Ethical considerations

ETHICAL PRINCIPLES  (Examples)

When ethical dilemmas arise, the best approach is to resolve the dilemma by considering the following ethical principles:

1. Beneficence and nonmaleficence (Nonmaleficence is the well-known adage: “Do no harm.”) /Welfare of the patient
2. Patient autonomy and consent
3. Telling the truth
4. Confidentiality
5. Preservation of life
6. Justice (in this context defined as fair and just treatment within groups or members of the same group).
   
   

According to the authors of the Substance Abuse Counselor, Ethics, Confidentiality, and Boundaries, Quantum Units Education, 2018 the ethical principles are the following:

Principle I: The Counseling Relationship

Principle II: Confidentiality and Privileged Communication

Principle III: Professional Responsibilities and Workplace Standards

Principle IV: Working In a Culturally Diverse World

Principle V: Assessment, Evaluation and Interpretation

Principle VI: E-Therapy, E-Supervision, and Social Media

Principle VII: Supervision and Consultation

Principle VIII: Resolving Ethical Concerns

Principle IX: Research and Publication

For a simplifying and a better understanding of the ethical principles,  we would like to develop the cornerstones of the health principles which will hopefully offer a broader view in the ethics field and will also facilitate the better understanding and behavior of healthcare professionals:

1. Beneficence and nonmaleficence:
2. Autonomy and consent
3. Justice

1. Cornerstone: Beneficence and Nonmaleficence

Patients enter the health care system in order to recover, improve their health or quality of life which is the core idea of the system and the foundation of a healthy society when we consider reducing pain and suffering and increasing the quality of life.

This cornerstone of ethics refers to acting in the patient’s best interest, considering his difficulties that might come from his pain, suffering or illness and adapting the health professional’s actions to enable recovery, treatment, health and wellbeing.

This principle must be considered as opposing the concept of nonmaleficence in order to be better understood. Doing harm can sometimes mean following the professional’s personal agenda rather than the patient’s best interest. It can also mean not being flexible regarding the adaptation of the professional behaviour to the needs of the patient, even this can be really challenging sometimes.

This principle refers directly to the professional’s duty in creating a health care system that can improve the situation of the patient and do no harm.

Firstly let’s talk about beneficence:

– from the healthcare professional’s perspective: Beneficence- the professional duty to do well, the responsibility to do what is in the patient’s best interest to improve the health of the patient and of the community.

Discussion:

Patient’s welfare does not mean that the professional will always put the patient’s wishes first, even though it may not be ethical to do so, but it does mean the professional will do his/her best to protect patients and ensure their health and safety in all their activities.

– from the patient’s perspective: Beneficence indicates the right to the highest quality health care available to society, in accordance with human, financial and material resources.

Healthcare means medical services, community services and services related to medical care; medical intervention means any examination, treatment or other medical act for the purpose of preventive diagnosis, therapy or rehabilitation.

Addiction professionals will take responsibility for the safety and well-being of their patients and will act in the best interests of each person, exercising respect, sensitivity and compassion.

They will treat each person with dignity, honor and respect and will act in their best interest.

Discussion:

Beneficence is met when therapists make accurate diagnoses and provide evidence-based treatments, i.e., treatments derived from research that provides statistical data on outcomes or from consensus-based standards of care.

Beneficence is compromised when diagnoses are questionable or when outcome data do not validate a diagnosis or treatment.

When MAT (Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment ) is conducted according to best practice standards, the principle of beneficence is realized (Bell and Zador 2000).

WHO DECIDES WHAT IS BEST FOR THE PATIENT?

Who defines best the well-being of the substance user?  Is it the patient, is it the healthcare organization/institution, is it the healthcare professional? How do we  know?

There will be times when the parties disagree on what is best, the patient expects an answer, the institution expects another answer from you, and you believe that another course of action is best.

Discussions:

However, it is important to remember that some medical interventions may seem beneficial, but may also have the potential to harm them.

We often think we know what is best for the patient, based on our experience and training and the relationship we have built with them. In many situations we are right, but in others our patients have a better idea of what is best for them than we do, or perhaps the healthcare professional (psychiatrist, psychotherapist etc) has a different view .

Our dilemma becomes how to decide what is best for the patient?

Example: A patient diagnosed with paranoid schizophrenia, refuses to follow the treatment indicated for the mental disorder, has been a substance user and addict for 3 years, with multiple suicide attempts, quit his job, lives on family support. The family turns to the general practitioner for advice and help.

The solution would be admission to a psychiatric ward for detoxification and adjustment of the antipsychotic treatment. The patient refuses admission to the psychiatric clinic but agrees to visit  the general practitioner  just to reduce conflict with the family. What is the solution? What is best for the patient?

The general practitioner, although lacking the experience and expertise to manage such a serious case, decides to accept the patient’s counselling at his practice.

Is it ethical to provide only outpatient care to a seriously ill patient who may require hospitalization?

Discussions:

Effective collaboration includes coordination of care plans, interventions and treatment approaches. Healthcare professionals involved in a patient’s care should work together to create a cohesive and integrated approach. This ensures that all aspects of the patient’s well-being are addressed and that there is consistency in the care provided.

Secondly let’s discuss nonmaleficence – the obligation to do no harm.

The only acts of aggression accepted in medicine are surgical interventions, cytostatic treatment with maximum doses after calculating the risk-benefit for the patient, violation of doctor-patient confidentiality if the patient is a danger to himself or to the community.

The principle of doing no harm

This principle requires the healthcare team to do no harm under any circumstances to the patient and to prevent possible harm.

Ioan Zanc and Iustin Lupu point out that the principle of doing no harm proposes: not to kill, not to cause pain to the patient, not to cause physical or mental disability or incapacity, not to cause inequality of opportunity for the patient, never to use a treatment or procedure that may harm the patient.

These proposals cover both the action of the healthcare professional and the context in which medical practice takes place.

Conclusion:

Doing no harm:  do not harm people;  do not cause pain or suffering;  do not cause disability;  do not cause offense;  do not kill.

Example:

Is it ethical for a physician (e.g. psychiatrist) to abandon the follow-up and treatment of his patients when he retires [retires from practice]?

Discussions:

Psychiatrists who retire from practice cannot be accused of abandoning patients if they provide patients with notice of this in good time and if they make every reasonable effort to find continuing care for their patients.

This could constitute abandonment unless the practitioner or outpatient institution establishes the necessary functional relationships for their patients to receive hospital care from another health care provider.

2. Cornerstone: Autonomy and consent

• Respect a person’s right to make their own decisions;
• Teach people to be able to make their own choices;
• Support people in their individual choices;
• Don’t force someone to do something;
• “Informed consent” is an important outcome of this principle.
• Recognises people’s right to make decisions for themselves based on their own values and beliefs.
  
  

Autonomy can be seen as a basic human right across the planet and it refers to the patients’ right to make decisions about their own life and health, free from anything that can influence them rather than their capacity to think and act without coercement.

This principle is linked directly to the relationship between the patient and the healthcare professional – the patient must fully trust the professional in guiding him through receiving the help and care that he needs and always acting in his best interest.

If they lack this trust they might be in the position of altering the process or even of stopping the patient from seeking help for good.

Informed consent refers to presenting the best options to the patient in a way that he can understand and take the best course in the treatment. This is usually done by providing the patient accurate information about every step that he will take in the treatment, the risk and benefits, this being done of course, before any kind of treatment or procedure occurs. Then the patient usually signs documents,  meaning that he accepts the treatment, while protecting his rights and those of the healthcare  professional, as well.

Of course there are some situations in which informed consent might not be needed (emergency situations) or some legal obligations that can overtake the consent. To keep in mind that, the healthcare professional must act in the patient’s best interest, respecting his autonomy – but also considering the patient’s ability to take the proper and necessary route for his health and well-being.

Shortly, autonomy means that regardless of the healthcare professional’s opinion the patient is the one who decides.

Unless it can harm others, it is the patient who decides!

In the medical field for example, if this principle is ignored by a medical specialist because he or she believes that another decision would be better for the patient, then it is called Paternalism.

Personal autonomy can also be restricted in certain circumstances, such as: (a) to stop that person from harming another person; (b) to stop a person from harming themselves (moderate paternalism); (c) to do good to that person (radical paternalism).

A healthcare professional-patient relationship in which the balance tips towards the healthcare professional (paternalism) has certain advantages and disadvantages.

• advantages: the healthcare professional chooses the best treatment for the patient using his/her knowledge, clinical experience and all medical and clinical resources.
• disadvantages: the patient is less compliant with the treatment and dissatisfied with the services received which can lead to complaints and litigation.

Discussions:

An autonomous decision should never be rejected by a healthcare professional, but not all decisions are autonomous. For patients to have autonomy, they must have the ability to receive, retain and repeat the information provided to them, provided that the information is complete and conveyed to them in a manner they can understand. Autonomy, like wellbeing, promotes the best interests of patients. Well-being emphasises the application of the provider’s knowledge and skills to improve the patient’s health, autonomy emphasises respect for the rights of patients to decide what treatment is in their best interests (Beauchamp and Childress 2001).

Usually the patients’ and the healthcare professional’s goals for treatment are identical, but when differences exist, physicians generally give patients the right to make their own decisions and accept that the patients’ values may differ from those of healthcare professionals.

For example, a healthcare professional might focus on prolonging the patient’s life, while the patient might be more concerned about the quality of that life.

“A legitimate question in different healthcare contexts would be: how much weight should we give to respect for a patient’s autonomy in the case of people in high danger? For example, what attitude should we take and how can we morally justify this choice if a patient no longer wants to live and begs the doctor to give him a drug that would quickly cause his death? How should a doctor behave if a mother refuses to vaccinate her children or refuses a treatment without which death is imminent? It is very difficult to set the limits of respect for personal autonomy.

The idea of patient autonomy is good in principle, but it is based on a kind of leveling of human diversity and the assumption that everyone is a perfectly rational person capable of making the best decisions for themselves or for the minor children in their care. This respect places much of the responsibility from the healthcare professional’s shoulders to those of the patient. But is the patient always ready to accept this? Patient autonomy counterbalances the authoritarian or paternalistic nature of traditional medical ethics, protecting the patient’s right to choose or reject a particular type of treatment. Respect for personal autonomy does not exclude the duty of healthcare professionals to support patients to reach their own medical decisions.

Practical Exercise:

R.S., a 35-year-old man who has been on MAT (Medication-Assisted Treatment) for 18 months, is in his second episode of MAT. The first one ended when he was arrested and jailed for armed robbery. R.S. hasn’t missed his medication appointments, but is less attentive at counseling sessions. He regularly uses alcohol and marijuana and sometimes cocaine. R.S. is unwilling to stop using alcohol and drugs. His position is that he has completely given up illicit opioids, which were his goal at the start of treatment. His use of other drugs is his choice, and the clinic should “leave him alone”.

A Conflict between Beneficence and Autonomy:

A conflict arises between the principles of beneficence and autonomy when a treatment provider and a patient disagree on what is in the patient’s best interest and how treatment should progress.

The example describes such a conflict in which a provider believes that stopping illicit drug use completely is feasible and in the patient’s best interest, but the patient does not agree or cannot comply. One or both of the following questions express the source of the controversy:

What is the right balance between respect for the patient’s autonomy and the provider’s  responsibility for that patient’s health?

Should the patient or clinician decide what is in the patient’s best interest?

Discussions:

Substance addiction treatment training provides treatment providers with an awareness and an understanding of patients’ tendencies toward denial, minimization and rationalization of their substance use. A practical familiarity with such studies offers treatment providers a reasonable basis for choosing beneficence over autonomy when concluding that they know better than patients what is in their best interests.

The conflict between beneficence and autonomy is not specific to MAT, but is particularly acute in MAT because of the fundamental power imbalance between treatment providers and patients.

Patients in OTPs (Opioid Treatment Programs) are dependent on their medications and are at risk of no longer receiving these medications through exclusion from programs if substance use is detected in urine tests during OTP treatments.

This dependence on treatment gives providers (and the benefit principle) the advantage.

Why do treatment providers in OTPs tend to lean towards the principle of beneficence and away from the principle of autonomy in their approach to patients?

Answer:

• The long and complex experience of health care providers favours a rule-governed perspective in OTPs
• Belief that non-compliant patients cannot act in their best interests; effects of non-compliant patients on staff, compliant patients and new patients.
  
  

Example:

Involuntary disconnection:

An OTP’s decision to exclude a patient against their will calls into question all ethical principles. Involuntary disconnection appears to violate the healthcare professional’s obligations to put the patient’s health first, to do no harm and respect the patient’s wishes and to avoid harm to the community by reintroducing the effects of untreated opioid use (especially criminal behavior and potential disease transmission). However, an OTP must often balance the interests of individuals experiencing disconnection with those of other patients, staff, future patients and the community and society as a whole.

CONSENT

Types of consent:

Implied consent is when a healthcare professional assumes that certain actions or the patient’s body language imply that the patient has consented to the healthcare professional’s planned action.

Orally expressed consent is when a patient has verbally given the healthcare professional permission to proceed with the desired action.

Written expressed consent is documented evidence that the patient, usually with a signature, has given consent for a procedure. Written consent should only be obtained after oral expressed consent.

Fully informed consent is consent given after all information about the procedure has been provided. Where possible, fully informed consent, both written and oral, should be obtained prior to any procedure, examination or treatment.

To obtain proper informed consent, the patient must have been informed about a specific treatment, about the therapeutic alternatives and their potential risks and benefits, and must be able to fully understand the provided information. The healthcare professional must obtain the patient’s consent, preferably by means of a signed form. The document should include an explanation of the procedures and their purposes, including the following: (1) identification of those procedures that are experimental; (2) discomfort and possible risks; (3) specification of alternative procedures that may be beneficial; (4) offer to answer any questions about the procedures; (5) specification that the patient is free to withdraw consent and terminate participation at any time without any harm to the patient.

Exceptions/limitations of Consent:

• When the patient is unable to express his or her wishes, but emergency medical intervention is necessary, the healthcare professional has the right to infer the patient’s consent from a previous expression of his or her wishes.
• If the patient requires emergency medical intervention, the consent of the legal representative is no longer required
• If the consent of the legal representative is required, the patient must be involved in the decision-making process as far as his/her capacity of understanding allows.
• If healthcare providers consider that the intervention is in the patient’s best interest and the legal representative refuses to give consent, the decision is referred to an institution specialized in this kind of situation.

In addictions: preparing the patient for informed consent before entering the program:

Patients who have an indication for substitution treatment should be given the following information at the initial assessment:

• the nature of substitution medication treatment (purpose, what can and cannot be achieved by substitution medication treatment, known advantages and disadvantages);
• programme policy and patient obligations (such as regular pick-up of substitution medication, urine testing, times of administration, doses taken on an outpatient basis, schedule of clinic or medication visits, rules on violence, on selling or using substances, etc.).
• long-term duration of treatment; side effects and risks associated with substitution medication treatment; information on the possible effect of substitution medication on activities such as driving, operating automatic machines, etc.; risks of using other substances (including alcohol) during substitution medication treatment; risks of using other substances during substitution medication treatment.

3. Cornerstone: JUSTICE

In the healthcare context, justice involves allocating healthcare resources in a fair way. This can be an equal distribution (egalitarianism) or a maximization of total or average welfare across society (utilitarianism).

Justice: Treating people fairly; Not disadvantageous to some individuals/groups at the expense of others; Acting in a non-discriminatory/non-prejudicial manner; Respecting people’s rights;  Respecting the law.

This means that people in similar situations should have access to the same healthcare and in no case should a patient be treated better or neglected. Every patient who is integrated into the healthcare system should have the opportunity to access the same healthcare resources. Everything involved in the treatment process is considered a resource (e.g. hospital bed, medication, therapy, professional time, etc.), even if sometimes these resources are limited, the principle of equitable distribution should not be *violated* Everyone should be treated equally.

Discussions:

Allocating resources on morally irrelevant criteria such as religion, gender, nationality, level of education, etc., is unfair, i.e. prohibited. There is no consensus in the healthcare system on the criteria by which people are treated as equal or unequal and hence a number of conflicts and questions arise regarding the fair allocation and distribution of health resources.

Example: which patient to prioritize? When should the best outcome be preferred over equal chances for each patient? When can we allow the aggregation of more modest benefits for more patients instead of much better outcomes for fewer patients? How much importance should we give to the sickest patients, with minimal chance of survival or social reintegration?

In the context of inevitably limited resources, when the healthcare professional has also become an “authorizing officer”, he must ensure a balance between requirements and possibilities, without becoming frustrated and above all without endangering health and life, consider Ioan Zanc and Iustin Lupu.

For example, respect for the value of all life, which is the basis of the principle of equality and of Hippocratic deontology, must be replaced, some bioethicists believe, with the respect for the quality of life. In other words, medical decisions, including those on the allocation of resources, are determined by the patient’s chances of satisfactory reintegration into society. This entails the risk of comparative judgments of individuals’ lives: from one extreme – socially useful young people, to the other extreme – old, sick and useless.

Example:

How can the concept of justice help us decipher what is best for the client? Patients have a right to fair treatment, including access to programs, on the one hand, and to equal rules and regulations of practice, on the other, based on treatment practices empirically proven to be effective in a similar population. Patients are entitled to the same treatment as others who are treated by the same clinician, agency and professional.

The addiction counselor agrees to provide equal and effective treatment, including referrals, to all individuals, regardless of their socioeconomic background and resources, including their ability to pay for services. Patients need equal financial arrangements.

 For example, patients may not be eligible for all insurance based on criteria, but all Patients are eligible for some type of insurance.

Justice requires institutions to either accept insurance, offer an alternative payment option, or refer to another agency that can help.