. In the modern system, where resources are shared on inequality, and doctors are no longer pre-eminent since their authorities are shared with health service managers and resources are not at their complete disposal. One can feel the pressure under which resources are strained, a lack of coordination and planning could lead to patients being overlooked, or being offered inadequate care. Under such circumstances, there has been concern that our original perceptions about the basic objective of the NHS, to promote the clinical well-being of patients, are being threatened. The reason is that the authority for decision making and management is shared between doctors and managers where the concern for taking into account ethical considerations remains trivial. References Dawson Angus and Verweij Marcel, (2007) (Eds) Ethics, prevention and public health. Oxford: Clarendon Press. Fleming Ian & Steen Linda, (2003) Supervision and Clinical Psychology: Brunner- Routledge: London. GMC, 2008 June 2, Consent: Patients and Doctors making decisions together. Humphreys J. Stephen (2007) accessed from Luna Joseph, (2006) 'Falling Sick: Britain's National Health Service', Harvard International Review. Vol. 28. No. 2, pp. 11. Parker Michael, (1999) Ethics and Community in the Health Care Professions: Routledge: London. Savulescu Julian, (Oct 3, 2007) Ethics etc accessed from Singleton Jane & McLaren Susan, (1995) Ethical Foundations of Health Care: Responsibilities in Decision Making: Mosby: St. Louis, MO. Sreenivasan Gopal, (2007) 'Health Care and Equality of Opportunity: One Widely Accepted Way of Justifying Universal Access to Health Care Is to Argue That Access to Health Care Is Necessary to Ensure Health, Which Is Necessary to Provide Equality of Opportunity but the Evidence on the Social Determinants of Health Undermines This Argument', The Hastings Center Report. Vol. 37. No. 2, pp. 21. Triggle Nick, (9 Nov 2005) accessed from UKCC, 2009 accessed from Williams Alan 'Economics, QALYS and Medical Ethics' In Dracopoulou Souzi, (1998) Ethics and Values in Health Care Management. Routledge. Read More