Ethics in the hospital environment


Introduction

There is probably no doubt in any of our minds that ethics is necessary, even though we may have
different views about what is ethical and what is not. We would like politicians, business people,
teachers and, of course, doctors and nurses to behave ethically.

I've been associated with the hospital my whole life. Whether it was various serious illnesses, job
or because the family of doctors and nurses. I've always had a connection to it. In all
departments, I have encountered a variety of ethical issues today and every day. Both the more
serious ones (death, euthanasia) and the less serious ones (communication with the families,
behavior, respect for patients' rights, etc.). I would like to dwell for a moment on those
so-called small ethical issues that we encounter almost daily and whose importance should not be
neglected. These are the issues of the everyday attitude and decent behavior of health
professionals towards patients/clients.


Ethical dilemmas

The classic ethical dilemmas in medicine are attitudes towards abortion, euthanasia, ex mortuo
organ donation and genetic manipulation.


Euthanasia

Euthanasia is generally defined as the act, undertaken only by a physician, that intentionally ends
the life of a person at his or her request (Deliens L, van der Wal G, 2003, p. 1)

·         Active euthanasia (overfilled syringe strategy) is the active killing of a patient at his
or her own request.

·         Unsolicited euthanasia is active euthanasia where the patient is unable to request it due
to

·         his/her medical condition. However, it is assumed that if he or she were able to do so,
he or she would do so.

·         Involuntary euthanasia is both unsolicited and unwanted.

·         Passive euthanasia (syringe diversion strategy) is withdrawal or discontinuation of
treatment. This is a DNR (do not resuscitate) designation with us.

·         Assisted suicide, where the patient dies by his/her own hand but with the assistance of a
physician or other health care professional.

·         Prenatal euthanasia refers to abortion for social reasons, called an unwanted child.

·         Social euthanasia refers to a situation where the patient receives only reduced care
given the economic, geographic and educational resources of the country.


In the Czech Republic, active euthanasia is a criminal offence. However, letting die is available,
i.e., withdrawing from further procedures when they are already unnecessary and excessively
burdensome and bring further suffering to the patient. Palliative medicine is currently dealing
with this issue. (Bužgová, 2013, p. 73).


Artificial termination of pregnancy

The second ethical dilemma is the field of reproductive ethics which includes many “hot button”
issues, some of which do not fit into the previous sections. In this final section, “Abortion,
Surrogacy, and Circumcisions abortion artificial termination of pregnancy. (L.Campo, 2017, p. 1)
Certain part of the public does not think of abortion in terms of morality and takes the
availability of abortion for granted to regulate fertility. It has been legal in the Czech Republic
since 1957.

The most common reasons that justify abortion include the likelihood of the birth of a disabled
child (eugenic), conceiving a child as a result of a criminal act, e.g. rape (ethical), another
child is an unbearable burden for the family, the problem of single mothers (social), a condition
where pregnancy seriously threatens the life of the woman (therapeutic) (Bužgová, 2013, p. 75-76).


ETHICS IN MEDICAL PRACTICE

Example one

In this example I will reflect on the ethical issues of "everyday life", that I encounter in my
workplace.


In the context of the accreditation of some hospitals, a number of research studies are being
conducted. Patients' views and own experiences are being reported in various journals and the daily
press. Unfortunately, they are not always pleasant and positive. A survey of patient satisfaction
with the behavior of doctors and nurses in state hospitals found that people are probably most
bothered by the impersonal approach. Few people remember who their attending physician was. A lot
of doctors are external. This means that doctors take turns at the patient's bedside, they don't
introduce themselves, which obviously doesn't help to build trust.  Doctors who have had the
opportunity to practice in a foreign hospital agree on one thing: the biggest change for them is
that they have to get used to behaving completely differently towards patients. "In Germany and
Austria, it's quite common for doctors to identify themselves legibly by name, shake hands with
patients, and introducing themselves by name is the normal way to start communication," says a
medic with a year's experience at the University Clinic in Leipzig.


There is also a lot of emphasis in the world on how the nurse and the doctor talk together in front
of the patient about the patient. They can't talk about him as a third person - Mr. Novak had a
temperature today, what are we going to do about it?" The level of communication between doctors
and paramedical staff also seems to me to be a problem. Often it seems to me that they are two
independent groups of workers who have no insight into the work of the other (figuratively: the
right hand does not know what the left hand is doing). Yet any layman would imagine a doctor and a
nurse as a "medical team". In a healthcare team, we should be consistent in what we say to the
patient (it often happens that the patient deliberately asks the same question of each member of
the team separately). Let us not forget that the patient's trust is the most important thing for
us. If we each say something different, it can easily happen that we lose it.

Another problematic fact that I still encounter in practice is the stereotypes that are ingrained.
Like the 5am wake-up calls when nurses take temperatures and take morning blood. They try to get
everything done by six o'clock, when they hand over to the day shift. She starts right away with
toileting and cleaning. They have to be "all right" because the big ward round starts at 6.30. And
it's really big! The head doctor and his assistant, at least two doctors from the department in
question (one of whom certainly does not know the patient at all). They are accompanied by the head
nurse together with the station nurse, and if we "get lucky" there are also 2-3 students of the
nursing middle school. Some might argue that it is okay to have so many people caring and
interested in the patient.  But let's try to turn the situation. How would we feel in the role of
the patient, (for example, after a night of pain or sleep disturbed by monitoring, therapy or a
snoring neighbor), when we barely open our eyes in the morning, we already have a needle with a
syringe in our hand, and on the other side a nurse is washing us with a rough washcloth with cold
water, because there is not much time to let out her and wait for the warm water to flow. And
before we fully "wake up" there is a whole "rounds team" standing by our bedside, consulting our
health condition in a pretty loud voice in front of the other three patients in the room. Here is a
quote from a newspaper article: "The rounds are a relic of the nineteenth century. It makes no
sense for a couple of doctors to hold something like a social banquet over a patient, and for the
patient to be stressed out because he doesn't understand the learned speech of the doctors and
doesn't know why the guys are there?!" (Facultas Nostra, 2010, s.20)

We certainly find more than enough ethics-related problems in every workplace on a daily basis.
Many of them should be handled with a great deal of empathy. But this ability is, apparently, more
or less innate in everyone and therefore difficult to teach. What can be learned, however, is
professional behavior. No one is born as a professional, they either become one or they don't. Let
us remember that even getting a diploma does not make one a professional. To communicate
successfully with a patient, it is enough to follow a few principles: every person is an
individual, we are individuals too. Our primary role in this world is that of a human being. In
communication with the patient, this should be our default position. The fact that I am also a
healthcare professional is a secondary consideration. Let us not allow this barrier to arise. Let's
be more of a friend and partner to the patient.


Example two

Let us now review the four basic ethical principles. I will try to relate to each principle an
experience from my own practice, either positive or negative.


The principle of non-harming

My colleague lived for many years in a childless marriage. After all available investigations, the
couple were offered the option of assisted reproduction, which they accepted and underwent several
times without success. Three embryos were implanted.  The rest of the embryos are frozen in liquid
nitrogen and after some time are offered to the same couple, for adoption or discarded. The
questions arise: "Are we killing the future generation? On what basis do we select embryos for
implantation?" Each implanted embryo has a 25 to 30% chance of getting a woman pregnant. If a woman
is pregnant with one or two children, that's fine. But if she's expecting triplets, it's
unphysiological, with risks. That's why women are offered the option of pregnancy reduction.  My
colleague had all three embryos implanted for the fourth time. As she was a first-born at the age
of 38, which carries with it certain risks, she was also offered the aforementioned reduction. I
ask: "Which embryo to choose?"  In our case, "fortunately" nature itself decided and intervened.
Two embryos spontaneously died after a few days and my colleague has one healthy and beautiful, now
12-year-old girl.


The principle of wellbeing

Here I would like to give the development of the hospice movement as an example. There has been a
recent tendency for families to leave their dying and terminally ill in medical facilities. The
reasons for this were, for example, a busy family with the inability to care for a relative all
day, or also some concern about whether they would be able to care sufficiently for a immobile or
dying patient. But even this person with an unfavorable prognosis and exhausted available treatment
options has the right to be treated with respect and consideration, to receive quality nursing
care. To be able to live the rest of his/her life with dignity in a team of people who fully
understand the problems related to his/her condition and who try to the last moment to make the
quality of these days as good as possible.


Respect for autonomy

Jana, a member of the Jehovah's Witnesses Society, refused to sign a consent form before her
delivery, in case she needed a blood transfusion. Just after the birth, doctors came to the
conclusion that the newborn baby urgently needed a blood transfusion to prevent the baby's
retardation and possibly its death. The parents refuse to consent to the transfusion. The doctor
decides that the baby should be given a blood transfusion despite the parents' protests. During
these decisions, Mrs. Jana becomes hemorrhagic and the doctor suggests a hysterectomy to prevent
further bleeding

The husband, also a Jehovah's Witness, agrees to a hysterectomy but does not agree to a blood
transfusion for his wife. No transfusion given. Mrs. Jana dies a few hours later, her child
survives.


The principle of justice

Today, doctors and medical institutions are existentially dependent on the number of patients they
treat. It happens that there are vacant beds in the intensive care unit, so a "suitable" patient is
selected from the standard ward and transferred to the ICU. This is economically advantageous, as
the hospital gets more money for a fully occupied ICU. If they bring in a severe case, the patient
is returned to the normal ward.

Another example would be the now very topical issue of vaccination against "swine" flu.  A vaccine
that is not available to everyone. How to select "suitable" patients? By a random selection method
or by the principle of "first come...?"


Conclusion

Health is a person's greatest asset. As long as a person is healthy, he takes it for granted. But
as soon as he falls ill, health is the only thing he desires. Moreover, health care is the field
that gave birth to the first code of ethics. Moral values have therefore been sought and, in most
cases, upheld throughout most of human history. Today, there has been a shift towards a more equal
relationship between health professionals and patients. From an ethical point of view, this
relationship should be a partnership, an open one.  It is very important, therefore, to maintain
ethical values and behavior not only on the part of health professionals, but also on the part of
their clients, the patients.


This is where I would like to conclude my reflections with the words of Stewart Potter:

 "Ethics is knowing the difference between what you have a right to do and what is right to do."



References

Deliens L, van der Wal G. The euthanasia law in Belgium and the Netherlands. Lancet.
2003;362:1239–40. doi: 10.1016/S0140-6736(03)14520-5.

BUŽGOVÁ, Radka. Ethics in health care. Ostrava: Distanční texty Ostravská univerzity v Ostravě,
2013 [cit. 2022-10-19]. ISBN 978-80-7464-409-2.

L. Campo a P. Burcher. Reproductive Ethics: New Challenges and Conversations Introduction[online].
Albany, NY, USA, 2017 [cit. 2022-10-19]. Dostupné z:
https://link-springer-com.proxy.k.utb.cz/content/pdf/10.1007/978-3-319-52630-0_1.pdf

Facultas Nostra: Vizita? Přežitek minulého století. [online]. 2010. Plzeň, 2010 [cit. 2022-10-19].
Available from: https://docplayer.cz/7750890-Rok-2009-mezinarodni-rok-astronomie.html

















Jakub Skulina, M22974