1. When Key Stakeholders Disagree: A Disability Manager’s Ethical Dilemma
Fred McGinn Ph.D.
Dalhousie University
Disability Management
School of Health & Human Performance

11. Case of Heinz
Heinz’s wife is dying from a special kind of cancer. There is one drug that doctors believe might save her. It is a form of radium that a druggist in the same town has recently discovered. The drug was expensive to make, but the druggist was charging 10 times what the drug cost to produce. He paid $200 for the radium and charged $2000 for a small dose of the drug. Heinz went to everyone he knew to borrow the money, but he could only collect $1000, which is half the cost. He informed the druggist that his wife was dying and asked him to sell it cheaper or let him pay later. The druggist said, “No. I discovered the drug and I’m going to make money on it”. Heinz has become desperate, and is contemplating breaking in to the store to steal the drug.
Question: Should Heinz steal the drug?

12. Should Heinz Steal the Drug?
A) No, Heinz should not steal because he might get caught.
B) Yes, Heinz should steal the drug, because he loves his wife and wants her to be with him for many years to come.
C) Yes, Heinz should steal the drug, because he knows that all good husbands should be willing to save their spouses.
D) No, Heinz should not steal the drug, because it is against the law.
E) Yes, Heinz should steal the drug, because it isn’t fair that the druggist should have the power to determine whether his wife lives or dies.
F) Yes, Heinz should steal the drug, because life is more important than property.
Utilitarian vs. deontological
Example of 2 rehab counselors (Frank and Donnie)

13. Some “Givens” About Ethics
Everyone needs to be treated with respect
Each person has a right to come to her/his own ethical conclusions.
Ethics that works only for the advantage of the individual with total disregard of others is not acceptable.
People are, or can be, rationale.
Different people have different values - there will be disagreements in ethics.

14. 4 opinions – 4 Characters )“Whatever makes me happy is right”
)“Whatever works is right”
)“Whatever is helpful to others is right”
)“Whatever is fair is right”

15. Beauchamp & Childress, (1989), “Principles of biomedical ethics”
Relevance of 5 ethical principles (beneficence, nonmaleficence, autonomy, justice & fidelity) for guiding behavior of health professionals.
The ability to understand the importance of content of Code of Ethics beyond the “I was told that this is how an ethical professionals behaves” level – is greatly dependent on knowledge of ethical principles.
Daily lives: rehab professionals face decision making situations involving conflicts between these ethical principles. – disagreements with others concerning which actions are best for the client.
Personal values of rehab professionals influence their interpretation of these ethical principles….therefore some principles have rank over others.

16. Five Ethical Principles
Beneficence: Desire to do good.
Code of ethics; Rehab professional must hold the interest of clients as primary and act in ways that promote their welfare. – Therefore, doing good (helping others) is central to practice of rehabilitation.

18. Beneficence
Providing a client with vocational training compatible with the recommendations contained in client’s vocational evaluation report.
Advocating for the client in the area of accessibility.
Funding a service to prolong a client’s productive life
Providing support services to the family that are necessary to facilitate the client’s rehabilitation gains.

19. Beneficence – number one reason students state as reason for choosing health professions.

20. Five Ethical Principles
2) Nonmaleficence: Desire to prevent harm.
CARP code of ethics…Principle II (Caring for the best interests of persons)
II 1) “Protect and promote the welfare of persons with a disability…avoid doing harm”
“Rehab professionals need to discern potential benefit and harm, to maximize benefit and minimize harm”. ---Example of phamaceutical sales rep.

21. Nonmaleficence
Confronting a client concerning his/her self-destructive lifestyle
Intervening to meet the specific health care and safety needs of a client
Hippocratic Oath: First, do no harm

22. Five Ethical Principles
3) Autonomy: Desire to promote the freedom of others to make personal choices.

24. Autonomy is Dependant Upon:
Rehabilitation Practitioner refrains from unnecessary interference in client’s choice-making actions.
Client is provided full disclosure of information, including informed consent.
Client has competence to use information in decision-making process.
No Interference
Client has all relevant information
Client able to make decisions

25. Five Ethical Principles
4) Justice: Desire to promote the fair treatment of people

27. Justice
Respect people as individuals and serve all in an equitable and fair manner
Keeping individual case service costs down in order to provide services to a large number of clients
Being equally accessible to all clients
Clearly separating professional from personal points of view

28. Five Ethical Principles
5) Fidelity: Desire to be true to one’s commitments

30. Fidelity Respecting policies and procedures in a professional manner
Carrying out a previous rehabilitation professional’s commitment to a client(s)
Is worthy of trust and recognizes the importance of confidentiality

31. Confidentiality – Duty to Warn
Tarasoff v. Regents of the University of California (1976).
Breaching Confidentiality – Definition of “Harm”
In your groups define definition of harm as it relates to breaching confidentiality

32. Ethics and Research Nuremburg Code – 1947
Respect for Persons (dignity and freedom of every subject)
Researchers must maximize benefits and minimize harm
Equitable selection and fair treatment of subjects

33. Five Ethical Principles
Beneficence
Nonmaleficence
Autonomy
Justice
Fidelity
Our experiences in the public and private world – understanding of our shared lives together…community or family depends on acknowledgement of these basic principles;
We ought to promote each others welfare
We ought to respect each others freedom of choice
We ought not to harm one another
We ought to be faithful to our promises
We ought to be fair

34. Examples of actions in the rehabiliation process that are associated with the 5 Ethical Principles:
Timely delivery of services (adhering to Beneficence)
Refrain from negligent behavior (adhering to Nonmaleficence)
Encouraging consumers to choose their own rehabilitation goals (adhering to Autonomy)
Refusing to spend limited available time assisting an unmotivated consumer who is not working toward his/her rehabilitation goals (adhering to Justice)
Adhering to organizational policies (Fidelity)

35. Types of Ethical Dilemmas That May Be Encountered
Providing comprehensive and costly rehabilitation services to a few individuals vs. providing adequate and timely service to a larger number of individuals.
Maintaining confidentiality vs. protecting harm by providing relevant information.

36. Types of Ethical Dilemmas (cont)
Keeping required paperwork up to date at any given time vs. allotting sufficient time to provide direct services.
Adhering to agency management guidelines vs. providing an optimal package of rehabilitation services to a client.

37. Ethical Dilemmas
For example, stealing government property for your own personal gain would be a “moral temptation” not an ethical dilemma.
Deciding whether scarce resources should go to a needy client or a group of less needy clients, and how you make that decision, might constitute an ethical dilemma.

38. Characteristics of an Ethical Dilemma
A choice must be made between two courses of action.
There are significant consequences for taking either course of action.
Each of the two courses of action can be supported by one or more ethical principles.
The ethical principles supporting the un-chosen course of action will be compromised.
CARP Code of Ethics states “In many dilemmas there is not one right or wrong answer” I would argue that this is required in ALL dilemmas.

39. Ethical Decision-Making Model
1) Review the case situation and determine the 2 courses of action
2) List the reasons supporting each action
3) Identify the ethical principles supporting each reason
4) List the reasons for not supporting each course of action
5) Identify the ethical principles that would be compromised if each action were taken.
6) Formulate a justification for the superiority of one of the 2 courses of action by processing all of the information from the previous 5 steps.
This process begins after you have done the obvious…located all relevant information, talked to supervisor etc.

40. Case of Susan
Susan is a 25 year old blind individual receiving CPP monthly benefits totaling $ prior to losing her vision, Susan worked for 5 years as a file clerk. Susan applied for rehabilitation services indicating that she would like to obtain work in order to improve the quality of her everyday life by reducing her social isolation. Given her 10th grade education and recent vision loss, Susan will need vocational training to enable her to obtain suitable employment. The jobs that are feasible via training for Susan all tend to pay about $ per month. Therefore, by being vocationally rehabilitated, Susan’s monthly income will slightly decrease. After being fully informed of the results of her vocational evaluation Susan indicates that she is very confused. Confusion is generally Susan’s reaction when confronted with making important decisions.

41. Case Susan (Cont.)
Through effective counselling you attempt to help her sort out the pros and cons of each alternative. However, all it does is raise her anxiety. Susan asks you to tell her what to do. Although you personally believe that Susan would benefit from returning to work, you suggest that she take a week to think about it and return. She returns more confused than ever and again asks you to tell her what you think she should do. You must decide whether to give her an opinion.

42. Case of Mary
Mary is a nurse at the Claiborne Correctional Institute. Injection drug use is frequent in the prison. Approximately one of every 60 inmates is known by the institution to be HIV-positive, and approximately one of 3 inmates is HCV-positive. Mary knows that the prisoners share needles because there are very few needles in the prison, and is very concerned about HIV and HCV transmission. However, the prison does not have a needle exchange or distribution program. This frustrates Mary, since she feels that this policy is directly contributing to the spread of HIV. However, bleach distribution is permitted, and the doctor encourages prisoners to use it to sterilize their needles. She knows, however, that the evidence that bleach is an adequate sterilizing agent is inconclusive. This adds to her guilt and frustration, since she feels she is providing her patients with sub-optimal advice and care.

43. Mary (Continued)
One morning, Mary is conducting a physical on an inmate. The patient is HIV-negative, but confesses to sharing needles. Mary knows that at least one of the people he shares with is HIV-positive. On the table between them are clean syringes that she normally uses for vaccination. She knows that if she turns away, the syringes may “disappear”. This is against prison policy, but could help prevent needle sharing. What should she do?

44. REMEMBER
There is no absolute right and wrong course of action to take when faced with an ethical dilemma.
The nature of ethical dilemmas is such that good reasons can be provided for either of two courses of action.
When dealing with an ethical dilemma the most that can be expected of the rehabilitation professional is an ethically sound decision regarding the chosen course of action.
An ethically sound decision for resolving an ethical defense for the chosen course of action involves giving equal consideration for each course of action. Therefore, it is not sufficient to state “I chose Action A or Action B because it felt right”