Ethical theories and principles provide the foundation for all ethical behavior. Contemporary ethical principles have evolved from many sources. These include Aristotle and Aquinas' natural law, Judeo-Christian morality, Kant's universal duties, and the values characterizing modern democracy. 5 , 6 Although some controversy exists, most ethicists agree that autonomy, veracity, nonmaleficence, beneficence, confidentiality, justice, and role fidelity are the primary guiding principles in contemporary ethical decision making. 1 , 5
Each of these ethical principles, as applied to professional practice, consists of two components: a professional duty and a patient right. For example, the principle of autonomy obliges health professionals to uphold others' freedom of will and freedom of action. The principle of beneficence obliges us to further the interests of others, either by promoting their good or by actively preventing their harm. The principle of justice obliges us to ensure that others receive what they rightfully deserve or legitimately claim.
Expressed in each duty is a reciprocal patient right. Reciprocal patient rights include the right to autonomous choice, the right not to be harmed, and the right to fair and equitable treatment. More specific rules can be generated from these general principles of rights and obligations, such as those included in a code of ethics.
The principle of autonomy acknowledges patients' personal liberty and their right to decide their own course of treatment and follow through a plan on which they freely agree. It is from this principle that rules about informed consent are derived.
Under the principle of autonomy, an RT's use of deceit or coercion to get a patient to reverse the decision to refuse a treatment is considered unethical. Likewise, it is unethical, and illegal, to threaten a patient who is unwilling to sign a consent form.
The principle of veracity is often linked to autonomy, especially in the area of informed consent. In general, veracity binds the health care provider and the patient to tell the truth. The nature of the health care delivery process is such that both parties involved are best served in an environment of trust and mutual sharing of all information. Problems with the veracity principle revolve around such issues as benevolent deception. In actions of benevolent deception, the truth is withheld from the patient for his or her own good.
When the physician decides to withhold the truth from a conscious, well-oriented adult, the decision affects the interactions between health care providers and the patient and has a chilling effect on the rapport that is so necessary for good care. In a poll conducted by the Louis Harris group, 94% of Americans surveyed indicated that they wanted to know everything about their cases, even the dismal facts. Other than with pediatrics and rare cases in which there is evidence that the truth would lead to a harm (such as suicide), the truth, provided in as pleasant a manner as possible, is probably the best policy. 7 Truth-telling can also involve documentation and medical recordkeeping. This type of dilemma is occurring more and more frequently under strict managed care reimbursement protocols.
The principle of nonmaleficence obligates health care providers to avoid harming patients and to actively prevent harm where possible. It is sometimes difficult to uphold this principle in modern medicine because, in many cases, drugs and procedures have secondary effects that may be harmful in varying degrees. For example, we might ask whether it is ethical to give a high dose of steroids to an asthmatic patient, knowing the many harmful consequences of these drugs. One solution to these dilemmas is based on the understanding that many helping actions inevitably have both a good and a bad effect, or double effect. The key is the first intent. If the first intent is good, then the harmful effect is viewed as an unintended result. The double effect brings us to the essence of the definition of the word dilemma. The word comes from the Greek di, meaning "two," and lemma, meaning "assumption" or "proposition." 8
The principle of beneficence raises the "do no harm" requirement to an even higher level. Beneficence requires that health providers go beyond doing no harm and actively contribute to the health and well-being of their patients. In this dictum lies many quality-of-life issues. Practitioners of medicine today possess the technology to keep some individuals alive well beyond any likelihood of meaningful recovery. This presents real dilemmas for those who are confronted with the ability to prolong life but not the ability to restore any uniquely human qualities.
In an attempt to allow patients to participate in resolving this dilemma, legal avenues, called advanced directives, have been developed. 9 Advance directives allow the patient to give direction to health care providers about treatment choices in circumstances in which the patient may no longer be able to provide that direction. The two types of advanced directives currently available and relatively widely used are the living will and the durable power of attorney for health care. A durable power of attorney for health care allows the patient to identify another person to carry out his or her wishes with respect to health care, while a living will states a patient's health care preferences in writing. Because of the Patient Self-Determination Act of 1990, most states require that all health care agencies receiving federal reimbursement under Medicare/Medicaid legislation provide adult clients with information on advanced directives. 9 , 10
The principle of confidentiality is founded in the Hippocratic Oath; it was later reiterated by the World Medical Association in 1949. It obliges health care providers to "respect the secrets which are confided even after the patient has died." Confidentiality, as with the other axioms of ethics, must often be balanced against other principles, such as beneficence.
The main ethical issue surrounding confidentiality is whether more harm is done by occasionally violating its mandate or by always upholding it, regardless of the consequences. This limitation to confidentiality is known as the Harm Principle. This principle requires that practitioners refrain from acts or omissions in which foreseeable harm to others could result, especially when the others are vulnerable to risk. For example, this principle would require that confidentiality be maintained for a patient with acquired immunodeficiency syndrome (AIDS) in matters involving his or her landlord. In this case, confidentiality is justified because the landlord is not particularly vulnerable. However, if the patient was planning to marry, the Harm Principle would require that confidentiality be broken because of the special vulnerability of the spouse.
Unfortunately, breaches of confidentiality more often result from careless slips of the tongue than from rational decision making. Such social trading in gossip about patients is unprofessional, unethical, and, in certain cases, illegal.
Because of the widespread use of computerized databases, confidential information, once highly protected, is now relatively easy to obtain. Clinical data are available for close scrutiny by the clerical staff, laboratory personnel, and other health care providers. The widespread use of these data systems represents a real threat to patient confidentiality. In an attempt to reduce this threat, most clinical databases are restricted to use by only those health care workers who have a need to know. Therefore, in addition to being unethical, an RT who reads the file of a patient whom he or she is not treating will likely be in violation of institutional policy.
The principle of justice involves the fair distribution of care. Rising health care expectations, coupled with the decreased availability of care because of cost, is making this principle an important one for health care workers. Population trends and the financial shortfalls in programs such as Medicaid and Medicare will contribute to the continuing importance of this principle.
The United States is rapidly approaching the point at which a balance must be found between health care expenses and the revenue available to pay for them. Efforts to achieve this balance will inevitably lead to some form of rationing of the delivery of health care services. This type of justice is properly referred to as distributive justice.
A second form of justice seen in health care is compensatory justice. This form of justice calls for the recovery for damages that were incurred as a result of the action of others. Damage awards in civil cases of medical mal-practice or negligence are examples of compensatory justice. Ironically, compensatory justice has played a major role in increasing the cost of health care. The cost of malpractice insurance and the practice of defensive medicine contribute significantly to the total cost of treating patients.
Because no single individual can be solely responsible for providing all of a patient's health care needs, modern health care is a team effort by necessity. Today there are more than 100 allied health professions, and allied health workers (excluding nursing and physicians) provide about 60% of all patient care. Each of the allied health professions has its own practice niche, defined by tradition or by licensure law. Practitioners have a duty to understand the limits of their role and to practice with fidelity. For example, because of differences in role duty, an RT might be ethically obliged not to tell a patient's family how critical the situation is, instead having the attending physician do so.
In deciding ethical issues, some practitioners try to adhere to a strict interpretation of one or more ethical principles (such as those just described). Others seek to decide the issue solely on a case-by-case basis, considering only the potential good (or bad) consequences. Still others would appeal to the image of a "good practitioner," asking themselves what a virtuous person would do in a similar circumstance.
Finally, many practitioners acknowledge that they largely follow their intuition for making ethical decisions. These different viewpoints represent the four dominant theories underlying modern ethics. 5 , 13 The viewpoint that relies on rules and principles is called formalism, or duty-oriented reasoning. The viewpoint in which decisions are based on the assessment of consequences is called consequentialism. The viewpoint that asks what a virtuous person would do in a similar circumstance is called virtue ethics. When intuition is involved in the decision-making process, the approach is called intuitionism.
Formalist thought asserts that certain features of an act itself determine its moral rightness. In this framework, ethical standards of right and wrong are described in terms of rules or principles. These rules function apart from the consequences of a particular act. An act is considered morally justifiable only if it upholds the rules or principles that apply.
The major objection to this duty-oriented approach lies in its potential for inconsistency. Critics of formalist reasoning insist that no principle or rule can be framed that does not have exceptions. Moreover, these critics claim that no principle or rule can be framed that does not conflict with other rules.
For the consequentialist, an act is judged to be right or wrong based on its consequences. Each possible act is assessed in terms of the relative amount of good (over evil) that it will bring into being. The most common application of consequentialism judges acts according to the principle of utility. The principle of utility, in its simplest form, aims to promote the greatest general good for most people.
Critics of this approach claim that it has two fundamental flaws. First, the "calculus" involved in projecting and weighing the amount of good over evil that might occur is not always possible. Second, reliance on the principle of utility to the exclusion of all else can result in actions that are incompatible with ordinary judgments about right and wrong. A classic example of this problem can be seen in the true World War II case of the battle for North Africa. In this scenario, there were two groups of soldiers but only enough antibiotics for one group. One group required the medication for syphilis contracted in the local brothels; the other group needed antibiotics for wounds sustained in battle. Thus, the dilemma arose as to who should receive the antibiotics.
Formalist or duty-oriented reasoning would base the decision about who should receive the antibiotics on some concept of justice, such as giving priority to the sickest or to those most in need. However, the actual decision in this case was a consequentialist one, based not on the desire to justly distribute the drug but rather on the need to obtain a quick victory with as few casualties as possible. Therefore, the scarce medication was given to those who were "wounded" in the brothels rather than in battle because these soldiers could be restored quickly and returned to the front lines to aid the war effort.
Mixed approaches to moral reasoning try to capitalize on the strengths inherent in these two major lines of ethical thought. One approach, called rule utilitarianism, is a variation of consequentialism. Under this framework, the question is not which act has the greatest utility but which rule would promote the greatest good if it were generally followed.
For example, the rule utilitarian would agree with the formalist that truth-telling is a necessary ethical principle, but for a different reason. To the rule utilitarian, truth-telling is a needed principle not because it has any underlying moral rightness but because it promotes the greatest good in professional-patient relationships. Specifically, if truth-telling were not followed consistently, trusting relationships between patients and health professionals would be impossible.
The rule utilitarian approach is probably the most appealing and useful to health professionals. It is appealing because it addresses both human rights and obligations and the consequences of our actions. Moreover, rule utilitarianism seems best able to account for the modern realities of human experience that so often affect the day-to-day practice of health care.
A theory of virtue ethics has evolved based in part on the limits of both formalism and consequentialism. Virtue ethics is founded not in rules or consequences but in personal attributes of character or virtue. Under this formulation, the first question is not, "How do I act in this situation?" but, rather, "How should I carry out my life if I am to live well?" or "How would the good RT act?"
Virtue-oriented theory holds that professions have historical traditions. Thus individuals entering a profession enter into a relationship not only with current practitioners but also with those who have come before them. With these traditions comes a history of character standards set by those who have previously distinguished themselves in that profession.
According to this perspective, the established practices of a profession can give guidance, without an appeal to either the specific moral principles or consequences of an act. 3 Thus, when the professional is faced with an ethical dilemma, he or she need only envision what the "good practitioner" would do in a similar circumstance. For instance, it is hard to imagine the good RT stealing from the patient, charging for services not provided, or smothering a patient with a pillow.
Rapidly changing fields such as respiratory care do pose some problems for virtue ethics. What might be considered good ethical conduct at one time might be deemed wrong the next time. An example of this change over time is the RT who is asked not only to disconnect a brain-dead patient from a ventilator but also to remove the feeding tubes and intravenous lines.
In addition to virtue ethic's difficulty with changing values, it provides no specific directions to aid decision making. Moreover, the heavy reliance of virtue ethics on experience rather than on reason makes creative solutions less likely. Last, practitioners often find themselves in conflicting role situations for which virtue ethics has no answers. A good example is the RT who practices the virtue of being a good team player but is confronted with the need to "blow the whistle" on a negligent or incompetent team member. 3 Despite these limitations, virtue ethics is probably the way most practitioners make their ethical decisions.
Intuitionism is an ethical viewpoint that holds that there are certain self-evident truths, usually based on moral maxims such as "treat others fairly." The easiest way to understand intuitionism is to think of as many timeless maxims as you can and you will have the basis for intuitionism. These maxims may range from "do not kill" to "look before you cross the street." 6
To aid in the process of decision making in bioethics, several comprehensive models have developed. The figure below depicts one example of a comprehensive decision-making model that combines the best elements of formalism, consequentialism, and virtue ethics.
As is evident in this approach, the ethical problem is framed in terms of the conditions and who is affected. Initially, an action is chosen based on its predicted consequences. Then, the potential consequences of this decision are compared with the human values underlying the problem. The short test of this comparison is a simple restatement of the Golden Rule that is, "Would I be satisfied to have this action performed on me?" The initial decision is considered ethical if, and only if, it passes this test of human values.
1 Identify the problem or issue.
2 Identify the individuals involved.
3 Identify the ethical principle or principles that apply.
4 Identify who should make the decision.
5 Identify the role of the practitioner.
6 Consider the alternatives (long-term and short-term consequences).
7 Make the decision (including the decision not to act).
8 Follow the decision to observe its consequences.
A somewhat simpler but nonetheless comprehensive model is used by many ethicists. The model uses eight key steps. With or without these models, RTs are often at a double disadvantage in ethical decision making. This is because RTs not only must live with their own decisions but must also support (and act on) the decisions of their physician colleagues. Unless excellent communication exists, misunderstandings can occur. Such misunderstandings may be an essential factor in the high job stress, burnout, and attrition in respiratory care.
Classes in ethics, decision making, and communication skills are critical components of the preparation of RTs for the often confusing and frustrating practice in today's medical settings. The specialty requires practitioners who can go beyond simple assertions of right or wrong and provide justifications that are both right and reasoned. Many hospitals have ethics boards or committees to review and set policy and to assist in making informed ethical decisions. In addition to administrators and medical staff members, these committees may include a member of the lay public, a chaplain, and one or more experts in bioethics.