Healthcare providers have a special relationship with their patients that is based on trust; indeed, trust is one of the pillars of the professionalism on which the healthcare relationship rests. When patients have an illness, injury, or disability, their increased vulnerability makes it even more important that we behave ethically.
Research reveals the public has lost trust in professionals in the helping fields; however, it also reveals that this loss of trust can be ameliorated with appropriate education in professional ethics (Sokol, 2015; Sutherland-Smith, 2011). This requires that professionals receive knowledge and training in ethical behavior (deOliveira, 2015; Rawson et al., 2013; Nijhof et al., 2012; Pantic, 2012).
Trust begins with respect and loyalty to your patients, which is the foundation for delivering the best possible care for their unique needs; however, it can sometimes be very difficult to reconcile with the organizational priorities and financial pressures associated within healthcare today.
Healthcare professionals have a fiduciary responsibility to both their employers and their patient and these are often contradictory. Ordering all the necessary laboratory and diagnostic tests to have certainty in a diagnosis and to manage treatment can be costly—and is often prohibited by the insurance company, which requires that the healthcare provider be discriminating when ordering tests. Balancing the two “customers”—the patient and the payor—can be challenging. What is medically appropriate may not be financially prudent.
For example, if we have the technology to save a 20-week pre-term infant who will require NICU attention for at least 4 months, should we?
Most people would emphatically declare Yes! But what if the mother of the premature infant is a young homeless teen who doesn’t have insurance and the infant is declared brain damaged from maternal opiate abuse?
Without extraordinary measures the infant would naturally expire. Is it still the best decision to have the hospital or state pay for the infant’s care? So, if the state insurance pays the bill for this extensive care for one individual, who else will suffer without state assistance when the money runs out? What if the cost of the brain-damaged infant’s care could be used to immunize the entire state’s school-aged children instead? Moral and ethical decisions like this are extremely difficult.
Most hospitals and many healthcare facilities have a specially designated ethics committee who can discuss the legal, ethical, medical, and moral issues regarding such difficult and complicated issues. The dynamics of an ethics committee are generally made of a physician, nurse, case manager, social worker, and often a patient legal representative (ombudsman). Each brings a different perspective to expand the group’s awareness and increase the number of options and resources.
The responsibility that a profession has to manage its own ethical “house” was identified almost forty years ago. Andrew Guccione (1980) stated: “The need to identify and clarify ethical issues increases as the profession assumes responsibility for those areas of direct care in its domain.”
The responsibility to practice ethically goes beyond just the specifics of any one profession:
The privilege and influence that accompany professional practice obligate healthcare providers to look beyond literal or superficial interpretations of their ethical code, and to consider the complexities of the ethical issues evident in the current practice environment.
Knapp et al., 2013; Sisola, 2013
Certified Case Manager (CCM) Code of Conduct
Case managers have their own established Code of Conduct that was originally adopted in 1996 to ensure quality and protect the public interest (CCMC, 2015). Eight principles are the foundation of the Code and include the following.
The 8 Principles of Case Manager Conduct
- Place the public interest above their own at all times.
- Respect the rights and inherent dignity of all of their clients.
- Act with integrity and fidelity with clients and others.
- Maintain their competency at a level that ensures their clients receive the highest quality of service.
- Honor the integrity of the case manager designation.
- Obey all laws and regulations.
- Maintain the integrity of the Code.
Source: CM, 2015.
Healthcare ethics are unique. Often patients cannot choose who they want as a healthcare provider. They are vulnerable to variations of assigned providers and must accept whoever is assigned to their care. The result of poor behavior on the part of the practitioner and poor communication between providers can have dire consequences (Caldicott, 2014; Mansbach et al., 2012; Hren, 2011). Public assumption is that the provider is making decisions in their best interest, which should be the standard. Patients also are generally not well educated in medicine and healthcare standards and rely on trained professionals to make healthcare decisions for them.
Not many years ago, physicians could receive a kickback (monetary payment for a referral) if they referred patients to other providers or ordered diagnostic tests in which they had a financial stake, which is a conflict of interest and clearly unethical. Equally alarming is that prescriptions often increase after a visit from a pharmaceutical representative who may have treated the physician and his office staff to special gifts, meals, or entertainment. What once started as friendly professional gifts has now required legislation to avoid unethical professional enticements and favoritism.
Professionalism, therefore, is tightly connected to moral and ethical behavior. It is vital that healthcare professionals understand the moral, ethical, and legal issues when making decisions that impact patients.
All case managers are held to these high professional standards. Because in large part case managers oversee the experience of their patients, they may be in a unique position to notice discrepancies and ethical infractions. When this happens, they have the moral and legal obligation to speak up. Thus, they are truly patient advocates.
Although case managers are nurses as well as other health professionals, nurse case managers are also held to the American Nurse Association (ANA) Code of Ethics Provision VIII, which declares
The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs.
Additional Principles for Case Managers Who Are Nurses
- Respect for human dignity
- Appropriate relationships with patients, colleagues and others
- The right to self-determination
- Patient privacy
- Conflicts of interest
- Professional boundaries
- Protection of patient rights
- Human rights in research
- Promoting a culture of safety
- Patient protection and impaired practice
- Accountability for nursing judgements
- Assignments, delegation and patient abandonment
- Duties to self and others
- Maintenance of competence and professional growth
- The environment and ethical obligation
- Contributions through research and scholarly work
- Advocacy for human rights
- Obligation to advance human rights and reduce disparities
- Integrity of the profession
- Integrating social justice and health policy
Source, ANA, 2015.
How is the American Nurse Association Code of Ethics different from or similar to the Certified Case Manager Code of Ethics? How is it different from that of any other healthcare professionals, such as Physical Therapists, Occupational Therapists, or Physicians?
- Respect for human dignity and patient privacy
- Ability to financially pay for healthcare services rendered
- Autonomy to make decisions and transportation resources
- Compliance to regimens and honesty
- Confidentiality of personal health information
- Patient advocacy
- Obey all laws and regulations
- All of the above
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