1. Develop an understanding of the application of ethical care in the community.
2. Increase attention to the need to apply ethics to everyday healthcare practice.
3. Explore the potential for conflict between individual autonomy and healthcare provision.
4. Explore the potential for interprofessional conflict in community care.
Living with Risk
While client autonomy and independence is often highly valued in community care, the choices that individuals make may conflict with the values of health professionals, or may leave them at risk for poor health or harm.
However, we all live with a degree of risk in our lives; different people will find different amounts of risk acceptable. There are many competent, independent people in the world who make decisions to smoke, eat fast food, drink alcohol more than is recommended, or exercise less than recommended. People also make decisions to skydive, rock climb, and ride their bikes on busy roads. No matter how health conscious, or risk averse, we may be in our daily lives, risk is unavoidable.
Why, then, do health professionals expect the individuals they serve to live risk-free lives? It is common for health professionals to recommend that older adults stop living independently because they are at risk for falls or unsafe when cooking (Baker et al., 2007), but it is not as common for them to examine what degree of risk is simply a normal part of life in the community.
This dilemma points out the conflict between individual autonomy, and the right to live at risk, and health professional beneficence, or the desire to care for those we view as requiring assistance.
Read Baker et al.’s (2007) article, and consider the case of Mary & George, who place more value on their autonomy than on their personal safety. If these were your family members, how would you feel? And, if you were a health professional involved in their care, would you feel differently? Post your 2 answers to your discussion group, and be sure to comment on at least one peer’s posting.
Baker, K., Campton, T., Gillis, M., Kristjansson, J., & Scott, C. (2007). Whose life is it anyway? Supporting clients to live at risk. Perspectives, 31,19-24.
Community Care Ethics Application
Three areas of community care will be explored in order to showcase potential ethical issues faced by health professionals. Community mental health practice, palliative care in the community and community care for older adults will all be presented as these are common areas where ethical issues present in the daily context of community care.
1. Community Mental Health Practice
In the past 4 decades in Canada, mental health practice has evolved from largely institution based to increased focus on service provision in the community. The process of “deinstitutionalization” moved many people into the community who now receive mental healthcare in their home environments (Whitehead & Sealy, 2004). Although this move to the community has supported client autonomy, healthcare practice in this area has a legacy of paternalism.
Paternalism can be defined as: “the policy or practice on the part of people in positions of authority of restricting the freedom and responsibilities of those subordinate to or otherwise dependent on them” (Pearsall, 1998, as cited in Roberts, 2004, p. 583). Paternalistic approaches to healthcare often directly conflict with individual autonomy, and may further stigmatize people with mental illness and deny their personal choice and freedom (Roberts, 2004). The potential for community mental health practice to restrict individual choice can lead to numerous ethical dilemmas for health professionals.
Paternalistic practices often arise from the desire to help individuals (beneficence) and to keep them from harm (non-maleficence). Unfortunately, this approach may lead to the restriction of the freedom of the individual, the right to choose one’s own destiny, and the right to live at risk. Healthcare practitioners may sometimes coerce individuals into preferred courses action, such as having them take medication, live in prescribed situations, or follow rules set out by the healthcare services (Davis, 2002). These issues highlight the intersection of individual autonomy and paternalism.
Recently, the Recovery Model has gained popularity in community mental health practice. The central concept is that people can lead fulfilling lives despite a diagnosis of mental illness, and that healthcare services need to reflect this belief. The Recovery Model fosters independence, empowerment and dignity for individuals (CMHA, 2011).
Read the Canadian Mental Health Association’s summary of “recovery”
Visit the Mental Health America of LA- MHA Village, housing with a recovery vision
Consider the concept of “recovery.” How does it fit with your own personal ethic of care? Which professions might embrace this model, and which may have philosophical differences? What are the potential ethical conflicts?
In any area of healthcare provision, the larger system and structures often conflict with the values of health professionals, those who receive care, and their support networks. The same is true in community mental health practice. Davis (2002) explores the tensions between self-determination and coercion, considering multiple perspectives. Trinh et al. (2008) consider the tensions in the daily work of a community mental healthcare team, providing three examples of ethical dilemmas frequently encountered by the team.
Read these two articles and reflect on the ethical dilemmas encountered in community mental health practice. Consider the varied perspectives of healthcare team members, and where ethical conflict may occur between team members’ values and approaches.
1. Davis S. (2002). Autonomy versus coercion: reconciling competing perspectives in community mental health. Community Mental Health Journal, 38, 239–50.
2. Trinh, Nhi-Ha, Moore, Derek & Brendel, David H. (2008). Ethics consultation to PACT teams: Balancing client autonomy and clinical necessity.Harvard Review of Psychiatry, 16, 365-372. doi:10.1080/10673220802564160
2. Palliative Care in the Community
“Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” (World Health Organization, 2002).
In Canada, palliative care is moving out of institutional environments, with more people now choosing to die at home. This move to the community poses unique challenges, and moves some ethical dilemmas from the clinical setting into the homes of those receiving palliative care, where resources may be limited. Health professionals providing palliative care in the community may offer practical assistance, such as coordinating services, assisting with symptom management, and offering emotional support (Brazil et al., 2010).
Enabling people to experience their final phase of life in the place of their choosing, which is often their own home, respects their autonomy and dignity. However, this process is often impossible without the support of family, friends, and health professionals (Karlsson & Berggren, 2011). The goal of palliative care is to provide the highest quality care possible, in the individual’s preferred environment. Fulfilling this goal often requires an interprofessional team that may involve physicians, pharmacists, nurses, occupational and physical therapists, personal support workers and others (Hutton, 2005). Medications must be managed, activities of daily living completed, personal care supported.
Community organizations may also assist with this goal. Hospice Kingston’s mission is “to provide comfort and support for individuals and families living with a life-limiting illness or coping with grief and loss.” Visit their website at: http://hospicekingston.ca/
Consider how health professionals, support networks and community organizations can work together to provide optimal care in the community.
The autonomy and dignity of the individual receiving palliative care is often paramount in caregiver and health professional’s minds, however, limited resources may conflict with this ideal. Brazil et al. (2010) completed a qualitative study of community health professionals (nurses, social workers, personal support workers, physiotherapists, occupational therapists and speech language pathologists) working in palliative care in Ontario. They identified numerous ethical issues they regularly encounter, including caregiver burden, competency, communication and decision making. Karlsson & Berggren (2011) completed a qualitative study of nurses in Sweden providing palliative home care and found that autonomy, integrity and safety were significant factors in providing high quality palliative care.
Read these two articles and reflect on the ethical dilemmas encountered in palliative care in the community. Consider the varied perspectives of healthcare team members, and where ethical conflict may occur between team members’ values and approaches.
1. Brazil, K., Kassalainen, S., Ploeg, J., & Marshall, D. (2010). Moral distress experienced by healthcare professionals who provide home-based palliative care. Social Science & Medicine, 71, 1687-91.
2. Karlsson, C., & Berggren, I. (2011). Dignified end-of-life care in the patients' own homes. Nursing Ethics, 18, 374-85.
3. Older Adults Living in the Community
The Canadian population is experiencing a shift in age demographics, with a continued increase in the proportion of Canadians over the age of 65 (Health Canada, 2002).
Visit the Human Resources and Skills Development Canada (HRSDC) website to view graphs that depict our changing population:http://www4.hrsdc.gc.ca/.3ndic.1t.4r@-eng.jsp?iid=33
Currently, 16% of the population is over the age of 65, but by 2051, it is projected that 1 in 4 people in Canada will be.
With the impending change in demographics comes attention to aging in the community. Many older adults value living independently in their own homes, even with physical health challenges and cognitive issues such as dementia (Baker et al., 2007; Culo, 2011; Strang et al., 1998).
The Ontario Government recognizes the need to support healthy aging in the community, both from a financial and quality of life perspective. They recently introduced an Aging at Home Strategy, which can be viewed here:http://www.health.gov.on.ca/english/public/program/ltc/33_ontario_strategy.html
HealthForceOntario has championed interprofessional care, funding a recent research project that raised the profile of interprofessional community care for older adults. See the Interprofessional Leadership Project on the Research Institute for Aging’s website:
Take note of the group poster presentations that showcase many interprofessional approaches to care for older adults in the community.
While the Ontario government and many organizations and healthcare providers are committed to high quality community healthcare services for older adults, providing these services can be challenging. Ethical dilemmas are frequently encountered in community care for older adults, especially when an individual experiences health challenges that limit their autonomy. Strang et al.(1998) explore these issues in the context of capacity to choose where one lives. This article was included in module 3 in the context of autonomy and capacity, and will be re-examined here from the perspective of aging in the community.
Culo (2011) raises the need to assess risk for vulnerable community dwelling individuals, and the potential ethical dilemmas in balancing safety and self-determination. She also points out on page 423 that health professionals may be overly reliant on cognitive tests to decide competency, when normal scores do not necessarily indicate competence, just as abnormal scores do not equal incompetence. The importance of approaching each case as unique, considering the environment, and the use of community supports to enable independence are discussed.
Read these two articles and reflect on the ethical dilemmas encountered in community care for older adults. Consider the varied perspectives of healthcare team members, and where ethical conflict may occur between team members’ values and approaches.
1. Culo, S. (2011). Risk assessment and intervention for vulnerable older adults. BC Medical Journal, 53, 421-425.
2. Strang, D.G., Molloy, D.W., & Harrison, C. (1998). Capacity to choose place of residence: Autonomy vs Beneficence. Journal of Palliative Care, 14, 25-9.
1. Choose one of the three community care areas (mental health, palliative care, older adults) and create a summary of how autonomy and beneficence conflict. You may wish to create a table that summarizes pros and cons to prioritizing autonomy over beneficence, and vice versa. Post your summary to your discussion group and be sure to comment on at least one peer’s posting.
2. In your interprofessional discussion group, meet in person or via web interface. Discuss your profession-specific views on each of the three community care areas. Agree to be respectful, but try to discuss both sides of an issue, and how conflict might be experienced between health professionals working in the community. Discuss strategies that might be used to address ethical conflicts.