Use this model to make ethical decisions

The health care delivery system is increasingly more complex. More health care options are available to patients than ever before at the same time the number of health care dollars is shrinking. A code of ethics may be the cornerstone of a true profession, but it takes a deeper understanding of what ethics is to make ethical decisions with limited resources, says M. Jan Keffer, PhD, RN, CS, ANP, assistant professor of family health nursing at Indiana University School of Nursing in Indianapolis.

"Case managers often have to negotiate between least beneficial options. You’ve got to juggle between several things you don’t want and negotiate and renegotiate as situations change," Keffer says.

She cites these four principles of bioethics, which many case managers learn in school, that can help with the juggling act, although they don’t provide all the needed tools:

1. Autonomy: An individual is self-governing and acts with a self-chosen and informed plan.

2. Beneficence: An obligation to weigh and balance the possible good against possible harm of an action.

3. onmaleficence: An obligation not to inflict harm.

4. Justice: An obligation to morally correct distribution of benefits and burdens in society.

Added to those basic ethical principles, Keffer says, are four ethical theories that drive health care delivery:

1. Utilitarianism: We should always produce the greatest possible balance of value over disvalue.

2. Deontology: Some actions are right for reasons other than their consequences.

3. Virtue: Virtuous people will perform virtuous acts or make virtuous decisions. The four virtues are integrity, compassion, courage, and honesty.

4. Relativism: Moral rightness and wrongness of actions vary from society to society, and there is no absolute universal moral standard binding all people at all times.

What do all those theories tell case managers about how to make ethical decisions with the limited resources of a managed care environment? The key, Keffer says, is to recognize when you’re faced with an ethical dilemma.

"Case managers cannot help resolve difficult decisions if they cannot recognize when they are in an ethical dilemma. An ethical dilemma stems from having to make a choice when neither option is good. At that point, you have to look at the situation with a systematic approach. An ethical decision can be made using a process that draws from scientific reasoning, problem solving, and nursing process," she explains.

Sorting ethical responsibilities

Keffer breaks ethical decision making into the following steps:

o identification of issues;

o assessment of components;

o decision making;

o implementation;

o evaluation.

The process for case managers is complicated by the weight of the many ethical obligations they bear, she says. "You have an obligation to the patient and family, yourself, to your employer, and to society. These obligations compete as a case unfolds and progresses from the acute stage, to the chronic stage, to the dying stage. And, of course, we often teach the ideal but have to live with the real."

Making ethical decisions is easier if case managers establish a clear understanding of their patient’s wishes and needs, Keffer says. During your first contact with patients, she suggests you explore their views on quality of life, their potential management plans, and their wishes and obligations for the end of life.

"The bottom line of your obligation as a case manager within managed care is to inform the patient of his or her options at the front end. Inform the patient of the coverage in the plan, and if the patient wants to go outside that plan, it is the patient’s choice," she says. (For an ethical case study that puts these principles in action, see story at right.)