Navigating Ethics in
Healthcare
Heather Fitzgerald, MS, RNC-NIC,
Clinical Nurse Ethicist
Children’s Hospital Colorado
CAPI Conference
September 8, 2013
Disclosures
No relevant financial relationships with any commercial
interests.
Objectives
1. Distinguish between ethics and morals.
2. Distinguish between medical ethics and professional
codes of ethics.
3. Identify core professional ethical standards for medical
interpreters.
4. Examine examples of medical ethics through case
review.
5. Discuss bias and impartiality through analysis of
temperament.
6. Reflect on the medical interpreter role in health care
conflict and tools you have to navigate effectively.
Ethics versus morals: What’s the difference?
What guides us?
Ethics versus morals
What do we mean by “ethics?”
Medical Ethics and Medical Interpreter Ethics
Medical ethics: principles of right or good conduct:
identify and analyze the interests, values and principles
at stake for the parties involved and provide guidance
to support decision making and problem solving in
ethically-complex situations.
Interpreter ethics: principles of right or good conduct:
expectations of professionalism, standards of behavior
Medical Ethics
“The goal of ethics deliberations is not to achieve absolute
certainty about what is right, but rather to achieve reliability and
coherence in behavior, choices, character, process, and
outcomes. Judgments necessarily have to be grounded by
appealing to ethical theories and principles to avoid making
decisions solely on the basis of individual opinions.”
“Ethical deliberation involves a process of discerning, analyzing,
and articulating ethically defensible positions and then making a
decision about which position is most ethically justifiable.”
-- Rushton and Penticuff, 2007
Medical Ethics
Principlism: 4 principles – autonomy (respect for persons),
beneficence (person’s well-being, doing good),
nonmaleficence (doing no harm), justice (fairness)
Values at stake (relationships, respect, compassion, fidelity,
quality of life, etc.)
Law, precedent
Confidentiality, privacy
Interpreter Ethics
National Code of Ethics for Interpreters in Health Care
Medical Interpreting Standards of Practice
Confidentiality
Respect for privacy
Accuracy and completeness (fidelity to the original
message)
Impartiality, refrain from counseling, advising,
projecting personal beliefs and bias (carefully manage
the power of being the only one who understands both
languages)
Interpreter Ethics, continued
Maintain boundaries, professional distance (refrain
from personal involvement)
Professional integrity
Advocacy
Client/patient well-being (beneficence)
Respect for culture and cultural differences (health
care itself is a culture)
Codes of Ethics
Are NOT:
•answer books for every complex situation you will
encounter
• rules about how to solve values in tension
• a codified set of transcultural ethical principles
• defense of your subjective opinions or beliefs
Baby Gabrielle
Anencephalic Donor
1987, Loma Linda University, prenatal diagnosis of anencephaly (lacking
majority of brain)
MOC decided to continue the pregnancy and deliver her and sustain her life
by medical means to allow her to donate her organs to help other children
live (anencephalic babies will die, but over a period of time that renders their
organs ineligible for organ donation).
Baby Paul, born 3 hours before Baby Gabrielle, had a potentially-fatal
congenital heart malformation
Baby Gabrielle’s heart was transplanted into Baby Paul
Ethical issues: beneficence, non-maleficence, benefits versus burdens, best
interest, surrogate decision-making, ordinary versus extraordinary measures,
informed consent.
Baby K
1992, Baby K born with anencephaly (had only a brainstem: autonomic
regulation), Virginia
Prenatal dx; MOC carried baby to term due to her Christian faith and belief in
the sanctity of life
Permanently unconscious, deaf, blind, non-responsive to painful stimuli, did
have basic reflexes
Hospital viewed care as futile
MOC requested vent support despite inability to treat/cure underlying
condition
Hospital encouraged MOC to approve DNR and withdraw ventilator
MOC refused
Baby was ventilated for 6 weeks while hospital searched for another hospital
to assume care
Baby K continued
•Baby K weaned off the vent, moved to nursing facility
•Multiple readmissions for resp. distress
•6 mos of age readmitted w/severe RD
•Legal action: hospital filed motion for guardian, sought court order to limit treatment to palliative care
•Trial: standard of care vs. religious freedom and sanctity of life
•District Court interpreted EMTALA (Emergency Medical Treatment and Active Labor Act) as supporting
that any pt who presents w/emergency must get “such treatment as may be required to stabilize the
medical condition” before transfer to another facility. Supported Baby K getting ventilator support
•Dissenting judge: medical condition is anencephaly, not RD
Baby Fay
1984, HLHS, Loma Linda University
“human experimentation”
Human heart transplant not offered
Xenotransplantation (cross-species transplantation) with a baboon heart
Baby Fae died 20 days after transplant from rejection complications
Ethical issues: beneficence, maleficence, benefits and burdens, ordinary
versus extraordinary means, best interests, experimentation and untested
technology, informed consent, surrogate decision-making
BREAK
10 minutes
When we come back:
Can We Ever Truly Achieve Impartiality?
Case Studies
Can We Ever Truly Achieve Impartiality?
Personal morals
Cultural influences
Life experiences
How alert are we to our own biases?
What role does temperament play?
Gregorc Brain Dominance Model
Concrete Random (CR),
Common Traits
Artisans - Improvisers
• Tend to be fun-loving, optimistic, realistic, and
focused on the here and now
• Pride themselves on being unconventional, bold, and
spontaneous.
• Make playful mates, creative parents, and
troubleshooting leaders.
• Are excitable, trust their impulses, want to make a
splash, seek stimulation, prize freedom, and dream of
mastering action skills.
Page 18
The Improviser Temperament
What others should know:
•I need space
•I enjoy people but find too many
expectations confining
•I want to do things, not just think,
plan, or talk about them
•I want to be appreciated for my
trouble shooting talents
•I want my ‘free-spirit’ ways to be
seen as viable and responsible ways
to live life
Page 19
How others perceive me:
•Fun, quick, a risk-taker
•Maverick, free spirit
•They believe that some things come
easy to me
• They see me as a lucky person
•Sometimes I lack focus and miss
important details
•Fun to be around but want me to
prove that I am reliable
The Concrete Sequential (CS)
Common Traits
Guardians - Stabilizers
• Pride themselves on being dependable, helpful, and
hard-working.
• Make loyal mates, responsible parents, and stabilizing
leaders.
• Tend to be dutiful, cautious, humble, and focused on
credentials and traditions.
• Are concerned citizens who trust authority, join groups,
seek security, prize gratitude, and dream of meting out
justice.
Page 20
The Stabilizer Temperament
What others should know:
How others perceive me:
•I need to feel appreciated for the
simple ways I support others
•A sincere thank you or gesture goes a
long way
•I like to be asked to be included in
projects even though I might not have
time to participate
•When people follow through on their
commitments, it is more than a courtesy,
it shows me respect as a person
•I love it when people ask me for my
experience and support
•Organized, courteous, responsible, and
loyal
•I am someone they can count on
•Sometimes I am too structured,
organized, and not spontaneous enough
•Change resistant even though my
intentions are to do what needs to be
done to make the change happen
•A good student, head of the class
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Abstract Sequential (AS)
Common Traits
Theorist – Rationals
•Tend to be pragmatic, skeptical, selfcontained, and focused on problem-solving
and systems analysis.
•Pride themselves on being ingenious,
independent, and strong willed.
•Make reasonable mates, individualizing
parents, and strategic leaders.
•Are even-tempered, they trust logic, yearn
for achievement, seek knowledge, prize
technology, and dream of understanding how
the world works.
Page 22
The Theorist Temperament
What others should know:
How others perceive me
•I need to be allowed to think for
myself and still need room to be
creative
•I want to be taken seriously
•I need people to see my critiques as
contributions towards improvements
•Work with me towards long term
goals, my strategic thinking is seen as
tough minded, even though my
intentions are working towards the
brighter future
•Intelligent
•Lacking true emotion, or people
misinterpret what emotion I do show
•People see me as having particular
talents even though my talents are
intrinsic of who I am.
Page 23
Abstract Random (AR)
Common Traits
Catalyst – Idealist
•Want to be authentic, benevolent, and empathic
•Search for identity, meaning, and significance
•Are relationship oriented, particularly valuing
meaningful relationships
•Tend to be idealistic and visionary, wanting to make the
world a better place
•Look to the future
•Trust their intuition, imagination, and impressions
•Focus on developing potential, fostering and facilitating
growth through coaching, teaching, counseling, and
communicating
•Generally are enthusiastic
•Often are gifted in the use of metaphors to bridge
different perspectives.
•Frequently are drawn to work that inspires and develops
people and relationships
Page 24
The Catalyst Temperament
What others should know:
How others perceive me:
•I need to have a personal connection
•I need to know that each person is
acting authentically towards me
•I expect open discourse and personal
sharing
•I love to tell my personal stories and
love when people listen
•I need feedback that people believe in
me
•I look for a willingness to stand together
in the face of conflict with the belief that
working through it will only strengthen a
relationships bond
•People person
•Empathetic, imaginative, idealistic,
mysterious, intuitive, gullible, friendly,
empowering, committed and genuine
•Make others feel good about who they
are
•Good communicator
•I wish for too much and people are
afraid they are not able to live up to the
ideal image I have for them
Page 25
Giant apples are falling
off the trees early this
season……
– What can I do with all them
apples (apple pie, apple jam, share
with friends, family etc.)
– Reminds of the bounty of and
nature and the fickle cycle of the
seasons…..
– What factors are causing the
apples to fall early?
– Someone better pick them
apples up!
Page 26
The Nature Of Temperament
•Temperament is inborn
•Temperament reveals inborn tendencies through themes and core
values of a personality
•Temperament remains constant
•As we grow and develop, our temperament pattern stays the same while
we evolve into a more mature version of what we were in the beginning
•Temperament drives behavior
•Temperament influences the pattern of growth and development of a
character
Discussion and The Bottom Line
Knowing your temperament
pattern can go a long way
helping you identify
tendencies, behaviors and
biases.
Page 28
Cases
When a family asks not to tell:
Pharmacist, Ms. Paulis
Maria Sanchez, getting prescriptions at hospital
discharge for cancer treatment for her mother
Mrs. Rodriguez, Mrs. Sanchez’s elderly mother, who has
a brain tumor and is going home today from the
hospital
When a family asks not to tell
With medical interpreter assistance, Mrs. Sanchez asks Ms.
Paulis not to tell her mother what the medications are for,
saying, “My mother doesn’t know she has a brain tumor. There is
no reason for her to know. She is not a candidate for surgery or
radiation, so they are trying these medications. She is already
dizzy and confused at times, I don’t want to add to her pain.
She’s going to be under my constant care, so you can just tell me
what you would have told her. I am a good daughter, and in our
culture, we take good care of our parents, so you don’t have to
worry.”
Ms. Paulis replies, “Well, I have to tell her about her medications.
It’s my ethical obligation.”
Conflict at the Bedside
You are paged to the bedside of a very agitated patient who
is yelling and distressed. The medical and nursing teams are
trying to calm the patient down but need your assistance
interpreting what the patient is saying to understand her
distress. The patient tells you she wants a different nurse.
Her nurse is African American and the patient says she
doesn’t want to be touched by (uses a very derogatory
term) an African American person. The medical provider
says that is racist and refuses to make a staffing change to
accommodate the patient.
Complex decision making
Teenage parents expecting their first child, who they
recently discovered has a life-threatening diagnosis: You are
interpreting during an office visit with the surgeon, who is
explaining the options to the young parents. Sitting back
with his arms crossed, he says, “You can either wait and
see, or (leaning forward toward the parents and uncrossing
his arms) you can take charge and do surgery now to fix it.”
The parents look at each other nervously and the father
says, “We’ll do the surgery.”
Some Takeaways
From Worlds Apart, a documentary film by Maren Grainger-Monson and Julia Haslett
Patients and health care professionals often have
different perspectives, values, and beliefs about health
and illness that can lead to conflict, especially when
communication is limited by language and cultural
barriers.
Discrimination and mistrust affect patient’s interactions
with providers and the health care system.
Some Takeaways
From Worlds Apart, a documentary film by Maren Grainger-Monson and Julia Haslett
Inadequate interpretation for people of limited English
proficiency in the health care setting is a form of
discrimination (USDHHS Office for Human Rights, title
VI)
The ethical and legal obligation of informed consent in
medicine is to assure a patient’s understanding of their
diagnosis and treatment options so they can participate
in decisions about their care, not just indicate they
have heard the information and sign a consent form.
Resources
A National Code of Ethics for Interpreters in Health Care, 2004. The National Council on
Interpreting in Health Care Working Paper Series.
Medical Interpreting Standards of Practice, 2007. The International Medical Interpreters
Association.
When a family asks not to tell, adapted from Case Studies in Pharmacy Ethics, Amy Haddad and
Robert Veatch.
ANA Code of Ethics with Interpretive Statements, 2001. The American Nurses Association.