Health Care Ethics
9To address the philosophical, religious and cultural diversity within society, health care has developed a set of general principles to serve as an analytical framework of basic principles that express the general values underlying the rules in common morality and guidelines in professional ethics. Three general moral principles have proved to be serviceable as a framework of principles for health care ethics: respect for autonomy, beneficence, and justice. Yet it is important to note that these princi- ples should not be construed as jointly forming a complete moral system or theory, but rather providing the beginnings of a framework through which we can begin to reason about problems in health care ethics.
Autonomy can be defined as deliberate self-rule and is a special attribute ascribed to all moral agents. Respect for autonomy is the moral obligation to respect the autonomy of others in so far as such respect is compatible with equal respect for the autonomy of all potentially affected parties. In health care, respecting a person’s autonomy has a number of important implications. How much information needs to be given to a patient before commencing a procedure or treatment? Can patients request procedures which the health care professional finds ethically repugnant and does the health care professional have to comply with this request? Examples of this would be the prescribing or dispensing of contraceptive medications. Or, the assist- ing of a patient to die in what is termed physician-assisted suicide. Can a patient request costly interventions which, in the judgement of the health care professional, would be futile treatment? Respecting autonomy also raises important questions for confidentiality. This is particularly relevant with regard to genetic information.
Does a person’s family have a right to this information if it has potential impli- cations for their own health? Questions continually arise as to what kind of infor- mation an employer or insurance company is entitled to know about a particular person.
The principle of beneficence is closely linked to the principle of non-maleficence as found in the traditional Hippocratic moral obligation of medicine to provide net medical benefit to patients with minimal harm, that is, beneficence with non- maleficence. Health care professionals need to ensure that they can provide the benefits they profess to be able to provide. They need to make sure that they are offering each patient net benefit. To do this they must respect the patient’s auton- omy, for what constitutes benefit for one patient may be harm for another. Although there are some general norms of human needs, benefits and harms, people vary in their individual perceptions and evaluations of their own needs, benefits and harms.
168 D. Smith, L. Drudy Jehovah’s Witnesses’ attitudes to blood are a vivid illustration of this variability.
Another example would be a decision by an elderly person to forego aggressive therapy for cancer. The reason given is that they do not want to put themselves through a potentially debilitating regime of treatment which would significantly diminish their quality of life.
Thus, even to attempt to benefit people with as little harm as possible requires, where possible, discovery of what the proposed beneficiary regards as a benefit, regards as a harm and regards as the most beneficial and least harmful of the avail- able options. Even if the person agrees that one available intervention would be more beneficial than another, he or she may simply wish to reject the beneficial intervention. It may be because of an idiosyncratic basis of assessment of harm – for example, the autonomous belief that a blood transfusion will lead to eternal damnation or some equivalently massive harm. Or, it may be a relatively trivial assessment.
When justice is considered, respect for autonomy must play an important role.
Justice can be subdivided into three categories: fair distribution of scarce resources (distributive justice) respect for people’s rights (rights-based justice) and respect for morally acceptable laws (legal justice). In health care, distributive justice cannot avoid a discussion of health economics and its application on a global, national and individual level. Legal justice and respect for morally acceptable laws have generated a lot of discussion recently when the issue of the involvement of doctors in torture began to be addressed. There is evidence that health care professionals have failed to report to higher authorities wounds that are clearly caused by torture and that they have neglected to take steps to interrupt this torture. In addition, they have turned over prisoners’ medical records to interrogators who could use them to exploit prisoners’ weaknesses or vulnerabilities. There is also evidence concerning the delay and possible falsification of death certificates of prisoners who have been killed by torturers.10
Business Ethics
There is no special code of business ethics; rather, there are questions and dilem- mas about remuneration, whistle-blowing, product safety and so on, which arise mainly in the course of business activity, but which can be dealt with in terms of moral principles. And there are values which we intuitively recognise as such.
Honesty, reliability, just and fair dealing are recognised as correct behaviour, just as lying, cheating, stealing, cowardice and irresponsibility are recognised as incorrect behaviour. Breaking agreements, treating people unjustly, telling lies, taking more than one’s due are wrong – in business as in any other aspect of life.
However there are some moral principles which are particularly relevant to busi- ness dealings. The first principle to consider is common decency. Although the more spectacular and public examples of unethical behaviour in business – insider trading or various kinds of corporate tragedy11– are the issues which make the headlines; it
Corporate Culture and Organisational Ethics 169 is in the normal, everyday activities of the business that ethical principles need most to be applied. It is largely about how people treat other people within the company that the ethical climate of the business is set. Without this awareness of personal relationships, the moral context of the business is lost and the grosser forms of unethical behaviour can emerge almost unchallenged. Because of this, one of the basic principles of business ethics is simply that of common decency. This is the maintenance of standards of ordinary decent behaviour by all to all associated with the business. It is as important to be honest with suppliers as it is with shareholders, and to be as decent with customers as with employees.
Common decency does not mean being nice to people or being altruistic but treating people in a way which allows their legitimate expectations to be met, so lib- erating them to pursue their roles in the business in the secure knowledge that their contributions will be recognised and their expectations fulfilled. Decency means honesty and responsible treatment of those with whom one comes in contact and this emerges as a principle from the identified aim of the business itself. If stake- holders cannot see that they will be dealt with honestly and in a responsible man- ner, there is little reason why they should commit themselves to the success of the business.
The second principle to consider is justice. This value emerging from the aim of business itself is justice in the distribution of rewards, privileges and responsibilities.
Distributive justice relates rewards to contribution so that, as far as possible, those who contribute most to the business and the fulfilment of its aim will be rewarded proportionately more than those who contribute less. The purpose of a business is to achieve long-term owner value, and pay and promotions should reflect contribution to this.
The unique development of a declaration on business practice12 by Christians, Muslims and Jews highlights four key concepts which are found in the literature of these faiths and form the basis of any human interaction. They are: justice (fair- ness), mutual respect (love and consideration), stewardship (trusteeship) and hon- esty (truthfulness). In applying them to business practice, the three faith traditions state that justice can be defined as just conduct, fairness, exercise of authority in maintenance of right. Fair dealings between each other and between believers and others are constantly reiterated in the Scriptures. The second principle – mutual respect or love and consideration for others – is also inherent in the moral teach- ings of each religion. The word love has many meanings in most languages. But, as is clear from the reading of the Scriptures, the God of justice and mercy is also the God of love. What the Scriptures express as love in business means a mutual respect or reciprocal regard – “love thy neighbour as thyself” – that ex- ists between two individuals. The application of this has come to mean that self- interest only has a place in the community in as much as it takes into account the interests of others. “My neighbour” in the business context can be defined as any person (individual or corporate) with whom the organisation comes into con- tact in the course of business life. Of paramount importance in this respect is the employee.
170 D. Smith, L. Drudy A third principle shared by all three faiths is that of stewardship (trusteeship) of God’s creation and all that is in it. The Scriptures testify to the beauties and wonders of nature as signs of God’s goodness and providence. Peoples’ use of creation is determined as stewardship and they are charged with its care and proper use. The fourth principle inherent to the value system of each of the three faiths is honesty.
It incorporates the concepts of truthfulness and reliability and covers all aspects of relationships in human life – thought, word and action. It is more than just accuracy, it is an attitude which is well summed up in the word “integrity”.
In general, business ethics will be served by the principles of decency (which in- cludes honesty, responsibility and reliability) and justice (which includes fairness).
These values will be the ones consistently referred to in analysing business ethics problems. They may have slightly different emphases in different contexts but they are generally applicable in all business situations.
The review of the principles which govern business ethics and health care ethics demonstrates a number of common features. But more importantly, it also highlights the potential for diversity and conflict. Business ethics tends to put the aim of the company or organisation as primary, while health care tends to place the emphasis on the individual patient. What happens when the needs of the individual conflict with the needs or plans of the organisation? Another potential area of conflict is between the values of the managers and health care professionals and the Mission or Values of the organisation.