The language of ethics related to healthcare, also commonly called bioethics, is applied across all practice settings, and four basic principles are commonly accepted. These principles include (1) autonomy, (2) beneficence, (3) nonmaleficence, and (4) justice. For Case managers, and other health professionals, veracity (truthfulness) and fidelity (trust) are also spoken of as ethical principles but they are not part of the foundational ethical principles identified by bioethicists (Drumwright, 2015).

The Principle of Autonomy

Autonomy is an American value. It is the ability to make decisions for oneself, also known as self-government. We hold great respect for individual rights and equate freedom with autonomy. Our system of democratic law supports autonomy and, as such, upholds the right of individuals to make decisions about their own healthcare.

Respect for autonomy requires that patients be told the truth about their condition and be informed about the risks and benefits of treatment in order for them to make informed decisions. Under the law, they are permitted to refuse treatment even if the best and most reliable information indicates that treatment would be beneficial, unless their action may have a negative impact on the well-being of another individual. These conflicts set the stage for ethical dilemmas.

The concept of autonomy has evolved, from paternalistic physicians who held decision-making authority, to patients empowered to participate in making decisions about their own care, to patients heavily armed with Internet resources who demand their own choice in any decision-making. This transition of authority has been slower to evolve in the geriatric population but, as the baby boomers age, they will assert this standard of independence.

Autonomy, however, does not negate responsibility. Healthcare is a partnership between the provider and the recipient of care. Each owes the other a position of partner and respect in healthcare decision-making (Veatch, 2016). An ethical surety is that the physician, or any other healthcare professional, cannot make a unilateral healthcare decision without the consent of that competent adult, or emancipated minor.

Emancipated minors are persons under the age of 18 who can make legal decisions for themselves without a parent’s consent. Emancipation can occur in several ways, including (1) reaching age of majority [age 18], (2) emancipation by court order, (3) by marriage or parentage, or (4) by active military service. What makes someone an emancipated minor includes being under the age of 18 and legally married, financially independent, a parent, or responsible for his or her own housing, or having been kicked out of a home by abusive parents (Larson, 2018). Healthcare professionals need to be familiar with these legal issues in advocating for patients who fall within the emancipation category. Case managers may need to advocate for emancipated minors in healthcare issues.

Answer: E

Rationale: Even if this girl is not an emancipated minor, she does not require parental consent for an abortion, birth control, or treatment of a sexually transmitted infection per current U.S. law.

Answer: A

The Principle of Beneficence

The beneficent practitioner provides care that is in the best interest of the patient. Beneficence is the act of being kind. The actions of the healthcare provider are designed to bring about a positive outcome. Beneficence always raises the question of subjective and objective determinations, of benefit versus harm. A beneficent decision can only be objective if the same decision would be made regardless of who was making it.

Traditionally the ethical decision-making process and the ultimate decision were the determination of the physician. This is no longer the case; the patient and other healthcare providers, according to their specific expertise, are central to the decision-making process. For example, case managers have expertise in quality-of-life issues, and in this capacity can offer much to the discussions of lifestyle and life-challenging choices, particularly when dealing with terminal diseases and end-of-life dilemmas (Leuwenburgh-Pronk et al., 2015).

The Principle of Nonmaleficence

Nonmaleficence means doing no harm. Providers must ask themselves whether their actions may harm the patient either by omission or commission. The guiding principle of primum non nocere, “First of all, do no harm,” is found in the Hippocratic Oath. Actions or practices of a healthcare provider are “right” as long as they are in the interest of the patient and avoid negative consequences.

Harm by an act of omission means that some action could have been done to avoid harm but wasn’t done. Omission would be failing to raise the side rails on the patient’s hospital bed, upon which the patient fell out and was injured. An act of Commission is something actually done that resulted in harm. An example of an act of commission would be delivering a medication in the wrong dose or to the wrong patient.

Case managers can be accused of maleficence by omission if they failed to coordinate a patient’s care correctly—for example, discharging a patient to an inappropriate level of care or leaving a patient in a dangerous living situation. A key role for the case manager is to be an advocate for the patient and neglecting this role could be maleficent. An unethical act of commission could be breaking confidentiality by releasing information that becomes harmful to the patient.

Answer: C

Patients with terminal illnesses are often concerned that technology will maintain their life beyond their wishes; thus, healthcare professionals are challenged to improve care during this end stage of life. Patients may even choose to hasten death if options are available. The right of the individual to choose to “die with dignity” is the ultimate manifestation of autonomy, but it is difficult for healthcare providers to accept death when there may still be viable options. Indeed, in most states it is still illegal to hasten death by any active means.

Here we see the principle of nonmaleficence conflicting with the principle of autonomy as the healthcare providers or case managers desire to be beneficent or, at the least, cause no harm. The active choice to hasten death versus the seemingly passive choice of allowing death to occur requires that we provide patients with all the information necessary to make an informed choice about courses of action available to them.

A complicating factor in end-of-life decisions is patients’ concern that, even if they make their wishes clear (such as through an advance directive), their family members or surrogates will not be able to carry out their desires and permit death to occur. Treating against the wishes of the patient can potentially result in mental anguish and subsequent harm to the patient or family members.

Euthanasia can be either active or passive. Currently active euthanasia, which is actively giving a medication to bring about death is illegal under federal law in the United States; however, passive euthanasia may be allowed. Removing ventilation equipment or withholding nutrition, which may cause a natural death, are permissible and currently identified in living wills or advance directives when patients state they desire no extraordinary measures be taken to sustain life.

The Principle of Justice

Justice speaks to equity and fairness in treatment. Hippocrates related ethical principles to the individual relationship between the physician and the patient. Ethical practice today must extend beyond individuals to the institutional and societal realms. This means that, in addition to providing fairness in treatment to the patient, the institution and staff must also be treated fairly. For example, it is not fair if a patient cannot make payments and the institution has to pay for the treatments already given for the patient’s benefit.

Justice may be seen as having two types: distributive and comparative. Distributive justice addresses the degree to which healthcare services are distributed equitably throughout society. Within the logic of distributive justice, we should treat similar cases similarly—but how can we determine if cases are indeed similar? Beauchamp & Childress (2013) identify six material principles that must be considered, while recognizing that there is little likelihood all six principles could be satisfied at the same time (see box).

Looking at the principles of justice as they relate to the delivery of healthcare, it is apparent that they do conflict in many circumstances. For example, a real-life system that attempts to provide an equal share to each person cannot distribute limited resources. There is a finite end to money and resources within the budget of an organization. When good patient care demands more than the system has allocated, there may be a need for adjustments within the marketplace.

An example would be when an insurance company has exhausted its allocated and contracted funds to care for a hospitalized patient. The insurance company can then demand that the patient be transferred to another facility of lesser cost. If, however, the acuity of the patient is too high to be transferred, then the patient’s healthcare costs continue to exceed the budget, which is unequitable for the insurance company. If the insurance company stops paying for services rendered, then it is unequitable for the hospital. If the hospital discharges the patient home before truly appropriate for the patient, it becomes unequitable for the patient. Clearly, these are unfortunately real-life ethical and moral dilemmas. Who is most important?

Comparative justice determines how healthcare is delivered at the individual level. It looks at disparate treatment of patients on the basis of age, disability, gender, race, ethnicity, and religion. Of particular interest are the disparities that occur because of age. Bias as a result of age compared to gender and race discrimination is referred to the practice as ageism (Chrisler et al., 2016). In our society, equal access to healthcare does not exist due to variations in health insurance, third-party payers, socioeconomic levels, and even availability of transportation to care facilities. There is valid concern about the distribution of resources, particularly as the population ages and the demand for services increases.

Currently those age 65 and older receive disproportionate levels of funding in healthcare because the number of individuals in that cohort continues to increase and because people tend to need more healthcare services when they are older. Equitable allocation of resources is an ever-increasing challenge as lives are extended through natural and technological means.

Political trends and changes also impact the principle of justice in healthcare decisions. Democratic President Barack Obama introduced the first government sanctioned healthcare aimed at covering all Americans, nicknamed “Obamacare” or more correctly called the Patient Protection and Affordable Care Act (ACA) (PPACA, 2010). The ACA was an attempt to decrease disparities in healthcare benefits.

All of these factors place greater stress on an already overburdened healthcare system and result in more difficult ethical decisions about workforce allocation and equitable distribution of financial resources.

The Principle of Veracity

Veracity (truthfulness) is not a foundational bioethical principle and is granted just a passing mention in most ethics texts. It is at its core respect for all persons by being truthful. Veracity is the opposite of the concept of paternalism, which assumes patients need to know only what their physicians choose to reveal.

Obviously there has been a dramatic change in attitudes toward veracity because it forms the basis for the autonomy expected by patients today. Informed consent is only possible if patients have been well informed of options, which then allows them to exercise autonomy with full knowledge.

Decisions about withholding information involve a conflict between veracity and deception. There are times when the legal system and professional ethics agree that deception is legitimate and legal. Therapeutic privilege is invoked when the healthcare team makes the decision to withhold information believed to be detrimental to the patient. Such privilege is by its nature subject to challenge and is taken very seriously by ethics committees.

The Principle of Fidelity

Fidelity is loyalty. It speaks to the special relationship developed between patients and their healthcare professionals. Each owes the other loyalty; although the greater burden is on the provider to be worthy of the patient’s trust and loyalty (Beauchamp & Childress, 2013). Fidelity often results in a dilemma, because a commitment made to a patient may not result in the best outcome for that patient (Veatch, 2016). At the root of fidelity is the importance of keeping a promise and being true to your word. Individuals see this differently. Some are able to justify the importance of the promise at almost any cost, and others are able to set aside the promise if an action could be detrimental to the patient.

For example, if a physician promises the patient they will always be there to care for them, yet leaves the organization and joins another healthcare facility, the patient may feel the physician betrayed their loyalty. The same may occur with a case manager who promises the patient and family they will be available to help them, yet leaves the employment, which may make the patient feel abandoned.

Answer: D

An Ethical Decision-Making Model

There are many models for ethical decision-making that help to organize the thoughts of the individual. Some are quite simplistic, for example, the tilt factor model.

Tilt Factor Model

The tilt factor model looks at the choices confronting the individual, with pros and cons defined and with the factors that would change the decision indicated as “tilt factors.” This simple model does not truly guide the practitioners’ actions, but it does help to frame the question.

Using this model to make ethical decisions provides the case manager with direction for collecting information about the problem, the facts of the situation, the identification of interested parties, and the nature of their interest: is it professional, personal, business, economic, intellectual, or societal? The healthcare professional then determines if an ethical question is involved and if there could be a violation of the code of ethics, or if there is a potential affront to personal moral, social, or religious values. This model also identifies any potential legal issue (eg, malpractice, a practice-act infringement). The case manager gathers more information if it is needed to make an appropriate decision. In the tilt model, this is the point where the case manager is encouraged to brainstorm potential actions and then analyze the course of the chosen action.

The RIPS Model

A model for ethical decision-making that is popular with case managers and other healthcare professionals is the Realm, Individual Process, Situation (RIPS) model. The steps of the RIPS model bring forward many of the aspects of a problem confronting the interdisciplinary team. This method essentially involves four steps (Dale, 2016). To better illustrate the ethical decision-making process, we will work through a case that involves issues of utilization. You will see that the three primary components of the RIPS model are implemented in the case.

Answer: D

Applying the Model to the Case

Clearly there is an unsettling gap between the outlined course of action for this patient, the legal billing codes and expectations, and the patient’s ability to meet the expectations for care. Using the RIPS model, let’s go through the steps in the decision-making process to identify the factors to address and potential options and solutions.

Step 1: Recognize and Define the Ethical Issue

Realm

Into which realm does this case fall—individual, organizational/ institutional, or societal?

This situation falls into mainly the institutional realm. The care of the patient is being dictated by institutional policy. There is also a societal component here, because of the policies dictated by a third-party payer (Medicare). The patient’s care is determined largely on payment parameters but a professional must weigh treatment outcomes vs. treatment options. In this case it appears that reimbursement is driving practice, not practice driving reimbursement (Hightower, 2012; Sujdak & Birgitta 2016).

Individual Process

What does the situation require of Tim, Casey, and the case manager? What individual process is most appropriate? There are four components to the individual process. To manage an ethical issue all four components of the process must come into play at some point, although there is no particular order in which the components are handled. The four components are defined as follows.

Moral Sensitivity

This involves recognizing that there is a problematic issue and being aware of its impact. The PT, OT and case manager all recognize that this is an ethical issue. They cannot rationalize treating Mr. Wilson at a level that he cannot tolerate; not only will it not be beneficial, but it also has a high probability of being detrimental to him.

Moral Judgment

The individual considers possible actions and what the effect will be on all parties. Tim and Casey recognize that, while they are right to insist that their patient not be forced into therapy that he cannot tolerate, if Mr. Wilson cannot participate fully in the program at the level it has been set, he risks being discharged to a lower level of care or to home without the benefit of the rehab program he needs. Tim and Casey are torn because they believe that Mr. Wilson just needs some time to build up his endurance, but they cannot document treatment not rendered. Will their honesty result in his loss of services and potential physical decline in a nursing home?

Moral Motivation

This is the force that compels the individual to consider possible courses of action. Casey and Tim are not willing to compromise their integrity or their loyalty to their patient. They want him to get the services to which he is entitled but they also want to protect him. Their supervisor appears to see only the financial ramifications of Mr. Wilson’s lack of treatment. They are faced with falsifying minutes to protect his treatment program, treating him at a level that he cannot tolerate, or risking early discharge by treating him to his tolerance and documenting appropriately. While they support each other in their ethical decision making, they do not feel they are getting much support from their superiors.

Moral Courage

This is a measure of ego strength, the strength to take action to correct a wrong. It is interchangeable with moral character. Tim and Casey feel strongly that Mr. Wilson should be given a lower RUG level—realistically, a rehab evaluation—until he can tolerate more therapy. Administration does not support this view, but the PT, OT and case manager are very emphatic. They cite the literature supporting this more moderate approach and attempt to get their supervisor to understand their discomfort with the treatment protocol. The treatment plan put in place by the administration compromises the autonomy to which they are obligated by the practice acts for each of their disciplines.

Moral Failure

This is a deficiency in any of the four components: (1) the failure to recognize that an issue exists, (2) the inability to plan a course of action, (3) the lack of motivation to take action, and (4) the inability to follow through on the action. The supervisors and administration in the facility are subject to moral failure with deficiencies in multiple areas.

Moral Potency

This is the element that, when absent, results in action not being taken.

Situation

What type of an ethical situation is this: a problem, a distress, a dilemma, a temptation, or a silence?

An ethical problem. An ethical problem exists when healthcare professionals are confronted with challenges or threats to their own moral duties and values. This results in an ethical problem that needs to be resolved.

An ethical distress. The focus is on the practitioner. The practitioner knows what action should be taken but there is a barrier in the way of doing what is right. The individuals experience some discomfort because they are prevented from being the kinds of persons they want to be or doing what they know is right.

An ethical dilemma. This type of problem involves two or more morally correct courses of action where only one can be followed. In choosing one course of action over another the practitioner is doing something right and wrong at the same time.

An ethical temptation. This involves two or more courses of action, one that is morally correct and one that is morally incorrect but, for reasons determined by the practitioner, they consciously choose the incorrect course of action.

Silence. The practitioner chooses to ignore the problem and takes no action.

So, from the above we see that the case manager, PT, and OT are faced with an ethical distress. They know the correct action they wish to take but they are unable to take that action because of institutional constraints.

Answers: D,B,D

Step 2: Reflect

This is the opportunity to gather the additional information necessary to make a decision.

What else do we need to know about the situation, the patient, and the family? Who are the stakeholders in addition to Mr. Wilson, the patient, the, Tim and Casey, and the case manager? The following people are also stakeholders, or potential stakeholders:

• The patient’s wife
• The institution, and the supervisor
• Other healthcare providers
• The insurance company
• The licensing board charged with protecting the public
• The professional association and its code of ethics

What are the consequences of action?

Determining a plan of care is based on the assessment of the patient and available resources for treatment. In this situation, the assessment indicates the need for care and the resources are available to the patient, but the rehab professionals have their plan of care dictated by institution/third-party reimbursement. The professionals find the care to be unreasonable and potentially harmful; however, if they refuse to carry out the care as it is proposed, they may endanger the patient’s access to care in their facility.

What are the consequences of inaction?

The members of the rehab team understand that failure to question the plan of care and, instead, attempting to impose the treatment parameters on this patient may place the patient in danger. Mr. Wilson is not stable enough to manage care at the level they are being forced to deliver it. In many cases this is a time-sensitive issue because the patient may be able in the future to benefit from the care, but the current level of recovery is insufficient to tolerate it. Healthcare professionals often find themselves caught between what they have determined is appropriate for the patient and external pressures regarding the delivery of care.

The last step of the reflection phase is associated with a proposal by Rushworth Kidder in How Good People Make Tough Choices (Kidder, 1996). Kidder initially proposed a four-standard test. Later, a fifth standard was added because the Kidder Test was being applied to professional ethics. The Kidder test asks questions based on five topics of questioning for solutions offered.

Kidder Test Adapted to Mr. Wilson

1. The Legal Test

• Are any laws potentially broken?
• What does the state practice act say about providing inappropriate care?
• What does the practice act demand of licensed professionals as to their autonomy and their individual responsibility to make decisions that are not dictated or controlled by other sources?
• Does the potential exist that the rehab professionals are culpable if they cannot achieve the minutes required, and the care is being billed at the higher level?
• How close do they come to billing in a potentially fraudulent manner?

2. The Stench Test

Does the situation feel “right” or does it stink? The uncomfortable feeling of a professional when integrity is challenged produces a positive response to the stench test. The individual knows that “it stinks.” In good conscious, professionals cannot pretend the situation does not exist or is beyond their control.

3. The Front Page Test

Is the potential publicity something you would not like to have on the front page? Healthcare providers generally take pride in the work they do. Positive publicity is welcomed by most professionals, but negative publicity reflects badly on all practitioners and is poorly received by the healthcare community. Negative publicity does considerable harm because it diminishes the public trust. Imagine the headline in our case: “Patient welfare compromised in a revenue enhancement scheme.”

4. The Mom Test

The Kidder Test looks at the background of the individual, recognizing that much of our ethical decision-making has strong foundations in our upbringing, reflecting the value system of those who influenced us along the way. Kidder calls this the “mom” test, but it is broader than the values instilled by your mother. It incorporates not just parental guidance but also those mentors, teachers, and colleagues who have influenced your values as a professional. The mom test integrates personal integrity with the professional values that every healthcare professional brings to the situation.

If the action you are contemplating would not be acceptable to those who helped you develop your value system, you must consider other actions more consistent with the values that you hold to be important. If this requires a change in behavior, then you are faced with an ethical challenge to develop a course of action that is different and would be acceptable. In this case, continuing to treat this patient despite Tim’s and Casey’s concerns about Mr. Wilson’s well-being would not pass the mom test.

5. The Professional Values Test

What guidance do we get from professional standards? The physical therapist involved with the care of this patient has access to guidance from his Code of Ethics as well as the case manager’s professional Code of Ethics. Codes and other professional documents help individuals determine what their responsibility is to the patient. The Case Manager Code of Ethics sheds light on the responsibilities to serve as a patient advocate with respect.

If the solution to the problem does not pass the Kidder test, there is no need to go any further. The only question remaining is whether the healthcare professional has the moral courage to follow through and take appropriate action. Action in this case must be taken in order to preserve professional integrity. For the therapists and the case manager, taking action to place their patient’s needs above those of the institution is more consistent with their professional values.

Step 3: Decide the Right Thing to Do

Step 3 presumes that all the factual material has been investigated and the individual is now ready to make a decision. The adaptation of Kidder questions tests the factual information against the five standards of law: legal, stench, front page, parent/mentor, and professional guidance.

If any of the Kidder tests are positive, action must be taken. Even if the situation passes the Kidder Test there may still be an ethical issue to consider. At that point the information you have gathered must be considered in view of three classical approaches to ethical decision making: rule-based, ends-based, or care-based.

Rule-Based Approach

People who take the rule-based approach follow that which they think everybody else should follow. These are the rules, duties, and obligations already in place. The procedures, techniques, and methods are what would be considered the “standard of care.” In addition, objective measurements are available to provide guidance about the ethical dilemma of overtreating a fragile patient in order to qualify for care from which he cannot yet benefit. Standardized assessments—such as those for blood pressure, heart rate, oxygen absorption, reaction to exercise—provide objective measurements that are easily applied and interpreted.

Applying a rules-based approach to our patient situation would ensure that care not be rendered to the patient if he could not tolerate it. Note that this approach does not protect the patient against the situation where care is no longer available because he cannot meet the standard.

Answer: B

Ends-Based Approach

Those using the ends-based approach do whatever produces the greatest good for the most people. The analysis of the action and the resulting outcomes look at the good and harm for all of the stakeholders, not just the patient. An ends-based approach looks more at the general good of society and less at the individual’s needs (eg, the PT/OT supervisor). This would be the least likely application in our case. An example would be when to share communicable disease information with a public health authority because the public good is at greater risk if not shared. Currently, public health authorities have clearly outlined what must be reported, and certain diseases take precedence over the rights of privacy of the individual.

Answer: C

Care-Based Approach

Those using the care-based approach follow the Golden Rule, which states “Do unto others as you would have them do unto you.” Situations are resolved according to relationships and concern for others. It is difficult for healthcare providers to remove themselves from the situation completely, but they can recall a personal experience or another patient-care situation that reminds them how important it is to integrate the ethics of care combined with compassion into the entire patient-care situation.

Step 4: Implement, Evaluate, and Re-assess

Implementing a plan does not end the opportunity to learn more and to develop a workable plan for managing future situations.

It is the responsibility of the professional to reflect on the chosen course of action and consider any steps needed to avoid this type of ethical situation in the future. The responsibility to modify behavior lies not only with the individual but also with the institution. Often after an ethical dilemma arises in an institution, policies and procedures are drafted and put into practice to prevent future controversies and delays in similar experiences.

The situation confronting the case manager and therapists points to the difficulty of implementing plans of care that are not at the discretion of the treating practitioner. The patient’s entire team needs to make the treatment a collaborative effort. To effect the most positive outcome, this includes the patient and family. For the team to work as a cohesive unit there must be mutual understanding and respect for the unique contribution of each team member and the way in which that contribution can benefit the approach to the patient (Badawi, 2016; McCarthy 2015).

Answer: A

Initially the professional must do some reflection and answer the following questions:

• What was learned from the case involving Mr. Wilson and his plan of care? For the case manager and the therapists, they confirmed their professional responsibility to be autonomous practitioners. They also recognized the constraints they have working in a setting that does not necessarily respect that responsibility.
• What are the strengths and weaknesses of the practitioner with regard to the individual processes? Does the individual exhibit moral sensitivity, judgment, motivation, and courage? They exhibited moral sensitivity, judgment, and motivation. Although we don’t know the outcome of this scenario, we do know that moral courage would require overt action on their part to protect their patient.
• If the provider needs to develop one or all of these skills, what type of professional activities would help to accomplish this?
• Was the outcome what was expected? Was there any collateral damage? When confronted with an ethical situation we may carry some preconceived concepts about what may result. It is important to look back at the outcome and compare it to what we anticipated. This is particularly important when collateral damage may be worse than the initial situation. Preventing collateral damage is always preferable to trying to address it after the fact. A thorough review of collateral damage—similar to a risk/benefit ratio—may be enough to suggest mechanisms to prevent them in the future.

Remarks

Case managers may no longer defer ethical decision making to other healthcare providers, such as physicians, with whom they share patient responsibility. They must recognize their responsibility as autonomous practitioners to work on ethical challenges in order to find a reasonable solution that is in the best interest of the patient.

To accomplish this professional mandate, case managers must know ethical principles and be able to apply them effectively to ethical situations and then analyze the outcomes before taking action.