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The concept of reason and impartiality as the minimum requirements for morality. It explains that moral judgments must be backed by the best arguments or reasons, and that morality requires impartiality with regard to those moral agents affected by a moral decision. The document also presents several models of ethical decision-making, including the 7-step moral reasoning model. It then explores a case study involving a patient with hiv who requests confidentiality from his physician, and the ethical dilemma this presents. The document emphasizes the importance of considering various moral principles, such as confidentiality and the duty to warn, when making ethical decisions in complex situations. Overall, the document provides a comprehensive overview of the role of reason and impartiality in moral reasoning and decision-making.
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Topic 2: Reason and Impartiality as Minimum Requirements for Morality Nominal Duration: 1.5 hours Learning Outcomes: Upon completion of this topic, the student must be able to:
Situation – "Please Don't Tell!" A twenty-year-old Hispanic male was brought to a hospital emergency room, having suffered abdominal injuries due to gunshot wounds obtained in gang violence. He had no medical insurance, and his stay in the hospital was somewhat shorter than expected due to his good recovery. Physicians attending to him felt that he could complete his recovery at home just as easily as in the hospital and he was released after only a few days in the hospital. During his stay in the hospital, the patient admitted to his primary physician that he was HIV positive, having contracted the virus that causes AIDS. This was confirmed by a blood test administered while he was hospitalized. When he was discharged from the hospital, the physician recommended that a professional nurse visit him regularly at home in order to change the bandages on his still substantial wounds and to insure that an infection did not develop. Since he had no health insurance he was dependent on Medicaid, a government program that pays for necessary medical care for those who cannot afford it. However, Medicaid refused to pay for home nursing care since there was someone already in the home who was capable of providing the necessary care. That person was the patient's twenty-two-year-old sister, who was willing to take care of her brother until he was fully recovered. Their mother had died years ago and the sister was accustomed to providing care for her younger siblings. The patient had no objection to his sister providing this care, but he insisted that she not be told that he had tested HIV positive. Though he had always had a good relationship with his sister, she did not know that he was an active homosexual. His even greater fear was that his father would hear of his homosexual orientation and lifestyle. Homosexuality is generally looked upon with extreme disfavor among Hispanics. The patient's physician is bound by his code of ethics that places a very high priority on keeping confidentiality. That is, information about someone's medical condition that he or she does not want known cannot be divulged by the physician. Some would argue that the responsibility of confidentiality is even greater with HIV/AIDS since disclosure of someone's homosexuality normally carries devastating personal consequences for the individual who is forced "out of the closet." On the other hand, the patient's sister is putting herself at risk by providing nursing care for him. Doesn't she have a right to know the risks to which she is subjecting herself, especially since she willingly volunteered to take care of her brother? If you were the physician, what would you do in this case? Would you breach the norm of confidentiality to protect the patient's sister, or would you keep confidentiality in order to protect the patient from harm that would come to him from his other family members, especially his father? Perhaps as good a question as "what would you do" in this situation is the question, "how would you decide what to do" in this situation? The process of making a moral decision can be as important as the decision itself, and many ethical decisions that people encounter are so complex that it is easy to exhaust oneself talking around the problem without actually making any progress toward resolving it. The response to many moral dilemmas is "where do I start?' and the person who is faced with these decisions often needs direction that will enable him or her to move constructively toward resolution and "see the forest for the trees." In order to adequately address the ethical dilemmas that people encounter regularly, the following is a model that can be used to insure that all the necessary bases are covered. This is not a formula that will automatically generate the "right" answer to an ethical problem. Rather it is a guideline that is designed to make sure that all the right questions are being asked in the process of ethical deliberation.
At this point, the task is one of eliminating alternatives according to the moral principles that have a bearing on the case. In many instances, the case will be resolved at this point, since the principles will eliminate all alternatives except one. In fact, the purpose of this comparison is to see if there is a clear decision that can be made without further deliberation. If a clear decision is not forthcoming, then the next part in the model must be considered. At the least, some of the alternatives may be eliminated by this step of comparison.
6. Weigh the Consequences If the principles do not yield a clear decision, then a consideration of the consequences of the remaining available alternatives is in order. Both positive and negative consequences are to be considered. They should be informally weighted, since some positive consequences are more beneficial than others and some negative consequences are more detrimental than others. 7. Make a Decision Deliberation cannot go on forever. At some point, a decision must be made. Realize that one common element to ethical dilemmas is that there are no easy and painless solutions to them. Frequently, the decision that is made is one that involves the least number of problems or negative consequences, not one that is devoid of them. Back to the situation – Please Don't Tell! Using the model, let's return to the case at hand. This will illustrate how the model is used and clarify exactly what is meant by each of the elements in the model. 1. Gather the Facts: The relevant facts in this case are as follows:
would be taking in giving him nursing care. The conflict could be summarized by the need for patient confidentiality vs. the duty to warn the sister of risk of harm.
3. What Principles have a bearing on the Case? Two moral principles that speak to this case come out of the way in which the ethical issue is stated. This case revolves around a conflict of rights, a conflict of duties that the physician has toward his patient and toward the sister. He is called to exercise compassion toward both, but what compassion (or the duty to "do no harm") demands depends on which individual in the case is in view. Thus two principles are paramount. First is the widely recognized principle that patients have a right to have their medical information kept confidential, particularly the information that could be used to harm them if it were disclosed. But a second principle that comes into play is the duty of the physician to warn interested parties other than the patient if they are at risk of imminent and substantial harm. One of the difficult aspects of any ethical decision is knowing what weight to give the principles that are relevant to the case. Here, the principle of confidentiality is considered virtually sacred in the medical profession and most physicians will argue that it is necessary to keep confidentiality if patients are to trust their physicians and continue coming for treatment. But confidentiality is often considered subordinate to the duty to warn someone who will likely be harmed if that information is not disclosed. For example, if a psychologist believes that his patient will kill his wife, or beat her severely, he has a moral obligation to inform the wife that she is in danger from her husband. The duty to warn someone from imminent and severe harm is usually considered a more heavily weighted principle than confidentiality in cases like these. The key question here in weighting the principles of confidentiality and the duty to warn (both fulfilling the Biblical notion of compassion toward those in need of it) is the degree of risk that the patient's sister is taking by providing nursing care for her brother. If the risk is not substantial, then that weights confidentiality a bit more heavily. But if the risk is significant, then the duty to warn is the more heavily weighted principle. This is particularly so given the fact that the sister has volunteered to perform a very self- sacrificing service for her brother. Some would argue that her altruism is an additional factor that weights the duty to warn principle more heavily. Others would suggest that his contracting HIV is an example of "reaping what one sows," and that minimizes consideration of the patient's desire for confidentiality. An additional factor that should be figured into the deliberation is that the risk to the patient, though it may have a higher probability of happening, is not as severe as the risk to the sister. After all, if the worst case scenario happened to the patient, his father would disown him and the gang would throw him out (though their action could be more severe than that). He would recover from all of that. But if his sister contracted HIV, she would not recover from that. Though the probability of the worst case scenario is higher for the patient, the results of the worst case are clearly higher for the sister. 4. List the Alternatives In this case, there are a number of viable alternatives that involve compromise on either the patient's part or his sister's. However, there are two alternatives that do not involve compromise and they each reflect a weighting of the principles. One alternative would be to tell the sister that her brother is HIV positive. This alternative comes out of taking the duty to warn principle as higher priority. On the other hand, a second alternative is to refuse to tell her that information, upholding the patient's request for confidentiality and taking the confidentiality principle as the one that carries the most weight. However, there are other alternatives. For example, the physician could warn the patient's sister in general terms about taking appropriate precautions for caring for these types of wounds. She is to wear gloves and even a mask at all times when handling the bandages. Should she get any blood on her clothes or body, she is to wash immediately with a disinfectant soap. In other words, she is to take universal precautions that any medical professional routinely takes in caring for patients. A further alternative is to request that the patient inform his sister of his condition. He could then request that she not tell any other family member or any or his friends. If he refused, then the next step might be to say to him in effect, "If you don't tell her, I will."
and patient is maintained. However, if the sister is nudged to ask her brother some pressing questions about why these precautions are so important, he may conclude that the physician has prompted his sister to ask these questions, leaving him feeling betrayed.
7. Make a Decision What would you decide in this case? Which principles are the weightiest? Are there others that you would include? Which alternatives are the most viable? Are there others that you would suggest? Which consequences seem to you the most severe? Are there others that you think will occur? It is important to realize that at some point you must stop deliberating and make a decision, as uncomfortable as that may be. Student Activity 2 : Form a group with 5 members in each group. Analyze the situation of Rebecca using the 7 step ethical decision model. Place your output in a word document and submit online. You are a resident assistant in a co-ed residence hall. One evening, a first year female resident named Rebecca comes to your apartment. She tells you that she had been grabbed on campus by an unidentified male who released her when she screamed. Rebecca explains that she tells you only because her best friend convinced her to approach you. She did not want to report the incident to the campus police, and, in fact, states she wants the information to stop at your level. After speaking with Rebecca for about an hour, you convince her to inform the police. She reluctantly details the same story to the police. Over the next several days, you see Rebecca a number of times. The police investigation has intensified and the information has been released to the student newspaper as a public safety announcement. Rebecca becomes more distraught and withdrawn. You convince her to visit a counsellor. She agrees, only if you accompany her. One day during an emotional and vague conversation, you and Rebecca are discussing the assault. You feel there is more to the story then you are being told. You assure Rebecca that anything she reveals to you will remain confidential. She offers nothing more. Over the next few days, Rebecca begins to respond to your continued prodding and becomes more comfortable with you. A week later, Rebecca comes to you with the "whole story." She had been drugged, detained and raped by another student (also a resident of your building) at a campus party. Rebecca is clearly traumatized by sharing her story with you. She repeatedly emphasizes her desire for confidentiality. You convince Rebecca to tell campus police the whole story, but she refuses to reveal to them the assailant. The police finally had the details of the assault, but they had no clues to aid in their investigation. Rebecca is the only person who knows the identity of the rapist, and only you know that the individual resides in your building. What do you do? Assessment Task: (15 points each item) Exercise 1 Name: Course & Year: Direction: Answer the following questions in a paragraph or two