1. Legal & Ethical Considerations
In the Practice of Respiratory Care

2. Philosophical Foundations
Ethics has its origins in philosophy - the love of wisdom & the pursuit of knowledge
Ethics is primarily concerned with the question, “How should we act?”
Ethics represents commitment to “respect humanity in persons.”

3. Ethical Viewpoints Formalism
Ethical standards of right and wrong are determined by rules or principles

4. Ethical Viewpoints Consequentialism
Ethical standards are judged based upon the consequences, the relative amount of good that an action will bring into being

5. Ethical Viewpoints Virtue Ethics
Ethical standards are based in personal attributes of character or virtue
The profession has a history of character standards
Action is based upon the answer to the question “How would a good RCP act?”

6. Ethical Viewpoints Intuitionism
Ethical standard based upon self-evident truths such as “Treat others fairly”

7. Ethics and Respiratory Care
AARC Code of Ethics – revised in July, 2004
General principles and rules ensuring safe, effective, and caring administration of care
Good Samaritan Law

8. Legal Terminology
Tort – civil wrong committed against an individual or property for which the court provides a remedy in the form of an action for damages
Negligent tort
Intentional tort
Difference is intent

9. Negligence Failure to perform one’s duties competently
Failure to take reasonable and prudent action
Res ipsa loquitur – “the thing speaks for itself”

11. Negligence May involve acts of omission or commission
Based upon what is reasonable and prudent action as determined by established guidelines (AARC), direct expert testimony, or by circumstantial evidence

12. Negligence Four “D”s of negligence
Practitioner owes a duty to the patient
Practitioner was derelict with the duty
Breach of duty was the direct cause of damages
Damage or harm came to the patient

13. Role Duty
Practitioners have duty to understand limits of role & to practice w/ fidelity
Respiratory therapists must not perform duties outside defined role

14. Negligence Respondeat superior – “let the master answer”
Physician assumes responsibility for the RT actions
The act was within the scope of practice of the RT
The injury to the patient was the result of an act of negligence
If RT acted outside the scope of practice, court will decide if physician retains liability; hospital may still be held liable

15. Malpractice
Form of negligence which involves professional misconduct, an unreasonable lack of skill, an evil practice, or unethical conduct
“Intentional Tort”

16. Malpractice Criminal Malpractice Civil Malpractice Ethical Malpractice
Includes assault, battery, and euthanasia (criminal court)
Civil Malpractice
Negligence or practice below a reasonable standard (civil court)
Ethical Malpractice
Violations of professional ethics (licensing board)

17. Slander
Verbal defamation of an individual by false words by which reputation is damaged

18. Libel
Printed defamation of an individual by written words, cartoons, and such representations to cause an individual to be avoided or held in contempt

19. Licensure
Regulated by the Respiratory Care Board of the state of California
RCB Wall of Shame

20. Respiratory Care Board
Sets requirements for initial licensure
Determines educational requirement for continued licensure (continuing education)
Undertakes administrative action for inappropriate care and/or unauthorized practice

21. Code of Ethics
Code of ethics : Essential part of any profession claiming to be self-regulating
AARC has Statement of Ethics & Professional Conduct
This code seeks to establish parameters of behavior for members of profession.
Moral obligations impose ethical duties on therapists

22. Confidentiality
The maintenance of privacy by not sharing or divulging to a third party privileged or entrusted information

23. Confidentiality
Qualified rather than absolute principle; may reveal information in specific instances
When required to so by law, e.g., incidents of child or elder abuse
Protect the welfare of the community at large, e.g., communicable diseases
Protect a vulnerable individual, e.g., spouse of an HIV positive patient

24. Confidentiality
Most instances of violations occur due to careless slips of the tongue
Discuss patients only with caregivers who have a need to know
Discuss patients only in secure areas – most common areas for breach: elevator, cafeteria

25. Confidentiality Record Keeping Common way to breach confidentiality
Never give out password for electronic charting to anyone
Only review patients’ charts to whom you are administering care

26. HIPAA
Health Insurance Portability and Accountability Act (HIPAA) of 1996
Privacy Rule
Designed to strike a balance between protecting information and not impeding the exchange of information necessary for quality care

27. HIPAA Protects all “individually identifiable health information”
Individual’s past, present, or future physical or mental health
Provision of health care to the individual
Past, present, and future payment for provision of health care

28. Confidentiality When doing case studies
Never use patient’s name or medical record number
Never divulge any of the patient’s personal information other than that necessary for the establishment of the case study

29. Advance Directives
Definition – document in which an individual specifies what medical care is desired in the future should the patient be unable to make decisions about medical treatment

30. Advance Directives
Durable Power of Attorney – allows patient to identify another person to carry out the wishes of the patient with respect to health care

31. Advance Directives
Living will – document which states the patient’s health care preferences in writing

32. Ethical Dilemmas
Presence of two or more right choices which are incompatible
Different priorities
Limited resources

33. Ethical Dilemmas
Presence of two or more right choices which are incompatible
Different priorities
Limited resources

34. Examples of Ethical Dilemmas
A certified technician wants to pass himself off as a registered therapist in order to move up in the department. After considering falsifying documents for a period of time, he decided not to because he feared sanctions and the loss of his position. Has the technician done anything unethical? Is this an example of an ethical dilemma?

35. Examples of Ethical Dilemmas
A patient has been diagnosed with end-stage lung cancer and has been told by the physician that his condition is terminal. The patient is due to be discharged through hospice care in two days. As the therapist administers routine therapy, the patient begins to ask questions regarding the pain medication that will be prescribed upon discharge. Questions include the normal dosage of the medication and the unsafe levels of the drug. Should the therapist answer these questions?

36. Examples of Ethical Dilemmas
A day shift therapist receives report in the department from the outgoing night shift therapist regarding a patient on life support. The incoming therapist proceeds to the ICU twenty minutes later to begin the shift and perform the first inspections. Upon arrival, the therapist notes that the alarms on the ventilator are in the “off” position and that the patient is apneic and in cardiac arrest. A Code Blue is called. The patient is successfully resuscitated, but dies later in the shift. The therapist charts the events as he found them. The next day, the department director meets with both the night shift therapist and the day shift therapist and tells the day shift therapist to modify the patient chart, removing references to the alarm being turned off.

37. Ethical Conflict
Conflict between patient’s rights and professional obligation
Autonomy
Veracity
Nonmaleficence
Beneficence
Beneficent deception
Justice
Role duty

38. Autonomy
The right and the ability to govern one’s self. It allows patients to make decisions about the medical treatment they will receive and decide which treatments they do not wish to receive.
Principle acknowledges patients’ personal liberty & their right to decide their own course of treatment
Basis for “informed consent”
Under this principle, any use of deceit to get patient to reverse decision to refuse treatment is considered unethical

39. Veracity
Truth. This principle implies that practitioners should tell patients the truth at all times.
Principle binds health care provider & patient to be truthful
Problems w/ veracity center around issues w/ benevolent deception (withholding truth from patient for his or her own good)
In most cases, telling truth is best policy
What is “benevolent deception”?

40. Nonmaleficence
The principle that requires therapists to avoid or refrain from harm and is often viewed as the opposite of beneficence.
Principle obligates health care providers to avoid harming patient & to actively prevent harm when possible
Problems occur when treatment has serious side effects or “double effect”

41. Beneficence
Charity or mercy and imposes the responsibility to seek good for the patient under all circumstances.
Raises “do-no-harm” requirement to higher level
Requires health care workers to contribute to health & well-being of their patients
Dilemmas in this domain have led to development of “advanced directives”
The debate over prolongation of life versus relief of suffering in elderly patients mainly involves differing opinions of beneficence

42. Beneficent deception
Not disclosing information to a patient in their best interest

43. Justice
The principle that deals with fairness and equity in the distribution of scarce resources, such as time, services, equipment, and money.
Involves fair distribution of care
Balance must be found between health care expenses & ability to pay

44. Fidelity Implies an obligation or faithfulness to duty.
Each practitioner has a duty to practice within a scope of practice (specific tasks and responsibilities), that is usually set by tradition or by the state legislature that regulates healthcare practice.

45. Ethical Issues
Human experimentation

46. Ethical Issues
Abortion for reasons of gender

47. Ethical Issues
Medical care of prisoners

48. Ethical Issues
Assisted suicide

49. Ethical Issues
Payments to physicians from pharmaceutical companies and other sources

50. Ethical Issues
Cloning

51. Ethical Issues
Medical student on call. The resident decided that there was an opportunity for the student to perform a femoral arterial stick. The patient was in a vegetative state and was not expected to recover. The stick was not medically necessary and was not able to understand or consent to the procedure.

52. Ethical Issues
Student saw physician constantly “putting off” adequate pain relief for a patient without giving any explanation to the patient or to the staff.

53. Ethical Issues
Medical student told to perform pelvic exams on patients under general anesthesia even though there was not medical justification for it and the patients had not signed a prior consent.

54. Ethical Issues
Student observed physician giving a women in the delivery room narcotics without informing her and after she had requested a natural delivery be done without use of narcotics.

55. Ethical Issues
Student assigned patient. In the course of the shift, the patient became unstable. When requested to help, the preceptor told the student to handle it and would not assess patient.