Ethical Dilemmas in Occupational Therapy: Elderly Care

Introduction

It is a generally accepted fact that the aged population across the world is 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 number of challenges, not least in terms of the burden placed upon national health care systems for those in need of care.

In more specific terms, the phenomenon of elderly care in occupational therapy is also not without its problems. Many ethical dilemmas arise 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 at the center of this discussion.

Although Mrs. DN is clearly in need of health care, her devoted visits to her husband's institution violate the Medicare requirement of being mostly homebound. It is also a fact that these visits place 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 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 — without abandoning Mrs. DN to her fate.

Ethical dilemmas are inherent in all caring professions. Sometimes legal issues and ethical issues simply cannot find any common ground, in which case a compromise by both sides becomes necessary. The argument remains, however, that it is indeed possible to provide 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 viewpoints on ethics while also considering the legal issues attached to the case. Research of the existing literature can provide valuable insight not only into the specific problem, but also into the broader issues surrounding it.

Nalette (2010) 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 the fiscal and institutional accountability they owe their employers. When considering the wider perspective of the countrywide health care system, the author also states that the U.S. system in particular has been shown to be ineffective — 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 does not apply this funding in such a way as to optimize care for those who need it most. This is particularly evident 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 they are required to serve.

In order to consider the problem in terms of specific situations, Nalette (2010) includes various ethical considerations that may also be applied to the case study in question. First, the author examines 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. Second, the author pays attention to the fact that health care resources are by nature limited, and that an ethics of constraint must be applied. Third, the author considers the practitioner's responsibilities in terms of both of these apparently divergent concerns within the profession.

In terms of an ethical relationship with clients, the physician is to concern himself or herself with the responsibility of helping the client overcome health conditions in accordance with the client's specific requirements and concerns. 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 occupational therapy, as in any other caring profession, practice is to be based upon the carer's recognition of the patient's humanity, operating from a foundation of compassion.

The problem is, however, that compassionate practice requires funding in order to operate effectively. Health care resources are not infinite, hence the inclusion of rules and regulations that govern the allocation of funding for certain types of care. The problem is that a lack of resources translates to a lack of care availability, which in turn leads to harm to patients — a violation of one of the fundamental principles of health care.

For this reason, there is a need not so much to increase resources as to apply them in such a way that patient care and benefit are optimized. There are two possibilities for achieving this: either revise institutional standards and requirements in order to allocate resources more efficiently, or change the care paradigm itself.

Carroll (2007, pp. 143–144) suggests a careful scrutiny of 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, where fairness is absent, these should be modified.

When rules and policies are not modified despite resulting in inefficient care, Carroll (2007) suggests a supplementation of pro bono services instead. When including this type of service in the clinical setup, physicians enable efficient care for those who need it while also adhering to the institutional drive for financial survival. This can be offered at two levels: by referring the patient to a free clinic, or by providing pro bono services within the institution itself. The latter is particularly helpful when patients require specialized care and when the therapeutic relationship between a specific carer and client is of clinical importance.

It is also important to distinguish between ethical codes and ethical theories. Codes of ethics may be based upon ethical theories, but vary according to individuals, institutions, and their views on what is important in terms of human relationships and professional conduct. Ethical theories have been constructed by philosophers and thinkers over the centuries in response to the conditions of their respective times, and are often used to construct individual or institutional codes of ethics.

Bevir and O'Brien (2003, p. 10) mention John Macmurray's ethical theory as an example, in which he defined ethics in terms of relationships among people and constructed a community-based ethical theory, as opposed to one based on abstract ideals of the common good. In the health care profession, the most applicable ethical theory should therefore focus upon communal relations rather than ideological ideals, since health care is fundamentally concerned with human well-being.

De Sousa e Brito (2008, p. 20) takes this a step further by suggesting that the carer place himself or herself in the position of the client to determine the best course of action in terms of the client's preferences. This similarly grounds the ethical code in human relationships rather than ideology, framing care as a duty to attend to the well-being and preferences of those in one's care.

This perspective also applies to the aged population, many of whom prefer to remain independent for as long as possible after retirement. Kerridge, Lowe, and McPhee (2009, p. 306) note that institutionalized older people tend to deteriorate as a result of the perception of being almost imprisoned, with restricted freedom. At the same time, optimized care is mandated by the medical code of ethics. If older people are 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 approach is to use specific codes of ethics to find an acceptable solution that satisfies both the drive to remain financially viable and the obligation to provide all clients with optimal care.

The Ethical Dilemma: Mrs. DN's Case

The dilemma involves Mrs. DN, an elderly woman who suffered a debilitating stroke that left her in a wheelchair. Because she was generally at home, she had the right to home care according to Medicare requirements. The dilemma arose when her husband suffered a cardiac event and had to be institutionalized. Mrs. DN's devotion to her husband compelled her to visit him for long periods every day, regardless of warnings that this could be detrimental to 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 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, as these conflict with her daily visits to her husband. For Mrs. DN, visiting her husband takes precedence over her commitments and obligations regarding her own health. In ethical terms, there are various viewpoints that must be considered.

There are three basic viewpoints:

1) Mrs. DN bases her ethical decisions upon her emotional relationship with her husband and upon the fact that he 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, and she is unlikely to change this position 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 be applied elsewhere to other deserving clients. This viewpoint is based upon fiscal efficiency, where limited resources are allocated only when the client meets all necessary obligations.

3) In the middle of these divergent viewpoints is the health care professional in charge of Mrs. DN's case. The carer's personal ethics oblige her to provide Mrs. DN with the care she needs. However, she is also obliged to uphold the legal principles and rules that regulate her institution. If Mrs. DN cannot be convinced to fulfill her obligations under those rules, she will have to be removed from the program that allows her to receive home care — which would violate the carer's personal sense of ethics.

The health care worker is therefore faced with a number of difficult choices. She could, as suggested by Carroll (2007), examine the discrepancy between institutional regulations and the needs of clients such as Mrs. DN and attempt to convince the committee to change the rules. She could also try to convince Mrs. DN to change her schedule, or she could seek an arrangement in which Mrs. DN'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 no realistic prospect of convincing Mrs. DN to spend fewer hours with her husband, this option was set aside as unlikely to succeed.

The carer determined that two remaining courses of action merited consideration: attempting to reveal the discrepancy between institutional regulations and Mrs. DN's need for care, or finding an arrangement in which Mrs. DN could both receive care and visit her husband as often as she wished. A community-based ethical theory is likely to be appropriate here, alongside the utilitarian viewpoint of creating the best possible outcome for as many people as possible.

Conclusion

Utilitarian, humanitarian, and communal ethics all play an important role in reaching a final decision regarding Mrs. DN's situation. 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 approach is to use specific codes of ethics to find an acceptable solution that satisfies both the drive to remain financially viable and the obligation to provide all clients with optimal care.

In Mrs. DN's case, a compromise is both possible and necessary. Whether through revision of institutional regulations or through the provision of free or pro bono care, the goal remains the same: to honor the ethical obligation to a vulnerable client without abandoning either personal or institutional integrity. As the literature reviewed here demonstrates, the tension between resource constraints and compassionate care is a defining challenge of modern health care — one that calls for ongoing reflection, dialogue, and creative problem-solving by all stakeholders involved.

References

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Bevir, M., & O'Brien, D. (2003, January 1). From idealism to communitarianism: The inheritance and legacy of John Macmurray. History of Political Thought, 24. Retrieved from http://escholarship.org/uc/item/95m6q13r.pdf

Carroll, M. J. (2007, December). Physical therapists' perception of risk of violating laws and rules governing the practice of physical therapy and/or their personal moral and ethical values when failing to provide treatment for an uninsured or underinsured patient. Graduate College. Retrieved from

De Sousa e Brito, J. (2008, August 8). From utilitarianism to Kantianism: Bentham's proof of utilitarianism, Mill and Kant. ISUS X, Tenth Conference of the International Society for Utilitarian Studies. Retrieved from http://escholarship.org/uc/item/4zn812s7.pdf

Kerridge, I., Lowe, M., & McPhee, J. (2009). Ethics and law for the health professions.

Nalette, E. (2010, June 1). Constrained physical therapist practice: An ethical case analysis of recommending discharge placement from the acute care setting. Physical Therapy. Retrieved from

Rice, D. P., & Fineman, N. (2004). Economic implications of increased longevity in the United States. Annual Review of Public Health, 25. Retrieved from http://escholarship.org/uc/item/4912f66t.pdf

Smead, R. (2009). Indirect reciprocity and the evolution of "moral signals." Biology & Philosophy, 25. Retrieved from http://escholarship.org/uc/item/1f85b66x.pdf