Table Of ContentETHICAL
DIMENSIONS
in the Health Professions
FIFTH EDITION
RUTH B. PURTILO, PHD, FAPTA
Professor Emerita of Ethics
MGH Institute of Health Professions
Boston, Massachusetts;
John Marsh Visiting Professor
University of Vermont
Burlington, Vermont
REGINA F. DOHERTY, OTD, MS, OTR/L
Lecturer
Tufts University
Department of Occupational Therapy
Medford, Massachusetts;
Senior Occupational Therapist
Massachusetts General Hospital
Boston, Massachusetts
3251 Riverport Lane
St. Louis, Missouri 63043
ETHICAL DIMENSIONS IN THE HEALTH PROFESSIONS,
FIFTH EDITION ISBN: 978-1-4377-0896-7
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Library of Congress Cataloging-in-Publication Data
Purtilo, Ruth B.
Ethical dimensions in the health professions / Ruth B. Purtilo, Regina F. Doherty. — 5th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4377-0896-7 (pbk. : alk. paper) 1. Medical ethics. I. Doherty, Regina F. II. Title.
[DNLM: 1. Ethics, Professional. 2. Patient Rights—ethics. W 50]
R724.P82 2011
174’.2—dc22
2010038396
Executive Editor: Kathy Falk
Associate Developmental Editor: Lindsay Westbrook
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Mary Pohlman
Senior Book Designer: Paula Catalano
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
With gratitude to
the patients, professional colleagues, and students
whose experiences have taught us
volumes about the value and meaning of care.
Foreword
As a nurse ethicist in a tertiary care institution, I observe, hear about, and
become involved in many of the complex cases that challenge interdisci-
plinary health professionals, patients, and surrogates on a daily basis.
Health professionals are immersed in day-to-day clinical decisions that are
increasingly complex and often require more from them than their requisite
professional specialty training can offer. Today’s health professional must
have the language, forums, interdisciplinary collaboration, and support to
effectively acknowledge and process these complex situations. Ruth Purtilo
and Regina Doherty provide a readily accessible and clinically relevant
format in the fifth edition of Ethical Dimensions in the Health Professions to
support interdisciplinary health professionals in this quest. Dr. Purtilo has
long been a leader in the concept and practice of interdisciplinary ethics and
my opportunity to work with Dr. Doherty in her position as Co-Chair of the
Massachusetts General Hospital Ethics in Clinical Practice Committee
successfully demonstrated her skill in highlighting the benefits of interdis-
ciplinary collaboration in ethically challenging cases.
This book makes ethical theory applicable for the practicing clinician by
placing its use within the Six-Step process of analysis and highlighting the
ethical decision-making process utilizing a wide variety of case studies.
The Six-Step model assists health professional students and practicing clini-
cians in approaching the often overwhelming nature of a clinical ethics situ-
ation that can be replete with high emotion, a multitude of facts, and lack of
clarity. For many years now, I have used the Six-Step process in teaching
students and practicing professionals. It is highly accessible to both. Its
common sense problem-solving approach allows a weaving in of ethical
theory in context that otherwise can become overly theoretical and difficult
for the student or professional to embrace in the absence of the model. The
fifth edition of Ethical Dimensions in the Health Professions continues to make
this contribution to both the student and the lifelong learner at a time when
ethical complexities are on the rise. The addition of new Chapter 2, “The
Ethical Goal of Professional Practice: A Caring Response” and Chapter 11,
“Communication and Information Sharing” represents topics that are
current and needed for ethical analysis and decision making. The “caring
response” as articulated in the text draws attention to behaviors that help to
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FOREWORD v
accomplish this essential goal, beautifully expressed in a way that is under-
standable and tangible. Never in the history of the professions is the recog-
nition of “empathic communication” more needed in both education and
practice. The authors urge readers to embrace reflection on the impact of
their roles as they practice. Through doing so the reader is better prepared
to provide ethically sensitive care.
As a consummate supporter of interdisciplinary collaboration in the
clinical setting, I am excited about the fifth edition of Ethical Dimensions in
the Health Professions. In my role as Co-Chair of the MGH Optimum Care
Committee, I have consistently observed that patients and their surrogates
benefit most when health professionals of all disciplines involved in their
care come together to share their expertise, challenge assumptions, and, in
the end, arrive at creative alternatives that could not possibly be derived
through the eyes of a single discipline. I am certain you will find that
use of this book will bring clinical ethics alive for you as a student and
practicing health professional.
Ellen M. Robinson, RN, PhD
Nurse Ethicist, Institute for Patient Care
Co-Chair, MGH Optimum Care Committee
Massachusetts General Hospital
Boston, Massachusetts
Preface
Every day health professionals confront ethical issues in their practice. This
text gives readers the basic tools to use for recognizing ethical issues, build-
ing understanding, and working toward the resolution of ethical problems.
The goal is to improve the lives of patients, the community, and themselves.
Practitioners in the health professions are members of society who are
transformed from simply caring to learn to also learning to care. The tone
of this book is practical throughout, designed for people on the front lines
of health care decision making. Society expects its health professionals to
be informed about current ethical issues and to be moral agents in helping
to address them.
This fifth edition of Ethical Dimensions in the Health Professions reflects the
authors increased awareness that ethics has to be taught, and taught well,
so that students will be well prepared for their role. Today’s health profes-
sional must not only have knowledge and skills, but effectively
balance these with sound judgment and responsibility for action. Effective
ethical decision making in clinical practice demands that the professional
use clinical reasoning—a complex thought process that entails thinking,
analyzing, decision making, acting, and reflecting upon professional prac-
tice. Ethical reasoning is not used in isolation, but rather in concert with
other types of clinical reasoning. Administrators and teachers in profes-
sional education continue to work toward offering more and better profes-
sional ethics courses, seminars, and continuing education opportunities
that emphasize this shift. Furthermore, in many educational programs, edu-
cators skillfully have woven ethics theory and practice into the very fabric
of the student’s learning experiences in the clinic as well as the classroom.
Our goal in preparing this updated and expanded edition has been to reflect
these positive changes.
What’s New in this Edition
At the outset you will notice the addition of Regina Doherty, a respected
occupational therapy clinician and educator as a co-author. Whose training,
professional experience, and expertise in ethical reasoning enhance the
pages of this text. Our collaborative work in interdisciplinary classroom
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PREFACE vii
teaching, the development of curricular materials, and leadership in the de-
velopment of an international consortium on ethics education, were prompts
to enrich this book through a co-authored effort. The text remains deeply
interdisciplinary and clinically oriented. Readers of previous editions will
notice signature features carried through into this edition, among them the
overarching goal of professional practice, a caring response; the three proto-
types of ethical problems; the six-step process of ethical decision making;
narrative accounts to illustrate relevant ethics themes in everyday practice;
built- in reflective exercises; summary statements; and questions for thought
and discussion at the end of each chapter. Cases and federal statutes and
regulations that have ethical bearing in practice have been updated.
In Section One the reader is introduced to the idea of morality and ethical
study, which includes an expanded section on law and ethics. A new chap-
ter is now devoted entirely to care. This includes the concept of care and
characteristics of a caring response in the health professions. A new section
on modes of clinical reasoning helps the reader to set the context for more
critical reflection on the various ethical dimension of practice. Section Three
has been reorganized to reflect updated national standards and challenges.
The most recognizable change is the addition of a new chapter on commu-
nication, a foundational aspect of therapeutic relationships. Given the
heightened reliance on new mechanisms of communicating in health care,
this chapter focuses directly on the ethical dimensions of information shar-
ing. It provides insights to help students examine communication through
the lens of ethical decision making. Given the increased awareness on
health disparities, Section Five includes an expanded emphasis on social
justice. As in previous editions, our intent is to help readers prepare for
their role as moral agents and enhance their ability to effectively confront
ambiguities in practice. The final chapter highlights moral agency and re-
sponsibility in its expanded forms. Here opportunities present in societal
spheres where the roles of the health professional and citizen meld.
The fifth edition stands on the shoulders of the previous four, grounded
securely in theory and those enduring concerns that have supported the
need for professional ethics and ethical professionals since the beginnings
of health care. It also builds on our abiding conviction that health profes-
sionals can and should assume a strategic position to help shape the con-
tours of today’s health care environment so that it embraces and protects
cherished social values. We hope that Ethical Dimensions in the Health Profes-
sions will serve as a guide and welcome companion on your journey
in professional ethics. This journey is, we believe, a key to finding self-
fulfillment in professional life.
Ruth B. Purtilo
Regina F. Doherty
Acknowledgments
Edition Five
The first edition of this book was co-authored by Ruth Purtilo and Dr. Christine
Cassel. Readers familiar with Dr. Cassel’s outstanding contributions to health
care and health policy will recognize her ideas and insights still woven into the
very warp and woof of the text.
We owe a debt of gratitude to the health professions students and col-
leagues we have had the opportunity to teach and learn from at our
respective current places of employment, including the MGH Institute
of Health Professions, The University of Vermont at Burlington, Tufts
University, and the Massachusetts General Hospital. We have led and
served on several ethics committees throughout our careers, and these
interdisciplinary discussions have expanded our understanding of how
ethical issues impact the lives of patients, their families, health profes-
sionals, and institutions. Our mentors and supporters along the way are
too numerous to mention here. We have benefitted greatly from their
generosity and care.
Lastly, a heartfelt thanks to our husbands, Vard Johnson and Dan
Doherty, whose deep support and respect for our professional endeavors
nourish our work and lives; and to Regina’s young daughter, Olivia Grace,
and Ruth’s goddaughter, Allison Cole, whose inquisitive spirits and open
hearts are sources of great motivation and joy.
Ruth B. Purtilo
Regina F. Doherty
viii
Notes to Instructors on Using
This Edition
The core purpose of this book is to provide the tools for addressing
common, everyday ethical issues in the health professions. Our hope is that
both you and your students will find it user-friendly! The goal of a caring
response (Chapter 2), and the concept of moral agency (Chapter 3) provide
a framework throughout the text for ethical analysis and action.
Instructional Tools
A Six-Step Process of Ethical Decision Making
The Six Steps Building Blocks
Step 1: Gather relevant One must pay critical attention to the details of a
information situation. This means learning to distinguish
clinical, legal, and ethical content.
Step 2: Identify the type The three prototypes of ethical problems
of ethical problem introduced in Chapter 3 help to organize the
details of a narrative into the appropriate
category (or categories) for ethical analysis.
Step 3: Analyze the In Chapter 4 the skills of ethical reasoning are
problem using ethics put into play.
theories or approaches The foundational theories, approaches, and meth-
ods of ethics (i.e., moral virtues, rights, duties, and
principles) are introduced here as tools for analysis.
Steps 4: Explore the This step focuses on the realistic options for
practical alternatives carrying through with ethically appropriate
action. Openness and creativity are essential.
Step 5: Act In this step, action is required. The resolve and
courage to proceed are needed.
Step 6: Evaluate the In this final step, the professional/s reflect on
process and outcome the ethical decision, action, and outcomes.
Attention is paid to what can be learned for
future situations.
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