Abstract
This paper seeks to explore the concept of ethical dilemma as faced by a medical practitioner, in this case, a doctor who is taking care of a patient who has just had a stroke and is physically incapacitated at the patient’s home. There are several factors that cause the ethical dilemma. These factors make this case viable as a good example in the explanation of ethical dilemma as a topic.
One of the factors is the obvious expectations of the patient, who, in this case, may also be interpreted as a consumer or a client of products provided by someone. The other factors that contribute to the dilemma are the expectations of the medical practitioner’s employer or a supervisory body as far as this case is concerned.
Finally, there is the doctor’s personal values, sense of professionalism, moral philosophies and perceived social values. This paper seeks to explore the ethical principles that are involved in this case and also suggests the methods available in the solving of ethical dilemmas.
The specific dilemma, in this case, is whether to treat the patient or not, since her medical diagnosis suggests that she urgently needs occupational therapy services, though she is only covered by Medicare, which is a government health insurance provision which has a questionable history of payments for home-care services.
Ethical principles
The patient, in this case, was physically incapacitated and was obviously restricted to her home; hence, she missed her daily appointments at the hospital. This, however, does not fit into the stipulations of the Medicare requirements that dictate that beneficiaries should have infrequent visits on the health facility, as well as the period under which home services provided should be short (Delay, 2005).
This is, however, a vague statement that leaves room for different interpretations as different stakeholders in the healthcare sector may wish.
The fact that the client’s expectations, based on her consumer rights that she is entitled to, medical services at home due to her condition, as well as the doctors personal obligation to provide medical services to the patient who needs it are in conflict with the fact that the interpretation of the regulations of Medicare may lead to lack of payment for services rendered. The particular ethical principles that are inherent in this case include the following:
Justice: the doctor, in this case, feels a strong sense of duty to serve the patient, though the patient can’t clearly satisfy the regulations stipulated for the qualification for payment of services rendered by Medicare. The just thing to do in this case is to provide justice to the patient and give her the medical services that she requires (Garber, 2008).
Beneficence: the patient, in this case, believes that she truly needs the home care services from the doctor and the services, if provided, will be highly beneficial for her. This belief is also held by the doctor though the benefit enjoyed by the patient will end up in conflicting with both the ethical and the legal tenets of healthcare service delivery for patients covered only under Medicare (Hartmann, 2003).
Veracity: though the doctor has great respect for patient autonomy, the professional obligation to inform others while acting truthfully about the situation in which the patient is in relation to the homebound services and the inability to make payments for services rendered, contradicts the autonomy principle.
Fidelity: there is obviously a dilemma, as the doctor harbors fidelity as a principle in which he has to uphold out most commitment to the patient, his own personal moral principles, his hospital and the government medical insurance scheme (Cohen, 2007).
Autonomy: there is the obvious question of whether to uphold the patient’s right to receive homebound occupational therapy, or the doctor’s personal autonomy in deciding whether he should give the service. In medical schools, doctors are taught the rules and regulations of their practices, as well as how to make legal judgment in regard to the treatment of patients.
There is, however, no training whatsoever on the non-medical issues that may be faced by doctors, such as the patients’ financial problems, and this is where the preference of the patients’ role is considered.
Ethical theories applicable to the dilemma
This case is also the case in most dilemmas in the health care sector. It involves ethical principles that are based on all the major ethical theories.
The theories are: consequential, where the doctor seeks to benefit the patient by saving her life from medical suffering; virtue-based ethics, where the doctor seeks to give the patient the same services that he thinks he would need if he were in the same position as the patient; value-based ethics, where the doctor seeks to uphold truthfulness, as well as professionalism by serving his patient effectively as his job requires; deontology, where the action, moral principles involved, and the consequences of the action are in question; finally, ethics of care, which is based on the fact that the doctor, through the process of treating the patient, has developed a concern for the patient’s care, and is, therefore, obliged to treat her.
As deontology suggests, the doctor should act in accordance with ethical rules and principles such as beneficence, autonomy, fidelity, justice, non-malfeasance and veracity, which then leads to the decision being made based on the doctor’s duty, rather than the results of his actions.
The resolution
The doctor, in this case, resolves to consult with the patient’s family, after which he decides to finally stop providing home-based care and direct the patient to outpatient rehabilitation. This decision was based on the CELIBATE method, which is an acronym for Clinical Ethics and Legal Issues Bait All Therapists Equally.
The decision, in this case, is based on the clinical situation, the inherent ethical issues, the inherent legal issues, the information available, brainstorming on action steps, analysis of action steps, the actual action and the evaluation of the results thereafter. The whole process can be, however, divided into three phases. These phases are the ethical encounter, the loading and the unloading.
The ethical encounter
This phase is characterized by the interaction of the human aspects and the organization aspects that are related to the ethical dilemma in question.
The parties involved in this phase are: the patient; the patient’s family; the doctor; the doctor’s home agency that employs him; the State Occupational Therapy Board that holds judicial powers as far as occupational therapy is concerned; and the Occupational Therapy Association which regulates and sets codes of ethics for occupational therapists, as well as the scope and standards of practice.
Ethical loading
In this phase, the doctor makes an analysis of the various issues involved in the ethical dilemma. This is, in relation to any laws that may be broken by the decision of the doctor, risk or the probability of being an ethical issue that has no legal implications whatsoever.
This dilemma involves the decision of the doctor to continue providing the patient with occupational therapy at home or to stop the service, while there is the obvious necessity to treat the patient though the client is unable to meet the stipulated criteria for qualification to cover under Medicare.
The legal issues that guide the doctor’s decision are based on the rules and regulations of Medicare, as well as the regulations are put in place by various organs that oversee the operations of doctors in such a case.
The decision is based on the available regulations, codes of ethics and standards of practice, and this phase is mainly concerned with the discovery and the weighing of legal and ethical risks that may arise if any possible course of action is taken, as well as analyze methods of decision making and future courses of action.
Ethical unloading
The doctor, in this case, weighed the ethical and legal aspects and realized that there were no legal violations in the possible courses of action that were available. He, therefore, concentrated his decision-making process on the ethical implications, as there were no separate legal actions involved other than those dictated by the ethical implications.
The actions of the doctor were directly related to the upholding of the identified deontological principles. The doctor does this by following his professional obligations as dictated by the Medicare and state practice regulations, and still ensuring the personal interpretation of the regulations do not interfere with it.
It is advised that when faced with a similar dilemma, medical practitioners should refer to the regulation in its most restrictive state so as not to cause further dilemmas by confusing the elements of the regulation (Lo, 2009). This phase is called “ethical unloading”, since it is where the doctor “unloads” the ethical burden involved in the dilemma through his choice of actions based on his conscience, training, and experience.
In this case, the patient’s autonomy was still upheld and she was also advised on how best to receive affordable medical care while still under the services of Medicare, in out-patient rehabilitation with the option of any other health care facilities that may be deemed viable.
The doctor’s decision also ensured beneficence and non-malfeasance since it ensure that, by the patient undertaking out-patient services, there was continuity of the treatment that the patient needed, as well as the fact that these services were enjoyed by the patient in an environment that was acceptable to her.
In any ethical dilemma, the ethical encounter is a phase where there is an analysis of all the demographics that are inherent in the case. The ethical loading phase, on the other hand, is involved with diagnostic process and the analysis of the ethical and legal issues inherent in the dilemma, as well as formulating a plan for intervention by investigating and selecting the best cause of action.
The final phase, that is the ethical loading phase, is involved with the application of the chosen cause of action with the sole aim of resolving the ethical dilemma in question, as well as reflecting on the effectiveness of the chosen action in comfortably satisfying the needs of all the parties involved in the dilemma.
Conclusion
The scope of this case is not to identify the weaknesses of the provision given by the government for the access of affordable healthcare to everyone, but to recognize one of the dilemmas that medical practitioners face in their everyday provision of medical care to patients.
This case presents an ethical dilemma that is common in the medical and health provision sector and specifically by most home-care health practitioners, in their quest to satisfactorily serve the patient’s needs while, at the same time, have to struggle with complex financial questions.
According to Jonsen, Seigler, and Winslade, (2005), there is a proposal to merge the much-valued freedom of choice with the available universal health coverage mechanisms that are in place, such as Medicare.
It is common knowledge that healthcare providers face similar dilemmas in almost all countries in the world, as there has been substantial advancement in patient awareness and education, which has led to increased applicability and sensitivity of patient’s autonomy and basic rights, as well as awareness and legal developments in the field of biomedical ethics in the world.
It is now important to health practitioners to be prepared to not only concentrate on decisions involving the medical needs of the patient, but also on the socio-cultural and ethical factors that are inherent in any such case. This can be boosted by the health care providers seeking sound knowledge on the ethical theories and principles that are related to work, so that they are better placed to make wise decisions in case of ethical dilemmas.
References
Cohen, M. (2007).101 ethical dilemmas. New York: Taylor & Francis.
Delay, J., V. et al. (2005).Center for Medicare and Medicaid Services. Home health manual (Rev. 302): Chapter II-Coverage of services. Baltimore (MD): Center for Medicare and Medicaid Services. Web.
Garber, P., R. (2008).The Ethical Dilemma.New York: Human Resource Development.
Hartmann, K. (2003). Center for Medicare and Medicaid Services. Home health manual (Rev. 302): Chapter II-Coverage of services. Baltimore (MD): Center for Medicare and Medicaid Services. Web.
Jonsen, A., R, Seigler, M. & Winslade, W., J. (2005). American Occupational Therapy Association. Standards of practice for occupational therapy. The Association. Web.
Lo, B. (2009). Resolving ethical dilemmas: a guide for clinicians.New York: Lippincott Williams & Wilkins.