Respiratory Care: Ethics and Legal Issues

Ethics in Respiratory Care

RTs regularly face situations requiring ethical and legal choices.

  • Ethics is a branch of philosophy concerned with how we should act.

  • It emphasizes respecting the humanity in persons, supplementing the golden rule.

  • Addresses the question: "How do we act?"

Legal Framework

  • State statutes regulate individual conduct and professional practice, setting minimum standards and CE requirements.

  • Common law imposes a duty to compensate injured individuals for negligent or intentional acts.

Ethical and Legal Challenges for RTs

  • Patient expectations

  • Staffing issues

  • Quality of care concerns

  • Rationing of care

  • Conflicts arising from third-party standards

  • Delivering appropriate care amidst cost constraints

  • Corporate influence

Code of Ethics

  • Essential for self-regulation in a profession.

  • Ensures effective and caring provision of public health needs.

  • A professional code limits competition, restricts advertisement, and provides conduct rules.

  • Ethical challenges often involve choosing between multiple right choices.

  • Review AARC Statement of Ethics and Professional Conduct (Box 5.1).

Ethical Principles

Autonomy

  • Respects patients' personal liberty and treatment decisions.

  • Forms the basis for informed consent: patients must be informed about procedures, risks, and benefits.

  • Patients are free to consent or withhold consent.

  • Deception or coercion to obtain consent is unethical.

Veracity

  • Requires truthfulness between healthcare provider and patient.

  • Involves providing the whole truth about medical care choices.

  • Challenges arise with benevolent deception (withholding truth for the patient's perceived good).

  • Truthfulness is generally the best approach.

Nonmaleficence

  • Requires healthcare providers to avoid harm to patients.

  • Upholding this principle can be difficult due to secondary effects of treatments and procedures.

  • Procedures carry risks of side effects and complications.

Beneficence

  • Goes beyond "do-no-harm" to actively contribute to patient health and well-being.

  • Dilemmas have led to the development of advance directives.

  • Addresses the challenge of knowing when to stop life-sustaining technology when meaningful recovery is unlikely.

Confidentiality

  • Requires respecting patient privacy, even after death.

  • Itis a qualified principle; state laws may require breaches under certain conditions (e.g., reporting gunshot wounds or child abuse).

  • Risks of inadvertent disclosure of protected health information (PHI) have increased with social networking.

Justice

  • Involves fair distribution of care.

  • Requires balancing healthcare expenses and ability to pay.

  • Population trends and rising Medicare/Medicaid costs pose challenges.

  • Distributive justice: allocation of resources.

  • Rationing of healthcare services: allocation of limited resources.

  • Compensatory justice: seeks recovery for damages caused by others' actions (e.g., medical malpractice, which represents a small percentage of healthcare costs).

Role of Duty

  • Allied health professions have practice areas defined by tradition or licensure laws.

  • Practitioners must understand their role limits and practice with integrity.

  • An RT might be ethically obligated to defer critical information disclosure to the physician.

  • Incident reports are essential for institutional protection, identifying system errors, and education needs.

Ethical Viewpoints and Decision Making

Formalism

  • Relies on rules and principles.

  • Moral rightness is determined by specific act features.

  • An act is justifiable only if it upholds applied rules or principles.

Consequentialism

  • Judges actions based on their consequences.

  • Involves the principle of utility: promoting the greatest good for the most people.

Virtue Ethics

  • Focuses on what a virtuous person would do in a similar situation.

  • Emphasizes personal attributes of character or virtue, not rules or consequences.

  • Asks, "How do I act in this situation to be a good RT practitioner?"

Intuitionism

  • Holds that there are self-evident truths, often based on moral sayings like "Treat others fairly."

Mixed Approaches

  • Combines strengths of different ethical thought lines.

Rule Utilitarianism

  • Focuses on which rule would promote the greatest good, rather than which act.

  • Differences in values and educational levels can lead to inconsistent decision-making.

  • Disadvantage: variability between caregivers.

Decision-Making Models

Ethical Decision-Making Model (Box 5.2)

  1. Identify the problem or issue.

  2. Identify the individuals involved.

  3. Identify the ethical principle or principles that apply.

  4. Identify who should make the decision.

  5. Identify the role of the practitioner.

  6. Consider the alternatives (long-term and short-term consequences).

  7. Make the decision (including the decision not to act).

  8. Follow the decision to observe its consequences.

Problem Perception

  • Frame ethical statement:

    • Conditions

    • Who

    • What

  • List Consequences

    • Immediate

    • Long-range

  • For each consequence, scan list of personal values and compare to consequences.

    • CONSISTENT: Ethical statement is valid

    • INCONSISTENT: Reconsider and restate

Legal Issues Affecting Respiratory Care

  • Errors leading to patient injury or death can result in professional liability.

  • Healthcare organizations implement quality review processes to reduce lawsuit risks.

  • Professional liability can contribute to increasing healthcare costs.

  • Most cases do not go to court.

Public Law

  • Two major divisions: criminal and administrative law.

  • Criminal law addresses acts against public welfare and safety.

  • Administrative law consists of regulations set by government agencies.

  • RTs must abide by these rules and regulations.

System of Law

  • Civil law protects private citizens and organizations from unfair and unlawful advantage.

  • Civil courts determine if a plaintiff has been wronged and the required reparation.

  • Tort law is the civil law category most relevant to respiratory care.

Tort Law

  • Civil wrong committed against an individual or property for which a court provides remedy.

  • Functions:

    • Maintain peace between individuals by settling disputes.

  • Forms:

    • Negligent torts

    • Intentional torts

    • Torts with liability regardless of fault (e.g., manufacturers of defective products).

Professional Negligence

  • Failure to use the degree of skill and learning ordinarily used under the same or similar circumstances by members of the profession.

  • Negligence is the failure to perform duties competently under licensure.

Malpractice

  • Professional misconduct, unreasonable lack of skill, or unethical conduct.

  • Classifications:

    • Criminal malpractice (e.g., assault and battery)

    • Civil malpractice (e.g., negligence)

    • Ethical malpractice (e.g., violations of professional ethics, possibly leading to disciplinary action)

  • Rules:

    • No intent to do harm

    • Patient provided consent for the procedure

Intentional Torts

  • Wrongs perpetrated by someone who intends to cause harm.

    • Slander and Libel

    • Defamation of character

    • Assault and battery

    • Invasion of privacy

Other Torts

  • Strict Liability: Theory in tort law that can impose liability without fault.

  • Breach of Contract: Patient injured due to incompetent service may claim failure to perform competently.

  • RTs are responsible for their actions.

Helping Avoid Lawsuits

  • Providing excellent care that meets professional standards and documenting it carefully is most effective.

  • Ensure RT license is active, be knowledgeable in research/CE, and stay updated with institution's policies and standards of care.

HIPPA

  • Health Insurance Portability and Accountability Act of 1996.

  • Establishes standards for privacy of individually identifiable health information.

  • Balances protecting individual health information with enabling quality healthcare and protecting public health.

HIPPA Privacy – Protected Health Information

  • An individual's past, present, or future physical or mental health or condition

  • The provision of healthcare to the individual

  • The past, present, or future payment for the provision of healthcare to the individual

  • Honor a patient’s right to privacy: do not walk away from your computer without securing it, don’t give information about the patient to family or friends over the phone or don’t speak of patients’ information in public area (like an elevator).

Medical Supervision

  • RTs are required by u“scope of practice” to work under competent medical supervision

    uRT’s employer, either physician or hospital, is liable for RT’s actions

    uIn some states, supervising physician may still be liable even if therapist is employed by hospital

    uLegal theory of “failure to supervise”

    uRespondeat superior (Latin: “that the master must answer”) in this case for the RT actions

National Labor Relations Act (NLRA)

uProvides protection to hospital workers, even if they do not belong to a union

uProtects worker when he or she engages in an act that would benefit of all employees

Respiratory Care Practitioner

uSocrates demanded that professionals acknowledge the social context of their activities and recognize their obligations toward the segment of society that they profess to serve.

uThe letters RCP are used to indicate “respiratory care practitioner.” The also suggest three important characteristics of the RT when confronted with ethical dilemmas:

  • Respect

  • Compassion

  • Professionalism