When Key Stakeholders Disagree: A
Disability Manager’s Ethical Dilemma
Fred McGinn Ph.D.
Dalhousie University
Disability Management
School of Health & Human Performance
Case of Heinz
Heinz’s wife is dying from a special kind of cancer. There is one drug that
doctors believe might save her. It is a form of radium that a druggist in
the same town has recently discovered. The drug was expensive to
make, but the druggist was charging 10 times what the drug cost to
produce. He paid $200 for the radium and charged $2000 for a small
dose of the drug. Heinz went to everyone he knew to borrow the
money, but he could only collect $1000, which is half the cost. He
informed the druggist that his wife was dying and asked him to sell it
cheaper or let him pay later. The druggist said, “No. I discovered the
drug and I’m going to make money on it”. Heinz has become
desperate, and is contemplating breaking in to the store to steal the
drug.
Question: Should Heinz steal the drug?
Should Heinz Steal the Drug?
A) No, Heinz should not steal because he might get caught.
B) Yes, Heinz should steal the drug, because he loves his wife and wants her
to be with him for many years to come.
C) Yes, Heinz should steal the drug, because he knows that all good husbands
should be willing to save their spouses.
D) No, Heinz should not steal the drug, because it is against the law.
E) Yes, Heinz should steal the drug, because it isn’t fair that the druggist
should have the power to determine whether his wife lives or dies.
F) Yes, Heinz should steal the drug, because life is more important than
property.
Some “Givens” About Ethics
Everyone needs to be treated with respect
Each person has a right to come to her/his own
ethical conclusions.
Ethics that works only for the advantage of the
individual with total disregard of others is not
acceptable.
People are, or can be, rationale.
Different people have different values - there will
be disagreements in ethics.
4 opinions – 4 Characters
)“Whatever makes me happy is right”
)“Whatever works is right”
)“Whatever is helpful to others is right”
)“Whatever is fair is right”
Beauchamp & Childress, (1989),
“Principles of biomedical ethics”
Relevance of 5 ethical principles
(beneficence, nonmaleficence, autonomy,
justice & fidelity) for guiding behavior of
health professionals.
Five Ethical Principles
1) Beneficence: Desire to do good.
Beneficence
Providing a client with vocational training
compatible with the recommendations contained
in client’s vocational evaluation report.
Advocating for the client in the area of
accessibility.
Funding a service to prolong a client’s productive
life
Providing support services to the family that are
necessary to facilitate the client’s rehabilitation
gains.
Five Ethical Principles
2)
Nonmaleficence: Desire to
prevent harm.
Nonmaleficence
Confronting a client concerning his/her selfdestructive lifestyle
 Intervening to meet the specific health care and
safety needs of a client
 Hippocratic Oath: First, do no harm

Five Ethical Principles
3)
Autonomy: Desire to promote
the freedom of others to make
personal choices.
Autonomy is Dependant Upon:
Rehabilitation Practitioner refrains from
unnecessary interference in client’s choicemaking actions.
Client is provided full disclosure of
information, including informed consent.
Client has competence to use information in
decision-making process.
Five Ethical Principles
4)
Justice: Desire to promote the
fair treatment of people
Justice
Respect people as individuals and serve all
in an equitable and fair manner
Keeping individual case service costs down
in order to provide services to a large
number of clients
Being equally accessible to all clients
Clearly separating professional from
personal points of view
Five Ethical Principles
5)
Fidelity: Desire to be true to
one’s commitments
Fidelity
Respecting policies and procedures in a
professional manner
Carrying out a previous rehabilitation
professional’s commitment to a client(s)
Is worthy of trust and recognizes the
importance of confidentiality
Confidentiality – Duty to Warn
Tarasoff v. Regents of the University of
California (1976).
Breaching Confidentiality – Definition of
“Harm”
Ethics and Research
Nuremburg Code – 1947
Respect for Persons (dignity and freedom of
every subject)
 Researchers must maximize benefits and
minimize harm
 Equitable selection and fair treatment of
subjects

Five Ethical Principles
1) Beneficence
2) Nonmaleficence
3) Autonomy
4) Justice
5) Fidelity
Examples of actions in the rehabiliation
process that are associated with the 5 Ethical
Principles:
1)
2)
3)
4)
5)
Timely delivery of services (adhering to
Beneficence)
Refrain from negligent behavior (adhering to
Nonmaleficence)
Encouraging consumers to choose their own
rehabilitation goals (adhering to Autonomy)
Refusing to spend limited available time
assisting an unmotivated consumer who is not
working toward his/her rehabilitation goals
(adhering to Justice)
Adhering to organizational policies (Fidelity)
Types of Ethical Dilemmas That
May Be Encountered
Providing comprehensive and costly
rehabilitation services to a few individuals
vs. providing adequate and timely service to
a larger number of individuals.
Maintaining confidentiality vs. protecting
harm by providing relevant information.
Types of Ethical Dilemmas
(cont)
Keeping required paperwork up to date at
any given time vs. allotting sufficient time
to provide direct services.
Adhering to agency management guidelines
vs. providing an optimal package of
rehabilitation services to a client.
Ethical Dilemmas
For example, stealing government property
for your own personal gain would be a
“moral temptation” not an ethical dilemma.
Deciding whether scarce resources should
go to a needy client or a group of less needy
clients, and how you make that decision,
might constitute an ethical dilemma.
Characteristics of an Ethical
Dilemma
1)
A choice must be made between two courses of
action.
2)
There are significant consequences for taking
either course of action.
3)
Each of the two courses of action can be
supported by one or more ethical principles.
4)
The ethical principles supporting the un-chosen
course of action will be compromised.
Ethical Decision-Making Model
1) Review the case situation and determine the 2 courses of
action
2) List the reasons supporting each action
3) Identify the ethical principles supporting each reason
4) List the reasons for not supporting each course of action
5) Identify the ethical principles that would be
compromised if each action were taken.
6) Formulate a justification for the superiority of one of the
2 courses of action by processing all of the information
from the previous 5 steps.
Case of Susan
Susan is a 25 year old blind individual receiving CPP monthly benefits
totaling $1209.00. prior to losing her vision, Susan worked for 5 years
as a file clerk. Susan applied for rehabilitation services indicating that
she would like to obtain work in order to improve the quality of her
everyday life by reducing her social isolation. Given her 10th grade
education and recent vision loss, Susan will need vocational training to
enable her to obtain suitable employment. The jobs that are feasible via
training for Susan all tend to pay about $1100.00 per month.
Therefore, by being vocationally rehabilitated, Susan’s monthly
income will slightly decrease. After being fully informed of the results
of her vocational evaluation Susan indicates that she is very confused.
Confusion is generally Susan’s reaction when confronted with making
important decisions.
Case Susan (Cont.)
Through effective counselling you attempt to help her sort out the pros
and cons of each alternative. However, all it does is raise her anxiety.
Susan asks you to tell her what to do. Although you personally believe
that Susan would benefit from returning to work, you suggest that she
take a week to think about it and return. She returns more confused
than ever and again asks you to tell her what you think she should do.
You must decide whether to give her an opinion.
Case of Mary
Mary is a nurse at the Claiborne Correctional Institute. Injection drug
use is frequent in the prison. Approximately one of every 60 inmates
is known by the institution to be HIV-positive, and approximately one
of 3 inmates is HCV-positive. Mary knows that the prisoners share
needles because there are very few needles in the prison, and is very
concerned about HIV and HCV transmission. However, the prison
does not have a needle exchange or distribution program. This
frustrates Mary, since she feels that this policy is directly contributing
to the spread of HIV. However, bleach distribution is permitted, and
the doctor encourages prisoners to use it to sterilize their needles. She
knows, however, that the evidence that bleach is an adequate
sterilizing agent is inconclusive. This adds to her guilt and frustration,
since she feels she is providing her patients with sub-optimal advice
and care.
Mary (Continued)
One morning, Mary is conducting a physical on an inmate.
The patient is HIV-negative, but confesses to sharing
needles. Mary knows that at least one of the people he
shares with is HIV-positive. On the table between them
are clean syringes that she normally uses for vaccination.
She knows that if she turns away, the syringes may
“disappear”. This is against prison policy, but could help
prevent needle sharing. What should she do?
REMEMBER

There is no absolute right and wrong course of action to take when
faced with an ethical dilemma.

The nature of ethical dilemmas is such that good reasons can be
provided for either of two courses of action.

When dealing with an ethical dilemma the most that can be
expected of the rehabilitation professional is an ethically sound
decision regarding the chosen course of action.

An ethically sound decision for resolving an ethical defense for the
chosen course of action involves giving equal consideration for
each course of action. Therefore, it is not sufficient to state “I
chose Action A or Action B because it felt right”