sources of your moral beliefs

Think about the reflection in your textbook regarding the sources of your moral beliefs. Who or what are 3 sources that have influenced your moral beliefs? Describe the impact of those beliefs on your nursing practice.

Paper must be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources that is less than 5 years old.

Book below must be used as one of the reference:

READ!!! Purtilo, R. & Doherty, R. (2016). Ethical Dimensions in the Health Professions (6th ed.). St. Louis, MO: Elsevier. ISBN: 9780323328920
Chapters 3, 4, and 5
3

Prototypes of Ethical Problems

Objectives

The reader should be able to:

• Recognize an ethical question and distinguish it from a strictly clinical or legal one.

• Identify three component parts of any ethical problem.

• Describe what an agent is and, more importantly, what it is to be a moral agent.

• Name two prototypical ethical problems.

• Distinguish between two varieties of moral distress.

• Compare the fundamental difference between moral distress and an ethical dilemma.

• Describe the role of emotions in moral distress and ethical dilemmas.

• Describe a type of ethical dilemma that challenges a professional’s desire (and duty) to treat everyone fairly and equitably.

• Discuss the role of locus of authority considerations in ethical problem solving.

• Identify four criteria to assist in deciding who should assume authority for a specific ethical decision to achieve a caring response.

• Describe how shared agency functions in ethical problem solving.

NEW TERMS AND IDEAS YOU WILL ENCOUNTER IN THIS CHAPTER

legal question

disability benefits

ethical question

prototype

clinical question

agent

moral agent

locus of authority

shared agency

moral distress

moral residue

ethical dilemma

Topics in this chapter introduced in earlier chapters

Topic

Introduced in chapter

Ethical problem

Integrity

Interprofessional care team

Professional responsibility

A caring response

Accountability

Social determinants of care

Justice

Introduction

You have come a long way already and are prepared to take the next steps toward becoming skilled in the art of ethical decision making. The first part of this chapter guides you through an inquiry regarding how to know when you are faced with an ethical question instead of (or in addition to) a clinical or legal question. A further question is raised: How do you know whether the situation that raised the question is a problem that requires your involvement? This chapter helps you prepare to answer that question too. You will learn the basic components of an ethical problem and be introduced to two prototypes of ethical problems. We start with the story of Bill Boyd and Kate Lindy.

The Story of Bill Boyd and Kate Lindy

Bill Boyd is a 25-year-old soldier who lives in a large city. Bill served in the U.S. Army for more than 6 years and was deployed to both Iraq and Afghanistan for multiple military missions in the past 4 years. During his final deployment, Bill suffered a blast injury in which he sustained significant shoulder and neck trauma and a mild traumatic brain injury (TBI) and posttraumatic stress. He was treated in an inpatient military hospital and transitioned back to his hometown, where he moved into his childhood home with his mother.

Kate Lindy is the outpatient psychologist who has been treating Bill for pain and posttraumatic stress. Bill is in a structured civilian reentry program. This competitive program is administered by a government subcontractor; its goal is to help injured veterans find meaningful careers or employment on return from the front lines. Bill reports that he is struggling with the transition to civilian life. He originally was prompt in keeping his appointments but recently has missed almost all of his sessions. Twice Bill has arrived for his appointment more than 30 minutes late and smelling of alcohol. Kate informed Bill that she could not treat him in this condition and that if he continued to arrive in this state, she would need to discontinue therapy. Bill responded to Kate and said “You have no idea what all of this is like. And don’t even go there on the alcohol; like you have never had a drink on a bad day.”

Kate is concerned about Bill. She calls his home and gets no answer. She then calls the case manager listed on his intake form. Kate tells the case manager about Bill’s regularly missed appointments (three in the last 4 weeks). She also tells the case manager that Bill has been charged for the missed visits because he has not called to cancel, which is the billing policy of the institution where Kate is employed.

The manager responds that Bill does not qualify for transitional career/employment services unless he is compliant with all outpatient care. She adds that in her experience patients like Bill have a hard time adjusting to the fact that they are no longer eligible for active duty.

The case manager says she will talk to Bill about the unacceptability of his failing to let the therapist know when he decides not to keep his appointment. In fact, if Bill keeps that up, the case manager continues, he will be kicked out of the civilian reentry program because the government cannot be expected to pay for his lack of responsibility. Kate responds that maybe Bill was unclear about the policy. The manager replies, “It doesn’t matter. He’s an army man; he knows better than that.”

A week goes by. At the scheduled time for Bill’s appointment, he again does not appear. Kate has been uneasy about the conversation with the manager, and when the time comes for her to fill out the billing slip for another missed appointment, she feels positively terrible.

Reflection

Do you share Kate’s feelings that something is not right? If yes, what do you think the problem is? Jot down a few thoughts here and refer back to them as the chapter progresses.

____________________________________________________________________________

Recognizing an Ethical Question

Health professionals face all types of questions in clinical practice. Some are ethical questions, but others are not. Many times, what may appear to be an ethical question is in fact something else, such as a miscommunication or a question about a clinical fact or a legal issue. Often, complex clinical situations include clinical, legal, and ethical questions; part of your challenge is to distinguish them and sort them out for their relevance to the patient and the delivery of care.

The following exercise is designed to walk you through one example of an issue that includes clinical, legal, and ethical dimensions, with a description of why the last is an ethical question.

Is this an ethical question? Answer Yes or No:

Can a person status post TBI drive?

If you answered “no,” you are correct. This is a clinical question because clinical tests and procedures can help answer it. Patients who pass various cognitive assessments and an on-road driving evaluation have the clinical ability to drive, and those who fail do not. Refer back to the story at the beginning of this chapter. In the narrative about Bill Boyd, Kate Lindy, and the case manager, what additional clinical information can help you better evaluate the situation?

Now consider the following question:

Must patients with TBI comply with medical advice in this type of situation if they want to continue to drive?

Is this a clinical, legal, or ethical question? If you said “a legal question,” you are on the right track. A tip-off is the word “must.” As you learned in Chapter 1, the laws of the state and other laws are designed to monitor public well-being and enforce practices that protect the public good. Almost all states include procedures to help ensure road safety. Relevant information about people who are dangerous behind the wheel is found in part through clinical examinations. Clinical and legal systems are interdependent in that and other situations, so the decision to ignore clinical recommendations is not always up to an individual patient.

Now, go to the specific legal implications of Bill Boyd’s situation. When the physician referred Bill for therapy, she assessed that the patient’s discomfort was from a combat-related injury. The time may come when Bill wants to apply for disability benefits for his condition. Veterans disability benefits are legally enforced governmental programs in the United States to help protect members of the military from financial duress when injured during service duty. And so, a related legal question relevant to this situation is: Do patients have the right to benefits provided by the government if for any reason they miss prescribed treatment and the professional reports this?

Eligibility usually requires that a patient comply with treatments that are prescribed; the fact that Bill missed multiple treatments may compromise his case. The case manager may choose to fight Bill’s claim for disability benefits now that Kate has contacted the manager with this information.

Finally, consider this question, which is an ethical question. As you read it, think about why it is an ethical question.

Should people with TBIs who refuse to take a recommended onroad driving assessment be allowed to continue driving? If so, under what circumstances?

The word “should” is the tip-off here. It points to something in society all have agreed to support and each individual has a responsibility to help do so. Kate’s reflection on whether she should have talked with Bill’s case manager and her ambivalence about having to charge for treatments that she did not administer are examples of ethical questions about the wrongdoing or rightness of her actions that she was pondering.

Summary

Ethical questions can be distinguished from strictly clinical or legal questions, although all of these questions often arise in health professional and patient situations. An ethical question places the focus on one’s role as a moral agent and those aspects of the situation that involve moral values, duties, and quality-of-life concerns in an effort to arrive at a caring response.

For your continued learning, we now introduce several prototypes of ethical problems, into which many different everyday ethical questions will fit.

Prototypes of Ethical Problems: Common Features

What is a prototype? Prototypes are a society’s attempt to name a basic category of something. Prototypes can be objects, concepts, ideas, or situations.1 Prototypes of ethical problems are recognizable as a group by three features they have in common. Each of the prototypes in this chapter appears different from the others; in fact, each has a different role to play when ethical questions have arisen. That said, the first step into this venture is to become familiar with the same basic structural features found in all the prototypes of ethical problems:

A: A moral agent (or agents)

C: A course of action

O: An outcome

Each feature is discussed in turn.

The Moral Agent: A

Which of the following best describes your idea of a health professional as an agent?

A. A person with more than one basic loyalty; a deeply divided loyalty (e.g., a double agent).

B. A person who has the moral or legal capacity to make decisions and be held responsible for them (e.g., a signee on a contract).

C. A person who plans schedules or events (e.g., a booking agent).

If you answered “B,” you are most clearly focused on the meaning of agency in the health professions roles you will assume. In ethics or law, an agent is anyone responsible for the course of action chosen and the outcome of that action in a specific situation. Obviously, being an agent requires that a person be able to understand the situation and be free to act voluntarily. Acting as an agent also implies intention: The person wants something specific to happen as a result of that action. A moral agent is a person who “acts for him or herself, or in the place of another by the authority of that person, and does so by conforming to a standard of right behavior.”2

Reflection

This book emphasizes your role as a moral agent in the health profession setting because as a professional, you must answer for your own actions and attitudes. If you have observed a situation in which someone in your chosen field has had to act courageously, then you have observed a moral agent at work. Briefly describe what you observed and why you feel the responsibility fell to that person to be on the front line of the decision.

____________________________________________________________________________

A moral agent intends the morally right course of action. The idea of responsibility that you learned about in Chapter 2 is in fact the description of what an agent does; when faced with an ethical challenge in the health professions, the actor assumes the role of a moral agent. Professional responsibility is exercised through moral agency, and professional accountability and responsiveness to the patient through ethical action. Kate and the case manager are both agents whose actions influence the outcome of Kate’s efforts and affect Bill’s health. As a health professional, Kate clearly is in the role of a moral agent.

Agents and Emotion

Moral agency is grounded in a relational context. The moral agent must have not only cognitive ability but also emotional capacity to demonstrate an attitude of respect for the other.3 Both reason and emotion operate as part of your internal processor where you can go and search to find the appropriate tools to exercise your professional responsibility. Much is said about ethical reasoning and problem solving in this book. Through the years, considerable debate about the significance of emotion in an agent’s activity has taken place. Strict rationalists view emotion as too subjective and unpredictable to serve as a reliable guide. However, a burgeoning body of current professional and lay literature lends new knowledge about the role of emotion in decision making more generally to support the essential role of emotion in ethical decision making. Such well-regarded bodies as the Harvard Decision Science Laboratory conduct research on the mechanisms through which emotion and social factors influence judgment and decision making. From their work and the work of others, we find convincing arguments for assigning emotion at least two functions in ethics.

First, emotion is an “alert” system that warns you that you may be veering off the road of a caring response. When you encounter a morally perplexing situation, you, who will be accountable, feel discomfort, anxiety, anger, or some other disturbing emotion. Nancy Sherman, a contemporary philosopher who is working on the place of emotion in morality, proposes that emotions are “modes of sensitivity that record what is morally salient and… communicate those concerns to self and others.”4 Sometimes, an emotional response stirs a person out of lethargy and moves him or her into thinking and action on someone else’s behalf.5,6 In other words, your emotions help grab your attention and motivate you to “do something.” We saw this in the process Kate was going through as she faced the reality of Bill’s missed appointments.

Second, according to current research, emotion kicks in again at the point of decision making to complete the human picture of what is happening.7 Even if you have been logical in your assessment of the ethical problem, emotion puts the last strokes on the canvas and brings the decision into focus as one example of how humans actually conduct their lives all around. In the end, emotion, attention, and behavior interact with each other for real-time decision making.8 Effective moral agents work to integrate emotional responsiveness with critical thinking, so that rather than disregarding emotion, they develop the right emotion, suited to the situation.

Summary

An agent has responsibility for an action. A moral agent has a responsibility to act in a way that protects moral values and other aspects of morality. An ethical problem requires attention to both reasoning and emotion in the process of decision making. Emotion alerts, focuses attention, motivates, and increases one’s knowledge about complex situations.

The Course of Action: C

The course of action includes the agent’s analysis, the judgment process of discerning the best likely resolution to the problem, and the decision to act in accordance with that judgment. The next two chapters explain how this process works within the context of ethical problem solving with ethical theories and approaches, so more detail about that is not necessary now. Kate Lindy used the information she had to analyze the situation. One attempt at resolution was to call the case manager looking for Bill. Kate’s emotional response afterward reflected a concern for her patient’s well-being, even though she was irritated when she made the call; her discomfort suggests she was unsure she had exercised the correct moral judgment in what she said to the case manager. As we know, Kate also felt a sense of responsibility to bill for the scheduled treatments Bill did not receive, although she did not like this policy in her workplace. This back-and-forth reflection about what she was feeling and doing kept the course of action alive to the possibilities of what should happen.

The Outcome: O

The outcome is the result of having taken a particular course of action. Of course, the goal is that a caring response is achieved in what actually happens as a result of the whole process. We need to have more information about what actually happened as a result of Kate’s conversation and what she thought about it to know whether she considered it a good outcome for her patient Bill Boyd.

Some ethical approaches that you will learn to use in the next chapter place much more weight on the outcome; others place moral priority on the course of action. In everyday descriptions of ethics, this tension is sometimes referred to as the “ends” one achieves and the “means” used. The important point is that real-life professional situations require your full participation in all three features of an ethical problem. The decision of which of the features takes precedence in a particular ethical problem depends in part on the approach or theory you adopt.

Summary

The two prototypes of ethical problems share three features in common: a moral agent (or agents), a course of action, and an outcome.

Considerations in Moral Agency

Locus of Authority

The role of the moral agent is not always easy. At times, one may have the emotional and cognitive capacity to act as a moral agent; however, constraints in the practice environment limit one’s authority to respond. A locus of authority conflict arises from an ethical question of who should have the authority to make an important ethical decision. In other words, who is the rightful moral agent (A) to carry out the course of action (C) and be held responsible for the outcome (O)? Locus of authority problems most often arise when ambiguities exist about who is in charge (Figure 3-1). Schematically, the situation looks like this:

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