Practical Ethics:

A Tool for the Ombudsman?

Sarah Trafton, JDFinger Lakes Health Systems AgencyRochester, NY

Presentation Outline

Why ethics? Ethical principles generally Ethical issues in long-term care Applying tools of ethics

Why Ethics?

Murky situations Conflicting interests Ombudsman role: person who

investigates complaints and mediates fair settlements, especially between aggrieved parties such as consumers and an institution

What is “Ethics”?

“That branch of philosophy dealing with values relating to human conduct, with respect to the rightness and wrongness of certain actions and to the goodness and badness of the motives and ends of such actions.”

“ethics” Dictionary.com. Dictionary.com Unabridged (v 1.1). Random House, Inc. http://dictionary.reference.com/browse/ethics (accessed: October 16, 2007).

“Ethics”, continued…

“That branch of philosophy dealing with values relating to human conduct, with respect to the rightness and wrongness of certain actions and to the goodness and badness of the motives and ends of such actions”

Key Elements of Ethics

Values related to human conduct, with respect to: Rightness and wrongness of actions Goodness and badness of motives

Values

Values are deeply held beliefs about what is good, right, and appropriate.

Values are deep-seated and remain constant over time.

“Ethical Dilemma”

A situation that will often involve an apparent conflict between moral imperatives, in which to obey one would result in transgressing another

A moral imperative is a principle originating inside a person's mind that compels that person to act.

Ethical Principles Generally

Beneficence Nonmaleficence: Least harm Respect for autonomy Justice

Mr. & Mrs. W______

Shared room in locked behavioral unit

No family Mr. W has dementia, wanders. Mrs. W? Language; socialization Well-intentioned social worker

Beneficence

Do what is good Strive to achieve the greatest amount

of good (utility)

Mr. & Mrs. W

Nonmaleficence

Don’t intentionally inflict harm In situations where neither choice is

ideal, choose that which is the least harmful and harms the fewest people

Mr. & Mrs. W

Respect for Autonomy

People should be allowed to ‘reign over themselves’ and to make the decisions that apply to their lives; control over their lives as much as possible

Paternalism (e.g. professionals)

Mr. & Mrs. W

Justice

Fair, equitable and appropriate treatment in light of what is due or owed a person

Distributive justice: fair, equitable and appropriate distribution in society determined by justified norms: taxation; donated organs

Mr. & Mrs. W

Ethical Issues in Long-term Care

Living options Independence vs. safety Capacity to make decisions Managing finances Patient/family/care provider

interactions Others?

Applying the Tools of Ethics

Assumption: All must be legal Step One: Analyze the Consequences

Who will be helped? Who will be hurt? What kinds of harms and benefits are

possible? How will this look both in the short-term

and in the long-term?

Applying the Tools of Ethics

Step 2: Analyze the Actions How do they measure up against moral

principles Do any “cross the line” from simple

decency to an important ethical principle? If principles or the rights of different

involved people conflict, is one principle more important than another?

Applying the Tools of Ethics

Step 3: Make a Decision Take both Step 1 and Step 2 into account

Examples from Real World

Ken H. Refuses to pay his

Medicaid spend-down to NH

NH court action No personal

allowance

Examples from the Real World

Mr. A, 81,stroke 2 years ago; NH rehab., now ready to go home

Wife, 55, visited seldom, “rebuilt her life”, unwilling to take Mr. A. home

Mr. A demands to go home

Examples from the Real World

Ms. L, 47, unmarried, lived alone In NH after hospitalization for MS, in

wheelchair, wants to go home Olmstead decision Ms. L’s is MS unstable

Examples from the Real World

The changing long-term care world: Policy (e.g Point of Entry) Case law (e.g. Olmstead) Personal and societal values (e.g. Baby

Boomers) Others?

Examples from the Real World

Your turn?

Take away message:

Think: Beneficence/Nonmaleficence/Autonomy/Justice

Analyze the consequences Analyze the actions Make a decision