Critical analysis of moral and ethical dilemmas in occupational therapy

Moral and Ethical Dilemma in Occupational Therapy

It is a generally accepted fact that the aged population across the world in increasing as a result of better general health consciousness and technology to prevent, treat and cure illnesses that would have caused death just a few years ago. The phenomenon of greater longevity is however not without inherent problems of its own. Indeed, it has created an increasing amount of problems, not least in terms of the burden upon national health care for those in need of it.

In more specific terms, the phenomenon of elderly care in occupational therapy is also not without its problems. Many ethical dilemmas are for example created, where there is a sense of conflict between a carer's personal code of ethics and values, legal codes and requirements, and the institutional code of conduct. This is the case with Mrs. DN, the case study of focus in this discussion.

Although Mrs. DN is clearly in need of health care, her devoted visits to her husband's institution violates the Medicare requirement of being mostly homebound. It is also however a fact that these visits places severe strain on her health to the detriment of her own recovery process. Several alternatives therefore need to be considered before a final decision can be made regarding the continued provision of care to Mrs. DN.

In order to do this, several viewpoints regarding ethical theories will be considered, including utilitarianism, community ethics, and deontology. In order to provide Mrs. DN with the optimal care that she needs, it may be not only possible, but also necessary for the carer to revise her personal set of ethical and moral codes, while attempting to bring these in line with institutional values while also not abandoning Mrs. DN to her fate.

Ethical dilemmas are inherent in all the caring professions. Sometimes legal issues and ethical issues can simply not find any common ground, in which case a compromised by both sides becomes necessary. The argument however remains that it is indeed possible to provide both optimal care to clients who need it while also adhering to a set of regulations that are put in place for the benefit of both clients and institutions.

INFORMATION NEEDED FOR ANALYSIS AND RESOLUTION

In order to analyze the problem, it is necessary to consider various different views on ethics, while also considering the legal issues attached to the case. Research of written work can for example provide valuable insight not only into the specific problem, but also into the issues surrounding it.

Nalette (2010) for example goes to the very heart of the problem with the assertion that managed care practitioners often have to find a balance between their own sense of commitment to their patients and problems, while also remaining committed to their employers in terms of fiscal and institutional accountability. When considering the wider perspective of the countrywide health care system, however, the author also states that the U.S. system particularly has been shown to be ineffective. This is said to be the result of unjust resource distribution. In other words, while the United States has sufficient resources to support the health care needs of its citizens, the system is not applying this funding in such a way as to optimize care for those who need it most. This is particularly so in what the author refers to as "conventional practice," where health care paradigms, norms and regulations are no longer sufficient to handle the changing demographic to which it is required to cater.

In order to consider the problem in terms of specific situations, Nalette (2010) includes various ethical considerations. These may also be used to apply to the case study in question. Firstly, for example, the author considers the attempt to balance ethics with institutional efficiency in terms of human relationships, and particularly the moral nature of the relationship between a carer and a client. Secondly, the author pays attention to the fact that health care resources are by nature limited, and an ethics of constraint is applied. Thirdly, the author considers the practitioner's responsibilities in terms of both these apparently divergent concerns within the profession.

In terms of an ethical relationship with clients, the physician is to concern him- or herself with the responsibility of helping the client to overcome health conditions in terms of the specific requirements and concerns of the client. At all times, the general professional code of ethics requires the carer to do the greatest good possible while doing the least possible harm. In short, human relationships must be seen in terms of "mutual respectfulness, helpfulness, and truthfulness" (Nalette, 2010). In terms of occupational therapy, or any other kind of caring profession, the practice is then to be based upon the carer's sense of the patient's humanity, while operating from a basis of compassion.

The problem is however that this compassionate practice needs funding in order to operate effectively. Health care resources are not infinite. Hence the inclusion of rules and regulations that determine the allocation of funding for certain types of care. There are several levels of constraint at both the general social and individual organizational level. The problem is then that a lack of resources means a lack of care availability. This translates to eventual harm to patients, which is a violation of one of the fundamental health care paradigms.

For this reason, there is a need not so much to increase resources, but to apply resources in such a way that patient care and benefit are optimized. There are two possibilities to ensure this: either revise institutional standards and requirements in order to allocate sources in a more efficient way, or change the care paradigm itself. This will be considered in more detail when discussing the case study itself.

Carroll (2007, p. 143-144) for example suggests a careful scrutiny of the possible discrepancies between the laws and rules of the profession and the personal moral and ethical values held by medical professionals. It is important to maintain a set of rules and policies to ensure that health care resources are allocated fairly. However, in the absence of fairness, these should be modified.

When not modifying rules and policies where these result in inefficient care to those who need better services, the author suggests a supplementation of pro bono services instead. When including this type of service in the clinical setup, physicians enable efficient care to those who need it, while adhering to the institutional drive for financial survival as well.

Again, this can be offered at two levels; by referring the patient to a free clinic, or at another level, to provide pro bono services within the institution itself. This is particularly helpful when considering the very specific and specialized care that some patients need, along with building a relationship between a specific carer and client. This becomes possible at the institutional level when patients receive specialized care at a reduced price or for free.

In this, it is also important to distinguish between ethical codes and theories. Codes of ethics may be based upon ethical theories, but vary according to individuals, institutions, and their view of what is important in terms of human relationships and professional considerations. For an individual, for example, an ethical code would include maintaining honesty in his or her communications, while institutions may consider it ethical practice to provide optimal care at a certain amount of compensation, or for free to certain deserving individuals.

Ethical theories have been constructed by philosophers and thinkers over the centuries in response to what they observed as important during their respective lifetimes. These are often used to construct individual or institutional codes of ethics. When considering ethical dilemmas, it is therefore often helpful to first refer to the original ethical theories upon which institutional and individual ethical codes came to be based.

Bevir and O'Brien (2003, p. 10) mention John Macmurray's ethical theory as an example, where he defined ethics in terms of relationships among people and constructed a community-based ethical theory, as opposed to an ethical code based upon ideas such as the common good. In the health care profession, the most applicable ethical theory should then rather focus upon communal relations rather than upon ideological ideals, because health care considers human well-being.

De Sousa e Brito (2008, p. 20) takes this a step further by suggesting that the carer place him- or herself in the place of the client to determine the best course of action in terms of preference. This then also bases the ethical code not so much on ideology as upon the human relationships involved in the caring process. It is as it were the "duty" of the health care professional to care for the well-being and preferences of those in his or her care.

This can also be said to apply to the aged population, many of whom prefer to remain independent for as long as possible after their retirement. Kerridge, Lowe and McPhee (2009, p. 306) for example note that institutionalized older people tend to deteriorate as a result of the perception of almost being imprisoned, with restricted freedom. 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 for as many people as possible.

Course of Action 1

The first course of action open to the health care worker is to examine the discrepancy between the institution's regulations and the needs of its clients. 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.