Leonard, a 78-year-old male, lives alone and was admitted to the hospital for failure to thrive after surgery to replace his hip four months ago. The hospital faces a financial challenge to pay for his care because his insurance has run out. Do you downgrade his care to get him discharged even though he has not been doing well in the hospital? What other issues do you need to consider for his failure to thrive? What resources are available to you and to him? How would you even begin to address this dilemma?
Ethical dilemmas are all too common for case managers who must ask hard questions, juggle resources, and make decisions that impact patients and their family members. As a case manager you are in a dilemma as you try to balance the care needed by Leonard with the finances of the hospital.
The Role of Ethical Standards
Ethical violations in government, industry, and the financial world make all-to-common tabloid headlines—and are all too often the cause of grief and even tragedy in work and personal lives. In every area of work, ethical violations make news. Clearly, we need to have a thorough understanding of our own ethical behavior and to avoid the behaviors that become ethical violations. Complying with ethical standards is vitally important because healthcare is a profession that impacts the lives of people, their families, and even our own reputations.
Even though case managers acknowledge their need to make ethical decisions in clinical settings, they may not have received special training for doing so. The case manager is a healthcare professional with an interdisciplinary scope of practice who frequently has to deal with complicated ethical decisions. To be an effective and ethical case manager requires that the professional “possess the education, skills, moral character, and experience required to render appropriate services based on sound principles of practice (CCMC, 2015).
This requires that case managers commit to provide evidence-based advice to clients, coordinate their care, make appropriate use of resources, and empower them to make good decisions regarding their own healthcare. Because case managers deal with patients and family members when they are ill, a very vulnerable stage in life, this compounds the necessity and responsibility for ethically dealing with others.
Because the role of the case manager inherently deals with challenges in healthcare delivery and payor systems, ethical dilemmas will be encountered. Case managers must abide by their professional code of conduct and use it to guide their professional behavior and decision-making (Airth-Kindree & Kirkhorn, 2016).
The Commission for Case Manager Certification (CCMC) has a formal code of ethics (see below) that can guide you in your role. In addition, case managers are generally nurses or social workers, and each profession has its own a code of ethics as well.
Education and training to manage ethical decision-making is a way to clarify the roles and expectations in professional behavior that is essential to effective moral behavior (Miles, 2016; Brody, 2014; Murrell, 2014). The public’s demand for transparency, the growing delivery of care by a variety of healthcare professionals in various roles, and the complicated relationship between healthcare professionals and insurance regulations have increased the pressure to be more accountable for your actions.
A Brief History of Bioethics
In medicine the topic of ethics began with the 2500-year-old Oath of Hippocrates to “First, do no harm”; this implies that, despite best intentions to provide effective care, errors can occur. In a human profession, unfortunately, sometimes those errors can be fatal. Hippocrates, known as the father of modern medicine, outlined the foundational virtues that any present or future physician should pledge to maintain. Virtues included the basics of autonomy, beneficence, justice, and nonmaleficence. He also stressed patient privacy and joining into a partnership with patients to create a health plan that would be best for each individual. (Kantarjian, 2014; Sugarman, 2000).
Medical ethics has evolved for millennia, but the primary four tenants of ethical standards have persisted. As early as 1767 a patient sued and won against his surgeons for breaking his leg as part of a surgical repair without prior consent (Leclercq et al., 2010). In 1914 a woman sued her surgeon for removing a fibroid during an abdominal surgery for another issue, which created the ruling that
Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages (Scholendorff v. Society of New York Hospital, 1914).
In 1947, following World War II, discussion of ethical standards turned from physician/patient concerns toward social issues. After awareness had grown of war atrocities such as the Nazi’s human experiments in the concentration camps and the Japanese experiments in China, news came of the Tuskegee controversy in the United States (in which medical research was done on black soldiers) and public outrage grew. Human rights cases were widely publicized, creating the need for stronger ethics standards.
Despite the world’s becoming more complicated, the original concepts of the Hippocratic Oath of autonomy, beneficence (doing good), justice, and nonmaleficence (doing no harm), are not outdated. What originally began as the moral principles of patient care evolved into the generally accepted practice of confidentiality, and then in 1996 came the legal Health Insurance Portability and Accountability Act, known as HIPAA.
Medical ethics has evolved from theoretical concepts of moral behavior to firm legal standards of practice meant to guide healthcare professionals. Not only do these ethical standards apply in moral issues but also in the ever- advancing use of digital record-keeping to navigating decisions created by new technology (Aicardi, 2016; Means, 2015; Pasztor, 2015; Wells et al., 2015). With the expansion of technology and digital communication, ethical standards have developed rules to use these advances ethically. Hospitals and other healthcare facilities outline the proper and legal use of sharing electronic images and photographs, digital records, and documents. As technology advances, so does the necessity for rules about how to use it.
Healthcare has always demanded impeccable behavior from its practitioners, and today there are renewed expectations of a high level of ethical behavior (Tenery, 2016). Trust is an integral component of the healthcare relationship and patients are generally in a vulnerable position when they encounter a healthcare professional.
As technology and the use of the electronic records have become widely used, healthcare professionals often find themselves facing new challenges as to how to navigate their moral and ethical use. Case managers often find themselves feeling the need for guidance in decision-making. A thorough understanding of the expected standards of practice for healthcare is essential in making good ethical decisions (Marques, 2012; Quigley, 2015).
There are numerous programs to help train healthcare professionals in ethics. Medical and nursing schools, as well as physical therapists, occupational therapists, and pharmacists include it in their training (Kearney & Penque, 2012). Questions related to ethics are found on the licensure exams for these healthcare professionals. Hospitals and healthcare facilities also now include required signatures and strict compliance of students and employees who access their electronic records.
- The Hippocratic Oath has long been outdated.
- Society today is steeped in immorality.
- Organizational priorities and financial pressures affect everyday decisions.
- There are more rules today than in earlier times.
- Patients are vulnerable.
- A lot of money is involved.
- Healthcare workers care about people.
- Patients have complete autonomy.
Ethical Standards of Practice
Professional ethics are incumbent only on those individuals who occupy a professional role. Beyond that, each of us has a moral threshold, a bar below which we will not compromise. To compromise below your moral threshold is to compromise your personal integrity.
The corporate scandals of the past decade and the response to them are relevant to the healthcare environment (Xu, 2016, Welsh & Ordonez, 2014). Specialists in ethical leadership have proposed that there is a key element currently missing, which they refer to as moral potency. The basis of their work stems from the question: Why do people who know what the ethically correct decision is fail to take action, even when action is clearly necessary? (Hannah, Avolio & May, 2011).
Ethical behavior is not as strongly influenced by judgment as it is by acting on a moral judgment. Moral potency can be defined as “the capacity to generate responsibility, and motivation to take moral action in the face of adversity and to persevere through challenges.”
Moral potency is built on (1) moral ownership, a sense of responsibility to take ethical action when faced with ethical issues; (2) moral efficacy,the beliefs of individuals that they can organize and mobilize to carry out an ethical action; and (3) moral courage, the courage to face threats and overcome fears to act. (Hannah, Avolio, & Walumbwa, 2011).
What is the last time you had to make a decision that was ethically difficult? What resources did you have? What support did your employer provide you?
Did you have a template or guideline to help you weigh the issues? Does your facility have an ethics committee? Have you ever attended a meeting with them?
- Compromise your integrity.
- Open your mind to new ideas.
- Increase your awareness of complex issues.
- Recognize the reality of healthcare.
- Repeating an action until you get the results you want.
- The capacity to take moral action responsibly in the face of adversity.
- Being willing to express your religious beliefs across all settings.
- Doing the right thing.
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