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Ethics in the nursing and occupational therapy communities is an ongoing concern that is being addressed in a number of different arenas and manners. This paper discusses national and international frameworks that have been created to address, define and provide ethical behavior guidelines for the healthcare communities that comprise measured and timely responses to the ethics issue as it pertains to those communities. Specifically, the paper will look at ethical decision making in healthcare regarding patient consent; how it is presented, used and documented. Additionally, the paper will seek legal and ethical frameworks as defined by a variety of Australian and international healthcare and medical entities.

National and International Ethical Frameworks

A number of organizations have established guidelines for ethical behavior by the members of those organizations. International and national healthcare organizations, such as the World Health Organization (WHO) and the United Nations (UN) have set forth guidelines that affect how not only their individual members, but entire countries behave. As an example, in 1948 the UN created the Universal Declaration of Human Rights that called on all nations and peoples to reaffirm "their faith in fundamental human rights, in the dignity and worth of the human person and in the equal rights of men and women" (United Nations, 1948) and by doing so ensured that each person implicitly had the right to consent to actions taken on or in behalf of the individual. By ensuring that each person in the global community participates in an equal manner and on equal footing, a standard is set that allows individuals the opportunity to exercise their right to say no, and conversely their right to say yes as well.

Other international organizations, such as the WHO, have provided additional and more specific guidelines regarding how issues in healthcare should be handled, and by whom. The WHO charter states that all peoples should benefit from medical, psychological and related knowledge in order to gain the fullest attainment of health and that "informed opinion and active cooperation on the part of the public are of the utmost importance in the improvement of the health of the people" (WHO, 1948, p. 1). In other words, individuals should take an interest in the own lives and gain the knowledge needed to make informed decisions concerning their health and well-being.

The Australian Charter of Health Care Rights (2014) defines seven specific areas of concern for Australian citizens. Those rights include; a right to health care as well as a right to safe and high quality care. The rights also extend to a right to be included in decisions about that care and a right to privacy and confidentiality. The other three stated rights include the right to be shown respect and dignity, the right to comment on care and have the comments discussed, and the right to be informed about the costs and options of the available treatments in a clear and open manner.

The United Nation also developed a document that contains the understanding of just what was expected of the international health care community with the introduction of the Convention of the Rights of the Child. The Convention, according to the United Nation's website became the most "rapidly and widely ratified international human rights treaty in history" (United Nations, 1989). The convention created a set of guidelines for treatment of children as human beings instead of "passive objects of care and charity." Since its creation the Convention has been instrumental in changing how children and youth patients are viewed by the medical community.

Thomas and Weisstub (2008) discusses the ethics and guidelines from different charters and conventions and concludes that many of the organizations have been quite effective in changing cultures around the world regarding health care, and in particular the manner in which children are now viewed and the rights that children are now expected to have.

In 1964, the World Medical Association prepared the Declaration of Helsinki. The Declaration was created as a way of providing guidelines to physicians engaged in biomedical research involving human subjects (WMA, 1964). One of the most intriguing aspects of the Declaration of Helsinki is that for the research subject there is an explicitly stated right to safeguard his or her integrity and that "every precaution should be taken to respect the privacy of the subject and to minimize the impact of the study on the subject's physical and mental integrity and on the personality of the subject" (p. 1). According to the Declaration, the physician is responsible for ensuring that the subject has the right information to make an informed decision, and that information includes the fact that the subject can change his/her mind at any time and for any reason.

Ethical theories and models

There are always going to be ethical issues within any organization, and when the organization is a medical clinic, hospital, or institution dealing with patients on a daily basis, and those patients are looking for the best medical treatment available, nurses and other practitioners need always be on their best behavior; always acting in an ethical manner. Current literature provides a number of studies addressing the issue of ethics in general and more specifically medical ethics.

This abundance of literature promotes discussion and response, especially in healthcare and healthcare management. Gallagher (2007) helped define areas in which ethical behavior and actions can best be described as being in possession of ethical knowledge, and then acting on that knowledge. He further expounds that ethical perception allows an individual the capability to see a situation which requires ethical reflection. According to Gallagher, ethical reflection allows the individual to gather the knowledge, talked about above, resulting in the determination of the correct ethical behavior, which then allows the individual to 'be' ethical. Gallagher follows the tradition of both Socrates and Aristotle (both Greek philosophers) who believed that ethical behavior was of paramount importance to a stable society. Socrates believed that a person had to become 'self-aware' and for the most part would act in a good manner, while Aristotle believed that while mankind was inherently good, not realizing full potential of that goodness could lead to a life filled with misery and disaster. When Gallagher is defining ethical behavior, he is only continuing the fine tradition started thousands of years ago by these famous Greeks.

Kert, Uz, and Gecu (2014) state that the most effective manner in which to cope with ethical issues is by implementing the ethical decision-making models offered by various researchers. One of the models offered as an example comes from Syracuse University (2015); it offers an 8-step process for making ethical decisions. Those steps include; 1) identifying the problem, 2) identifying the potential issues, 3) reviewing the ethical guidelines, 4) knowing the laws, regulations and policies, 5) consultation with stakeholders and relevant personnel, 6) considering the various available options, 7) listing the consequences of the options, and 8) deciding on a specific course of action that will yield the best results.

Mules (2010) stated there are a number of responsibilities are assumed by businesses as business entities. Medical practices are, in essence, small business entities, therefore they have responsibilities to their patients similar to the responsibilities that businesses have to their customers. According to Mules, the business responsibilities include the interests of stakeholders, customers, management and employees. Comparatively, the medical practice has stakeholders that consist of the doctors, patients, nurses, administrators and even family members. Mules believes that treating the stakeholders in a fair manner and that all stakeholders should know, understand, comprehend and adhere to ethical behaviors is a good model for business. Another study (Keshmiri, Sohrabpour, Farahmand, Kamran, Shahi, Saleh, Shirazi, 2013) determined that a proficient ethical model to follow is one that allows for teamwork-based care through implementing ethical standards, guidelines and values in teamwork for small-group settings.

Code of Ethics, Position Statements, Code of Conduct

Each organization is likely to have a Code of Ethics, Code of Conduct, or a Position Statement that the individual nurse or therapist will be asked to read, understand and comply with. Standards are set for a wide variety of organizations; standards that address many ethical issues such as financial considerations, patient consent, treatment equalities, and as Kulju et al. (2013) stated 'professionalism and self-determination'.

There are differences between a Code of Ethics, Code of Conduct and a Position Statement that need to be understood by the individual nurse or therapist, but primarily all three provide guidance to the individual. As an example the International Council of Nurses (ICN) has a Code of Ethics that is "a guide for action based on social values and needs" (ICN, 2012). According to the ICN website the Code spells out the fact that inherent in nursing is the respect for a patient's right to life, right to dignity and right to be treated with respect. Additionally, the Code of Ethics is presented as a nurse's guide to everyday activities and choices with an emphasis on the nurse's right to say no to any activities that do not focus on patient care and healing. Kerridge, Lowe and Stewart (2009) provides additional information on medico-legal issues using an approach that assists medical nurses with information on ethical issues primarily from an ethical viewpoint. Kerridge et al. (2009) found that teaching ethical behavior, and then adhering to it can be based on a number of common sense scenarios; their book discusses many of the day-to-day situations that affect nurses not only in Australia but around the globe as well. Regard & Isled (2012) provides a complementary tome to Kerridge et al. that covers updated standards and advice for nurses in Australia in particular.

What the author of this paper found interesting was that for occupational therapists Position Statements address more than just the ethics of how to treat certain patients, some statements provide insight into the 'professional identity' of occupational therapists. For example, Sahrmann (2014) states that many health care professions are more easily recognized as being concerned with preventing, diagnosing and treating patients suffering from dysfunctions of the system when compared to a healthcare profession such as occupational therapy.

Sahrmann applauds the fact that the American Physical Therapy Association (APTA) adopted a statement that transforms physical therapy from a "technical field to an identified profession" (p. 1035). The question could be asked as to whether such a position statement addresses ethics, which could be answered by the concept that an official statement that provides the therapist with an understanding of who and what he or she is attempting to accomplish via healthcare for individuals could be considered an ethical approach. Not knowing what is being attempted means that the vast majority of the time, nothing noteworthy will likely be accomplished. Unlike nurses who are addressing specific treatments for specific ailments, injuries or diseases, an occupational therapist is usually addressing patient care in a preventive mode. Just because the therapist works more in a preventive mode than his/her counterparts does not mean facing less ethical circumstances, and a Code of Ethics by the Australian Association of Occupation Therapists (OT Australia) has addressed those issues in a comprehensive manner.

A summation of the Code states that the ethos of the profession requires its members to discharge their duties and responsibilities at all times with no individual professional, ethical or moral compromises with any individual whom they have professional contact (2001). The Code not only addresses such items as Professional Conduct it also addresses Professional Competence, Professional Relationships and Responsibilities, and Professional Integrity.

Australian Laws of Consent

A search for relevant Australian laws that are applicable to the issue of consent provides a plethora of rules and regulations that apply directly to the issue.

There are laws of consent for both the occupational therapist profession as well as for nursing professionals. A search of current literature for occupational therapists provides a directive from the New South Wales government (2005) that gives specific and detailed information on how exactly occupational therapists should gain patient consent and under what circumstances patient consent is required. The directive answers questions such as why is it necessary to obtain patient consent and why is it necessary to warn the patient about material risks.

It also clarifies when consent is required and whether the consent has to be written or verbal. The directive also provides guidance on whether a patient can refuse treatment and what type of information can be legally withheld from the patient. The directive specifically addresses who can be legally responsible for the consent, as well as when and who obtains the consent from the patient.

The Australian Commission on the Safety and Quality in Health Care (2008) presented the world with the Australian Charter of Health Care Rights. The document applies to all health settings anywhere in Australia including private and public hospitals, general practices and clinics, and any community medical facilities and environments. The document spells out the rights of the patients as well as the rights of their families, the health care and service providers. The charter seeks to develop a "common understanding of the rights of people receiving health care" (Australian Commission, 2008).According to much of the available information, patient consent obtained by nurses is not that much different than what is obtained by occupational therapists.

Diamond (2008) provided the following information on Australian nursing law regarding patient consent by stating that the patient in entitled to a change of mind and has to be mentally capable and understanding of the nature of the procedure as well as the risks involved. Diamond further states that there should be no coercion, inducement or untoward influence on the patient and that all significant information on the risk of any substantial harm has to be provided to the patient. Consent, in both nursing and occupational therapy, can best be described as a patient knowing and understanding the possible risks and outcomes of any procedure gives the therapist or doctor permission to continue. The patient can change his/her mind at any time, and must be willing to accept any possible outcomes to the procedure(s).