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Ethics and the Interprofessional Health Care TeamWeek 611Lecture OverviewEthical Dilemmas in Healthcare and Interprofessional TeamsProfessional Codes of Ethics Ethical Framework and Decision Making

2Learning ObjectivesIdentify the distinction between moral and ethical dilemmasUnderstand ethical reasoning and ethics frameworks as they relate to teamsApply ethical reasoning skills to scenarios3Morals vs. EthicsA criminal defense lawyer will keep aside his morals when defending a criminal and murderer in court. It does not matter whether he considers the killing of another person to be against a moral code but, according to his ethics, he has to defend the client as strongly as possible.

Source: Difference Between Ethics and Morals | Difference Between | Ethics vs Morals http://www.differencebetween.net/science/nature/difference-between-ethics-and-morals-2/#ixzz1m4qj1BOc

4Real-Life StoriesA nurse who is married to a police officer is asked to provide care to a gun-shot patient who is under guard and has been charged with the murder of a copThe colleague of a lab technician, a fellow technician who performs phlebotomy, reveals she is HIV positiveA health care professional who is a devout practitioner of a faith that condemns abortion is asked to care for a patient undergoing an abortionA drug seeking patient has lost a prescription for narcotics and is seeking a replacement and is in obvious painWhat morals might be in conflict with ethical codes? How might individuals vs. teams react in these scenarios?5Morals vs. EthicsMorals are values-based and are influenced by culture, religion, family, peers, society, philosophyEthics are codified and describe a societal view of appropriate behaviours6EthicsEthics is, simply put, the study of what is good and bad, right and wrong, and of moral duty and obligation. It also includes the values and principles of conduct governing an individual or a group. In health care ethical issues are usually conceptualized as standards of practice linked to the dyadic responsibilities of individual providers toward their patients and each other as professionals (Clark, Cott & Drinka, 2007, p. 591)7Ethical Principles in PracticeBeneficence promoting well-beingNon-maleficence do no harmRespect for autonomy supporting patient choice Justice distribution of risks and benefitsVeracity truthfullnessSubstitute judgement standard someone else deciding based on knowledge of the will of the patientBest interest standard deciding for a patient when they cannot decide for themselves(Beauchamp and Childress, 1994, 2001)8Morals & Ethics in the MediaKaren Ann Quinlan (1975)Robert Latimer (1994)Dr. Jack KevorkianSue Rodriguez (1994)Shafia family (2012)Obama Health reform law and contraception (2012) 9Quinlan legal battle initiated by the family to remove their daughter from life supportLatimer father charged with second degree murder for causing the death of his severely disabled daughterKevorkian Dr. Death staunch advocate for assisted suicideRodriguez woman with advanced ALS seeking doctor assisted suicide denied by the Supreme Court of Canada assisted one year later by an unknown physicianShafia family moral perspective of honour in conflict with societal views of moral and ethical conduct 6. As part of Obama's healthcare reform law, all insurance plans were to cover preventive care, including contraception, at no cost. But when the Department of Health and Human Services announced Jan. 20 that the exemption from the mandate was only for churches not church-run hospitals, schools and charities the ensuing ideological split tore along some new seams.SourceObama broadens exemption for religious groups, but keeps contraception option for their employees - The Denver Post http://www.denverpost.com/breakingnews/ci_19939501#ixzz1mBAsZ2rR 9Moral & Ethical DilemmasThe crucial features of a moral dilemma are these:the agent is required to do each of two (or more) actions;the agent can do each of the actions; butthe agent cannot do both (or all) of the actions. The agent thus seems condemned to moral failure; no matter what she does, she will do something wrong (or fail to do something that she ought to do)*When two or more ethical values apply to a situation, but these values support diverging courses of action, an ethical conflict or dilemma exists. (CNO, 2009)*Source: http://plato.stanford.edu/entries/moral-dilemmas/#ConMorDil

10Moral & Ethical ConflictsHealth professionals and families who believe that human life should not be deliberately shortened and that unpreventable pain should not be tolerated face a conflict in deciding whether to withdraw life support from a dying patient*.A nurse has explained to his client the benefits of taking medication and firmly believes that the medication is in the clients best interest. The client understands Normans explanation, but refuses to take the medication. The client states that the side effects of the medication cancel out any benefits. (CNO, 2009)*Source: http://plato.stanford.edu/entries/moral-dilemmas/#ConMorDil

11Moral conflict arises when values are at steak not necessarily codified professional requirementsIn this second example the ethical values described in the College of Nurses of Ontarios Ethics Practice Standards that are in conflict are client well-being and client choice;11Practice #1In your group, discuss the case Keeping Tabs on MomIdentify the practical considerations and ethical principles (slide 8) that are relevant to this case.

Bruce, C. (2011). Keeping tabs on mom: The ethics of motion sensor based monitoring of the elderly. Retrieved from http://www.scu.edu/ethics/practicing/focusareas/medical/sensor-based-monitoring.htmlFor more case studies, visit: Markkula Centre for Applied Ethics, Santa Clara University, http://www.scu.edu/ethics/practicing/focusareas/medical/12Relevance of Ethics in Health Care OrganizationsDisclosure policiesConsent policiesDo Not Resuscitate ordersConflict of interest guidelinesSubstitute decision makersLiving willsInterprofessional Team Work13Various organizational policies and procedures are impacted by ethical codes13Relevance of Ethics in Health Care OrganizationsDisclosure policiesConsent policiesDo Not Resuscitate ordersConflict of interest guidelinesSubstitute decision makersLiving willsInterprofessional Team Work (our focus)14Various organizational policies and procedures are impacted by ethical codes1415Collaboration across healthcare professions and within varied care settings is increasingUnique moral & ethic dilemmas are arising from collaborative team workNew questions have to be asked and answered as expanded teamwork practice grows

Why Do Ethics in Interprofessional Teams Matter?15Quality Hc requires being ethicalLessons from the Bacteria: How Good Culture Trumps Bad Leadership (podcast)http://www.globalethics.org/lessons-bacteria.php

(6 min)Institute for Global Ethics (www.globalethics.org)

16Ethical Principles in TeamsReasonablenessResponsibilityRespectTrustJusticeHonestyIntegrityThink about your group norms and team contracts any similarities?From Morality and the Professional Life: Values at Work by Cynthia Brincat and Victoria Wilk (as cited by Frey, 2012)17From William Frey Downloaded from: http://cnx.org/content/m13760/latest/

Reasonableness: Resolving differences and disagreements with civility and respect. Avoids extremes of giving in and holding on. Openness to arguments of others and willingness to validate ones own argumentsResponsibility: To stand committed to carrying out the tasks associated with ones social and professional role. (Being a good leader, devils advocate, recorder.Seeing through on ones commitments)Respect: To treat each individual (including oneself) always as an end and never merely as a means to an end.Trust: According to Solomon, it is the expectation of moral conduct from others, especially ones group membersJustice: Giving to each his or her due. A just or fair distribution of work and responsibility integrates equality, need, and merit. You and your group need to think carefully about how you will distribute the benefits and burdens of group workHonesty: disclosing the truth while avoiding the extremes of brutal indifference (making the truth hurt) and dishonesty (deception or withholding of vital information)Integrity: This meta-value sheds light on the overall coherence of the other values as they are expressed in character and action. The opposite of integrity is corruption where there is a breakdown at an individual or organizational level or both17Ethical FrameworkA framework aids in thinking about & understanding the ethical dimensions of interprofessional teamwork Clark, Cott and Drinka propose three elements:principles that suggest general guidelines for behaviour, structures (both formal and informal) that encompass established forms of knowledge and patterns of behaviour within an organization for individual and collective practices related to teamwork, and processes that are factors related to the procedural aspects of ethical practice, focusing less on what is important than on how things are done in the health care setting.(2007, p. 593)

18Point out that students have modeled the development of their groups ethical framework by

Reflecting and articulating personal valuesIdentifying group normsCodifying principles (guidelines for behaviour), structures and processes through their team contracts18Ethical framework (cont.)Ethical dimensions can be analyzed at three different levels: the individual, the team, and the organization

(Clark, Cott & Drinka, 2007, p. 593)

See Table 1 in Week 6 folder for full framework

1919Ethical Framework - Principles(Clark, Cott & Drinka, 2007, p. 594)

IndividualTeamOrganizationTo develop knowledge of oneself and competency in ones own discipline as the basis for mutual respect among the professions on the team, To understand the norms and practice standards of the other professions on the team, and To master the basic knowledge and skills required for effective teamwork. the responsibility of each member for promoting and protecting the team as a distinct structure, and the shared accountability of each member for the teams decisions and outcomes.respect the unique relationship between the team and the patient as a part of the team approach to providing care, understand the basic principles of teamwork, andprovide sufficient resources for the team to be able to accomplish its work and fulfill its mission. 2020Ethical Framework - Structures(Clark, Cott & Drinka, 2007, p. 594)

IndividualTeamOrganizationDevelop standards of professional practice for personal relationships with other team membersAcquire insights into basis for practice of other professions on teamEstablish a personal structure for teaching new members about ones profession and role on teamIntegrate professional knowledge with other team membersDevelop integrated patient problem definitions and a structure for assessment and care planningPromote and protect team as distinct structureProvide sufficient resource foundation for teamEstablish evaluative structures for assessment of teams work2121Ethical Framework - Processes(Clark, Cott & Drinka, 2007, p. 594)

IndividualTeamOrganizationPractise active awareness of respectful communication with other team membersDiscuss controversies and problems with othersGet to know and assimilate new members into teamwork processesDevelop ethic of open communication and dialogueArrive on time for team meetingsDevelop and implement integrated patient care plansSupport team development and functionAppoint facilitator to address communication and ethics issues and mediate team conflicts2222Ethical Decision-Making Framework: ISSUES23

Source: Hamilton Health Sciences Centre Ethics FrameworkPost an example of a alternate ethical framework to your Group Work Discussion forumPractice 2: Integrating A New Team MemberApply the framework proposed by Clark et al. (see separate handout in Week 6 folder) to illustrate how the various components can be used in a real-life situation.Reflect on the differences between ethical situations impacting teams and those discussed earlier.

24Related ReadingsCommunity Ethics Toolkit : http://www.jointcentreforbioethics.ca/partners/documents/cen_toolkit2008.pdfMeadus, J. & Wahl, J. (2008) Transfer from hospital to long-term care: reframing the ethical debate from the patients Perspective. Retreived from www.acelaw.caMeadus, J. (2010). First available bed policies & discharge to a long-term care home from hospital. Retrieved from www.acelaw.caMeadus, J. (2009). The role of community care access centres in admission to long term care from Hospital. Retrieved from www.acelaw.ca

25For next classNo class February 21 reading weekWeek 8 (February 28) will be Organizational Change: Collaborating in Times of Change Review Assigned readings from reading list

Enjoy your break!26ReferencesBeauchamp, T. L., & Childress. J. F. (2001). Principles of Biomedical Ethics (5th ed.). New York, NY: Oxford University Press.Bruce, C. (2011). Keeping tabs on mom: The ethics of motion sensor based monitoring of the elderly. Retrieved from http://www.scu.edu/ethics/practicing/focusareas/medical/sensor-based-monitoring.htmlClairmont, S. (2011, November 1). Forced apart after nearly 70 years. The Hamilton Spectator. Retrieved February 12, 2012 from http://www.thespec.com/news/local/article/617797--forced-apart-after-nearly-70-yearsClark, P., Cott, C., & Drinka, T. (2007). Theory and practice in interprofessional ethics: A framework for understanding ethical issues in health care teams. Journal of Interprofessional Care, 21(6): 591 603. Retrieved from http://www.cihc.ca:8180/library/bitstream/10296/382/1/ClarkEtAl_InterprofessionalEthics_Dec2007.pdfCollege of Nurses of Ontario (2009). Ethics. Retrieved from http://www.cno.org/Global/docs/prac/41034_Ethics.pdfFrey, W. (2012). New Ethics of Teamwork (presentation). In Ethics of Team Work (on-line course module). Retrieved February 12, 2012 from http://cnx.org/content/m13760/latest/?collection=col10491/1.9 Hamilton Health Science Centre. (2010). Ethics framework. Retrieved from http://hamiltonhealthsciences.ca/workfiles/CLINICAL_ETHICS/HHSEthicsFramework.pdfMcConnell, T. (2010). Moral Dilemmas. In E. N. Zalta(Ed.), The Stanford encyclopedia of philosophy (Summer 2010 ed.). Retrieved from http://plato.stanford.edu/archives/sum2010/entries/moral-dilemmas

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