Fig. 6.1
A model for ethical analysis from the Swedish code of ethics for occupational therapists
An Ethical Dilemma
Examining the case presented below provides opportunities for understanding this model of ethical analysis.
A 45-year-old man is being treated at a mental clinic after a serious suicide attempt. He is deeply depressed after having lost his job, where he had been employed for the past 20 years. Occupational therapy is prescribed. Initially, he is entirely apathetic, but after some time, he recovers his zest for life and can cope well with everyday activities. He starts a program of preparatory occupational training, during which he comes into contact with people who are undergoing treatment as outpatients. The man expresses a wish to live at home and to come to his therapy sessions during the day. The OT encourages this initiative, since she is convinced that he can now cope, but agrees only on condition that he can first try several weekend furloughs. However, the patient’s wife questions the professional competence of the OT. She states that weekend furloughs for her husband are out of the question; she does not consider him well enough to come home at all, even for a weekend.
Formulation of the Problem
In the first step, it is important for the OT to formulate and clarify the ethical problem by using the information available and applying the OT’s own interpretation of the situation. The problem often focuses on how to behave in a correct, ethical manner—that is, in a professional way. In this case, there exists a conflict between the OT’s professional opinion about the rights of her patient, on one hand, and the rights of the patient’s wife, on the other.
Analysis of the Problem
In the second step, the OT must ask the following questions: What alternative actions are possible in this situation? Whose rights should take priority—those of the patient or those of the relative? Are there strong reasons for considering the rights of the wife? If so, what are they? Is there any way of satisfying the rights of both people?
Based on OT’s professional competence, the OT reflects on various options: Is more than one person affected by my actions? How will they be affected? What other information is important for my decision? Is it possible to try a short stay at home supported by professionals? Is it possible to propose that the wife receive support from a psychologist during the upcoming time of her husband’s transition? What are the consequences of the various options?
In order to take a decision, the OT must relate the choices to his or her own fundamental values, which comprise personal morality, and to the code of ethics for OT. The Swedish code underlines that the OT should conduct treatment based on the patient’s own will as far as it is consistent with the profession’s goal. This suggests that the husband’s wants should prevail over the wife’s.
Decisions and Actions
In the third step, the OT decides how to act and also determines what motivates that decision. Following this model for analysis, the choice is a result of reasoning—it is rational and understandable both in content and structure. It is based on correct information, as well as on values and norms that the OT believes to be correct and can argue for, and in most cases, share with others. By referring to information, to possible courses of action, and to fundamental values insofar as possible, the OT can justify his or her choice and actions.
In the example case, the OT decided that, to begin with, she needed more information about what support the wife might need in order to accept that her husband could go home. How would you yourself act in a similar situation?
Ethical Guidelines for Priority Setting
Leaving the ethical dilemma concerning conflicts of interest, we turn attention to the conflict of having to set priorities. The conditions for health care have changed over the years in most countries. The increasing gap between possibilities, demands, and diminishing resources is real, creating difficult choices and ethical dilemmas for OTs. Am I, as an OT, concentrating on the right problems? Could I consider my choices fair? Choices, of course, do not arise only in times of restriction: What should be expanded when expansion is possible? Whose need for health care should take priority over others’?
States with publicly funded health-care systems are trying to find ways of accepting prioritisation and rationing within health care. One approach has been to establish national ethical guidelines for priorities, guidelines that could gain broad public acceptance. Sweden is one of several countries that have such guidelines; Norway, Denmark, Finland, the Netherlands, and New Zealand are others. Being an OT in these countries requires that one be aware of and act in accordance with these guidelines.
Since 1997, an ethics platform has been part of the laws that regulate health care in Sweden at all levels, from national political decisions to everyday work. The platform consists of three ethical principles: the human dignity principle, the needs-solidarity principle, and the cost-effectiveness principle. These principles seem, more or less, to be part of official or unofficial ethical norms even in countries that have not established national ethical guidelines (National Center for Priority Setting in Health Care 2007).
The Human Dignity Principle
The human dignity principle states that every individual has equal value and equal rights, regardless of personal characteristics and function in society. It is inconsistent with this principle to allow needs to be pushed aside because of, say, chronological age, gender, lifestyle , or socioeconomic circumstances. This principle is easy to embrace but nevertheless raises questions in OT practice. Should an OT prioritise, for example, a person aged 55 (working age) over a 70-year-old retiree? In many countries, there are no seldom age-related borders for cross-professional rehabilitation in specialized teams. Or could one claim that children should automatically have high-priority access to OT? The principle also forbids positive discrimination, which is to give high priorities only because of age.
Another dilemma lies in choosing between people who have or those who do not have a functioning social network. The social circumstances of an OT’s patients are often highly relevant and must be considered because an individual’s functioning and disability occur in contexts that could be facilitators or barriers. In the World Health Organization’s framework for measuring health and disability, the International Classification of Functioning, Disability, and Health (ICF), environmental factors are essential (WHO 2001).
The human dignity principle addresses only factors that should not determine the priorities, and therefore it must be supplemented with additional guidance.
The Needs-Solidarity Principle
Needs are a central priority principle almost worldwide. In Sweden, the needs-solidarity principle means that when it is necessary to prioritise among effective interventions, more health-care resources should be given to those in greatest need, those with the most severe conditions, and those with the lowest quality of life . This applies even if not everyone can have their needs met in part or at all. The concept of need here entails a gap between one’s current and one’s desired state of health and that care (e.g. occupational therapy) is necessary to achieve the desired state of health. It means that both the severity of the disability and the patient’s potential to benefit from an intervention must be integrated into the assessment for prioritisation.
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