At the same time, optimized care is mandated by the medical code of ethics. If older people are therefore sufficiently able to function independently, access to care should be available to them, because this is their preference, and professionals have an obligation to honor these preferences. In the medical profession, there are no simple solutions to the discrepancy between the fiscal limitations of health care and the ethical obligations of professionals to their clients. The best ideal is to use specific codes of ethics in order to find an acceptable solution that satisfies both the drive to remain financially viable and the obligation to provide all clients with the optimal care.

DILEMMA

As mentioned, above, the dilemma involves Mrs. DN, an elderly woman who suffered from a debilitating stroke that left her in a wheel chair. Because she was generally at home, she had the right to home care according to the Medicare requirements for payment. However, the dilemma arose when her husband had a cardiac event and had to be institutionalized. Mrs. Den's devotion to her husband obliged her to visit him for long periods of time every day, regardless of warnings that this could be to the detriment of her recovery and her general health. She can only leave her home with the help of family and friends, and is assisted to her husband's bedside until she returns home again.

The problem with this is that she is no longer able to meet the obligations stipulated for receiving home care. She cannot for example keep her regular appointments with her health care professional anymore, as these interfere with her daily visits to her husband. For Mrs. DN, visits to her husband take precedence to her commitments and obligations regarding her own health. In ethical terms, there are various viewpoints that should be considered.

There are three basic viewpoints that should be considered:

1) Mrs. DN bases her ethical decisions upon her emotional relationship with her husband, and the fact that he had always supported her in her times of need. She feels ethically obligated to be with him in response to his tireless care over the years of their relationship. This obligation is more important to her than any regard for her own personal well-being. She is unlikely to change this, regardless of any attempts to reason with her.

2) The health care institution and insurer's viewpoint is that Mrs. DN is violating the terms of her right to home care. Violating these terms disqualifies her from Medicare benefits, which can then again be applied elsewhere for other deserving clients. This viewpoint is based upon the consideration of fiscal efficiency, where resources are limited and applied only when the client meets all the necessary obligations.

3) In the middle of these divergent viewpoints is the health care professional in charge of Mrs. Den's case. The health carer's personal ethics obliges her to provide Mrs. DN with the care that she needs. However, she is also obliged to uphold the legal principles and rules that regulate her health institution. If Mrs. DN can therefore not be convinced to fulfill her obligations in these terms, she will have to be removed from the facility that allows her to have home care. This would however violate the carer's personal sense of ethics, which demand that Mrs. DN receives the care she knows she needs.

The health care worker is then faced with a number of difficult choices regarding her course of action for the future. She could for example, as suggested by Carroll (2007), examine the discrepancy between the institutional regulations and the needs of clients such as Mrs. DN and try to convince the committee to change this. She could also try to convince Mrs. DN to change her schedule. Alternatively, she could provide an environment in which Mrs. Den's situation is modified to find a compromise between her drive to be with her husband and her need to care for her own health and rehabilitation. Because there was not way in which Mrs. DN would be convinced of her need to spend fewer hours with her husband, this course of action was discarded as unlikely to be successful.

The care worker then decided that the two remaining courses of action to consider included an attempt to reveal the discrepancy between institutional regulations and Mrs. Den's need for care, or alternatively to find an arrangement in which Mrs. DN could both receive care and visit her husband for as long as she likes. A community-based ethical theory is likely to be in order here, along with the utilitarian viewpoint; creating the best possible outcome...

When considering the community-based ethical viewpoint, the needs of the client must be taken into account in terms of the institution's ethical obligation to care for the community in which it functions. Health is a basic human need, and should therefore be at the heart of the institutional care paradigm. At the same time, the institution must provide the best possible care to as many as possible of its clients, according to the utilitarian theory.
Hence, this course of action would involve a thorough examination of Mrs. DN's needs and the institution's list of obligations for Mrs. DN. By definition, Mrs. DN remains homebound. She can only leave with the assistance of her family members and friends. Furthermore, when she visits her husband, this is not a highly energetic endeavor, but does place considerable strain upon Mrs. DN, which makes her health care needs even more pronounced.

This in turn could affect the economic impact of continuing to provide Mrs. DN with healthcare. This is an important consideration in terms of the increasingly aged demographic in the United States and across the world. Rice and Fineman (2004, p. 2) for example emphasize that the need for healthcare among this demographic will place increasing strain upon such services, and the financial implications must be addressed. On the other hand, financial implications cannot be the only concern in Mrs. DN's case.

The stucy of cooperation and mutually beneficial interaction among human beings is known as the theory of reciprocity (Smead, 2009, p. 34). Not only the economic implications of health care for the elderly, but also the rights and quality of life of this demographic, must be kept in mind. From this perspective, it is therefore perhaps better to consider how a compromise between economic and human rights considerations might be achieved.

According to Bever (2002, p. 22), social relationships should have as their focus the maximum benefit for all concerned. This also promotes a compromise between cost and benefit for both the health care institution and the client.

The health care worker can then approach her superiors with the problem, asserting that there is no specific elements in the institutional documents that apply to Mrs. DN's situation. She is for example homebound, but spends significant amounts of time away from her home. The carer can then explain that the rules must be modified to include Mrs. DN's situation.

Outcome 1a

The first possible outcome is that the committee could accept the carer's argument and modify the rules to include Mrs. DN's situation. This would then eliminate the problem of Medicare payment and Mrs. DN will be able to continue receiving care at her home. Furthermore, the carer's sense of ethics will also be satisfied, as a balance will be obtained between her obligation to her client and her obligation to her institution.

Outcome 1b

The second possible outcome is that the committee may not accept the carer's request, which leaves Mrs. DN without care. If the carer honors this decision, she knows that Mrs. DN will suffer for a wrongdoing no greater than caring for her husband. Furthermore, the carer's belief that the institutional regulation is in fact erroneous could cause her to choose her personal sense of ethics above those of the institution, and provide Mrs. DN with care regardless.

This in turn could lead to legal difficulties for the carer as well as for Mrs. DN. Both could be prosecuted for a violation of institutional and insurance ethics. This could again result in lengthy and expensive legal battles; something that neither the carer nor Mrs. DN may be financially equipped to survive.

Course of Action 2

Perhaps a better course of action for all involved is to find a compromise between the existing institutional regulations and Mrs. DN's need for care. The carer could for example request the committee to provide a platform for free home care to Mrs. DN. This therefore would not restrict Mrs. DN to certain regulations, while also enabling her to continue enjoying the benefit of optimal healthcare. Another possibility for free care is to refer Mrs. DN to a free care clinic for her health care needs.

Outcome 2a:

Being provided with free home care, Mrs. DN is freed from the practical Medicare obligations that limit her…