4.

Ethical issues regarding

patients and community

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Introduction
 To be an effective manager, it is important to understand basic
legal and ethical principles that influence the work
environment including the legal relationship between the
organization and the consumer – the health care provider and
the patients
 Ethical behavior must also be described, because the health
care industry is fraught with difficult situations that involve
ethical dilemmas
 Ethical standards are considered one level above legal
standards, because individuals make a choice based on what is
the “right thing to do” or what one ought to do, not what are
the minimal actions required by the law

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 Introduction…
 Ethics or a right action involves a number of guiding
principles with which most community activists and service
providers would probably agree:
 Do no harm
 Respect participants' ability to play a role in determining
what they need
 Don't assume that professional staff or program
planners necessarily know what's best for a community
or individual
 Respect everyone's human, civil, and legal rights - issues
such as non-discrimination and cultural sensitivity

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Introduction…
 Do what is best for everyone under the circumstances
 Don't abuse your position or exploit a participant to gain
a personal advantage or to exercise power over another
person
 This refers to taking advantage of participants or
others for political, social, sexual, or financial gain
 Don't attempt an intervention in areas in which you're
not trained and/or competent
 Actively strive to improve or correct, to the extent
possible, the situations of participants in your program
and the community
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Importance of ethical behavior regarding
patient and community
 In addition to its simply being the right thing to do, always
acting ethically brings some particular advantages with it
 It makes your program more effective;
 it cements your standing in the community – respect, raise
money and public support
 it allows moral credibility and leadership in the community;
 it assures that you remain in good standing legally and
professionally - Medical professionals can lose their licenses,
and may be sued if not ethical

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What are the ethical issues that need to be
considered regarding patient and community?
 Health service providers have responsibilities in their
daily practice to handle the following ethical issues,
among others:
 Confidentiality
 Communication and consent
 Decision-making for incompetent patients
 Respect and equal treatment
 Decision on beginning of life issues
 Decision on end of life issues
 Conflict of interest

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Confidentiality

 Probably the most familiar of ethical issues -- perhaps

because it's the one most often violated/overlooked
 communications and information from participants in
the course of an intervention (including
conversations, written or taped records, notes, test
results, etc.) will be kept confidential
 It protects both participants and the organization from
invasion of privacy, and establishes a bond of trust
between the participant and the program

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Confidentiality…
 People have the right to control who has access to
information about them
 the ability to provide high quality medical care depends
on patients feeling free to communicate fully and
truthfully with their caregivers
 individuals could face stigmatization and discrimination if
certain medical information, such as about sexually
transmitted diseases or mental illness, is not carefully
protected
 Respecting privacy and confidentiality carries special
importance in an era of electronic medical records

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Confidentiality…
 No one but the individual working with a particular patient will
have access to information about or records of that patient
 records and notes are usually kept under lock and key, and

computer records should be protected by electronic coding

 Information may be shared among staff members for purposes
of consultation and delivering better services to the patient
 Information may be shared with staff members of other
organizations to improve services for the patient, or to contribute
to the other organization's reporting data
 Information is not confidential under certain circumstances -
legal requirements

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Communication and consent
 The right of patients to make decisions about their
healthcare and related issues depends on how likely they
are informed about the consequences of the decisions
 Service providers must provide capable patients and
community with all the information needed to make
decisions
 Patients are empowered to make treatment decisions by
being informed about their diagnosis and prognosis,
reasonable options, the harms and benefits of each option,
and the consequences of not having treatment

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Communication and consent …

 There are really three faces of consent

 Consent to sharing of information
 Informed consent for services, treatment, or
research - an informed consent form is important
in some cases
 community members consenting to the location or
operation of an intervention

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Communication and consent …
 However there are challenges to balance the right to
information with the need to avoid information overload
 How much information is adequate?
 How should complex medical information be communicated to
patients who may be frightened or feeling ill, and may have
trouble assessing risks, benefits and alternatives?
 Do all patients even want a great deal of information?
 Some may prefer to trust their health provider to do what is
best for them
 is it permissible for a provider to withhold information from a
patient because the patient does not appear to want it?

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Communication and consent …
 Competent patients have the right to refuse treatment,
even when the refusal will result in disability or death
 The physician has no obligation to offer a patient futile
or non-beneficial treatment
 To what extent patients and their families have a right
to services not recommended by physicians is
becoming a major topic of controversy in ethics, law
and public policy

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Communication and consent …
 There are two exceptions to the requirement for
informed consent by competent patients:
 Situations where patients voluntarily give over their
decision making authority to the physician or to a third
party. “Do what you think is best”
 where the disclosure of information would cause harm
to the patient
 It allows physicians to withhold medical
information if disclosure would be likely to result in
serious physical, psychological or emotional harm
to the patient
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Decision-making for incompetent patients

 Many patients are not competent to make decisions for

themselves
 Examples include young children, individuals affected
by certain psychiatric or neurological conditions, and
those who are temporarily unconscious or comatose
 These patients require substitute decision-makers,
either the physician or another person

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Decision-making for …
 The ethical challenges are
 Is paternalism (i.e. acting to bring about something
for another individual’s own good) ever
permissible?
 What criteria should be used to assess whether a
patient has the capacity to make his or her own
decisions about treatment?
 How much preparation and information should a
surrogate or proxy have before making a health
decision for someone else?

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 Decision-making for …
 The physician was considered to be the appropriate decision-
maker for incompetent patients
 In some countries patients are given the opportunity to name
their own substitute decision makers to act for them
 In some states specify the appropriate substitute decision-makers
in descending order (e.g., husband or wife, adult children,
brothers and sisters, etc.)
 If different family members, do not agree among themselves, the
senior member of the family decide or by voting
 But the decisions should be based on the patient’s best interests

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Respect and Equal Treatment
 The belief that all human beings deserve respect and
equal treatment is relatively recent
 In most societies disrespectful and unequal treatment
of individuals and groups was regarded as normal and
natural like:
 Slavery
 Discrimination against color, age, sex, race …
 Lack of respect and unequal treatment for women
 Clearly, these remains considerable resistance to the
claim that all people should be treated as equals

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 Respect …
 The medical profession has addressed the issues of
patient equality, rights and respect
 Physicians should not to permit considerations of age,
disease or disability, ethnic origin, gender, political
affiliation, race, sexual orientation, social standing or
any other factor to intervene or to provide the service
 In this regard ethical issues may be the only means to
prevent abuses of human rights rather than law or
disciplinary authorities

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Beginning of life issues
 Many of the most prominent issues in medical ethics
relate to the beginning of human life
 In many countries there are laws, regulations and
policies dealing with these issues
 Contraception - right of women
 Assisted reproduction - agreement is needed
 Prenatal genetic screening - decision is based on the
findings
 Abortion - as per law
 Severely compromised neonates
 Research issues

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End of life issues
 End-of-life issues range from attempts to prolong the lives of
dying patients through highly experimental technologies to
efforts to terminate life prematurely through euthanasia and
medically assisted suicide

 In between these extremes lie numerous issues regarding the

initiation or withdrawing of potentially life-extending
treatments, the care of terminally ill patients and the
advisability and use of advance directives

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 Conflict of interest
 A conflict of interest is a situation in which someone's personal
(financial, political, professional, social, sexual, family, etc.)
interests could influence his judgment or actions in a financial
or other decision, in carrying out his job, or in his relationships
with patients
 In community interventions, conflicts of interest may change --
to the community's disadvantage -- how a program is run or
how its money is spent
 Conflicts can also affect an organization, especially where a
Board of Directors is involved
 conflicts of interest are virtually always unethical

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Some examples of conflict of interest
 A decision by a program director to purchase office
equipment for the program from a company his wife owns
 A staff member entering into a sexual relationship with an
intern, a patient or someone they supervise
 A researcher financing a study with money from a company
that stands to benefit from a particular result of that study
 The researcher's conclusions could be influenced by what
the company wants

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conflict of interest…
 providing services to a family member or ex-lover
 The issues that exist between the two may reduce
both the objectivity of the therapist and the
effectiveness of the therapy
 A doctor in a public hospital owning an interest in a
private specialty clinic to which he refers patients
from the hospital
 A doctor referring patients to a pharmacy or
laboratory center for the interest of splitting fees

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grossly unethical behavior

 In some cases, grossly unethical behavior may stem from

taking advantage of a conflict of interest situation
 Having sexual relationships – even consensual sexual
relationships – Doctor – patient
 Exploiting for financial gain people with whom you have a
professional relationship
 Defrauding funders
 Denying necessary medical services to those uninsured and
unable to pay
 Discriminating in service delivery by race, gender, ethnicity,
etc.

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