1. Practical Ethics: A Tool for the Ombudsman? Sarah Trafton, JD Finger Lakes Health Systems Agency Rochester, NY

2. Presentation Outline Why ethics? Ethical principles generally Ethical issues in long-term care Applying tools of ethics

3. Why Ethics? Murky situations Conflicting interests Ombudsman role: person who investigates complaints and mediates fair settlements, especially between aggrieved parties such as consumers and an institution

4. What is “Ethics”? “That branch of philosophy dealing with values relating to human conduct, with respect to the rightness and wrongness of certain actions and to the goodness and badness of the motives and ends of such actions.” “ ethics” Dictionary.com. Dictionary.com Unabridged (v 1.1). Random House, Inc. http://dictionary.reference.com/browse/ethics (accessed: October 16, 2007).http://dictionary.reference.com/browse/ethics

5. “Ethics”, continued… “That branch of philosophy dealing with values relating to human conduct, with respect to the rightness and wrongness of certain actions and to the goodness and badness of the motives and ends of such actions”

6. Key Elements of Ethics Values related to human conduct, with respect to:  Rightness and wrongness of actions  Goodness and badness of motives

7. Values Values are deeply held beliefs about what is good, right, and appropriate. Values are deep-seated and remain constant over time.

8. “Ethical Dilemma” A situation that will often involve an apparent conflict between moral imperatives, in which to obey one would result in transgressing anothermoral imperatives A moral imperative is a principle originating inside a person's mind that compels that person to act.

9. Ethical Principles Generally Beneficence Nonmaleficence: Least harm Respect for autonomy Justice

10. Mr. & Mrs. W______ Shared room in locked behavioral unit No family Mr. W has dementia, wanders. Mrs. W? Language; socialization Well-intentioned social worker

11. Beneficence Do what is good Strive to achieve the greatest amount of good (utility) Mr. & Mrs. W

12. Nonmaleficence Don’t intentionally inflict harm In situations where neither choice is ideal, choose that which is the least harmful and harms the fewest people Mr. & Mrs. W

13. Respect for Autonomy People should be allowed to ‘reign over themselves’ and to make the decisions that apply to their lives; control over their lives as much as possible Paternalism (e.g. professionals) Mr. & Mrs. W

14. Justice Fair, equitable and appropriate treatment in light of what is due or owed a person Distributive justice: fair, equitable and appropriate distribution in society determined by justified norms: taxation; donated organs Mr. & Mrs. W

15. Ethical Issues in Long-term Care Living options Independence vs. safety Capacity to make decisions Managing finances Patient/family/care provider interactions Others?

16. Applying the Tools of Ethics Assumption: All must be legal Step One: Analyze the Consequences  Who will be helped?  Who will be hurt?  What kinds of harms and benefits are possible?  How will this look both in the short-term and in the long-term?

17. Applying the Tools of Ethics Step 2: Analyze the Actions  How do they measure up against moral principles  Do any “cross the line” from simple decency to an important ethical principle?  If principles or the rights of different involved people conflict, is one principle more important than another?

18. Applying the Tools of Ethics Step 3: Make a Decision  Take both Step 1 and Step 2 into account

19. Examples from Real World Ken H. Refuses to pay his Medicaid spend- down to NH NH court action No personal allowance

20. Examples from the Real World Mr. A, 81,stroke 2 years ago; NH rehab., now ready to go home Wife, 55, visited seldom, “rebuilt her life”, unwilling to take Mr. A. home Mr. A demands to go home

21. Examples from the Real World Ms. L, 47, unmarried, lived alone In NH after hospitalization for MS, in wheelchair, wants to go home Olmstead decision Ms. L’s is MS unstable

22. Examples from the Real World The changing long-term care world:  Policy (e.g Point of Entry)  Case law (e.g. Olmstead)  Personal and societal values (e.g. Baby Boomers)  Others?

23. Examples from the Real World Your turn?

24. Take away message: Think: Beneficence/Nonmaleficence/ Autonomy/Justice Analyze the consequences Analyze the actions Make a decision