11. Ethical communication
CHAPTER OBJECTIVES
• Explain the importance of ethical communication
• List and understand the characteristics of ethical communication
• Appreciate the ethical responsibility of health professionals when communicating about their professional life
• Consider and develop strategies that ensure ethical communication and practice.
Ethical communication is essential in any health profession. Ethical communication relates to appropriate behaviour when communicating and is necessary for the maintenance of harmonious, productive and beneficial therapeutic relationships. The ability to communicate ethically requires motivation, character and self-awareness (Dossey et al 2003, Dossey et al 2005, Tyler et al 2005). Awareness of and commitment to ethical communication may depend on the familial, social and cultural background of the health professional (Egan 2007, Harms 2007). Violation of ethical responsibilities when communicating has serious consequences for both the person seeking assistance and the health professional (Egan 2007). Thus, it is important for the health professional to know the rules or codes of behaviour expected by the government, their profession and their particular health service (Higgs et al 2005, Purtilo & Haddad 2002). This chapter examines some of these expectations and rules.
GROUP ACTIVITY
• Discuss what is right and what is wrong when communicating. Consider possibly inappropriate topics, places of communicating, styles of communicating and reasons for communicating. Your answers here should look beyond personal preference.
• Use the ideas raised in this discussion to list the possible fundamental elements of ethical communication in the health professions.
Mohan et al (2004) state that most health professionals, while being aware of ethical requirements at a theoretical level, rarely consider them during everyday practice. However, it is not awareness or consideration of ethical requirements alone that produces ethical communication. It is the knowledge of, commitment to and application of these requirements into communicative behaviours that creates an ethical communicator. Devito (2007) considers every communicative act to have the potential to be constructive or destructive. This reality indicates that every communicative interaction in the health professions, if ethically sound, has the potential to create and sustain constructive therapeutic relationships (Rider & Keefer 2006).
The main purpose of this chapter is to outline the characteristics of, and strategies to achieve, ethical communication.
Respect regardless of differences
An overall characteristic and value of the health professions is respect of all people, whether those seeking assistance or those working alongside the health professional (see Ch 2). Every health professional must respect the rights of all individuals. These rights include equal opportunities, equal consideration and equal treatment regardless of status or condition (Harms 2007). Ethical communication requires health professionals to express unconditional positive regard for all human beings (Purtilo & Haddad 2002, Rogers 1967; see Ch 7). These are fundamental steps in achieving the ultimate purpose of the health professions – family/person-centred practice (see Ch 2). Expression of unconditional positive regard for all human beings is ethical and is in accordance with the Universal Declaration of Human Rights (United Nations 1948), the Human Rights Council (United Nations 2006) and the Convention on the Rights of Persons with Disabilities (United Nations 2006). The challenge for the health professional is not usually in respecting rights, however, but in respecting the actual person.
REFLECTIVE ACTIVITY
• How do you demonstrate respect for someone who is quite different from you? For example, someone who
– Lives on the street
– Works the streets
– Will only wear/not wear designer clothes
– Hates/loves football
– Has a different religious code than you
– Believes terrorism is/is not appropriate
– Has a different political allegiance?
• List the values or beliefs a person may have that make it difficult for you to demonstrate respect.
• What can you do to ensure you demonstrate respect regardless of such differences?
Demonstration of respect for others requires health professionals to first respect themselves. Respecting and valuing self begins with an awareness of the thoughts about self that affect self-image and self-esteem; some of these thoughts may have their origin in comments made by others. Regardless of their origin, these thoughts require reflective consideration and adjustment (Backus & Chapian 2000). If health professionals find it difficult to value and respect themselves it is imperative they seek expert assistance to maximise their potential to be effective communicators.
Health professionals demonstrate respect through verbal and non-verbal communicative behaviours. Such behaviours automatically reflect the underlying values and beliefs of an individual (Brill & Levine 2005, Tyler et al 2005). Thus, critical awareness of personal values and beliefs is essential for establishing and practising ethical communication (Harms 2007).
Honesty
The truthful statement of thoughts, feelings and desires is the common understanding of honesty. The New Shorter Oxford English Dictionary on Historical Principles (1993) suggests that honesty is a characteristic, not merely a linguistic or social occurrence. Words such as ‘honourable character’ and ‘uprightness of disposition and conduct’ imply that honesty is about more than truthful statements; it is an underlying characteristic of an individual. The dictionary presents the opposites of honesty as being cheating, stealing and lying. These definitions provide ‘food for thought’ that may assist the health professional when considering honesty. They suggest that honesty is a characteristic that generates honest statements and produces consideration of the needs of all interacting individuals.
CASE STUDY
You are very busy today, with more than the usual number of people to assist. The young person seeking assistance is the same age as you and has similar interests. They are usually optimistic and relaxed when they attend, but today they suddenly begin to tell you all the things that are going wrong in their life and how depressed they are feeling.
A holistic communicative approach alone, without consideration of the therapeutic relationship that is essential for positive outcomes, dictates that you should stop, actively listen, empathise and seek permission to refer the person to another professional if appropriate.
However, you are extremely busy and not interested in hearing any more because you have problems in your life too! You do not want a reminder of those things while at work, nor do you want to fall behind today because you have a personal appointment immediately after work. Besides, there are other people waiting to see you.
GROUP DISCUSSION
• Consider the possible ways of responding. Discuss the potential outcomes of each response.
• What is an ethically appropriate response?
• Which needs are the appropriate ones in this situation – the needs of the person or those of the health professional?
Honest responses from a health professional are important. Many people seeking assistance are able to recognise a verbal or non-verbal response that does not reflect honesty. Such responses affect the level of trust in the relationship and if detected potentially create anxiety in the person seeking assistance concerning reasons for the lack of honesty. It is important to consider particular situations and questions that could cause difficulty for the health professional and prepare possible responses (Higgs et al 2005). This consideration will assist in the development of a therapeutic relationship and contribute to family/person-centred practice.
DISCUSSION
• What do you need to consider before responding to the following?
– Someone is reluctant to follow a treatment regimen.
– Someone is unhelpful when you have asked for their assistance.
– Someone is dismissive when you have asked them a question.
– Someone relates differently from their previous interactions.
– Someone shares that they are lonely and depressed but asks that you tell no-one.
– Someone requests your assistance and what they are asking is inappropriate.
– Someone waiting for results asks Do I have cancer? You know they do.
• Consider other possible situations that require honest responses.
If the health professional genuinely seeks the wellbeing of those with whom they interact, honest responses will develop trust and safety for all communicating individuals.
Clarification of expectations
When entering a new situation or environment, most individuals strive to understand that situation or environment. They may feel tentative or insecure and thus appreciate a friendly health professional who demonstrates genuine interest and concern. In such situations it is reassuring for the person to know what to expect and how to gain answers or assistance through either verbal or written information. Asking the person seeking assistance to voice their expectations of the service allows the health professional to clarify any uncertainties and will also serve to reassure the person.
REFLECTION AND DISCUSSION
• As a health professional, what do you feel a person seeking your assistance should know about your expectations and their rights before they receive your assistance?
• What do you feel such a person would like to know about their rights and the services available as they seek your assistance?
• What would you like to know about their expectations of your service?
There are various ways of communicating about the available services and the rights of the individual seeking assistance. Verbal and written explanations of rights and procedures with opportunity for clarification are usually successful and potentially improve the outcomes of both the communication and the service.
Consent
Agreement about information
In an attempt to achieve ethical behaviour from staff, particular health services use signed agreements that outline privacy and related issues. All people seeking assistance are asked to sign such agreements. These agreements are explicit statements of the usually implied rules that guide the relationship between the health professional and the person seeking assistance. Such rules assume that health professionals will never seek to harm the person seeking assistance and that they will always seek to assist and fulfil appropriate goals for that person (Purtilo & Haddad 2002). Signed agreements may provide information about the service, what to expect when receiving assistance, the responsibilities of all stakeholders and guidelines for lodging a complaint. They usually make statements about responsible use of gathered information based upon the assumption that every individual has a right to privacy (Mohan et al 2004). For more information relating to privacy in Australia, see Australian Government policies and acts such as the Privacy Act 1988, Disability Services Act 1986 and Commonwealth Disability Strategy 2003. For a similar policy in New Zealand see the New Zealand Government Privacy Act 1993. These acts may state that the health service agrees to protect privacy. They may indicate that health professionals might share revealed information with other health professionals but only for the benefit of the person seeking assistance, never for illegal or inappropriate reasons.
REFLECTION AND DISCUSSION
• If you sign an agreement to protect your privacy, what would you expect that to mean regarding the information you provide to different health professionals about your needs or condition?
• Would you feel it was appropriate for a particular health professional to discuss your information with another person? If so, with whom and why?
• Would you like to have access to and explanation of any notes or reports the health professional(s) wrote about you?
• What are the implications of your answers for a health professional?
It is important to remember that the person seeking assistance will be more willing to provide information if the health professional has explained how the information will be used and why it is necessary for the health professional to have this information (Harms 2007, Stein-Parbury 2006). To encourage sharing of information, health professionals must act to indicate they are worthy of trust (Brill & Levine 2005).
Informed consent
Although the ‘informed consent’ type of agreement often refers to research involving humans (Malone 2003), within the health professions it usually refers to procedures associated with a particular health profession. This type of agreement requires the health professional to provide clear information about the procedure, the associated risks and the expected outcome of the procedure (Purtilo & Haddad 2002). Informed consent is an attempt to give the vulnerable individual a sense of control in a situation where they often feel they have little power, control or autonomy. In many places there is a legal requirement to provide such information at an appropriate level of complexity for the person seeking assistance.
GROUP DISCUSSION
Read and discuss excerpts from Malone’s (2003)‘A fully informed consent letter’ article titled Ethics at home: Informed consent in your own backyard at the end of this chapter.
• What are the implications of this letter for
– The health professional?
– The person signing the informed consent letter?
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