Essay on "Ethical and Legal Aspects of Therapeutic Relationships"

Quoted Instructions for "Ethical and Legal Aspects of Therapeutic Relationships" Assignment:

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Bibliography and citation style: Havard

Number of Source: Must be more than 5 Primary sources (books or Journals)+other sources

Language style: British



‘Choose a case in which you have been involved from the context of clinical training and identify the responsibilities and accountabilities of the

Professional practitioner. Discuss this case with an analysis of ethical aspects of the therapeutic relationship and with particular attention to the implications of the current legal framework.’

Learning Outcomes:

1. Demonstrate a detailed understanding of selected legal issues in medicine and critically discuss responsibilities and accountabilities of the professional practitioner within the current regulatory framework

2. Articulate the main principles used in analysis of medical ethical issues and critically an***** arguments for and against particular views in medical ethics.

3. Critically assess key concepts in health psychology, including the relationships between personality, stress and health, and their significance in therapeutic practice.



- The case study for the essay can be real, or from a book, amended or not. can do pretty much what we want on that front.

can mix case studies, or completely make it up. a good book to get ideas, or lift case studies is the one by Stone. the case doesn't have to have dramatic issues and big problems. it should be half a page long more or less and in the beginning of our essay.

- we then need to an***** this case with the 4 principles

-The principle of respect for autonomy

-The principle of beneficence

-The principle of non-maleficence

-The principle of justice

(actually 3, since last one doesn't apply for Traditional Chinese Medicine practitioner), and the 2 theories (utilitarianism and deontology). before analysing, we should talk about the principles and theories, discuss them. we need to use both frameworks.

so, after discussing each one of he principles, we would say something along the lines of 'when we apply these principles in the case study..'. frequently contrasting 'results' will arise from the principles or between frameworks. we should discuss that too. talk about what directions the different frameworks take us. ' ..if we follow the utilitarianism approach then in this case we will do such and such, but if we follow the deontology view bla bla bla..'.

- we'll have to do some reading to talk about the frameworks. check out books given in the references. also a good, small one is by Ran Gillon Philosophical medical ethics

- we should use elements of law (British) wherever they fit in the essay, in any way we want, but have to include it.

- can also talk about, and then apply, other things. e.g paternalism.

- we don't need to arrive to a definite conclusion. we can say that after all this thinking, and application of the theory etc

- essentially the structure is: present case study, talk about the theory, apply the theory to the case, conclusion.







Recommended Readings:

Brazier, M. (2003) Medicine, patients and the law. Third edition. London:Penguin.

Stone, J. (2002) An ethical framework for complementary and alternative therapists.

Routledge.

Applebe, G & Wingfield,J. (1997) Pharmacy law and ethics. The Pharmaceutical Press

(also listed as Dale and Applebe’s Pharmacy Law and Ethics.)

Association of Traditional Chinese Medicine (UK). Code of ethics and code of practice.

Brazier, M. (2003) Medicine, patients and the law. Third edition. London:Penguin.

Dimond, B. (1998) The legal aspects of complementary therapy practice. London: Churchill Livingstone.

Gillon, R. & Lloyd, A. (eds.) (1993). Principles of health care ethics. Wiley.

Kennedy, I. and Grubb, A. (1994) Medical law: Text with material. London: Butterworths.

Mason, K. and McCall Smith, A. (2002) Law and medical ethics. Sixth edition. London:

Butterworths.

National Institute of Medical Herbalists (1991) Code of ethics: Code of practice: Disciplinary procedure. Exeter: NIMH.

Stone, J. and Mathews, J. (1996) Complementary medicine and the law. Oxford University

Press.

Stone, J. (2002) An ethical framework for complementary and alternative therapists.

Routledge.















ETHICS SESSION ONE

What are ethical/moral issues? How are they distinguished from other issues (e.g. factual, legal, conceptual)?

• Certain terms are used, e.g. morally right, obligatory, permissible, unacceptable

• Actions have to do with the benefit/harm of others

How can we deal with/resolve ethical problems?

• The limitations of our intuitions

• The limitations of codes of practice

-Meaning of terms

(‘the practitioner has a duty to place the well-being of the patient

before all other considerations’)

-Conflict of requirements

(‘be willing to collaborate and cooperate with colleagues from your own and other

healthcare professions and recognise and respect their particular contribution’)

-Not exhaustive

(fail to account for complexities)

-Lack justification

(what is their rationale?)

Critical ethical approach: the need for reasons/ethical underpinning

• The framework of the four ethical principles:

-The principle of respect for autonomy

-The principle of beneficence

-The principle of non-maleficence

-The principle of justice

• What is this framework? What are the four moral principles?

• Let’s consider the case of Mrs G

THE CASE OF MRS G

Mrs G, a lady in her early eighties who lived alone, was admitted to hospital after lighting an openfire in her front room, under the impression that her coal-effect electric fire was broken. The hospital doctor wished an early discharge as there were no acute medical needs, and the patient wished to return home. The house had suffered some damage because of the fire. The social worker found that although the patient appeared to be rational in many respects, the daughter and lodger whom she spoke about as waiting for her at home had died respectively eleven and four years previously.

Further investigation revealed several other serious health concerns - Case study adapted from Clark, C L (2000). What should the social worker do?

Analysis of the possible courses of action that the health and social worker might decide to take:

• She might decide to allow Mrs G to return home â€***** appealing implicitly to the principle of respect for autonomy, that the wishes of autonomous people should be respected. After all, Mrs G seems quite rational and competent and she might have simply lied about her daughter and lodger.

• She might decide that it is best for Mrs G to be rehoused, in view of the damage in her house and further health concerns â€***** appealing implicitly to the principle of non-maleficence, that one ought to avoid doing harm.

• She might decide, in addition to rehousing Mrs G, to arrange for support packages, so as to contribute to Mrs G’s quality of life â€***** appealing implicitly to the principle of beneficence, that one ought to promote the well-being or benefit of others

• She might think about the issue of the just distribution of resources, for example whether Mrs G is in fact eligible for all the packages â€***** appealing implicitly to the principle of justice, that equals should be considered equally.

The four moral principles:

• Are part of our ordinary conception of morality (common morality)

• Have been used to form an explicit framework for the analysis of ethical issues (originally in healthcare)

• Often conflict

Autonomy or self-determination and the principle of respect for autonomy

• Definition of ‘autonomy’: The capacity to think, decide and act on the basis of such thought and decision, freely and independently

• The importance of the elements of freedom and rationality

• Difficulties in determining an individual’s autonomy

• The distinction between autonomy and the principle of respect for autonomy

• Restrictions on respect for autonomy (Mill’s ‘harm to others’ principle)

• Enhancing an individual’s capacity to be autonomous

The principle of beneficence

• The obligation to act for the benefit of others

• extension of the principle of beneficence: the obligation to act in the net benefit of others (balancing benefits and harms)

• The obligation of beneficence in ordinary ethics and in professional ethics. Duty of care

The principle of non-maleficence

• The obligation to avoid doing harm

• Stands at the opposite end of a continuum with beneficence

• Can conflict with beneficence e.g. vaccinating an individual

The principle of justice

• The obligation to treat equals equally; has to do with just allocation of resources.

The framework of the principles

• Is meant to remind us of all important moral concerns

• give us direction as to how to act (functions as an action guide)

3

CASE SCENARIOS

1. The Jehovah witness case

A Jehovah Witness is at risk of dying unless he is given a blood transfusion during a major operation. On religious grounds he has refused to give consent to the use of blood, even if this means that without it he will die. What should the medical team do? Should his life be saved if the only way to achieve this is the use of blood?

2. The Diane Pretty case

Diane Pretty was suffering from motor neuron disease, which progressively weakens muscles to the point at which death occurs from the inability to breathe or to swallow. The 43 year old, mentally competent woman, wanted her husband to assist her to end her life, so that she dies in a humane and dignified manner, rather than in a distressing manner that would be caused by her disease. However, her husband was not legally allowed to assist her to that end. Would it have been right for her husband to have helped her to die in the way she wanted?

3. The pain killer example

A consultant has decided that a patient has become too dependent on certain pain-killing drugs that will ultimately have harmful consequences. It is decided to wean the individual off these drugs without informing her. The nurse is required to continue this deception even though he patient is clearly distressed and asks why her pain killers are not having their usual effect (Singleton and McLarren 1995)

4. The High velocity thrust case

A chiropractor knows from past experience that if she explains to a patient what a high velocity thrust feels like before she does it, the patient is likely to become tense and stiffen up, so she tends to act first and explain later (Stone 2002).

5. The urinary infection case

A homeopath treating a fourteen-year old girl for recurrent urinary tract infection is concerned that the girl is being abused by her step-father but is unsure whether, or to whom, this information should be disclosed (Stone 2002).

6. The depression case

For six months a medical herbalist has been treating a nineteen year old male suffering from mild depression. When the patient commits suicide, his family threaten to sue the therapist for failing to realise the severity of his condition (Stone 2002).

7. The bowel cancer case

A reflexologist who suspects that this patient has bowel cancer feels that the patient’s spirits are so likely to be damaged by disclosing bad news that he keeps his opinion to himself (Stone 2002).





ETHICS SESSION TWO

The framework of the four principles - continued

Autonomy and the obligations of truth-telling, informed consent and confidentiality

• These obligations are especially important in professional ethics.

• Are all supported by the principle of respect for autonomy:

-An agent needs information in order to act autonomously.

-Asking for people’s consent and respecting their secrets are direct

expressions of respecting their autonomy.

The conflict of the moral principles and paternalism

• Conflicts between beneficence/non-maleficence and respect for autonomy. Examples.

• Conflicts between beneficence/non-maleficence and justice. Examples.

• When the principle of beneficence/non-maleficence conflicts with the principle of respect forautonomy, and we act in accordance with the first and against the second, we act paternalistically.

Paternalism (better: parentalism)

• Definition: A refusal to accept or to acquiesce in an autonomous person’s wishes, choices or action in order to act for that person’s benefit.

• Associated with the recipient service user being passive, legitimising the power of the professional.

• Examples of paternalistic action in health and social care.

• Recent shift from the paternalistic model: The empowerment of the service user.

• Varying degrees of dominance in paternalism: strong paternalism and weak paternalism. Examples.

• Can paternalism be morally justified?

• Beauchamp, T and Childress, J (2001): strong paternalism is justified when:

• The person is at risk of harm

• The paternalistic action will prevent it.

• The benefits of the paternalistic action outweigh the harm done.

• The action is the least autonomy restrictive alternative.

• Paternalism can also be justified if the autonomy of the individual is restored through it. Think of the example of crossing the unsafe bridge.

• Problems with the determination of a person’s autonomy.

• Suicide intervention.

Evaluation of the four principles approach

• Widely accepted because of its simplicity

• Problems:

-The scope of the principles: to whom do they apply?

-The conflict of principles

-Principles too abstract, harsh; cannot account for the complexities of situations

Interlude

What is ethics?

• Actual moral norms followed about what is morally right, wrong, etc; moral standards; ‘morals’. (Used in plural)

• The philosophical study of these normsâ€***** moral philosophy. (Used in singular)

Two branches of ethics/moral philosophy

• Metaethics - the analysis of moral knowledge and moral concepts

• Normative ethics â€***** the development of ethical theories about what kinds of actions are morally right, wrong etc (general normative ethics); the study of particular moral problems (applied normative ethics), e.g. is abortion morally right?

Ethics/moral philosophy contrasted to descriptive ethics - the scientific study of morality; concerned to describe and explain accepted moral norms

Two main normative ethical theories

• Utilitarianism

• Deontology

The framework of the two ethical theories: Utilitarianism and Deontology

The framework of normative ethical theories and moral (or ethical â€***** used interchangeably) problems in healthcare

• Like the four principles, normative ethical theories can be applied to healthcare moral problems and dilemmas in order to address these problems (an***** them/hopefully resolve them)

• Thus they constitute a framework that can be used to guide us in ethical decision making in healthcare

Utilitarianism (a Consequentialist theory)

Act Utilitarianism:

• An action is right if it produces (has as a consequence) the greatest balance of good over evil â€***** typical example of ‘good’ or ‘utility’ is happiness.

• Examples of Act-Utilitarian reasoning.

Rule Utilitarianism:

• An action is right if it falls under a rule which, if followed, would produce the greatest balance of good over evil.

• Examples of rule-utilitarian reasoning.

Critical Assessment of Utilitarianism:

• Conflicts with the idea of individual rights

• Does not allow for experience of significant relationships

Deontology - Duty-Based Theory

• Immanuel Kant (1724-1804)

• Morality is a matter of acting out of a sense of duty (the Greek work deon)

• Humans have intrinsic worth because they are rational agents

• The Categorical Imperative: ‘Act so that you treat humanity…always as an end and never simply as a means’- one formulation (amongst several), the one that is of most relevance in health and social care ethics

• Duty of ‘respect for persons’: never use people to achieve your own ends, promote people’s welfare, respect their rights, avoid harming them. Specific duties never to lie, never to kill an innocent person, to keep promises.

• Examples of duty based reasoning - e.g experimentation with human subjects

Critical Assessment of Deontology:

• Too rigid: e.g lying may be justified in certain circumstances

• Good intentions/motives should not justify