Barbara Russell
It's useful to first define "ethics." In academic circles, "ethics," a Greek word, is usually about the study of individuals' conduct, and "morality," a Latin word, is about such conduct. Sometimes, however, the definitions are switched; at other times, "ethics" and "morality" are considered synonyms. It can be confusing. From my perspective, Accreditation Canada is most interested in what actually happens at a hospital when staff and physicians work with clients and families and when managers, executives, and board members make administrative decisions that affect not only current clients and families, but future clients and families, too.
To define "ethics" for Accreditation Canada's purposes, I suggest focusing on what people should consider "good or bad" and "right or wrong" and how such values should guide their interactions, decisions and behaviour. The word "should" is important here because what people actually value and how they actually behave may or may not be ethically justified. To determine whether pursuing a goal, desiring an object or behaving in a certain way is or is not ethically justified, we have to figure out why the person values something or behaves that way. Is it because they want a good reputation (i.e., they value their own interests and ego) or because they know their perspective may not be definitive (i.e., they value other people's experiences and knowledge)? Is it because they want more money (i.e., so they acted competitively) or because they want to correct an error made by someone with more power (i.e., so they acted bravely)?
Accreditation Canada provides some helpful points to explain an ethics framework in its Guide for Developing Qmentum Plans and Frameworks. An ethics framework: (1) is an analytical tool to guide ethical decision-making, (2) defines processes for handling ethics-related issues and concerns, (3) links with the organization's core values and (4) is not a code of ethics. The reason why a framework is not a code is, I think, that codes tend to be a list of "You must do X, must not do Y and are permitted to do Z" statements. These lists typically omit the values that explain or justify these statements. Moreover, the lists tend not to countenance situations that are unclear or situations in which statements will conflict with one another.
An ethics framework should identify ethics-related values that are used in making decisions, as well as guiding everyday interactions with clients, families, colleagues and people external to the hospital. Because people and their communities involve many ethical values, health care involves many ethical values. The framework should also identify a process for making decisions and guiding interactions. The process should include such steps as determining who is responsible and accountable for addressing the issue or answering the question, whose knowledge, experience and perspective needs to be considered, who qualifies as a "special resource" to help address the issue or question (e.g., is there a bioethicist, a research ethics board, a spokesperson for all clients or a professional practice leader?), and how to implement the option or provide the answer in an ethical way.
With this said, though, it is not enough to just figure out the option or response that is ethically strongest. It must be implemented or "done" ethically, as well. Otherwise what is a thoughtful, sound option or response can transform into an unappreciated, ineffective or even damaging one. As Arthur Frank, a sociologist at the University of Calgary, wisely noted in the Internal Medicine Journal in 2004, "Being ethical ... is never anything that one has." Ethics involves more than understanding various concepts or principles. It also involves ethically skilful behaviours. This is why the familiar notion that "having common sense and good intentions" is adequate for ethical interactions and decisions is, I think, simplistic and superficial.
I am often asked, Why is it so important to be explicit about the ethical values that apply to a particular dilemma or question? What is valued ethically differs substantially. For instance, in terms of material and immaterial "situations" or "things," think about how different diverse relationships, having a home and individuals' creativity are. In terms of praiseworthy character traits or virtues, think about honesty versus loyalty versus generosity. The relevance of an ethics-related situation, "thing" or virtue to a specific dilemma or question will vary. Moreover, what a person does - her statements, actions and timing - to be honest will differ from what she does to be loyal or generous.
A ready example of inattention to ethics-related behaviours involves respect and caring, two values routinely emphasized in health care contexts. In my experience, it is not uncommon for health care workers to have difficulty identifying behaviours that demonstrate care for a client (which is not the same as "care of a client") that are dissimilar from behaviours that demonstrate respect for the same client. Yet we know that we can care for a person without respecting him, just as we can respect him without caring for him.
If I had to summarize what an ethics framework for health care settings is in 50 words or less, I would say that it is fundamentally about which ethics-related values are considered important or relevant (i.e., the "what"); health care employees' use of them in their everyday decisions and interactions (i.e., the "how"); and the organization's efforts to ensure these values and processes are well considered and alive.
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Barbara Russell, bioethicist at the Centre for Addiction and Mental Health in Toronto, answers ethics questions that arise in the mental health and addiction fields. She is connected with the University of Toronto's Joint Centre for Bioethics and heads the neuroethics interest group of the Canadian Bioethics Society. She is also a contributing editor to the Journal of Ethics in Mental Health.
Do you have an ethics question for Dr. Russell? Submit questions to be considered for this column to CrossCurrents editor Hema Zbogar at hema_zbogar@camh.net. Please omit personally identifiable health-related information in order to respect people's privacy and follow privacy legislation.
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