Healthcare - Week 11

Health inequities

-Health inequities: health disparities or health inequalities that are modifiable, associated with social disadvantage, and considered ethically unfair.

2) Support intersectoral collaboration.

-brings together partners from many sectors to recognize the links between health and other issue and policy areas, -break down silos, -build new partnerships to promote health and equity and increase government efficiency.

4) Engage stakeholders

-engages a variety of stakeholders, such as community members, policy experts, advocates, members of the private sector, and funders. -robust stakeholder engagement to ensure that work is responsive to community needs and garners valuable information necessary to create meaningful, impactful, sustainable change

5) Create structural or procedural change

-goal is to create permanent changes in how agencies relate to each other and how government decisions are made. -maintenance of both structures which can sustain intersectoral collaboration and mechanisms which can ensure a health and equity lens in decision-making processes across the whole of government. - "embedding" or "institutionalizing" Health in All Policies within existing or new structures and processes of government.

1)Promote health, equity, and sustainability.

-incorporating health, equity, and sustainability into specific policies, programs, and processes, and -embedding health, equity, and sustainability considerations into government decision-making processes so that healthy public policy becomes the normal way of doing business.

3) Benefit multiple partners

-simultaneously addressing the goals of public health agencies and other agencies to benefit more than one end (achieve co-benefits) and create efficiencies across agencies (find win-wins) -negotiation, patience, and learning about and valuing others' priorities necessary to finding a balance between multiple goals

5 Key "Health in All Policy" Elements

1.Promote health, equity, and sustainability. 2.Support intersectoral collaboration. 3.Benefit multiple partners. 4.Engage stakeholders. 5.Create structural or procedural change.

Comments on RIPS model

Limitations ▫Rational, linear approach What about the emotional aspects? Limited moral dialogue within the framework •Strengths ▫Useful for preliminary analysis in an organized manner

Methods of Ethical Decision-making

Set format/formula, helps go through all steps before making a decision •The Systems Approach (Scott 2009) •Delaney: Active Engagement Model •Swisher: RIPS model

Steps in RIPS decision making (Step 1)

Step 1: Recognize and define using RIPS 1.RI-What is the Realm?-Individual vs. Societal vs. organization 2.P-What is the individual Process-what does this ethical situation require of me? 3.S-What is the ethical Situation?

Steps in RIPS decision making (Step 2)

Step 2. Reflect: 1.Is information needed? 2.Who are the stakeholders? 3.Legal? 4.Ethical principles involved? 5.Professional Guidance-code of conduct, code of eithics 6.Right vs. Wrong tests (e.g. legal, what would ....say?, gut)

Steps in RIPS decision making (Step 3)

Step 3. Decide right thing to do (generally for ethical dilemmas): 1.Rules-based-using ethical principles - Established rules, duties, ethics 2.Ends-based-projected consequences - Outcomes good/bad 3.Care-based- Decisions based on relationships/golden rule

Steps in RIPS decision making (Step 4)

Step 4. a.Implement - take course of action b.Evaluate: process, outcomes, lessons learned c.Assess: to make changes so problem won't occur in the future

RIPS model

•"Ethics in Action", N. R. Kirsch, PT In Motion. (ongoing series) ▫Reported work by Swisher, JW Glaser, Purtillo •RIPS: model for ethical decision-making ▫R: Realm ▫IP: individual process ▫S: ethical situation

Social Justice

•"all people share a common humanity and therefore have a right to equitable treatment, support for their human rights, and a fair allocation of community resources." -Regardless of gender, sexuality, religion, political affiliations, age, race, belief, disability, location, social class, socio-economic circumstances, or other characteristic of background or group membership

APTA Code of ethics-Principles

•1 Duty to all individuals •2 Duty to patients •3 Accountability for sound judgement •4 Integrity in relationships •5 Fulfilling legal and professional obligations •6 Lifelong acquisition of skills, knowledge and ability •7 Organizational behaviors and business practices •8 Meeting the health needs of people

Health in All Policies (HiAP)

•A collaborative approach that integrates and articulates health considerations into policymaking across sectors to improve the health of all communities and people. •HiAP recognizes that health is created by a multitude of factors beyond healthcare and, in many cases, beyond the scope of traditional public health activities. •The HiAP approach may also be effective in identifying gaps in evidence and achieving health equity.

Interests of Society: Rationing of Healthcare

•Definition: "..conscious policy of equitably distributing needed resources that are in limited supply." ▫Not all care that is expected to be beneficial is provided to all patients AND ▫Distribution of limited resources is done in a fair manner •Current limited resources in US: commodities (ED beds, donor program, primary care docs and money) Example of rationing: Organ Transplantation

Social Justice - Equality, Distribution

•Equality of rights and opportunities •Equity in living conditions •Distribution of: -goods, opportunities and rights, income, opportunities for work and remunerated employment, access to knowledge, opportunities for civic and political participation, health services...

Ethical Dilemmas: Individual vs. Society?

•Ethical dilemma ▫Conflict between one or more of the ethical principles of autonomy, justice, beneficence, nonmaleficence ▫Could be a conflict between an individuals autonomy and society (or just the individual) ▫Must understand biomedical ethical principles in order to thoughtfully resolve dilemma ▫Creates legal and policy issues/conflicts ▫Can be at the level of the individual but impacting society as a whole

National Organ Transplant Act (1984)

•Example of ethical issues at societal level shaping policies •The NOTA established: ▫OPTN: Organ Procurement & Transplantation Network Puts people on a list and determines who gets the organs To prevent buying and selling of organs ▫UNOS: United Network for Organ Sharing •Private, non-profit organization under federal contract which operated OPTN. National Organ Transplant Act (1984) •Recommendations for standards: ▫Severity of illness ▫Length of time on waiting list ▫Age-younger vs older at the top of this list ▫Probability of successful outcome •Paid for by Medicare, some Medicaid programs and some private insurance companies ▫Uninsured: no access ▫underinsured - maybe not

Ethical Standards in Healthcare Professions (Fiduciary, Duty, Ethical Standards)

•Fiduciary: a person to who holds a legal or ethical relationship of trust with someone else or an organization. ▫MD who holds the trust of the patient, also trusted by the organization to act in an ethical manner •Fiduciary Duty: an obligation to act in the best interest of another person or organization ▫Violation of this duty is an ethical breach •Ethical standards: must be high due to patient vulnerability ▫Treatment ▫Confidences ▫Research

To illustrate Individual vs Society (Health care proxy, rationing)

•Health Care Proxy - preserves interests of individuals ▫Two landmark cases that considered the legal limits of autonomy ▫Rulings led to Health Care Proxy •Rationing - interests of society....

Health Equity

•Health equity is the attainment of the highest level of health for all people. -Requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, history and contemporary injustices and the elimination of health and health care disparities. - CDC

APTA Code of Ethics

•Helps PT's to apply ethical principles in every day practice •Protects patients and families •Are enforceable •First developed in 2010 •Includes 8 priniciples with subprincipals as well

Issues in Clinical Practice

•Historically PT relied on others for ethical knowledge •End points in PT Treatment ▫Often unclear as to who decides (pt, PT, MD?, Insurance company?) •Recognizing & Maintaining Professional Boundaries ▫Examples: friendships, romantic relationships with patients, etc. •Actively engaging patients in PT ▫Whats the best way-need to balance trust, autonomy, benificence, justice...

Individual process: considering what is right vs. wrong (moral sensitivity, judgement, motivation, courage)

•Moral sensitivity - being able to recognize, interpret and frame the ethical situation ▫Ex: sensitive enough to understand that something is not right •Moral judgment - deciding between rt vs. wrong; select ethical principle(s) and apply ▫Deciding right vs wrong, thinking about what actions you might take •Moral motivation - prioritizing ethical values over self-interest ▫Placing ethical values over something else/another value that would stop them from taking action; motivated to follow principles •Moral courage - doing something; implementing chosen ethical action ▫Choosing to act, even when not in individual best interest to act

Morals vs. ethics

•Morals: An individuals own principles or definition of right vs. wrong ▫Everyone has their own •Ethics: Rules provided by an external source, codes of personal/professional conduct ▫More general term ▫Ways that people should act-what you do based on what you perceive as right vs wrong ▫An individuals morals impacts how they approach ethical questions

Basic Principles of Biomedical Ethics (nonmaleficence, beneficence, autonomy, justice)

•Nonmaleficense: the duty of healthcare providers to do no harm •Beneficence: the obligation of healthcare providers to help those in need-actions that benefit the patient •Autonomy: the right of the individual to choose-basis for informed consent-includes confidentiality, truth telling. •Justice: being fair to everyone ▫Universal justice: rights & equal opportunity, food shelter ▫Distributive justice: the allocation of benefits and burdens

Ethical Situation (problem, ethical tempation, distress, dilemma, silence)

•Problem or issue: situation in which our moral values are being challenged •Ethical Temptation: need to decide right vs wrong, you may benefit from either (but you know which one is right) •Distress: barrier to ethical behavior encountered, you know what you should do (something preventing you from making a decision, pushed against morals) •Dilemma: 2 or more choices are right - need to choose 1 (which choice is more right) •Silence: lack of acknowledgement/discussion (elephant in the room, hoping it will go away)

Realm:

•The context(s) where the decision is made •Individual - focus is on rights, duties, relationships, behaviors of individuals ▫Practitioner ▫Patient •Organization/institution - focus is on goals of organization; structures/systems •Societal - good of the community