You can also find all the drug and disease information. In this app, you will find all the medical books you need. You can also download all of them in PDF format and on top of that, it is completely free. Uploaded by No1 Doctor on June 4, Internet Archive's 25th Anniversary Logo. Search icon An illustration of a magnifying glass. User icon An illustration of a person's head and chest. For example, an individual who is in financial difficulty or angry at a supervisor might be tempted to steal from an employer, even though doing so is patently immoral.
In general, knowing what is right is one thing; doing it is something else. Living up to ones moral responsibilities requires having integrity, self-discipline, and commitment and avoiding apathy, weakness of will, and selfishness.
In this book, we sometimes discuss compliance issues, especially in Chapter 9. The main emphasis, however, is on issues where there is some unclarity about what ought to be done, whether owing to disagreements, vagueness, or dilemmas. After action has been taken and the consequences are better known, think back on the process used to reach a decision, and decide if changes are needed. One can never know with certainty what will happen in the future, and one cannot guarantee a desired outcome.
People can, however, learn from their decisions and mistakes and strengthen their skills in reasoning and decision making. People can also take further action based on reviewing their initial decision. For example, if Shirlaine finds both the coach and the principal unresponsive, then perhaps structural changes in handling student problems need to be developed and clearly outlined in a policy that is accessible to parents, students, faculty, and administrators.
The new policy will not solve the problem, but it will make the decision making more uniform and transparent, which offers some protection to Shirlaine. In concluding we note that, ironically and regrettably, ethics sometimes has a bad name. For some people, it brings to mind negative things like blaming, self-righteous hypocrisy, and congressional ethics committees that themselves sometimes act in suspect ways.
Or it evinces a groan by reminding us of the seemingly intractable disagreements involved in the culture wars over such issues as abortion, affirmative action, and the death penalty, if not more personal battles we have had with our parents and friends. Then, too, there is the tongue-in-cheek remark reportedly made by Nobel Laureate Saul Bellow: Socrates said, The unexamined life is not worth living.
My revision is, But the examined life makes you wish you were dead. Yet, ethics involves much more that is positive. Moral values permeate the daily.
All services to clients have a moral dimension grounded in caring and respect. Professionalism implies a continual sensitivity to and mindfulness of these values in ways that contribute to meaning-giving relationships with patients and other clients such as family members, surrogate decision makers, and companies.
We turn in the next chapter to a fuller discussion of relationships and caring in ethics, in addition to the role of moral principles. Which entries are directly applicable to the case, and do the entries provide the solution to any dilemmas involved? As you answer these questions and listen to others points of view on the case, can you begin to characterize some of the values central to your view of ethics, both in personal and professional life?
Ethics includes moral inquiry into policies and laws. Which policies would help lessen the kinds of dilemmas faced by Shirlaine? Would the policies have any negative side effects? Do all the. Identify the possible conflict and hence ethical dilemma that might arise between Section Then identify one additional possible conflict between two additional entries. Research and discuss the Realm-Individual Process-. Swisher42 and used by Dr.
The RIPS model helpfully distinguishes the Realms of individual concerns, organization setting, and society in general. The Individual Process reminds you that moral sensitivity, reasoning, motivation, and courage are all part of the process of responsible decision making. The RIPS model addresses the Situation defined as ethical temptations, issues, problems, or dilemmas. Kirsch identifies four steps in resolving dilemmas: recognition, reflection, deciding,.
Compare and contrast these steps to the six steps we identified above. Some social critics believe that distinguishing certain. Other critics believe that professionalism is primarily a ruse designed to gain more money from clients. Are these criticisms warranted, at least in part?
If so, what remedies might be offered so as to strengthen public trust in professions and professionals? Bruckner J. Flanagan O. Cambridge, MA: Harvard University; American Psychiatric Association. Callahan D, Bok S, eds. Ethics Teaching in Higher Education. New York: Plenum; See also Davis M. Ethics and the University. New York: Routledge; Simon RL, ed. Neutrality and the Academic Ethic. Resnick L, Hart DL. Using clinical outcomes to identify expert physical therapists.
Resnick L, Jensen GM. Using clinical outcomes to explore the theory of expert practice in physical therapy. Expert practice in physical therapy. Jensen GM, Givens D. Clinical reasoning: Linking theory to practice and practice to theory. Neuro Rep. Attribute dimensions that distinguish master and novice physical therapy clinicians in orthopedic settings.
Clinical reasoning of an experienced physiotherapist: Insight into clinical decision-making regarding low back pain. Physiotherapy Res. Defining and assessing professional competence. Epstein RM. Mindful practice. Sisola SW. Moral reasoning as a predictor of clinical practice: The development of physical therapy students across the professional curriculum.
J Phys Ther Education. Diseker RA, Michielutte R. An analysis of empathy in medical students before and following clinical experience.
J Med Education. Empathy in medical students as related to academic performance, clinical competence and gender. Med Education. Personality style and empathy in medical students. Moral reasoning and malpractice: A pilot study of orthopedic surgeons. Am J Orthop. Changes in the components of moral reasoning during students medical education: A pilot study. Moral judgment as a predictor of clinical performance.
Eval Health Prof. The Jefferson scale of physician empathy: Development and preliminary psychometric data. Educ Psychol Meas. Halpern J. What is clinical empathy? J Gen Intern Med.
Empathy scores in medical school and ratings of empathetic behavior in residency training 3 years later. J Soc Psychol. Hoffman ML. The contribution of empathy to justice and moral judgment. In Eisenberg N, Strayer J, eds. Empathy and Its Development. New York: Cambridge University Press; A fuller list of criteria is given by Bayles MD.
Professional Ethics, 2d ed. Belmont, CA:Wadsworth; See also Callahan JC, ed. Ethical Issues in Professional Life. New York: Oxford University Press; American Physical Therapy Association. Available at: www. Accessed September 8, Accessed September 12, A Historical Perspective. Accessed March 16, Magistro CM. Twenty-second Mary McMillan lecture.
Martin MW. MeaningfulWork: Rethinking Professional Ethics. Michael Davis gives even greater importance to codes in Thinking Like an Engineer. Unger SH. Controlling Technology, 2d ed. New York: John Wiley and Sons; Fluehr-Lobban C. Cultural relativism and universal rights. In Sommers C, Sommers, F, eds. Vice and Virtue in Everyday Life, 4th ed.
Philadelphia: Harcourt Brace; ; Sifton E. The Serenity Prayer. New York:W. Norton; Self-Deception and Morality. Department of Transportation, Auto Accident Statistics. Eliot G. The Mill on the Floss. New York: New American Library; Benjamin M.
Moody-Adams MM. McDowell B. Bellow S. Seeing the earth with fresh eyes. New York Times. May 26, ; The real-individual processsituation RIPS model of ethical decision-making. HPA Resource. Edward received early admission to his college of first choice on his birthday. As a double celebration, he and his brother Lyle took a skiing weekend.
Around 4 p. He was airlifted to the local community hospital, where he was treated for a head injury. As soon as he was medically stable, although comatose, he was transferred to Westover Rehabilitation Hospital. There he began to regain consciousness.
Within the first week of rehabilitation, he started to make progress, but his team of therapists predicted a prolonged rehabilitation process of up to a year. The HMO that carries his health insurance allows only 45 days of rehabilitation. The CEO, George, was a physician and a rehabilitation specialist. He immediately began negotiations with the HMO to provide a longer stay, assuring their administrator that with intense and continuous rehabilitation Edward would probably return to a state similar to where he was prior to the accident.
To discharge him at 45 days would severely limit his lifetime potential, although he would most likely be semi-independent in many daily living skills. The representatives of the HMO would not hear of it and stuck with the day limit. The negotiations had taken nearly a month, and George realized that, in a matter of days, he had to make some decisions.
The family could not afford the extensive rehabilitation needed, without selling their modest home. George checked out all the nursing homes in the hospitals geographic area but could not find one offering the specialized therapy and team members needed to maximize Edwards recovery. There was a special fund at the hospital that could cover some of the expenses for an extended stay, but it was modest and did not come close to supporting the full time needed.
The head of physical therapy and nursing believed they could rally support within the hospital to do fundraising, but it would be necessary to personalize the effort, and they were not sure the family would want their financial and medical histories on public display. Besides, in the past these efforts did not raise substantial money and served more to build community support for this very unusual private hospital with a commitment to the public good.
At this point George called a meeting of his advisors. Westovers administrative structure was nearly flat, with George having enormous power, thanks to a board of trustees confidence in him.
He asked his risk management officer what kind of liability the hospital would incur if he discharged Edward at the end of 45 days, even though he had not reached his potential.
The response was a confident none. At that point, without hesitation, George announced the hospital would pay the bill for Edwards extensive rehabilitation. Georges reasons included Edwards potential, Georges duty as a physician to do no harm, and his job as CEO to make sure the patient was always the first priority.
When the head of nursing asked what would happen if their razor-thin profit margin evaporated because of this patient, George replied that his first move would be to reduce the staff, not the patients. George told Edwards family his decision, and they were overjoyed. The father stated that this was the first time his prayers had been answered. George faced an ethical dilemma between conflicting responsibilities to Edward, to the staff, to future patients whose quality of care depends on maintaining adequate staff and other resources, and to investors.
Did George make a responsible choice, and was it the best choice? Was he sufficiently sensitive to other stakeholders in the hospital, including staff, future patients, and investors? We leave these questions as study questions. For now, we explore some of the dimensions of care and caring relationships. We begin with a relationship-centered model for thinking about caring for patients and others involved.
Then we turn to Carol Gilligans ethics of care, which introduces the issue of how good character and moral rules are related. Next we comment on caring as both a virtue and a set of moral requirements in the form of rules and principles. We conclude by commenting on moral motivation in connection with the question, Why be moral? Providing health care is a complex task. Various models have been developed to highlight this complexity and identify important aspects of therapeutic interventions.
Thus, biomedicalcentered models emphasize technical and theoretical knowledge in restoring physical health. Patient-centered models accent patient needs and desires as the locus in healing. Codecentered models highlight the key role of a code of ethics in unifying and ensuring shared moral commitment throughout a profession.
Care-centered models emphasize caring professionals who are devoted to helping patients. Each of these models can be useful, but we find it most helpful to begin with a relationship-centered model that accents care relationships, including those between physical therapists and patients, between physical therapists and other health professionals, and between physical therapists and wider communities.
The Pew-Fetzer Task Force developed such a model: The phrase relationship-centered care captures the importance of the interaction among people as the foundation of any therapeutic or healing activity. This relationship is important to patients and professionals alike, and it plays a key role in the healing process. Crucial, too, are relationships among health-care professionals who work in interdisciplinary teams.
So are relationships with wider communities, whether the community is defined as a hospital or the profession itself. All these relationships have legal contractual aspects, but essentially they are moral relationships. They embody and are guided by moral values. Thus, regarding professional-patient relationships, the Pew-Fetzer Task Force emphasizes concern for patients, sensitivity to their needs, empathy for their suffering, respect for their rights, and the value of health understood holistically, as biopsychosocial.
The task force highlights the need for patients trust and participation in the healing process. The task force moves comfortably between several meanings and dimensions of patient care: 1 care-giving, that is, providing health-care services taking care of patients ; 2 exercising due care, that is, meeting appropriate standards in providing health care; 3 caring for patients as persons by providing professional services with attitudes and values of concern for patients, and 4 manifesting the virtue of caring.
Virtues are desirable features of character. They are habits or tendencies to feel, perceive, reason, and act in morally valuable waysways beneficial to others and to oneself. Thus, an honest person acts in certain waysavoiding lying, cheating, and stealingand in addition routinely tries to be truthful and trustworthy because relationships of trust are valued. A generous person gives more than is customary and does so from motives of concern for others.
A courageous person confronts dangers rather than fleeing them and does so with good judgment and motivated by a desire to protect what is of value and being threatened. In contrast, vices are morally undesirable features of persons, such as dishonesty, selfishness, and cowardice. Many virtues are relevant to health care, but the virtue of caring has special importance.
With regard to patients, the virtue of caring refers to desirable habits of concern for and helping them. It refers to reliable tendencies to promote the health of patients according to appropriate standards, motivated at least significantly by concern for their well-being. Caring is an umbrella virtue that includes many more specific virtues, including sensitivity perceptiveness to morally relevant features of contexts , empathy identifying with the feelings of others , compassion in response to suffering , kindness nuanced and sensitive helpfulness , and conscientiousness in meeting responsibilities.
What is the relation between virtues, as features of persons, and moral rules and principles? This is an important issue in ethical theory. Virtue ethics, discussed in Chapter 12, regards virtues as morally primary and foundational, while moral principles and rules are secondary.
Other ethical theories regard the virtues as important but secondary to principles. Here we emphasize that both virtues and rules have great importance in ethics and are interwoven.
For example, an honest person will pay heed to rules such as tell the truth and do not steal. According to their interests, ethicists organize virtues into different groups. We find it helpful to cluster virtues into three categories: self-valuing and self-directing, reciprocity between oneself and others, and caring about and for others.
The categories are overlapping rather than mutually exclusive. Self-Valuing and Self-Directing A. Self-Valuing: Self-respect, self-caring, self-love,. Self-Directing a. Cognitive:Wisdom, prudence, foresight b. Volitional: Self-control, self-discipline, temperance, courage, determination, perseverance, responsibility, integrity c. Skill: Competence, craftsmanship, excellence II. Reciprocity A. Justice, fairness, tolerance B.
Trust: Honesty, truthfulness, trustworthiness C. Gratitude, cooperativeness, reliability, dependability, civility, sense of community III. Caring About and for Others A. Nonmaleficence: Non-recklessness, non-negligence, non-vengefulness, non-fanaticism B. Beneficence: Caring, benevolence, compassion, kindness, considerateness, sensitivity, tactfulness, politeness, altruism, generosity, loyalty.
We turn now to caring about and for others, focusing on its more positive dimensions beneficence , exploring it both as a virtue and as implying a set of moral rules and principles. We begin with the context of moral development. The emphasis on caring in thinking about health-care ethics was greatly influenced by the psychologist Carol Gilligan.
Gilligan is a specialist in moral development, that is, the psychological study of how individuals develop moral understanding.
Early in her career, she noticed that previous thinkers, including her mentor Lawrence Kohlberg, understood moral development as a progression from ways of thinking in terms of rules; in addition, the studies had been conducted by males studying males. Her own studies, which used females as experimental subjects, led her to think more in terms of caring relationships. Her book, In a Different Voice, which appeared in at the height of the feminist revolution, drew an enormous audience, in part because of its provocative suggestion that women and men might think differently about morality, with different voices.
She suggested that women employ an ethics of care that emphasizes carebased relationships, whereas men employ an ethics of justice that is more rule-oriented. Subsequent studies provided little support for this hypothesis, but her emphasis on caring continues to be influential in both ethical theory and theories of moral development. To elaborate, Kohlberg distinguished three levels of psychological development: preconventional, conventional, and postconventional. The stages are distinguished according to how individuals engage in moral reasoning and to which motives or reasons they respond.
Thus, at the preconventional level, typical for most children ages 4 to 10, individuals are narrowly egoistic in their reasoning and motivation. This level is akin to the outlook of ethical egoism, although children at this age are not yet able to envisage their long-term good in the way required by the ethical egoist.
At stage 1 they think in terms of avoiding punishment and deferring to physical power. At stage 2 they begin to pursue their desires by using stratagems to gain rewards, such as You scratch my back, and Ill scratch yours. At the conventional level, the emphasis is on meeting the expectations of family, organizations, and wider society. Stage 3 accents stereotypes of good boy and nice girl. Stage 4 accents doing ones social duty so as to maintain the social order.
The level is akin to ethical relativism. According to Kohlberg, many adults never grow beyond this level. At the postconventional level, individuals move in the direction of autonomy, self-directing their lives in light of. Stage 5 is a social contract perspective in which principles are seen as justified when they represent agreements among rational participants in society.
There is an emphasis on legal rules but not an assumption that all legal rules are reasonable. Stage 6 is reasoning in terms of abstract principles that are comprehensive, universal, consistent, and ranked in a hierarchy of importance.
The general principles of justice and human rights are examples of fundamental principles. Gilligan agreed with Kohlberg that moral development includes movement away from childlike narcissism and uncritical social conformity; it includes movement toward autonomous moral reasoning and conduct in terms of wider values. But Gilligan challenged Kohlbergs assumption that the highest stages of moral reasoning are defined by universal principles ranked in order of their general importance.
To see what is at issue, consider Kohlbergs most famous example, the Heinz Dilemma. A pharmacist in a European town where Heinz lives controls the drug and will provide it, but at ten times the cost to make it. Heinz cannot afford the drug, nor can he find friends who will loan him the money to buy it. After trying to convince the pharmacist to lower the price or to let him pay for it later, Heinz breaks into the pharmacy and steals the drug.
The question is whether he was justified in doing so. Kohlberg presented this and other dilemmas to people of many ages and studied how they reasoned about them. He concluded that those who said Heinz should worry about himself primarily were at the pre-conventional level. Those who argued that Heinz should not steal the drug because stealing is wrong according to social conventions were at the conventional.
Those who reasoned that Heinz was justified either permitted or obligated in stealing the drug maintained that the rules Save lives or Help ones wife override the rule Do not steal illustrated higher stages of moral development. When Gilligan began asking young females to comment on the Heinz dilemma, she noticed they often suggested talking further with the pharmacist, trying to change his mind, and perhaps encouraging others to talk to the pharmacist as well.
Kohlberg interpreted such respondents as being indecisive rather than firmly principled. In contrast, Gilligan suggested that such dialogue-oriented and context-sensitive approaches, aimed at maintaining moral ties with the pharmacist and others involved, represented legitimate and perhaps even preferable responses to the dilemma.
In contrast, she invoked an ethics of care to interpret young females as growing in the direction of effectively balancing their needs with the needs of others. Gilligan adapted much of the basic structure of Kohlbergs levels of moral development, but she redescribed the three levels: 1 preconventional reasoning consists of exaggerated self-concern, 2 conventional consists of reasoning in terms of what society demands, and 3 postconventional implies being able to reasonably balance the legitimate needs of oneself with those of others.
The latter is accomplished by paying close attention to context, maintaining personal relationships, sustaining communication, and making reasonable compromises. Rather than a hierarchy of abstract rules of the sort Kohlberg emphasized, what matters for Gilligan is nuanced and responsible contextual reasoning.
The contrasts between Kohlberg and Gilligan are summarized in Table Self-centered, with concern for 1 avoiding punishment and 2 satisfying ones own needs.
Expectation-meeting, with concern for 3 pleasing others and 4 meeting societys expectations. Mature care ethic: able to reason toward a balance of ones own and others needs. We should take note of an important philosophical question about psychological theories of moral development.
How can one tell whether Gilligan or Kohlberg has most accurately portrayed the highest stages of moral development? Clearly, highest means the most valid or justified way of reasoning. Hence, to rank the stages requires defending a moral viewpoint. Do not assume that a particular psychologist is more adept than another in determining which moral viewpoint is most justified.
In general, psychologists cannot be relied upon to indicate what the best way of moral reasoning is. Only a serious study of normative ethics can perhaps do that, and even then there can be disagreement among reasonable persons. Everyone, as morally responsible and autonomous agents, must engage in such a study and gain from the insights of others along the way. Having said that, we affirm that Gilligans ethics of care has greatly enriched health-care ethics by bringing renewed attention to care relationships and to the virtue of caring.
Gilligan does not speculate about the extent to which human capacities for caring are most affected by social influences or biological evolution in addition to personal effort. Evolutionary scientists are beginning to shed light on this nature-nurture question. Their investigations are still in their infancy, but they are provocative and promising, especially in light of human genome research. According to Frans De Waal and others, evolutionary theory has been misconstrued to mean survival of the fittest defined solely as one of power or force.
Instead, there is abundant evidence to support that survival of the fittest also means survival by those who are cooperative and mutually supportive. Solitary animals are the exception to survival. Communal living has offered a multitude of survival benefits not limited to procuring food and mutual protection. Indeed, the greatest evolutionary struggles have not been within species but between groups and the external environment. Qualities that support communal life have been selected and perpetuated because of the benefits they offer, and those communal qualities have been refined in a progressive gradient between species.
Moral judgment and reasoning are capacities found primarily among humans, although there are some striking vestiges demonstrated by apes. But the building blocks for those highest functions have footings and progressive development in empathy, reciprocity, and concepts of fairness that can be scientifically observed over a range of species.
De Waal offers the taxonomy of altruistic behavior, shown in Figure 21, as just one of many buildings stones for moral reasoning.
The extent of this hard-wiring is a subject of ongoing scientific investigation. The new field dedicated to the discovery of these hard-wired pathways is called neuroethics. Thus far, through brain imaging studies, it appears that witnessing unethical conduct triggers an initial emotional reaction that in turn is modulated by higher reasoning centers.
Although neuroethics is still in its infancy, it appears to support at least part of the theory that James Rest developed in his interpretation of Kohlbergs theory of moral reasoning. Rest maintained that moral action was contingent not only on moral reasoning but also on moral sensitivity recognizing that something is troublesome , moral motivation willingness to engage in problem solving , and moral courage willingness to take a stand. Greenfield argues that moral reasoning cannot be entirely separated from emotion and that in fact the emotional responses registered in neuroethics studies that examine moral reasoning perhaps enlighten the mechanism of moral sensitivity, the recognition that people should engage in moral reasoning.
Most animals Many social animals Humans, some large-brained animals Humans, some large-brained animals. NOTE: Altruistic behavior falls into four categories dependent on whether or not it is socially motivated and whether or not the actor intends to benefit the other or itself. The vast majority of altruism in the animal kingdom is only functionally altruistic in that it takes place without an appreciation of how the behavior will impact the other and absent any prediction of whether the other will return the service.
Social mammals sometimes help others in response to distress or begging socially motivated helping. Intentional helping may be limited to humans, apes, and a few other large-brained animals. Helping motivated purely by expected return benefits may be rarer still. Taxonomy of altruistic behavior. Reprinted with permission from DeWaal F.
In Macedo S, Ober J. Primates and Philosophers: How Morality Evolved. Princeton: Princeton University Press; Emotional responses, perhaps often unintended or even unrecognized, play a daily part in clinical work and shape the way people perceive and interpret their surroundings.
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