Ethics Game

Ethics Game

Write a 700- to 1,050-word reflective journal in which you answer the following questions:

o What were the ethical issues presented in the simulation?
o What decision-making steps did you take to ethically address these issues?
o What ethical perspectives, or lenses, did you use to make your decisions in the simulation?
o How did these ethical perspectives, or lenses, influence your decisions?
o How might concepts from this simulation relate to your workplace?

Dilemma  1
You are a supervising nurse in Seva Medical Center’s Ob/Gyn department. Earlier today, a minor unwed mother in the early stages of labor was admitted, accompanied by her parents. As your night shift begins, you see a few emails about the situation….

From     Subject
Brenda Willis    Patient to watch
From:     Brenda Willis
To:    MORGAN

Patient to watch

Just a quick note as your shift starts:

Near the beginning of my shift we admitted a 16-year-old mother, Rachel Banks. She’s in her tenth hour of labor now. Her parents have been with her, and they have chosen to limit the amount of medication and other medical assistance we’ve administered for personal reasons. Given the length of her labor, however, her situation could worsen. Keep a close eye on her. I’m not sure her parents understand how dangerous her situation could get.

Brenda Willis, RN
Shift Supervisor
Seva Medical Center
Harold Mills    Staffing Adjustment
From:     Harold Mills
To:    MORGAN

Staffing Adjustment

Greetings:

Due to recent financial shortfalls, we’ve had to cut back on staff in your department. This readjustment of personnel will reduce the number of on-call physicians available during your shift. We have confidence that our exemplary nursing staff, under your capable leadership, can adjust to this restructuring with a minimum of difficulty.

Harold Mills
VP of Human Resources
Seva Medical Center
Stan Kirk    Visitor
From:     Stan Kirk
To:    MORGAN

Visitor

Hey:

We just had a visit from a Joseph Banks, brother of a sixteen-year-old patient, Rachel Banks. He was really upset. He said Rachel’s parents were “punishing” her for getting pregnant before she was married and withholding painkillers and treatment. According to Joseph, the whole family had a big argument and the father said Rachel was being “judged” and “if God wants the child to survive, it will be Him, not the hospital, who protects her.”

I told him the staff here would do everything they could to keep Rachel and her child safe, but I also reminded him that Rachel’s a minor, and legally that means the parents make the call. The last thing we need is a big lawsuit.

In the end, I convinced him not to go into Ob/Gyn and make a scene, but I thought I should tell you about the incident just in case.

Stan Kirk
Reception
Seva Medical Center

Harold Mills    Annual Performance Review
From:     Harold Mills
To:    MORGAN

Annual Performance Review

Just a reminder: We’ll be conducting your annual Performance Review this week. Be sure to review your Job Description so you can discuss with us in detail how you fulfill the requirements of your role and how you’ve attempted to meet your goals. Also, please keep Rian’s advice on ethical decision making in mind. Finding leaders who can make ethical decisions is one of Seva’s highest priorities.

Here’s your current job description:

Shift Supervisor
Assists the Head Nurse in managing nursing staff by shift. Is clinically knowledgeable and able to perform all duties of staff under their supervision. Collaborates with physicians in assuring that care regimens for all patients are carried out by shift staff. Skilled in communication, team-building, and electronic medical records systems.

Keep up the good work,

Harold Mills
Human Resources
Seva Medical Center

You check Rachel’s chart and notice that she has not been given any meds or been seen by the physician on duty, who is attending another emergency. Fetal distress is not currently critical, but it has been increasing gradually, as has Rachel’s own distress and fear. The parents have clearly stated they don’t want any assistance, and the assigned nurse has acquiesced in that desire, but you are concerned that Rachel and the baby may be moving toward irreversible medical danger if some intervention is not made. Although the unit is short-staffed, the hospital does have a chaplain on staff who could be summoned quickly.

As you reflect on the situation, you realize that it’s all a pretty sticky mess. However you don’t have to face the problems alone, since Seva has Rian Brown, the company’s Ethics Officer, to assist. The time seems right to contact the Ethics Coach.

Issues in your Dilemma

Thanks for visiting with me today. You’re right…you have a tough problem. I am pleased that you are willing to work through the problem by email today. I think you will find this method useful.

The first step is to figure out exactly what the problem is – what the issue is that you are facing. By breaking the problem down into small parts, you can see the dilemma more clearly. If you want some additional help in sorting through the issue, check my Ethics Coach posting for this page. Remember that the Ethics Coach changes on each page with information specific to your current task.

Now, based on our conversation, I’ve included a list of possible issues for this problem.
•    Check the one that you think applies to this situation.
•    Then, submit your answer.
•    I’ll let you know whether or not you hit the mark.

Which issue applies to this problem?
How to overcome parental objections to appropriate care without filing a dependency action.

How to assure nurses are trained to provide care for minors in the face of parental opposition.

How to accommodate patients’ religious views when these conflict with optimal medical care.

How best to assure that Rachel and her baby get appropriate and timely medical care.

re: Issues in your Dilemma

Thank you for your reply. When analyzing a complex problem, I find it critical that the issues be identified and clearly understood.

Here’s how to read the chart:
•    A  appears before the issue you selected as applying to the situation.
•    An  appears before those issues that you did not select.
•    If I disagree with your choice, these symbols are marked as  and  .
•    For answers on which we agree, the text is highlighted in blue.
•    For answers on which we disagree, the text is highlighted in yellow.

Which issue applies to this problem?
How to overcome parental objections to appropriate care without filing a dependency action.
(Incorrect) This is not the primary ethical issue you must resolve. Instead, this is a statement of concern about legal liability. While you do not want to provoke a lawsuit unnecessarily, making this your primary concern is unlikely to result in the best solution to the actual ethical dilemma.
How to assure nurses are trained to provide care for minors in the face of parental opposition.
(Incorrect) Although this is something that you want to be sure happens in any case, this is not the primary ethical issue. Instead this is a long-range planning need. Thinking long-term is useful, but don’t let the long-term goals distract you from solving the immediate problem.
How to accommodate patients’ religious views when these conflict with optimal medical care.
(Incorrect) In this situation, apparent religious views are a red herring. Challenges to providing adequate care for each patient come in all shapes and sizes, not just religious views. This framing of the issue is both too broad and too narrow to best resolve the specific ethical dilemma in this case.
How best to assure that Rachel and her baby get appropriate and timely medical care.
(Correct) This is the primary ethical issue you must resolve in this situation. The core values in conflict include providing equal care for all and deferring to parental wishes. Best solutions will allow you to do both, once you have properly identified this as the issue.

Stakeholders in your Dilemma

Nicely done. So, we have now determined the question we will answer.

The next step is to name the primary stakeholders – those people who are:
•    directly involved in this situation;
•    have to carry out the decision;
•    directly affected by the decision; or
•    whose direct interests are to be protected.
Those who have delegated responsibility to others are not primary stakeholders. Also those who are interested observers are not primary stakeholders. If you want more information, check the Ethics Coach.

Now, based on our conversation, here’s a list of people who might qualify as the primary stakeholders, but only six of the eight of them are directly involved. Check the box next to anyone who you think is a primary stakeholder.

Who are the primary stakeholders in this problem?
The Shareholders
Actions that affect the value of the company affect their ownership interest.

Dr. Emerson Rogers, Chief of Staff
He is responsible for everything that goes on in the organization and often liable for ethical mistakes.

Rachel Banks
She is the pregnant patient who may need more medical care than her parents want.

MORGAN, Staff Nurse
You have to make and implement the decision.

Mr. and Mrs. Banks, Rachel’s parents
They are the patient’s legal guardians and do not appear to want additional care for their daughter.

Yvonne Napier, RN
She is the one primarily responsible for assuring Rachel has a safe delivery.

Lily, Rachel’s unborn child
This is the child who is about to be born and may need medical intervention to assure safety.

Other Ob/Gyn nurses
They are also responsible for assuring that Ob/Gyn patients receive appropriate and timely medical care.

re: Stakeholders in your Dilemma

Thank you for working with me on this matter. As I’m sure you’ll agree…before making a decision, understanding who will be directly affected by your action is critical.

I used the same mark-up as was done before when critiquing your answers:
•    A  appears before any stakeholder you selected as being directly involved.
•    An  appears before those stakeholders that you did not select.
•    If I disagree with your choice, these symbols are marked as  and  .
•    For answers on which we agree, the text is highlighted in blue.
•    For answers on which we disagree, the text is highlighted in yellow.
Let’s see how you did.

Who are the primary stakeholders in this problem?
The Shareholders
(Correct) Because the purpose of a company is to maximize shareholder value, they are always stakeholders. Although originally shareholders were considered the only stakeholders, the stakeholder theory reminds us there are others whose interests should be considered.
Dr. Emerson Rogers, Chief of Staff
(Incorrect) Excluding the Chief of Staff may seem odd. However, he has delegated responsibility for the day to day running of divisions within the hospital to appropriate staff. Remember that those who have delegated their responsibilities to others are not primary stakeholders.
Rachel Banks
(Correct) Whatever decision you make will impact her directly. Your decision may very well affect whether she becomes a mother today as well as life-long health issues. Your decision is also likely to impact her relationship with her parents.
MORGAN, Staff Nurse
(Correct) You are always a stakeholder in the decisions you make. How you balance your own interests with those of other stakeholders shows your level of ethical maturity. In this case, your decision will also impact several lives and an on-going family system.
Mr. and Mrs. Banks, Rachel’s parents
(Correct) They are both directly involved – legally they are responsible for their daughter – and will be directly impacted by your decision. You will either affirm or challenge their decision about necessary medical intervention for their daughter. Thus, they are primary stakeholders.
Yvonne Napier, RN
(Correct) Because she is the person with primary responsibility in this setting for assuring that Rachel gets appropriate care, your decision will impact her directly. She is therefore a primary stakeholder. Your decision will impact her work conditions and her future.
Lily, Rachel’s unborn child
(Correct) Although this dilemma is not about the question of broad legal rights for fetuses, this baby long ago crossed the threshold of viability and is on the edge of live birth. The baby’s direct interests need to be protected, just as her mother’s do. Here, the baby is a stakeholder.
Other Ob/Gyn nurses
(Incorrect) Your decision will not directly impact their work. Ultimately, depending on what you decide to do and whether the baby has a healthy delivery, they may be affected. However, this conditional and tangential potential for impact means they are not primary stakeholders.

Rights/Responsibilities Lens

Now that we’ve identified the issue and determined the stakeholders, let’s start looking at the problem through the Rights/Responsibilities Lens.

The Rights/Responsibilities Lens helps you identify your obligations – your duties – as well as your rights in this situation. The idea is that as we think carefully about our choices we will know our rights and responsibilities, no matter what anyone else says.

The first step is to identify your duties to the various stakeholders. This lens requires that we treat people the way they have agreed to be treated…either because of our stated agreements (contracts) or our implied agreements.

Below is a list of the duties that you might owe the stakeholders. Three of the six of them are actually your responsibility. Considering your leadership role in the company, check those which you believe apply to you in this situation.

Which duties do you owe the stakeholders?
Duty to abide by the parents’ wishes.

Duty to support your staff’s professional improvement.

Duty not to interfere with competent staff in doing their jobs.

Duty not to accommodate parents who are harming their child.

Duty to provide the best patient care possible.

Duty to make parents do the right thing for their daughter.

re: Rights/Responsibilities Lens

Defining your duties can be difficult. Are you surprised by the answers?

People who find the focus of this lens appealing are often called idealists:
1.    each person is supposed to work to be the very best that they can be;
2.    as individuals use reason, they identify the principles that all people should follow;
3.    people often do not live up to the ideals and so need rules; and
4.    punishment or the threat of punishment keeps people in line.
As before, I have marked your responses:
•    A  appears before any stakeholder you selected as being directly involved.
•    An  appears before those stakeholders that you did not select.
•    If I disagree with your choice, these symbols are marked as  and  .
•    For answers on which we agree, the text is highlighted in blue.
•    For answers on which we disagree, the text is highlighted in yellow.
Now, let’s review your duties.

Which duties do you owe the stakeholders?
Duty to abide by the parents’ wishes.
(Incorrect) In reviewing the list of duties created by W.D. Ross to flesh out Kant’s theories, we see there is no duty such as this. Indeed, due to the fact that the parents seem to be making decisions that are not in their daughter’s best interests, duties exist to go against their wishes.
Duty to support your staff’s professional improvement.
(Correct) Not only is this good professional practice in all settings, it corresponds to the duty of beneficence. This duty requires that, if you have the capacity to do so, you should improve the capacity of others for virtue, intelligence, or pleasure. You have this capacity with your staff.
Duty not to interfere with competent staff in doing their jobs.
(Incorrect) Although a good supervisor will tend to give staff wide latitude, no duty to avoid intervening exists. However, competing duties exist that may require you to intervene if staff who are generally competent make decisions that violate the general medical duty to do no harm.
Duty not to accommodate parents who are harming their child.
(Correct) This combines the duties of non-maleficence and justice. Justice requires a proportional response. Here the parents do not appear to have their daughter’s best interests at heart and so justice – as well as your duty to do no harm – requires that you not defer to their wishes.
Duty to provide the best patient care possible.
(Correct) This is primarily an expression of the duty of fidelity. In part it is also an outgrowth of the duty of non-maleficence. The hospital has at least implicitly, and in many cases explicitly, promised its patients to avoid harming them and to provide the best care they are capable of providing.
Duty to make parents do the right thing for their daughter.
(Incorrect) In rare cases, you may have an obligation to comply with a court order to provide treatment against a parent’s wishes. However, legal obligations are not the same as the duties of the Rights/Responsibilities Lens, and the duty of beneficence only requires you to encourage parents to do the right thing, not force them.

re: Rights/Responsibilities Lens

Just to review . . . we’ve determined that you have the following duties owed your stakeholders in this problem:
•    Duty to support your staff’s professional improvement.
•    Duty not to accommodate parents who are harming their child.
•    Duty to provide the best patient care possible.
Now let’s take a look at your options.

I’ve made a list of what I think are the possible choices in this situation. Considering your duties to your stakeholders, choose the option that you think is the most ethical.

Which option best fulfills the duties owed the stakeholders?
Option 1
Confront the parents about their daughter’s need for medical attention.
Option 2
Ask the nurse to do a thorough check to verify that the situation has not reached the point where intervention is necessary.
Option 3
Trust your nurse to provide sufficient care to prevent the fetus from going into medically dangerous distress.
Option 4
Call the physician on duty without seeking input from or informing the parents or the assigned nurse.
Option 5
Ask the assigned nurse to call a physician and a chaplain. Make sure that the mother is assessed medically and that the parents are provided a ministerial response.
Option 6
Involve the assigned nurse and the parents in assessing need for medical intervention to ensure a safe delivery. Provide contacts for aftercare support and education.

re: Rights/Responsibilities Lens

Based on the duties you owe the stakeholders, you chose the following option:
Ask the assigned nurse to call a physician and a chaplain. Make sure that the mother is assessed medically and that the parents are provided a ministerial response.
With this option you have fulfilled all your duties to the stakeholders. You have fulfilled your own duties and have supported others in doing their duties voluntarily, which bodes well for the future of this small family system.

Well done! You chose the best option for this lens!

The Rights/Responsibilities Lens is just one of the tools at our disposal. Let’s continue onwards and examine this problem from another perspective.
Results Lens

The Rights/Responsibilities Lens focused on your duties. Now it’s time for a change of perspective. The Results Lens is going to focus on what results will make the stakeholders happy or, in other words, what goals they want to accomplish.

Below is the list of stakeholders that you made earlier. The first step is to decide how much each of the stakeholders will be affected by your decision on this problem, regardless of what your ultimate decision might be.
•    Select “high” for those stakeholders who will be affected the most. For instance, if a decision puts someone’s job on the line, or could drastically change their current situation, or has a serious impact on their well-being, the impact would be high.
•    Select “low” for those stakeholders who will be affected the least. For instance, if a decision inconveniences a stakeholder, slightly increases their workload, or has a very remote chance of affecting them at all, the impact would be low.
•    Select the middle radio button for those stakeholders where the impact will be between these extremes. If a decision causes a stakeholder to be exposed to some risk, or to suffer a temporary setback or punishment, the impact would be medium.

I think you’ll find that the stakeholders are evenly divided between these three groups.

How much will each stakeholder be affected by your decision?
Low         High
The Shareholders
Actions that affect the value of the company affect their ownership interest.

Low         High
Rachel Banks
She is the pregnant patient who may need more medical care than her parents want.

Low         High
MORGAN, Staff Nurse
You have to make and implement the decision.

Low         High
Mr. and Mrs. Banks, Rachel’s parents
They are the patient’s legal guardians and do not appear to want additional care for their daughter.

Low         High
Yvonne Napier, RN
She is the one primarily responsible for assuring Rachel has a safe delivery.

Low         High
Lily, Rachel’s unborn child
This is the child who is about to be born and may need medical intervention to assure safety.

re: Results Lens

At times, this exercise takes a fair bit of thought.

People who find the focus of this lens appealing are often called realists:
•    each person is basically good but sometimes misguided;
•    as individuals follow their hearts and seek happiness, they will know how to behave ethically;
•    people need role models and encouragement to do the right thing; and
•    relationships and respect keep people in line.
Here’s how I marked up your response:
•     appears wherever you noted a low impact on a stakeholder.
•     appears wherever you noted a medium impact on a stakeholder.
•     appears wherever you noted a high impact on a stakeholder.
•    If I disagree, the annotations are marked as  ,  , and  .
•    For answers on which we agree, the text is highlighted in blue.
•    For answers on which we disagree, the text is highlighted in yellow.
So, let’s look at your assessments.

How much will each stakeholder be affected by your decision?
The Shareholders
The impact is LOW . . .
This situation is unlikely to be known beyond the Ob/Gyn unit. Thus, there is little chance it will impact the value of their shares. The shareholders are always stakeholders, but in this case the impact of your decision on them is very low.
Rachel Banks, the patient
The impact is HIGH . . .
Because of the potential your decision has for serious medical consequences, your decision will have a high impact on her. Only her child will be more greatly impacted by your decision.
MORGAN, Staff Nurse
The impact is MEDIUM . . .
This decision will impact you more than a little bit. However, your decision will not impact your livelihood or your health. Thus, the impact on you relative to other stakeholders is medium.
Mr. and Mrs. Banks, Rachel’s parents
The impact is LOW . . .
The parents will certainly have a strong opinion about your decision. However, the impact on them is unlikely to be significant. In a perfect world, whatever you decide would help them re-evaluate their position, but even so, the impact on them is low.
Yvonne Napier, RN
The impact is MEDIUM . . .
Your decision will have a greater impact on her, than on you or Rachel’s parents. You can help her improve her decision-making, ride roughshod over her, or leave her to her own devices. However, the impact on her is not as high as on others.
Lily, Rachel’s unborn daughter
The impact is HIGH . . .
Your decision may very well be the deciding factor in whether the baby suffers irreparable harm in delivery. Although many people may have an opinion about your decision, no one will be impacted more than the fetus.

re: Results Lens

Once you understand the impact your decision will have on the stakeholders, the next question is determining what is important to them. This process is a bit tricky because each of us is an individual and has different criteria for action:
•    Non-negotiable Criteria – What event would be so horrendous or outside of their personal integrity that a stakeholder would take immediate action?
•    Tipping Points – What patterns of action would become so annoying that the stakeholder would eventually take action or leave?
Below is our list of primary stakeholders. For each stakeholder, choose the two items that you believe (given your knowledge of these people) are the most important for them to be happy. In this context, happiness is a work place that supports them and enables them to contribute to the world.

What are each stakeholder’s criteria for happiness?
The Shareholders – who want to maximize their profit, are happy in this situation if…
Staff do not provoke lawsuits by clashing with patients over adequate care and religious beliefs.
The hospital provides care efficiently, ethically, and legally.
The value of their shares increases each year.

Rachel Banks – who wants her baby to be delivered safely, is happy in this situation if…
The hospital gives her medication to reduce pain or advance her labor.
The hospital staff do not make her situation with her parents worse.
The hospital provides care so that she is not in unnecessary pain and her baby is delivered safely.

You – as you have to make and implement the decision, are happy in this situation if…
Your nurses do not provoke patients to sue the hospital by giving them necessary medical care.
Your nurses give appropriate and necessary care to all patients without discrimination.
Your nurses do not provoke lawsuits because of their religious beliefs.

Rachel’s parents – who do not agree with their daughter’s choices, but do not want her or their grandchild to be harmed, are happy in this situation if…
Their daughter and their grandchild receive the care they need to be safe.
They do not have to raise their grandchild.
Their values are respected by medical care providers.

Yvonne Napier – Rachel’s nurse, who is primarily responsible for Rachel having a safe, uneventful delivery, is happy in this situation if…
She is trusted to determine when patients assigned to her need additional medical attention.
She is able to promote the safe delivery of healthy children.
She is allowed to determine when patients assigned to her should not receive additional medical care.

Lily – Rachel’s daughter, who is about to be born and may need medical attention to prevent injury, is happy in this situation if…
Her mother’s choices are validated.
Her mother gets the medical attention she needs for a safe delivery.
She is born without injury or unnecessary pain.

re: Results Lens

In applying the Results Lens, discerning what makes each stakeholder happy is critical. If you are wrong or don’t pay attention, your employees will either grumble or leave.

Below, you will find my analysis with the following mark-up:
•    A  appears before any item you selected as a primary criterion for happiness.
•    An  appears before those criteria that you did not select.
•    If I disagree with your choice, these symbols are marked as  and  .
•    For answers on which we agree, my analysis is highlighted in blue.
•    For answers on which we disagree, my analysis is highlighted in yellow.
Now, let’s look at the criteria.

What are each stakeholder’s criteria for happiness?
The Shareholders – who want to maximize their profit, are happy in this situation if…
Staff do not provoke lawsuits by clashing with patients over adequate care and religious beliefs.
The hospital provides care efficiently, ethically, and legally.
The value of their shares increases each year.
Research shows investor tolerance for reduced or no profits when ethics are strong. So long as the staff don’t provoke lawsuits and the hospital runs its business well, shareholders will put up with the occasional flat period or even loss in share value.
Rachel Banks – who wants her baby to be delivered safely, is happy in this situation if…
The hospital staff do not make her situation with her parents worse.
The hospital provides care so that she is not in unnecessary pain and her baby is delivered safely.
The hospital gives her medication to reduce pain or advance her labor.
She is less concerned with specifics than she is with getting the care she needs without further compromising her situation with her parents. If medication isn’t the best remedy, she will be satisfied with what a nurse or doctor determines is the best medical care.
You – as you have to make and implement the decision, are happy in this situation if…
Your nurses do not provoke patients to sue the hospital by giving them necessary medical care.
Your nurses give appropriate and necessary care to all patients without discrimination.
Your nurses do not provoke lawsuits because of their religious beliefs.
Ideally, your nurses do not provoke lawsuits at all. However, your interest is to make sure that the nurses in your charge provide adequate care. If providing necessary medical care results in the occasional lawsuit, you should not quit your job – or even consider firing the nurse.
Rachel’s parents – who do not agree with their daughter’s choices, but do not want her or their grandchild to be harmed, are happy in this situation if…
Their daughter and their grandchild receive the care they need to be safe.
Their values are respected by medical care providers.
They do not have to raise their grandchild.
Their disappointment in their daughter does not make them want her or their grandchild to be harmed. If they feel their values are respected, they are likely to trust hospital staff about medical care. Raising their grandchild is unlikely to be a factor in remaining at this hospital.
Yvonne Napier – Rachel’s nurse, who is primarily responsible for Rachel having a safe, uneventful delivery, is happy in this situation if…
She is able to promote the safe delivery of healthy children.
She is allowed to determine when patients assigned to her should not receive additional medical care.
She is trusted to determine when patients assigned to her need additional medical attention.
The difference here is between trusting her judgment and giving her control over decisions she has neither the right nor the medical training to make. Your nurse wants to do her job without being micro-managed, not to do the doctor’s job or deny patient autonomy.
Lily – Rachel’s daughter, who is about to be born and may need medical attention to prevent injury, is happy in this situation if…
Her mother gets the medical attention she needs for a safe delivery.
She is born without injury or unnecessary pain.
Her mother’s choices are validated.
This is a tricky question: what is the tipping point for an unborn child? The primary concern is simply to be born healthy, without permanent injury and as free of pain as possible, then to be loved and cared for. Other people’s choices are irrelevant except as they relate to these primary interests.

re: Results Lens

The final step in this lens is to determine which of the options make each of the stakeholders the happiest. When combined with your analysis of how much each stakeholder is affected by your decision, one option should ultimately rise to the top as being the best.

Here are the ones that we are considering:
Option 1
Confront the parents about their daughter’s need for medical attention.

Option 2
Ask the nurse to do a thorough check to verify that the situation has not reached the point where intervention is necessary.

Option 3
Trust your nurse to provide sufficient care to prevent the fetus from going into medically dangerous distress.

Option 4
Call the physician on duty without seeking input from or informing the parents or the assigned nurse.

Option 5
Ask the assigned nurse to call a physician and a chaplain. Make sure that the mother is assessed medically and that the parents are provided a ministerial response.

Option 6
Involve the assigned nurse and the parents in assessing need for medical intervention to ensure a safe delivery. Provide contacts for aftercare support and education.

In the section below, choose the one option that will make each stakeholder the happiest. Beneath each of the stakeholders, I’ve listed the two criteria for happiness that we deduced in the previous exercise. Please note that no single option may make every stakeholder happy — that’s to be expected.

Which option makes each stakeholder the happiest?

The Shareholders
1.    Staff do not provoke lawsuits by clashing with patients over adequate care and religious beliefs.
2.    The hospital provides care efficiently, ethically, and legally.

—— OPTIONS ——
1  2  3
4  5  6
Rachel Banks
1.    The hospital staff do not make her situation with her parents worse.
2.    The hospital provides care so that she is not in unnecessary pain and her baby is delivered safely.

—— OPTIONS ——
1  2  3
4  5  6
MORGAN, Staff Nurse
1.    Your nurses give appropriate and necessary care to all patients without discrimination.
2.    Your nurses do not provoke lawsuits because of their religious beliefs.

—— OPTIONS ——
1  2  3
4  5  6
Mr. and Mrs. Banks, Rachel’s parents
1.    Their daughter and their grandchild receive the care they need to be safe.
2.    Their values are respected by medical care providers.

—— OPTIONS ——
1  2  3
4  5  6
Yvonne Napier, RN
1.    She is trusted to determine when patients assigned to her need additional medical attention.
2.    She is able to promote the safe delivery of healthy children.

—— OPTIONS ——
1  2  3
4  5  6
Lily, Rachel’s unborn child
1.    Her mother gets the medical attention she needs for a safe delivery.
2.    She is born without injury or unnecessary pain.

—— OPTIONS ——
1  2  3
4  5  6

re: Results Lens

In this lens, you have determined the impact that your decision will have on the stakeholders. You have also assessed which option should make each stakeholder the happiest. A summary of your analysis is provided below:
Impact    Happy with…    Stakeholder
HIGH    Option 4    Rachel Banks, the patient
HIGH    Option 4    Lily, Rachel’s unborn daughter
MEDIUM    Option 5    MORGAN, Staff Nurse
MEDIUM    Option 3    Yvonne Napier, RN
LOW    Option 5    The Shareholders
LOW    Option 5    Mr. and Mrs. Banks, Rachel’s parents

Given this analysis, you must now choose the option that will create the greatest good for the greatest number.

Giving more weight to the happiness of those who will be impacted the most . . .
which option will make the most people the happiest?
Option 1
Confront the parents about their daughter’s need for medical attention.
Option 2
Ask the nurse to do a thorough check to verify that the situation has not reached the point where intervention is necessary.
Option 3
Trust your nurse to provide sufficient care to prevent the fetus from going into medically dangerous distress.
Option 4
Call the physician on duty without seeking input from or informing the parents or the assigned nurse.
Option 5
Ask the assigned nurse to call a physician and a chaplain. Make sure that the mother is assessed medically and that the parents are provided a ministerial response.
Option 6
Involve the assigned nurse and the parents in assessing need for medical intervention to ensure a safe delivery. Provide contacts for aftercare support and education.

re: Results Lens

By trying to create the greatest good for the greatest number of stakeholders, you chose the following option:
Ask the assigned nurse to call a physician and a chaplain. Make sure that the mother is assessed medically and that the parents are provided a ministerial response.
With this option you have fulfilled all your duties to the stakeholders. You have fulfilled your own duties and have supported others in doing their duties voluntarily, which bodes well for the future of this small family system.

You chose the second best option – a perfectly ethical choice, but one that doesn’t use the criteria of the Results Lens.

We have now looked at the problem through two lenses. Let’s see what options you have chosen as you get ready to make the final decision about what to do with this situation.
Reaching a Decision

Clearly, you were quite consistent…settling on a single option for both of the lenses. At this stage, I would normally ask you to choose a best option and thereby determine your final course of action. However, you have already made up your mind.

What is your decision?

Rights/Responsibilities Lens
+
Results Lens
Option 5
Ask the assigned nurse to call a physician and a chaplain. Make sure that the mother is assessed medically and that the parents are provided a ministerial response.

Evaluating your Decision

In order to close the loop, I’d like to show you where your choices fell in the possible range of choices that we developed. In particular, I have highlighted your final decision in blue.

As I evaluate this decision against the possibilities, you chose the option for the Rights/Responsibilities Lens, which shows that you tend to be an idealist who strives for the highest expression of our values and expects the very best in people.

The point of this final exercise is to show that while many choices are ethical, some choices are better than others. You will notice that the best options are the complex ones.
•    Using the Rights/Responsibilities Lens, the best decision tilted toward rationality as you assured that patient care isn’t compromised even for those who can’t speak for themselves.
•    Using the Results Lens, the best decision tilted toward sensibility as you honored the need in this situation to consider parental wishes and for aftercare.
Both choices are perfectly ethical. The difference is your understanding of human nature, how best to assure that we are all responsible members of the community, and your core values.
Rights/Responsibilities    Results
Best    5. Ask the assigned nurse to call a physician and a chaplain. Make sure that the mother is assessed medically and that the parents are provided a ministerial response.    6. Involve the assigned nurse and the parents in assessing need for medical intervention to ensure a safe delivery. Provide contacts for aftercare support and education.
Good    4. Call the physician on duty without seeking input from or informing the parents or the assigned nurse.    2. Ask the nurse to do a thorough check to verify that the situation has not reached the point where intervention is necessary.
Poor    1. Confront the parents about their daughter’s need for medical attention.    3. Trust your nurse to provide sufficient care to prevent the fetus from going into medically dangerous distress.

Avoiding an Orange Jumpsuit

The reason for putting you through this drill is to make sure that you never have to wear an orange jumpsuit because of an action you took as an employee of Seva. So, here’s the bottom line….

You chose the following option:
Ask the assigned nurse to call a physician and a chaplain. Make sure that the mother is assessed medically and that the parents are provided a ministerial response.
On a scale of 0 to 5, from low to high risk, your decision rates a 0. It represents virtually no risk.
•    You have fulfilled your primary duties to Rachel and her baby.
•    Involving the hospital chaplain may be the best way to bring the parents on board, given their apparent religious concerns; this may also assist the nurse in taking appropriate action.
•    You have also increased the capacity of others to do their duty.
•    This course of action does not increase the risk of a lawsuit and is likely to preserve or even improve a variety of relationships.
Settled Law

Legal issues involved in this scenario include equal access, decision-making, accommodation of religious beliefs, and legal liability for foreseeable harm. Unless a minor mother has been legally emancipated, her parents have legal authority to make decisions for her. In the vast majority of cases, courts will defer to the wishes of competent parents about their children’s medical care. In rare cases, such as where a routine medical treatment means the difference between life and death for a child, a court may order that treatment be provided in the face of parental opposition.

Because neither the mother nor the fetus is a “legal person,” the adult parents have a great deal of control in this case. Ham-fisted interference by medical providers may very well provoke a lawsuit by the parents. They might sue simply on the basis that the hospital has illegally interfered with their parental rights – which are virtually sacrosanct under the law. In addition, they might sue on the basis that the hospital violated not only their parental rights but also their religious rights by forcing unwanted medical care on their daughter.

At the same time, if the hospital fails to act and the mother and/or the baby are harmed because of the lack of medical attention, the parents may also sue. The hospital is in a real bind in either case. Whether the hospital would prevail at trial is the least of its worries, as there would be little or no hope of recovering legal fees, and reputational damage may be significant. While the legal ramifications of action in this case may be significant, they are only one factor among many that should govern decision-making in this case.

Beyond Compliance

So long as the baby in this dilemma is born healthy and without incident, the likelihood of a lawsuit is relatively small (unless the parents believe their religious views have been compromised). This is unfortunate, because this situation is rife with opportunities to improve both decision-making and the delivery of care.

Family members typically do not plan for emergencies and extraordinary medical care, making everything more complicated for family as well as medical providers when emergencies do occur. However, just because most patients don’t prepare for emergencies does not mean that medical providers can’t develop protocols to help people in crisis make decisions they can live with long-term. Doing so may not be the medical providers’ “responsibility,” but it can help reduce legal liability.

Regardless of medical outcome, those who feel they have had a full opportunity to participate in the process or make fully-informed decisions are less likely to sue than those who do not. Routinely thinking in terms of “what’s the worst that could happen?” can be a helpful tool in avoiding crises and reducing the consequences of those crises which do occur despite best efforts. More work may need to be done up front, but patient outcomes are likely to improve, which translates into more job satisfaction for medical providers. In other words, everyone benefits in the long-run.
DILEMMA 2
For this second dilemma, you are assuming a new role as Staff Nurse for the night shift of Seva Medical Center’s Intensive Care unit. You will also be solving this dilemma using two new ethical lenses, the Relationship Lens and the Reputation Lens. Be sure to keep these new perspectives in mind as you consider the dilemma you face.

The Case of the Policies and Politics

One of the ICU’s patients, Alain Trottier, has been unconscious for nearly a day and as yet no definitive diagnosis has been reached. Alain was brought to the hospital by his domestic partner, Yves, who was with him while he was in the ER, but was prevented from visiting him in the ICU by Carlotta, the shift supervisor for the day shift.

Hospital policy states that domestic partners are to be treated as married couples, for the purposes of access and, most importantly, when it must be determined who can make medical decisions for a patient unable to give their own consent. You take a moment to read your email before your shift begins to get caught up on the situation….

In-Box of MORGAN
From     Subject
Eugene Moreland    RE: Hospital Policy
From:     Eugene Moreland
To:    Supervising Staff

RE: Hospital Policy

It has come to my attention that certain points of hospital policy have been ignored or countermanded by some of the administrative, admissions, and/or supervising staff. I do not mean to accuse everyone to whom this email has been sent – I will handle the specific incidents I become aware of privately – this email is only to serve as a reminder that the following guidelines are strict hospital policy, and must be followed.

Domestic partners of same-sex patients are to be treated in the same manner as traditional married couples. To wit, those with durable power of attorney, or other legal documentation certifying their partnership, or one party’s legal right to make medical decisions on behalf of the other, are to be a) given access to visit their partner as family members, b) given disclosure of medical procedures or tests conducted on their partner, and c) given the right to approve or disapprove of decisions pertaining to those procedures or tests as family members.

Eugene Moreland
Chief Legal Officer
Seva Medical Center
Dr. Breanne Nichols    Alain Trottier
From:     Dr. Breanne Nichols
To:    MORGAN

Alain Trottier

I wanted to check up on Alain Trottier and his partner Yves. They’re such a sweet couple, and it broke my heart to see some people giving Yves condescending looks or putting him through increased difficulty. All he wants is to keep someone he loves safe and to be there for him.

Just look out for them, okay?

Breanne Nichols, MD
Seva Medical Center
Carlotta Simons    Patient Access
From:     Carlotta Simons
To:    MORGAN

Patient Access

It has come to my attention that Alain Trottier’s ‘friend’ Yves has requested and has been given access to see Alain in the ER, despite the fact that Yves has provided only out-of-state documentation that is flimsy at best.

No notation has been made on Alain’s file of any family members with permission to approve or refuse courses of treatment.

Putting aside the ridiculous sentimentality of some of our staff, I have followed the rules as written, and have only allowed actual family members access to and decision-making authority for their relatives in the ICU.

Carlotta Simons, RN
Shift Supervisor
Seva Medical Center

It’s clear that Carlotta isn’t following the hospital’s policy, but the question of what to do next remains. The time has come again to consult the Ethics Coach.

Issues in your Dilemma

Wow! I didn’t think I’d see you again so soon. However, we know that you can sort your way through this second problem, although it is more complex than your last problem.

As you remember, the first step is to figure out exactly what the problem is – what the issue is that you are facing. By breaking the problem into small parts, you can get to the core of the problem. Don’t forget to check the Ethics Coach on every page for a refresher and more information whenever you need it.

Now, based on our conversation, here is a list of possible issues for this problem.
•    Check the one that you think applies to this situation.
•    Then, submit your answer.
•    I’ll let you know whether or not you hit the mark.

Which issue applies to this problem?
How best to challenge Carlotta’s narrow interpretation of ‘domestic partner.’

How best to assure access for gay partners of Seva’s patients on equal footing with straight couples.

Whether Yves can sue the hospital for denying access if he and Alain are not domestic partners.

Whether gay couples should be required to provide documentation of their relationship.

re: Issues in your Dilemma

Thank you for your reply. When analyzing a complex problem, I find it critical that the issues be identified and clearly understood.

Here’s how to read the chart:
•    A  appears before the issue you selected as applying to the situation.
•    An  appears before those issues that you did not select.
•    If I disagree with your choice, these symbols are marked as  and  .
•    For answers on which we agree, the text is highlighted in blue.
•    For answers on which we disagree, the text is highlighted in yellow.
Let’s see how you did.

Which issue applies to this problem?
How best to challenge Carlotta’s narrow interpretation of ‘domestic partner.’
(Incorrect) Challenging Carlotta is one of your options for resolving this situation. However, it is not the only one. Framing an option as the issue may narrow your thinking about the best way to deal with the situation.
How best to assure access for gay partners of Seva’s patients on equal footing with straight couples.
(Correct) This is indeed the primary ethical issue you must resolve. This framing is neither so narrow as to be a mere option nor so broad as to represent a public policy perspective that doesn’t benefit the couple right in front of you.
Whether Yves can sue the hospital for denying access if he and Alain are not domestic partners.
(Incorrect) You have identified a potential legal issue, but not the primary ethical issue you must resolve. You do not want to create liability needlessly, but you also want to be sure that the issue you address is “what is ethical here?” not merely “what is legal?”
Whether gay couples should be required to provide documentation of their relationship.
(Incorrect) This framing addresses the generic ethical issue of whether discrimination among some types of families is permissible. However, this is a public policy issue, not the specific ethical issue you must resolve.

Stakeholders in your Dilemma

Nicely done. So, we have now determined the question we will answer.

The next step is to name the primary stakeholders – those people who:
•    are directly involved in this situation;
•    have to carry out the decision;
•    are directly affected by the decision; or
•    whose direct interests are to be protected.
Those who have delegated responsibility to others are not primary stakeholders. Also those who are interested observers are not primary stakeholders. If you want more information, check the Ethics Coach.

Now, based on our conversation, here’s a list of people who might qualify as the primary stakeholders, but only some of them are directly involved. Check the box next to the six you think are primary stakeholders.

Who are the primary stakeholders in this problem?
The Shareholders
Actions that affect the value of the company affect their ownership interest.

Dr. Emerson Rogers, Chief of Staff
He is responsible for everything that goes on in the organization and often liable for ethical mistakes.

Eugene Moreland, Chief Legal Officer
He would have to manage any litigation arising from this situation.

Carlotta Baldwin, RN, Shift Supervisor
She believes the hospital’s policy on who is family does not include Alain and Yves.

MORGAN, Staff Nurse
You are the one that has to make and implement the decision.

Alain Trottier, Patient in ICU
He is the one whose family is in question on the basis of Carlotta’s decision.

Yves St. Martin, Alain Trottier’s Partner
He believes he is a member of Alain’s family and entitled to access to his partner.

Amelia Finch, Director of Nursing Services
She is your supervisor as well as Carlotta Baldwin’s supervisor.

re: Stakeholders in your Dilemma

Thank you for working with me on this matter. As I’m sure you’ll agree…before making a decision, understanding who will be directly affected by your action is critical.

I used the same mark-up as was done before when critiquing your answers:
•    A  appears before any stakeholder you selected as being directly involved.
•    An  appears before those stakeholders that you did not select.
•    If I disagree with your choice, these symbols are marked as  and  .
•    For answers on which we agree, the text is highlighted in blue.
•    For answers on which we disagree, the text is highlighted in yellow.
Let’s see how you did.

Who are the primary stakeholders in this problem?
The Shareholders
(Correct) As you learned in the first dilemma, the shareholders are always stakeholders because the legal purpose of a company is to benefit them. Even when consequences seem remote, all ethical dilemmas potentially impact the value of the company and thus the shareholders’ interests.
Dr. Emerson Rogers, Chief of Staff
(Incorrect) Excluding the Chief of Staff may seem odd. However, he has delegated responsibility for minimizing legal liability such as this to other members of the staff. Remember that those who have delegated their responsibilities to others are not primary stakeholders.
Eugene Moreland, Chief Legal Officer
(Incorrect) Handling this situation poorly could provoke litigation. However, litigation is unlikely at this point and you do not need the CLO to implement what you know is hospital policy about who is considered family. Thus, the CLO is not a primary stakeholder.
Carlotta Baldwin, RN, Shift Supervisor
(Correct) Because her decision is the one you will either reverse or continue, she is directly involved in this situation. She may also have to carry out your decision, depending on what that is. She is thus a primary stakeholder.
MORGAN, Staff Nurse
(Correct) You are always a stakeholder in the decisions you make. How you balance your own interests with those of other stakeholders shows your level of ethical maturity. In this case, your decision will also impact your job as well as your job satisfaction.
Alain Trottier, Patient in ICU
(Correct) Alain falls into three of the four categories of those who are primary stakeholders: those directly involved, directly affected and whose direct interests are to be protected. Your decision will either allow his partner’s express wishes to be honored or not.
Yves St. Martin, Alain Trottier’s Partner
(Correct) His partner is in critical condition, unable to make decisions for himself. Your co-worker has denied him access to his loved one. Your decision will directly and immediately impact him, reducing his anxiety and determining whether he is permitted to make medical decisions on Alain’s behalf.
Amelia Finch, Director of Nursing Services
(Correct) Your decision as her direct report will impact her. Not only that, your decision will impact another of her direct reports, as well as indirect reports. Your mature ethical decision makes her job easier. Your poor ethical decision makes her job and everyone else’s more difficult.

Relationships Lens

You are about to look at the third lens, the Relationship Lens, which focuses on the processes – the systems – needed for an ethical organization. The first two lenses, the Rights/Responsibilities Lens (duty focus) and the Results Lens (happiness focus), had the individual as the primary concern. The Relationship Lens moves the community to center stage.

The first concern of this lens is protection of the basic liberties of all people:
•    each of us is entitled to a limited number of rights, regardless of wealth or status;
•    the rights are procedural: we have a right to a fair process; and
•    the emphasis is on protecting those without power, the least advantaged.
These rights are as follows:
1.    Right to notice:
To know what the rules are and what process is to be used to enforce the rules.
2.    Right to voice, not a veto:
To share concerns and critiques about the rules and the process. Each stakeholder is entitled to a seat at the table where decisions are being made.
3.    Right to have contracts honored:
To have the terms of a contract honored once an agreement is made, and not to have those terms changed on a whim.
As you can see, the list is pretty abstract. Given the problem you have to solve, let’s see if you can identify which of the following list of rights is covered under the category of basic liberties. Check the three items on the list you believe are consistent with the basic liberties.

Which of the following rights represent basic liberties?
Right to participate in decision-making for an unconscious family member.

Right to have hospital policy regarding participation by family members implemented.

Right to have access to family members at all times.

Right to have your relationship acknowledged.

Right to be informed that your interpretation of hospital policy is inaccurate.

Right to refuse to follow hospital protocols you do not agree with.

re: Relationships Lens

Once again, let me thank you for the time you’re investing. Examining a problem from multiple viewpoints does take time. However, the rewards can be significant in the form of highly effective decision-making. Choose three.

Here’s how I marked up your answers:
•    A  appears before any right you selected as representing a basic liberty.
•    An  appears before those rights that you did not select.
•    If I disagree with your choice, these symbols are marked as  and  .
•    For answers on which we agree, the text is highlighted in blue.
•    For answers on which we disagree, the text is highlighted in yellow.
So let’s see how you did.

Which of the following rights represent basic liberties?
Right to participate in decision-making for an unconscious family member.
(Correct) This is a concrete expression of the Basic Liberty of the right to voice. Everyone is equally entitled to this right to participate in the process. You do not need to be physically present and you do not have a right to control the outcome – just to participate in the process.
Right to have hospital policy regarding participation by family members implemented.
(Correct) The right to have a policy implemented or enforced is typically an expression of the right to have contracts honored. The policy is a promise the hospital makes to behave in a certain way. Everyone has an equal right to have that promise enforced.
Right to have access to family members at all times.
(Incorrect) You do not actually have this right for a variety of reasons, making it not an expression of a Basic Liberty. The family member may need to be isolated for your or their safety, you may not be physically present or the family member may not wish to see you.
Right to have your relationship acknowledged.
(Incorrect) Many good things flow from acknowledging relationships. However, having someone else “acknowledge” your relationship is not an expression of the right to voice or notice or to have contracts honored. Thus, this is not an expression of a Basic Liberty.
Right to be informed that your interpretation of hospital policy is inaccurate.
(Correct) This would be an expression of the Basic Liberty of the right to notice. All have an equal right to know what is going on in order to determine whether to participate in a process or to know that some corrective action may follow.
Right to refuse to follow hospital protocols you do not agree with.
(Incorrect) While providing for the needs of the least advantaged may require you to refuse to implement an unjust policy, doing so is not an expression of a Basic Liberty. In fact, by doing so, you would be refusing to honor a contract you had entered into.

You did quite well in this exercise. In consequence, I am pleased to award you 600 points! I trust that my explanations made sense. However if you need more information, check the Ethics Coach site for help. Now, let’s see how the liberties play out in organizational choices by advancing to the next step.

Relationships Lens

People become confused about basic liberties – those rights of which we all have an equal amount – and other rights of which people get various amounts, like education or health care. The interesting feature of considering basic liberties is that we can take an option for action which is not ethical and by adding a process for guaranteeing basic liberties make the option perfectly ethical.

On the previous screen you identified the following basic liberties:
•    Right to participate in decision-making for an unconscious family member.
•    Right to have hospital policy regarding participation by family members implemented.
•    Right to be informed that your interpretation of hospital policy is inaccurate.
Below is a list of actions that you could take in this situation. Check three actions that would meet the requirements of adding basic liberties to the process.

Provide all employees with written policies upon hire and periodically re-issue those policies to all.
Establish a task force consisting of stakeholders to review and change policies when necessary.
Give information about family access policy to those who ask for it.
Conduct yearly audit to determine whether policies are being implemented.
Appoint a guardian to act on behalf of gay patients who have no family other than a partner.
Require gay couples to provide documentation of their relationship.

re: Relationships Lens

I hope that as we get deeper into the analysis of your dilemma, that elements actually become clearer and the decision-making easier.

I’ll continue to use the mark-up that we’ve employed before:
•    A  appears before any action you selected as supporting the basic liberties.
•    An  appears before those actions that you did not select.
•    If I disagree with your choice, these symbols are marked as  and  .
•    For answers on which we agree, the text is highlighted in blue.
•    For answers on which we disagree, the text is highlighted in yellow.
Now, let’s examine the results.

Which actions add a process for guaranteeing basic liberties?
Provide all employees with written policies upon hire and periodically re-issue those policies to all.
(Correct) Following this practice with company policies is a good way to ensure that everyone knows what the policies are, has immediate access to them if needed, and learns of changes. This, in turn, ensures everyone is able to implement the policies consistently.
Establish a task force consisting of stakeholders to review and change policies when necessary.
(Correct) Knowing what the policies are is not always enough. Sometimes policies need to be revised – laws change or gaps between intent and practice are revealed. Periodic review by interested stakeholders may also be necessary to assure policies are implemented.
Give information about family access policy to those who ask for it.
(Incorrect) Although this isn’t a bad policy, it does not guarantee the basic liberties. Failing to provide information for everyone, whether they know to ask for it or not, allows some to slip through the cracks. This then creates problems for all.
Conduct yearly audit to determine whether policies are being implemented.
(Correct) In order for patients to benefit from the policy, it must be known, understood, and implemented. Auditing gives you valuable information to assure all the rights, which reinforce each other, are guaranteed so that patients benefit as intended.
Appoint a guardian to act on behalf of gay patients who have no family other than a partner.
(Incorrect) While this might sound like a good idea, it is really the worst of all worlds. Rather than assuring the basic liberties, this method discriminates against one class of people. You guarantee that patients’ rights are not as well protected and increase the risk of lawsuits.
Require gay couples to provide documentation of their relationship.
(Incorrect) This also establishes a discriminatory practice for one group of people, increasing the likelihood of a lawsuit. Not only does this practice not guarantee any of the basic liberties, it further disadvantages those who are already the least advantaged.

Your efforts at identifying those actions that support the basic liberties were quite near the mark. As a result, I’m pleased to award you 600 points! Please review my explanations where we differed. If you need additional information, visit the Ethics Coach page. Once you’re done, let’s move to the next step.

re: Relationships Lens

In this lens, we identified the basic liberties entitled to our community:
•    Right to participate in decision-making for an unconscious family member.
•    Right to have hospital policy regarding participation by family members implemented.
•    Right to be informed that your interpretation of hospital policy is inaccurate.
We also identified some actions that are representative of those that would help ensure that the basic liberties are supported:
•    Provide all employees with written policies upon hire and periodically re-issue those policies to all.
•    Establish a task force consisting of stakeholders to review and change policies when necessary.
•    Conduct yearly audit to determine whether policies are being implemented.
You must now choose the option that best guarantees that the community’s basic liberties are upheld.

Which option best supports the community’s basic liberties?
Option 1
Note on Alain’s chart that Yves is to be given access and treated as family. Notify your supervisor that hospital policy is not being followed.
Option 2
Advise Yves to say he is Alain’s brother and identify them as siblings on Alain’s chart.
Option 3
Give Yves access and involve him in decision-making during your shift and advise your replacement to continue the practice.
Option 4
Note on Alain’s chart that Yves is to be given access and treated as family. Speak to Carlotta about your decision and let your supervisor know.
Option 5
Tell Yves nothing as to whether he can or cannot be in the room. When he comes into Alain’s room, don’t take any action.
Option 6
Note on Alain’s chart that Yves is to be given access and treated as family.

re: Relationships Lens

By trying to guarantee that the community’s basic liberties are upheld, you chose the following option:
Note on Alain’s chart that Yves is to be given access and treated as family. Notify your supervisor that hospital policy is not being followed.
You have provided immediate access and used the chain of command to promote consistent application of the hospital’s policy. You have activated the system to protect the least advantaged – the unconscious patient.

Well done! You chose the best option for this lens!

Let’s see if looking at this problem from the fourth lens, the Reputation Lens, makes any difference.
Reputation Lens

We’re almost done! The final lens we are going to examine is the Reputation Lens, which explores the virtues that are important for leadership.

The first concern of this lens is identifying the core competencies of your role – Staff Nurse. Each leadership position in an organization has a responsibility for moving ahead the goals of the organization as well as a gatekeeper function…making sure that individuals and the company do not violate ethical norms.

The list of core competencies is personal. Each of us sees ourselves fulfilling the role in a somewhat different fashion, bringing together a unique blend of skills and abilities to the organization. Nonetheless, there are certain competencies that must be fulfilled in order that we meet the ethical requirements of our job.

In the list below, choose nine competencies that you believe are important for the role you have at Seva Medical Center. See if you can identify the ethical requirements of your job.

What are the core competencies of your role?
Strategic agility     Managing diversity
Priority setting     Perspective
Career ambitions     Decision quality
Motivating others     Embody company values
Conflict management     Understanding others
Fairness     Creativity
Problem solving     Peer Relationships
Self-knowledge     Manage through systems
Comfort around higher management     Persistence

re: Reputation Lens

Below, I have listed all your selections, as well as any competencies representing ethical requirements for your job that you might have missed. Similar to our earlier emails, I have provided an analysis – though in this case, I have only attached an analysis to those competencies that are required.

Here’s how I marked up your responses:
•    A  appears before the competencies that you selected.
•    An  appears before any competency that you did not select, but is required.
•    For required competencies that you selected, my analysis is shown in blue.
•    For required competencies that you missed, my analysis is shown in yellow.
Let’s find out if you had any difficulties in selecting the competencies that are at the heart of your role.

What are the core competencies of your role?
Managing diversity
(Required) You demonstrate this competency by managing people equitably regardless of difference. A nurse must be able to assure the best, most appropriate care for each patient by treating them without regard to differences – even when provider and patient have different values.
Priority setting
Understanding others
Fairness
(Required) Treating people fairly means giving them the information they need without spin or games, playing by the rules, sharing, and refusing to take advantage of others. Being open-minded, listening objectively to others, and not casting blame carelessly are also demonstrations of this competency.
Problem solving
(Required) By thinking both creatively and logically to identify issues and potential solutions you can reach outside the box to generate solutions which go beyond immediate needs and which do not generate equal or worse problems.
Peer Relationships
Self-knowledge
(Required) This competency is essential for both personal and professional growth. To live into it you must be able to see both your strengths and weaknesses without rose-colored glasses or shame. Being able to learn from constructive feedback as well as your own mistakes and to balance pride and judgment appropriately demonstrates a high level of maturity in this competency.
Comfort around higher management
Persistence
Decision quality
(Required) You must use appropriate judgment to assess a situation and the best course of action, considering legal, medical, and ethical ramifications. Others look to you as one whose decisions can be trusted to turn out well for everyone involved more often than not.
Embody company values
(Required) Acting in line with corporate core values is an important part of any role. As one with authority it is crucial you be able to communicate the corporate vision in a compelling manner, inspiring and motivating an entire unit or organization. You live more fully into your role by being committed to acting and inspiring others to act based on the company’s core values.

Your efforts at identifying the ethical requirements of your position were well done. Consequently, I’m very pleased to award you 600 points! I still recommend that you review my explanations where we differed. If you need additional help, please visit the Ethics Coach page. Otherwise, let’s advance to the next step.

re: Reputation Lens

We now have a sense of the competencies that are essential to your role. These competencies include certain ethical requirements given your position. They also include aspects that uniquely reflect you. Taken together, these qualities are:
•    Managing diversity
•    Priority setting
•    Decision quality
•    Embody company values
•    Understanding others
•    Fairness
•    Problem solving
•    Peer Relationships
•    Self-knowledge
•    Comfort around higher management
•    Persistence
At this point, I’d like you to choose the options that you believe would allow you to meet the requirements of your role. Do not mark those that you believe would keep you from meeting the requirements of your position.

Which options allow you to meet the requirements of your role?
Option 1
Note on Alain’s chart that Yves is to be given access and treated as family. Notify your supervisor that hospital policy is not being followed.
Option 2
Advise Yves to say he is Alain’s brother and identify them as siblings on Alain’s chart.
Option 3
Give Yves access and involve him in decision-making during your shift and advise your replacement to continue the practice.
Option 4
Note on Alain’s chart that Yves is to be given access and treated as family. Speak to Carlotta about your decision and let your supervisor know.
Option 5
Tell Yves nothing as to whether he can or cannot be in the room. When he comes into Alain’s room, don’t take any action.
Option 6
Note on Alain’s chart that Yves is to be given access and treated as family.

re: Reputation Lens

Four core virtues are important in any role:
Integrity: To exercise this virtue, you must be committed to the truth as well as your own personal values and core commitments.

Contributory Justice: To exercise this virtue you should assure, to the best of your ability, that people are rewarded or compensated based on their contribution. People with similar contributions should be compensated equally.

Retributive Justice: To exercise this virtue, you should assure that those who violate the norms of the community are disciplined appropriately. Again, similar infractions should receive similar discipline.

Moral Courage: To exercise this virtue, you should be willing to take a stand for ethical action even when the action is not popular.
Choose the one option that you believe best demonstrates the virtues required for excellence as member of the community.

Which option best meets the requirements of the core virtues?
Option 4
Note on Alain’s chart that Yves is to be given access and treated as family. Speak to Carlotta about your decision and let your supervisor know.

re: Reputation Lens

By trying to meet the requirements of the core virtues, you chose the following option:
Note on Alain’s chart that Yves is to be given access and treated as family. Speak to Carlotta about your decision and let your supervisor know.
Taking matters into your own hands this way demonstrates the core competencies of your role. Letting your supervisor know short-circuits any attempt by Carlotta to again deny Yves access.

Well done! You chose the best option for this lens!

We have now looked at the problem through both the Relationship Lens and the Reputation Lens. It’s time to make a final decision.

Reaching a Decision

In the process of working through the two lenses, you chose two different options. Now you must choose one best option – the action that you will take.

What is your decision?

Relationships Lens
Option 1
Note on Alain’s chart that Yves is to be given access and treated as family. Notify your supervisor that hospital policy is not being followed.

Reputation Lens
Option 4
Note on Alain’s chart that Yves is to be given access and treated as family. Speak to Carlotta about your decision and let your supervisor know.

Page     42

Evaluating your Decision

In order to close the loop, I’d like to show you where your choices fell in the possible range of choices that we developed. In particular, I have highlighted your final decision in blue.

As I evaluate this decision against the possibilities, you chose the option for the Relationship Lens, which shows that you tend to be an idealist who strives for the highest expression of our values and expects the very best in people.

The point of this final exercise is to show that while many choices are ethical, some choices are better than others. You will notice that the best options are the complex ones.
•    Using the Relationship Lens, the best decision tilted toward rationality as you focused on assuring that hospital protocols are consistently implemented.
•    Using the Reputation Lens, the best decision tilted toward sensibility as you focused on assuring the best care for the particular patient.
Both choices are perfectly ethical. The difference is your understanding of human nature, how best to assure that we are all responsible members of the community, and your core values.
Relationships    Reputation
Best    1. Note on Alain’s chart that Yves is to be given access and treated as family. Notify your supervisor that hospital policy is not being followed.    4. Note on Alain’s chart that Yves is to be given access and treated as family. Speak to Carlotta about your decision and let your supervisor know.
Good    6. Note on Alain’s chart that Yves is to be given access and treated as family.    3. Give Yves access and involve him in decision-making during your shift and advise your replacement to continue the practice.
Poor    5. Tell Yves nothing as to whether he can or cannot be in the room. When he comes into Alain’s room, don’t take any action.    2. Advise Yves to say he is Alain’s brother and identify them as siblings on Alain’s chart.

Now, let’s give your option the “orange jumpsuit” test.

From:     Rian Brown
To:     MORGAN

Avoiding an Orange Jumpsuit

The reason for putting you through this drill is to make sure that you never have to wear an orange jumpsuit because of an action you took as an employee of Seva Medical Center. So, here’s the bottom line….

You chose the following option:
Note on Alain’s chart that Yves is to be given access and treated as family. Notify your supervisor that hospital policy is not being followed.
On a scale of 0 to 5, from low to high risk, your decision rates a 1. It represents very low risk.
•    The system is designed to protect the least advantaged, and you have done just that.
•    By assuring that the system works like it is supposed to, you have reduced the risk of litigation.
•    As you decrease the risk of liability, you increase the opportunity to improve the hospital’s standing in the community.
•    Although you may have assured access, you might not have made a friend of Carlotta.
Settled Law

Although inequities in access to health care plague the United States health care system, once a patient is admitted to a hospital, most disparities in care disappear. Married couples generally assume that they will be given access to a spouse who is a patient and consulted for decision-making purposes if the patient spouse is unable to make their own decisions. Hospitals tend to gather family and friends of a patient for decision-making purposes when the patient is unable to make their own decisions. Visitation by anyone who meets generic criteria is generally permitted so long as the visitor poses no risk of harm to the patient or others.

For Gay, Lesbian, Bisexual, and Transgendered (GLBT) patients, however, this is not always the case. Despite an increase in hospitals with non-discrimination policies and the proliferation of legally recognized same-sex relationships in many states, common wisdom in the GLBT community still suggests you may be better off identifying as a partner’s brother or sister to assure access and participation in decision making. The patchwork of state laws and hospital policies makes it difficult even for married same-sex couples with Advanced Healthcare Directives (AHDs) to be certain they will be treated the same as opposite-sex couples or provided access to a loved one in the event of a catastrophic emergency.

Hospitals who deny access to same-sex partners may be liable in a variety of circumstances. In addition, the cost to a hospital’s reputation for discriminating in patient care and access may do far more damage than a lawsuit. Hospitals must initially comply with the federal Patient Self-Determination Act, providing information to patients at the time of admission about their decision-making rights and the hospital’s policy on AHDs. Even if the patient is not conscious when admitted, many hospitals have Patient’s Bill of Rights, which may include a right to visitors or to have one’s designated decision maker act on one’s behalf. Hospitals which receive federal funding are required to comply with the federal government’s non-discrimination policies, which include prohibitions of discrimination based on sexual orientation. A number of states also have state non-discrimination requirements for public accommodations, which typically include hospitals. In some cases, a hospital’s accreditation is dependent on compliance with non-discrimination requirements which explicitly prohibit discrimination on the basis of sexual orientation.

When a patient who is unable to make decisions does not have an AHD, the hospital will turn to a state-designated list of default decision makers. Default decision-maker lists, although different from state to state, tend to identify and rank relatives similarly. The lists can be grouped into three categories with respect to same-sex partners: 1) same-sex partners are explicitly listed along with spouses as the first choice of surrogate decision maker, 2) “special friend” is listed as a final category, but is only chosen after all other categories of biological and legally recognized family have been exhausted, and 3) no provision at all is made for same-sex partners. This matters because in many states, the hospital is shielded from liability only if they choose a surrogate decision maker from the state-designated list.

Beyond Compliance

Who people love is not a medical issue. Treating people with the best possible care includes assuring that the people a patient cares for and trusts are available for them and allowed to participate in their care and treatment. Treating people with the best possible care does not mean you condone their behavior or need to compromise your values. Medical ethics do not permit care providers to refuse to treat a GLBT person even on the basis of religious conviction.

The best facilities use a broad definition of family that takes into consideration the increasing diversity of actual families. They train their staff on non-discrimination policies and are explicit about prohibiting discrimination on the basis of sexual orientation and gender identity; they consistently update their policies to reflect current state law. Hospitals which provide the best care also train staff and inform patients at the point of admission about ADHs so that wherever possible, patients can assure in advance of any need that the person they want to make decisions if they are incapacitated is allowed to do so.

The Gay and Lesbian Medical Association and the Human Rights Campaign administer an annual Healthcare Equality Index (HEI) for the purpose of benchmarking and sharing best practices in the treatment of GLBT persons and their families. Information about the HEI can be found at http://www.hrc.org/issues/hei.asp Far too many stories exist of same-sex partners and their children being excluded from the bedside of a loved one, who died alone despite the partners having taken every legal precaution to support and care for each other. No court decision and no damages award can ever undo the fact that one was unable to be present at the death of a loved one, because someone misunderstood hospital policy or refused to acknowledge a legally valid ADH.