Clinical Ethics for Out-of-Hospital Providers

Dr. Alexandra Olmos Perez
Reviewed: March 31, 2021

PHSA is committed to promoting reflective practice in the delivery of health care within a culture that values ethics.  An ethical culture requires explicit values and principles which help to foster decisions that are ethically justifiable, appropriate, and accountable.  By extension, there is an expectation of ethical behavior from all individuals in the organization.

Ethics is about determining the ‘right’ thing to do in each situation.  In healthcare, we develop relationships with other health care providers, patients, and family members, and at times find that we have differing views, values, and expectations which may differ from situation to situation.  Ethics provides a toolbox of theories, concepts, and processes to navigate the complexity of the relationships developed within the health care context through conversations about values and principles.

Ethics: A philosophical discipline that studies the moral phenomenon (why do we think something is right/wrong, and is it really right/wrong).  It also studies normative systems, such as morals (concrete rules about what we consider to be right/wrong) and the law.  Questions about ethics are questions about values.

Values: They represent what is important to us.  They drive our decisions, attitudes, behaviour, and are at the centre of what we define as culture.  Theoretically, values are the result of the interaction of a (moral) subject, and an object (real things we can see or touch, or ideas, like love, friendship, justice, and happiness) in which the first performs a value action (which means we are not ambivalent and we react to something).  That makes values very dynamic and therefore diverse.  Even if we share some values with other individuals or groups, their interpretation of what is important or valuable could change because of how this interaction occurs (which is why there are different value systems).  Also, value is an inter-subjective action, which means we never perform it in isolation, but in context and within our relationships with other people (other moral subjects).  This influences how we interact and interpret things, and therefore how we value them.

Principles: Normative standards that outline a course of action within a specific framework.  They express value in concrete situations, but unlike rules they are not prescriptive (if you don’t follow them, consequences are not explicit) and they operate on optimization, which means that more than one principle can be applicable to the same situation and they can be balanced accordingly.  To learn more about principles in the context of biomedical ethics, please refer to PHSA Ethical Practice Guide (this link usually doesn't work via the app; please use the desktop version to access).

Ethical issues arise when there is more than one option or course of action to choose from but the decision creates a conflict between two different values or principles.

Ethical issues in health care occur on a daily basis and include, but are not limited to the following domains:

• Shared decision making with patients/families
• Assent, consent, and surrogate decision-making
• Ethical practices in end-of-life care
• Patient privacy and confidentiality
• Professionalism in patient care
• Ethical practices in research
• Ethical practices in resource allocation

Healthcare providers, like anyone, have their own value systems or personal moral compass: our own conceptions about what is right and wrong.  Nonetheless, because of their role as healthcare professionals to provide services that are “vital to the organized functioning of society” (Bayles, 1989), they therefore have obligations towards the public that should steer their actions when practicing healthcare including interactions with patients and families.

Professional integrity requires that we hold our convictions on the basis of reasons that could be, in principle, defensible: “a standing commitment to having the sort of judgment worth standing for” (Scherkoske, 2013).  This means that every time we are faced with the question “what’s the right thing to do?” we need not only to look for the answer within our personal moral compass, but reflect on how we can justify our decision to other people who might not share our views and values.

This means that when we are providing care, we need to be willing to be reasonable; respect others and be prepared to take into account their views and feeling to the extent of allowing one’s own perspective to be changed by others (Pritchard, 2006).

In order to make sure that there is full consideration of ethically relevant factors in a given situation, there are tools that can help, such as ethical decision making frameworks.  These frameworks are tools that aim to establish a systematic process for analyzing a case and identifying the main ethical issues and relevant considerations to determine the best course of action, all things considered.  Using a framework helps to illuminate values in tension, possible options, and ethically justifiable decisions.  This process can facilitate identifying and addressing systemic and personal biases and create a safe space for all relevant perspectives to be considered.  While frameworks will not typically lead to an ideal or perfect solution, and disagreement may well persist, these tools do offer a basis for consensus as they aim to provide a fair, inclusive, and transparent process, where participants can feel engaged in a conversation that aims towards an ethically justifiable solution.

Bias: Prejudice or unsupported judgments in favour of or against one thing, person, or group compared with another, usually in a way considered to be unfair.  To learn more about how to identify unconscious biases and about anti-racism, click here to see the resources on the PHSA POD.

Procedural Justice focuses on the fairness in the processes by which decisions are made.  From this point of view, the quality of interpersonal interactions and experiences along the decision making process affect the perception that those involved and affected have about the outcome.

The frameworks enable individuals and teams to work together by introducing a shared systematic process, developing a shared language, facilitating communication, and building a common understanding of how to approach ethical challenges.  Moreover, adhering to such a systematic process can ensure procedural justice which is essential in reaching socially acceptable, publicly accountable, and ethically appropriate decisions.  To learn more about the available tools to support decision making in the context of out-of-hospital and inter-facility care, please refer to the PHSA Ethical Practice Guide (this link usually does not work via the app; please use the desktop version to access).

PHSA Ethics Service contact information

Please visit ethics on the POD and this page on the Intranet for quick links to frameworks, ethics resources, and educational opportunities.