Principles of Health Care Ethics Rels 300 / Nurs Sep 2014

Shouldering the Burden of Care TW, a fifty-two-year-old Ohio woman, cares daily for her elderly mother … TWs mother requires constant supervision, so she came to live with TW and her family. Since TW could not afford a home health aid during the day, she reduced her hours and now works part time… In recent months, TWs mother has declined rapidly… TW's mother told TW on many occasions that she never wanted to be placed in a nursing home… TW faces a dilemma. She can place her mother in a nursing home to ease her own burdens… Alternatively, she can respect her mother's stated wishes by continuing to care for her at home… Sanders, S. J., & Eva, F. K. (2005). Shouldering the burden of Care/commentary/commentary. The Hastings Center Report, 35(5), Retrieved from 300/330 appleby 2

What can a feminist ethic of care offer in response to this dilemma?  The subordination of women is morally wrong and harms both women and men.  Both men and women should be treated as equals  Both are deserving of justice rather than discrimination or privilege  Moral obligations arise out of our relationships with others and our mutual duties of caring  Human persons are interdependent and formed through personal relationships.  Maintain caring relations  Avoid harm; Respond to need  Recognize and respond to vulnerability 300/330 appleby 3

One Feminist Analysis: Eva Feder Kittay “[C]aregiving is a human capacity, not a gendered one” For caregivers to be able to express love, they “need to be able to maintain [their] own selves from which our gift can flow” “Imagine a world where familial caregiving was remunerated through paid family leave policies and funds to provide care” “If nursing homes were personalized and varied places… then they would not be a dreaded specter hovering over old age” “distribute the burden of caregiving more equitably…if her brother cannot contribute time, he must assist in other ways, such as contributing funds for home assistance” “To continue the current situation can only further embitter TW, alienating her from her mother and her family, and this fracturing of relations would be the most injurious of all outcomes.” 300/330 appleby 4

Synthesizing and applying a range of moral theories 300/330 appleby 5

Moral Principles Not tied to any one moral theory Emerged from critical analysis of medical research which was proven to violate the human dignity of the research subjects Developed as an attempt to provide a common language for healthcare professionals, researchers and members of the public Goal = to provide a means of determining & identifying morally right and morally wrong attitudes, actions and behaviours ▫Within contexts of both clinical care and research 300/330 appleby 6

4 Principles of Bioethics Can be evaluated within a virtue, deontological, utilitarian, natural law, feminist or care framework ground rulesBut the 4 principles form the ground rules for the moral alternatives considered by the health care team People can use any form of moral reasoning and still discuss each of these principles 300/330 appleby 7

The 4 Principles are: 1.Autonomy 2.Beneficence 3.Non-maleficence ▫(also called non-malfeasance, but this term is not generally used in Canada) 4.Justice 300/330 appleby 8

1.Autonomy auto / nomos = self / rule  respect the right of competent persons to make their own decisions  respect the personal dignity and worth of persons  respect the right of persons to be free to act without external restraints or manipulation 300/330 appleby 9

2.Beneficence  healthcare professionals have a duty to promote the health and well-being of the patient  Contribute to their benefit  healthcare professionals have a duty to further the important and legitimate interests of others  patients may not be treated in ways that only bring benefit to others 300/330 appleby 10

3.Non-maleficence  healthcare professionals have a duty to refrain from injuring or inflicting harm  minimize the pain and suffering caused by disease and medical treatment  “First, do no harm” 300/330 appleby 11

4.Justice  everyone has a duty to ensure fair treatment of patients  equals should be treated equally and unequals unequally  healthcare resources should be distributed in a fair manner  persons should not experience prejudice, discrimination or bias 300/330 appleby 12

What’s the value of adding another theoretical approach? Whether on deontological grounds, or according to utilitarian reasoning, or according to any other moral theory (i.e. virtue, natural law, care ethics), everyone is in agreement that patient autonomy must be respected ▫reasons for respecting autonomy may differ according to moral perspectives, but all agree that it must be respected in providing health care for patients 300/330 appleby 13

Case Study #1 Ms. Jones, a 28-yr-old woman, comes to her primary care physician for advice. Her 25-yr-old brother, her only sibling, has developed renal failure. He & her parents, as well as the nephrologist, have urged her to be tested for suitability as a kidney donor. She is extremely anxious and says that while she feels guilty, she does not want to be a donor. How can the doctor help her make a decision? How can this decision be communicated to her parents and brother? 300/330 appleby 14

Case Study #2 Mr. Minto is a 67-yr-old man who has been institutionalized for mental retardation since he was 1 year old. His mental age is estimated at a 3-yr-old level, and his IQ is 20. He develops acute nonlymphoblastic leukemia. His guardian says, “His life is of such poor quality. Why should we try to extend it when medical treatment would be painful? He wouldn’t understand what was going on.” How should the nurse respond to this? How can she articulate her perspective and/or concerns? 300/330 appleby 15

Case Study #3 A frail patient recovering from recent surgery has been receiving intra-muscular antibiotic injections four times a day. The injection sites are very tender, and though the patient now is able to eat without problems, the intern refuses to change the order to an oral antibiotic because the absorption of the medication would be slightly less. What should the nurse do? How can he explain his ethical concerns to the intern? 300/330 appleby 16

What Connections do you see between the Principles and these Moral Theories AUTONOMYAUTONOMY BENEFICENCEBENEFICENCE NON-MALEFICENCENON-MALEFICENCE JUSTICEJUSTICE UTILITARIANISMUTILITARIANISM DEONTOLOGYDEONTOLOGY VIRTUEVIRTUE ▫NATURAL LAW FEMINIST / CAREFEMINIST / CARE 300/330 appleby 17

AUTONOMY Why would the utilitarian support or limit patient autonomy? Why would the deontologist support or limit patient autonomy? Why, or how, would the virtue ethicist support patient autonomy? Why, or how, would patient autonomy be respected by the care and/or feminist ethicist? 300/330 appleby 18