chapter 6: ethical decisions and challenges

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Chapter 6: Ethical Decisionsand Challenges


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Introduction

• Challenges confronting the HIM professional are almost limitless

• Study of ethics can be applied to everyday situations

• Focus of this chapter:– Recognition of ethical challenges and learning

how to address them– Application of ethical reasoning and decision

making to resolve issues


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Ethical Decision Making

• We all face ethical dilemmas in life• Decisions are made

– Individual level: affecting personal life– Organizational level: affecting others

• No one right answer that applies to every situation

• Decision maker must consider:– Factors that influence decision making– Process to be followed


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Ethical Decision Making:Influencing Factors

• Numerous factors may influence the decision maker:– Professional code of ethics– Ethical concepts or theories– Patients rights– Religious beliefs– Personal experience


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Influencing Factors: Codes of Ethics

• Written list of a profession’s values and standards of conduct

• Embody professional concepts– Differentiate members from other occupations

and careers– Present professional as autonomous decision maker– Endorse promise of loyalty to clients and

fellow professionals– Elevate the client above the interests of self or

fellow professionals


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Influencing Factors:Codes of Ethics

• Codes are open to change over time• Historically:

– Were more a statement that limited competition and promoted image

– Imposed restrictions• Modern codes of ethics

– Statements of ethical and moral principles– Govern the conduct of the profession’s members

• Almost every professional association has an ethics code– For example, AOA, AHIMA, medical associations,

nursing associations, etc.


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• Physician code of ethics – Obligation to provide competent

medical service– Confidentiality of communication with patient– Duty to study and advance

scientific knowledge– Recognize patient’s right to chose a physician– Must not discriminate


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• Health information manager– Ethics are a cornerstone of the profession.– AHIMA has promulgated the code of ethics.

• HIM has ethical obligations – To the patient– To other members of the health care team– To her professional association– To the public– To herself


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• Effective communication is key

• Professional education – Applicability of code in workplace– Consequences of unethical behavior– Case-by-case analysis

• Successful approach stresses need to think for oneself


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• Ethics committee– Group within an organization– Establishes, evaluated, and enforces ethics code and

related corporate policies– Addresses ethical issues that arise

• In health care organization, may consult on bioethical issues– End-of-life decision making support– Treatment of seriously ill newborn– Procedures for organ procurement– Medical research, new treatments, or equipment


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Influencing Factors:Patient Rights

• Role of patient in treatment has changed• Limitations on patient participation in care

– Physician must approve admission to hospital

– Insurance may require pre-approval for treatment and/or physician

– Third-party payer controls funding for care• Expanded recognition of rights of patient

– Rise in consumer activism– Move away from paternalism in medicine


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Influencing Factors:Patient Rights

• Recognition that patient is entitled to decide for herself– Consent to treatment– Refuse care

• Patient’s Bill of Rights (1970s)– Privacy, confidentiality and informed consent

• Patient care partnership (today)– Expanded to cover what to expect in hospital– How and where to express concerns


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Influencing Factors:Patient Rights as Law

• Incorporation of ethical concept into laws• May be penalties for breach of patient right that

are enforced by law• Patient Self Determination Act (PSDA)

– Right to determine extent of care– Right to make advanced directives (per state law)– Right to accept or refuse care– Hospitals must inform patients of rights– Hospitals must have related policies and procedures


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• Health Insurance Portability and Accountability Act (HIPAA) of 1996– Federal law that protects health information

• Under HIPAA patient has a right to:– Access, inspect, maintain copies of PHI– Notified of privacy practices– Limit use or disclosure of PHI– Request that steps are taken to keep communication

confidential– Request and accounting of disclosed PHI– File a complaint concerning privacy practices


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• American Recovery and Reinvestment Act of 2009 (ARRA)

• Federal law• Patient right to obtain copies of PHI in

electronic format– If health care entity used an electronic

health record– At patient direction, entity must transmit

information to another as requested


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Influencing Factors:Other Factors

• Religious beliefs

• Advances in science and technology– Embryonic stem cell research– Scarce resources

• Legal factors – Civil rights transformed into legal protections– Law may address ethical concern but serves

as minimum standard


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Ethical Decision Making Process

• Different aspects of ethical problems


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Ethical Decision Making: Steps

1. Clearly define the issue

2. Determine the facts of the situation

3. Identify stakeholders– Values at stake– Obligations and interests of

each stakeholder

4. Determine available options– Evaluate each option


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• Evaluating options– Compare each against an ethical theory

• Which option presents greatest good for greatest number?– Utilitarianism

• Which option supports one’s duty?– Deontology

• Which option promotes rights and dignity?– Social equality and justice


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5. Decide what should be done• Do analogous situations exist? • What was done? What was the outcome?• Are there legal implications?• What option makes the most sense?• Will option stand up to scrutiny?• Can you sleep at night with choice?• Are you comfortable if others know?


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6. Justify the decision• Identify reasons that support decision

7. Implement decision

8. Evaluate the outcome• Compare what actually occurs to

predicted outcome

9. Examine how to prevent recurrence of this ethical problem


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Ethical Challenges

• Difficult choices with no clear “right” answer

• General challenges in work place– Conflict of Interest– Impaired colleague– Disparagement– Truth telling and disclosure


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Ethical Challenges

• Conflict of interest– Self interest versus obligation to group– Use of position to promote self interest– Appearance of impropriety– Examples

• Accepting favors from a vendor• Second job with a competitor


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Ethical Challenges

• Impaired colleague– Impede performance and safety risks– Balance between no-tolerance and support

person with disease of substance abuse

• Disparagement– Criticizing skills of another professional– Codes of ethics consider such personal

attacks to be professional misconduct– Focus should be on merits of issue


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Ethical Challenges

• Truth telling– Lack of full disclosure versus protecting trade

secrets or security– Deceptive communications versus puffery– Copy of another’s work (plagiarism) – Unethical practices lead to erosion of trust


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Role of Ethicsin Supervision

• Role model– Set a good example– Accept responsibility for mistakes

• Encouraging ethical behavior– Communicate ethical standards clearly– Enforce standards fairly– Respect, rewards, and punishment

• Monitoring employee conduct– Review compliance with policies and procedures– Explicit part of performance evaluation


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Health Care Challenges

• Conflicts of interest– Joint ventures and self-referral practices– Inappropriate relationships with patients

• Substance abuse/impaired colleague– Increased risk to patient safety– Situation must be addressed properly

• Financial issues– Third-party payer affecting medical decisions

• Bioethical issues


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Health Information Management Challenges

• Changes in care environment– Accreditation critical

• Pressure to “fudge” statistics to reflect compliance or excellence

– Sensitivity of information• Genetic • Drug and alcohol and mental health • Abuse

• Documentation, access to, and release of information– Access to sensitive patient information – Celebrity patients– Demands from third parties: insurers, vendors


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Health Information Management Challenges

• Technology developments– Data resource management– Audit trails

• Changes in reimbursement systems– Coding properly– Pressure for maximum reimbursement– Standards for ethical coding (AHIMA)

chapter 6: ethical decisions and challenges

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