Chapter 6: Ethical Decisions and Challenges

1. Chapter 6: Ethical Decisionsand Challenges

2. Introduction • Challenges confronting the HIM professional are almost limitless • Study of ethics can be applied to everyday situations • Focus of this chapter: • Recognition of ethical challenges and learning how to address them • Application of ethical reasoning and decision making to resolve issues

3. Ethical Decision Making • We all face ethical dilemmas in life • Decisions are made • Individual level: affecting personal life • Organizational level: affecting others • No one right answer that applies to every situation • Decision maker must consider: • Factors that influence decision making • Process to be followed

4. Ethical Decision Making:Influencing Factors • Numerous factors may influence the decision maker: • Professional code of ethics • Ethical concepts or theories • Patients rights • Religious beliefs • Personal experience

5. Influencing Factors: Codes of Ethics • Written list of a profession’s values and standards of conduct • Embody professional concepts • Differentiate members from other occupations and careers • Present professional as autonomous decision maker • Endorse promise of loyalty to clients and fellow professionals • Elevate the client above the interests of self or fellow professionals

6. Influencing Factors:Codes of Ethics • Codes are open to change over time • Historically: • Were more a statement that limited competition and promoted image • Imposed restrictions • Modern codes of ethics • Statements of ethical and moral principles • Govern the conduct of the profession’s members • Almost every professional association has an ethics code • For example, AOA, AHIMA, medical associations, nursing associations, etc.

7. Influencing Factors:Codes of Ethics • Physician code of ethics • Obligation to provide competent medical service • Confidentiality of communication with patient • Duty to study and advance scientific knowledge • Recognize patient’s right to chose a physician • Must not discriminate

8. Influencing Factors:Codes of Ethics • Health information manager • Ethics are a cornerstone of the profession. • AHIMA has promulgated the code of ethics. • HIM has ethical obligations • To the patient • To other members of the health care team • To her professional association • To the public • To herself

9. Influencing Factors:Codes of Ethics • Effective communication is key • Professional education • Applicability of code in workplace • Consequences of unethical behavior • Case-by-case analysis • Successful approach stresses need to think for oneself

10. Influencing Factors:Codes of Ethics • Ethics committee • Group within an organization • Establishes, evaluated, and enforces ethics code and related corporate policies • Addresses ethical issues that arise • In health care organization, may consult on bioethical issues • End-of-life decision making support • Treatment of seriously ill newborn • Procedures for organ procurement • Medical research, new treatments, or equipment

11. Influencing Factors:Patient Rights • Role of patient in treatment has changed • Limitations on patient participation in care • Physician must approve admission to hospital • Insurance may require pre-approval for treatment and/or physician • Third-party payer controls funding for care • Expanded recognition of rights of patient • Rise in consumer activism • Move away from paternalism in medicine

12. Influencing Factors:Patient Rights • Recognition that patient is entitled to decide for herself • Consent to treatment • Refuse care • Patient’s Bill of Rights (1970s) • Privacy, confidentiality and informed consent • Patient care partnership (today) • Expanded to cover what to expect in hospital • How and where to express concerns

13. Influencing Factors:Patient Rights as Law • Incorporation of ethical concept into laws • May be penalties for breach of patient right that are enforced by law • Patient Self Determination Act (PSDA) • Right to determine extent of care • Right to make advanced directives (per state law) • Right to accept or refuse care • Hospitals must inform patients of rights • Hospitals must have related policies and procedures

14. Influencing Factors:Patient Rights as Law • Health Insurance Portability and Accountability Act (HIPAA) of 1996 • Federal law that protects health information • Under HIPAA patient has a right to: • Access, inspect, maintain copies of PHI • Notified of privacy practices • Limit use or disclosure of PHI • Request that steps are taken to keep communication confidential • Request and accounting of disclosed PHI • File a complaint concerning privacy practices

15. Influencing Factors:Patient Rights as Law • American Recovery and Reinvestment Act of 2009 (ARRA) • Federal law • Patient right to obtain copies of PHI in electronic format • If health care entity used an electronic health record • At patient direction, entity must transmit information to another as requested

16. Influencing Factors:Other Factors • Religious beliefs • Advances in science and technology • Embryonic stem cell research • Scarce resources • Legal factors • Civil rights transformed into legal protections • Law may address ethical concern but serves as minimum standard

17. Ethical Decision Making Process • Different aspects of ethical problems

18. Ethical Decision Making: Steps • Clearly define the issue • Determine the facts of the situation • Identify stakeholders • Values at stake • Obligations and interests of each stakeholder • Determine available options • Evaluate each option

19. Ethical Decision Making: Steps • Evaluating options • Compare each against an ethical theory • Which option presents greatest good for greatest number? • Utilitarianism • Which option supports one’s duty? • Deontology • Which option promotes rights and dignity? • Social equality and justice

20. Ethical Decision Making: Steps • Decide what should be done • Do analogous situations exist? • What was done? What was the outcome? • Are there legal implications? • What option makes the most sense? • Will option stand up to scrutiny? • Can you sleep at night with choice? • Are you comfortable if others know?

21. Ethical Decision Making: Steps • Justify the decision • Identify reasons that support decision • Implement decision • Evaluate the outcome • Compare what actually occurs to predicted outcome • Examine how to prevent recurrence of this ethical problem

22. Ethical Challenges • Difficult choices with no clear “right” answer • General challenges in work place • Conflict of Interest • Impaired colleague • Disparagement • Truth telling and disclosure

23. Ethical Challenges • Conflict of interest • Self interest versus obligation to group • Use of position to promote self interest • Appearance of impropriety • Examples • Accepting favors from a vendor • Second job with a competitor

24. Ethical Challenges • Impaired colleague • Impede performance and safety risks • Balance between no-tolerance and support person with disease of substance abuse • Disparagement • Criticizing skills of another professional • Codes of ethics consider such personal attacks to be professional misconduct • Focus should be on merits of issue

25. Ethical Challenges • Truth telling • Lack of full disclosure versus protecting trade secrets or security • Deceptive communications versus puffery • Copy of another’s work (plagiarism) • Unethical practices lead to erosion of trust

26. Role of Ethicsin Supervision • Role model • Set a good example • Accept responsibility for mistakes • Encouraging ethical behavior • Communicate ethical standards clearly • Enforce standards fairly • Respect, rewards, and punishment • Monitoring employee conduct • Review compliance with policies and procedures • Explicit part of performance evaluation

27. Health Care Challenges • Conflicts of interest • Joint ventures and self-referral practices • Inappropriate relationships with patients • Substance abuse/impaired colleague • Increased risk to patient safety • Situation must be addressed properly • Financial issues • Third-party payer affecting medical decisions • Bioethical issues

28. Health Information Management Challenges • Changes in care environment • Accreditation critical • Pressure to “fudge” statistics to reflect compliance or excellence • Sensitivity of information • Genetic • Drug and alcohol and mental health • Abuse • Documentation, access to, and release of information • Access to sensitive patient information • Celebrity patients • Demands from third parties: insurers, vendors

29. Health Information Management Challenges • Technology developments • Data resource management • Audit trails • Changes in reimbursement systems • Coding properly • Pressure for maximum reimbursement • Standards for ethical coding (AHIMA)