Course talk:DHYG400/September2009ETP

Group A Ethical Dilemma Interviews:

Oct. 23rd, 2009 Priscilla Ojeda

Ethical Dilemma Interview

Interview was conducted with a clinic manager of a multi-disciplinary rehabilitation and wellness clinic that provides Physiotherapy, Chiropractic, Kinesiology, and Massage Therapy as their principle services.

Q: What kind of ethical dilemmas do you face or have you faced in your practice?

We want to provide as much access as possible, but we face clients with financial issues. Balancing what is fair and consistent in terms of rates that others pay for the same services, the ability to pay the therapist and to be consistent with college guidelines. The principle goal of the business is to provide the best health outcome. Developing policies that are sensitive to those in financial restraints is a common issue, especially when an optimal plan is not affordable to certain patients and thus it affects their implemented plan and health outcomes..

Q: Did you receive formal training or education regarding dealing with ethical dilemmas?

Yes, briefly in school, but majority in post-secondary and business specific professional development courses. First obtained degree in kinesiology and then took extra business courses that addressed ethical dilemmas with business structuring.

Q: Do you use any ethical framework to guide you through your ethical decision-making?

You may use your judgment to ensure the fair application of the core principles of honesty, respect, equality, and well- being of others at all levels of our system. For example at an individual level, group level, organizational level and societal level.

The development of a code of conduct and ethics policy for the business is also a document created to ensure a framework. The development policy handbook allows everybody to understand the guidelines.

The development of this document was from gathering several resources from multi-disciplinary practices and from personal experience, as well as from regulatory associations.

Q: How would you define an ethical dilemma?

An ethical dilemma is a situation in which a decision to act upon one’s moral beliefs or standards results in a compromise or less than desired outcome, in comparison to a decision that would be made without the dilemma being present.

Q: At what point would you go to your regulatory body to deal with a situation?

In a situation where there is a potential threat to the safety or well being of our staff and/or patients that if addressed would result in a breach of confidentially.

Q: Provide an example of an ethical dilemma you have faced?

Had an ethical dilemma with a new employee where the employee was trying to perform at their fullest capability, but were unsuccessful in accomplishing the required duties. The individual was a good person who really wanted and needed the job. After multiple efforts in trying to work with this individual and repeated failures, it became evident that the group that she worked together with increasingly began to suffer. It came to the point where the correct ethical decision had to be to let go of the individual because the negative effect on the group outweighed the potential negative impact of letting go of this individual.

Q: What were the ethical principles at risk?

The ethical principles at risk were benevolent action and concern for the well being of the individual, versus the increased unwarranted duress that was imposed on the other individuals of the group and the group as a whole.

Q: What are the theories of ethics applicable to your dilemma?

We do not operate by any ethical theories, just by ethical principles and guidelines document that we developed.

Q: What was the resolution and what methods were used?

Letting go of the individual was the resolution and method used, and thinking the existing staff for their patience and hard work during this challenging time. In retrospect there are no regrets or changes to how the situation could have been handled. Even the individual agreed and respected the decision and thanked the owner for providing multiple opportunities and came to the realization that a different type of job would probably be better suited to that individual and bring them more happiness.

Ethical Dilemma Interview- Jenny Jamen (Group A)

The following are responses from a 28 year old, female, occupational therapist. She is a graduate of the UBC occupational therapy masters degree program. She graduated in 2006. Her alias name for confidentiality purposes is "Casey".

1.What kinds of ethical dilemmas do you face or have you faced in your practice?

Casey works in private practice and often the "fee payer" is not the client. For example Work Safe BC is the fee payer for people who were injured at work. Ideally all of her work is "client centred", however if WSBC decides that a client should not receive services then the client's well being is irrelevant. Casey works for the fee payer (WSBC, ICBC, Lawyers, life insurance co's ect) and this interferes with her client centered intentions.

2. Did you receive formal training or education regarding dealing with ethical dilemmas?

Yes, to a point. Casey reviewed the ethics codes created by COTBC (OT college and licensing board) in school. She had to incorporate ethics into class discussions, projects and case studies. She also had to write exams that included codes of ethics. However she did not really understand how ethics interfered with client centeredness until she started working in private practice.

3. Do you use any ethical frameworks to guide you through your decision making.

She uses COTBC code of Ethics to guide her through her decision making. As well Casey signed a contract with her company and must adhere to those codes of conduct while she works there.

4. How would you define an ethical dilemma? She defines an ethical dilemma as: "A situation where 2 parties want something different and only 1 decision can be reached so clearly 1 of the parties is not going to be happy with the decision".

5. At what point would you go to your regulatory body to deal with a situation? When the issue is too big for either her or her supervisor to sort out she would consider going to the regulatory body. Or when the issue conflicts with a code of ethics (COTBC). Casey considers that her integrity is vital to her success and she can not comprimise on this; she would always go to supervisor first, then the COTBC board.

6. Describe an ethical dilemma you have encountered.

The following is Casey's description of an ethical dilemma she faced: I can think of one from when I worked at Sunny Hill Hospital. I worked with physically disabled kids, this one had suspected dysphagia and was 2 yrs old. She had been living on Formula paid for by health care (MSP). Mom did not have money and was a single mom. In order to keep getting formula paid for she needed to keep the dysphagia diagnosis. Swallowing assessment showed the 2 year old had improved and could now swallow with some difficulties. Mom insisted that the 2 year old needed formula and that she had more trouble at home. It was evident that she needed our support to feed her daughter. In the end we decided the dysphagia diagnosis stays because there was still some difficulty swallowing

Ethical Dilemma Interview- Jackie Chen (Group A)

The interview was conducted with a registered nurse working in the Children’s Hospital. She received her degree from the University of Toronto Nursing program.

Q1: What kinds of ethical dilemmas do you face or have you faced in your practice?

A1: The most ethical dilemmas we face here is when patients' or parents' expectation of care come in conflict with decisions or suggestions from medical service team. (Refer to example in Q6)

Q2: Did you receive formal training or education regarding dealing with ethical dilemmas?

A2: Yes, I did receive formal training in ethical decision making in nursing school. It was a course called Personal and Professional Growth, which was mandatory to take throughout my 4 year program. A heavy component of this course was based on ethics.

Q3: Do you use any ethical frameworks to guide you through your decision making.

A3: I'm not sure exactly what ethical framework we use here in children's hospital.

Q4: How would you define an ethical dilemma? A4: I define ethical dilemma as the "grey area" between right and wrong. It occurs whenever we find ourselves in a situation where we cannot tell clearly between the greater good or the lesser bad.

Q5: At what point would you go to your regulatory body to deal with a situation? A5: We try to address any concerns as early as possible. I always report any issue I find immediately to my Superior, just so we try to solve the problem at the first sign of it instead of letting it snowball and spin out of control. We may not have to take any interventions at first, but it's appropriate to keep the team informed.

Q6: Describe an ethical dilemma you have encountered. A6: A 15 year old boy had been having recurrent cancers throughout the past 10 years. He had gone through numerous rounds of chemo, surgeries, and radiation therapy sessions, and his cancer always came back in different forms and worse yet, most of these times, even more aggressive than before. He had been in hospital for most of the past ten years, and suffered more than enough in our medical opinion, and it was clear to the medical team that there was nothing we could do for him to improve his quality of life. The doctors had suggested to his parents to treat him as a palliative patient which means to provide comfort measures only and let him go in peace. But his parents could not accept that. They could not come to term with fact that their son is running out of time and options. So till this day, we are still treating him acutely, putting him through all kinds of painful procedures only to see all of them fail to help. We are keeping him alive to suffer, against our clinical judgment, because that's his parents’ decision.

Ethical Dilemma Interview- Rosie Gao

Ethical Dilemma Interview

My interview was conducted on a pharmacist who graduated from the University of British Columbia. She works at Shoppers Drug Mart and as well as a health care facility in Greater Vancouver.

Q: What kind of ethical dilemmas do you face or have you faced in your practice?

I am constantly faced with clients who demand for more prescription than they need because of possible withdrawal symptoms they may be receiving. They often would ask for a prescription that is not stated on the prescription note provided by the physician. Many are also not covered by a medicare service plan or more specifically the pharmacare plan. These clients are often the ones with the greatest needs for the medication.

Q: Did you receive formal training or education regarding dealing with ethical dilemmas?

Learning about ethical dilemmas was incorporated into the UBC Pharmacy curriculum. I did take a philosophy course during first year of university and they talked about ethical dilemma. During pharmacology years, I did case scenarios with ethical dilemma issues as well. It was a big component of pharmaceutical sciences. There are also pharmacy ethics course that I can take online.

Q: Do you use any ethical framework to guide you through your ethical decision-making?

The most important factor that come into play when I make ethical decision making is equality. I believe every Canadian deserves equal and respectable access to medication and treatment.

My job as a pharmacist is also to allow clients to have their own voice. I sometimes feel like a psychiatrist who listens to the clients' views and opinions because I believe their voices should be heard regardless of whether it is scientifically based or not.

My personal favorite framework revolves around putting my every effort into ensuring that the client is satisfied and benefited from my service. I exist to please clients and improve their overall health and satisfaction of life.

Q: How would you define an ethical dilemma?

An ethical dilemma can be seen as complex situation in which one may be afflicted between values, beliefs and laws and the interests of an individual or group. An ethical dilemma may also result in the harm of one party in order to fulfill the interest of another.

Q: At what point would you go to your regulatory body to deal with a situation?

All Canadians have their right to safety. I will report to the regulatory body if the safety of my clients are at risk or if any laws or regulations are breached.

Q: Provide an example of an ethical dilemma you have faced?

Many patients ask me to distribute medications without prescriptions. These patients may be on vacation or couldn't book an appointment with a doctor in time for the medication or refill. As a pharmacist, it is my duty to follow regulatory guidelines.

One time, an elderly patient asked for a medication for his mental illness. He persisted for a long time, stating that he was in pain if he did not receive the medication. When I rejected his request, he started to mutter and yell at himself with nonsense.

Q: What were the ethical principles at risk?

The ethical principles at risk include beneficence and autonomy. Every patient has the right to receive treatment. Also, if the situation calls for it, sometimes medications are more beneficial to the patient and outweighs the risks. On the other hand, if I were uncertain of the patient's medical condition of history, I do not believe it is beneficial to the patient to distribute drugs without a prescription. At the same time, if I know that the patient is in dire need of the prescription, then perhaps breaking the law may be the only option. Many Ontario pharmacists break the law by giving out short courses of long-term medications when the patient cannot get a prescription under any circumstances.

Q: What are the theories of ethics applicable to your dilemma?

Beneficence is huge in this situation. I also need to use my professional judgment and look at each case on an individual basis.

Q: What was the resolution and what methods were used?

My belief is to abide to the laws and regulations. First thing, I asked for the patient's physician number so I can call him to confirm the prescription. When the man failed to provide a doctor's name, my last resort was to provide a list of walk in clinics the patient can attend to receive a prescription. Thus, I did the best to find alternatives to solve the problem to avoid administrating drugs without prescription. Although this made the man very angry, I believe that administering drugs without the credentials and recommendations of a physician can also be detrimental to the patient's health.

Kim Lightheart

I interviewed a Constable of the Vancouver Police Department.

1. What kinds of ethical dilemmas do you face or have you faced in your practice?

Encountering a situation where you are put in the middle of what you should do as an officer and what you want to do as a decent person. For example; Pulling over a vehicle with a fellow police member that has been drinking and driving and having to go through the regular impaired investigation as you would any member of the public. Another example would be knowing that someone from your social circle may be dating a known offender, or you know something incriminating about this person and cannot tell your friend this fact, as it would be a breach of security and policy.

2. Did you receive formal training or education regarding dealing with ethical dilemmas?

Ethics is a central part of all of our learning processes and is a core value in the police community. It is instilled in us throughout our training at the JIBC and continues to be offered to us in various courses at work. It is part of our regulations and procedures manual and states the following:

As a member of the community and as a police officer I recognize that my fundamental duty is to protect lives and property, preserve peace and good order, prevent crime, detect offenders and enforce the law.

I will faithfully discharge my duties in a just, impartial and reasonable manner, preserving the equality, rights, and privileges of all persons as guaranteed by the Canadian Charter of Rights and Freedoms.

I will keep my private life unsullied as an example to all, maintain courageous calm in the face of danger, scorn or ridicule and be constantly mindful of the welfare of others. Honest in thought and deed in both my personal and official life, I will be exemplary in obeying the laws of the land and the regulations of the Vancouver Police Department.

I will preserve the dignity of all persons. I will be faithful in my allegiance to Her Majesty the Queen and my country. I will honor the obligations of my office and strive to attain excellence in the performance of my duties.

3. Do you use any ethical frameworks to guide through your decision making.

I try to live my life and make my decisions based on what would be ultimately be best for my career and others around me. I try to reflect on how I would want to be treated in any given situation and what others expect of me during my decision making process.

4. How would you define an ethical dilemma?

An ethical dilemma is anything that puts you in a position to test the rules and principles that define right and wrong conduct.

5. At what point would you go to your regulatory body to deal with a situation?

I would address a regulatory body when I feel that a situation is far beyond my realm of control or where I need approval of what decisions I will be taking as my actions may result in serious consequences for a particular party.

== Summaries ==

Kim Lightheart's Summary

I interviewed a constable of the Vancouver Police Department. I found that even though our professions are very different, there are many similarities when it comes to ethics. The most prominent similarity I found between our professions was the issue of confidentiality.

An example of an ethical dilemma that a constable in the Vancouver Police Department would face may be when they pull over a vehicle and find that that the driver is a fellow police officer who has been drinking and driving. The on duty officer is required to go through the regular impaired investigation as they would with any impaired driver. The ethical dilemma occurs when they realize that charging this officer with a DUI may cost the fellow officer their job. This dilemma is very similar to a situation in a dental office when a hygienist is required to report any practice negligence of a fellow hygienist while knowing that the hygienist may have to give up their licence. The College of Dental Hygienists of British Columbia states that a hygienist must "report to their licensing body or other appropriate agencies any illegal or unethical professional decisions or practices by dental hygienists, or others".(1)

A second example of an ethical dilemma possibly experienced by a police officer also involved confidentiality. In this case an officer is required to keep the confidentiality agreement even though one of their close friends may be dating a known offender. A parallel example of an ethical dilemma is discussed in Neish and McDonald's article where a dental hygienist's son has begun dating one of the hygienist's clients who has tested positive for HIV.(2) Both these professions have to deal with extreme situations where keeping informed consent may have significant consequences to the other parties involved. The CDHBC states in the code of ethics that a dental hygienist must maintain confidentiality and maintain a client's privacy. This is also in accordance to the British Columbia legislation of the Health Act, Freedom of Information and Protection of Privacy Act and the Health Professionals Act.(1)

Both the Vancouver Police Department and the College of Dental Hygienist's of British Columbia have a code of ethics that their members must obey in order to provide the best services. One statement in the VPD regulations and procedures manual states: "As a member of the community and as a police officer I recognize that my fundamental duty is to protect lives and property, preserve peace and good order, prevent crime, detect offenders and enforce the law." The College of Dental Hygiene have similar regulations stating "Hold paramount the health and welfare of those served professionally" as well as "Provide competent and appropriate care to clients".(1) It is evident that both these regulatory bodies main focus is to protect the public by implementing high levels of professionalism by their members. As is evident the actual profession being implemented is very different, but the basic fundamentals are very similar.

Both the Vancouver Police Department and the College of Dental Hygienists of British Columbia require ethics training before anyone can become licenced. Ethics is a central component of the training at the Justice Institute of British Columbia as well as at the University of British Columbia. In both situations, the basic ethics fundamentals must be applied to everything else learned in the programs.

The ethical framework that us as hygienist's use would most likely be the code of ethics of the CDHBC and the BCDHA. These ethics protect both the public as well as ourselves as hygienists. It is important to always reflect back to these codes when confronted with an ethical dilemma as well as during a situation where there is no ethical dilemma. Even though both these codes are very important, our own common sense and intuition is very important to follow. This is often the first trigger that an ethical dilemma is occurring. As stated in the article by Neish and McDonald, the code of ethics does not give the answers to the ethical dilemmas that we as professionals may face.(2) We must use the code of ethics as a guideline to help us determine the best course of action to take.(2)

The Vancouver Police Department also abides by their regulations as well as by their intuition. As reported by the Constable, she makes decisions based on what would ultimately be best for the public, the profession and her safety.

As a dental hygienist I would define an ethical dilemmas as any situation where one has to make a decision that will have an impact on the parties involved either negatively or positively. A constable from the Vancouver Police Department would define an ethical dilemma as "anything that puts you in a position to test the rules and principles that define right and wrong conduct". The College of Dental Hygienist's of Ontario states that an ethical dilemma "occurs when two or more principles are in conflict".(2)

The interviewed police officer states that she would address a regulatory body when she feels that a situation is far beyond her realm of control. She would also contact the regulatory body in a situation where she requires approval of the decisions she makes as her actions may result in serious consequences for a particular party. I agree with these situations that she has stated. If a hygienist is not able to resolve a conflict within their practice setting, it may be necessary to contact a regulatory body such as the CDHBC or BCDHA to obtain information on the appropriate steps that must be taken. For a conflict involving the safety of a client, the CDHBC would be contacted, and if the conflict involved the safety of the hygienist, the BCDHA would be contacted.

References

1. CDHBC. Code of ethics. Victoria, BC: Author, 2004.

2. Neish N, MacDonald L. CDHA Code of Ethics Workshop: Application to Day-to-Day Work. Probe 2003; 37(1):27-33.

Priscilla Ojeda's Summary:

A common ethical dilemma faced at this multi-disciplinary rehabiliation and wellness clinic is proving optimal treatment plans to provide the best clincial outcome while being faced with the financial constraints of the clients, which may limit their ability to choose the best treatment plan. This is a similar dilemma we may face in our clinic when providing different treatment options, the plan with the best prognosis may not always be the most affordable one for the client. This in turn will effect the clinical outcomes of their treatment and may not result in the best prognosis for their health. Another dilemma is ensuring that the costs of treatment are consistent with college guidelines, while ensuring that the all the employees are paid fairly. I think this could be analogous to UBC dental hygiene services fee being reduced to a current standard rate of $25 as compared to the previous cost 6 months ago of a minimum of at least $60- $160.(1) UBC realized that in order to meet the unmet needs of a lower socioeconomic population they would have to offer competitive pricing when comparing the fee guides of the other local educational dental hygiene facilities. UBC also has to make the decisional balance of ensuring that the fee reduction does not affect the dynamic of budget and staffing costs. In private practice, the dental hygienist must also adhere to charging the costs on the Dental Hygiene Services Provincial Fee Guide to ensure that no costs be charged less than stated on the guide, as laid out be the Canadian Dental Hygiene Association (CDHA). (2)

Another ethical dilemma that the owner faced was dealing with a new employee that was trying to perform at their fullest capability, but were unsuccessful in accomplishing the required duties. The individual was a good person who really wanted and needed the job. After multiple efforts in trying to work with this individual and repeated failures, it became evident that the group that she worked together with increasingly began to suffer. It came to the point where the correct ethical decision had to be to let go of the individual because the negative effect on the group outweighed the potential negative impact of letting go of this individual. Letting go of the individual was the resolution and method used, and thanking the existing staff for their patience and hard work during that challenging time. In retrospect, the owner had no regrets or changes to how the situation could have been handled. Even the individual agreed and respected the decision and thanked the owner for providing multiple opportunities and came to the realization that a different type of job would probably be better suited to that individual and bring them more happiness.

The ethical principles at risk were benevolent action and concern for the well being of the individual, versus the increased unwarranted duress that was imposed on the other individuals of the group and the group as a whole.(3) I can relate to this situation when working in groups. Sometimes a situation may arise that an individual will not be contributing to the group in a equally and it affects the outcome of the team assignment. Although we may not be able to "dismiss" a group member, we are still faced with utilizing professional communication and managing conflicts. We can also some what report to our regulatory body, student services or professors, by performing peer evaluations that will report unsatisfactory work when it impacts the team. In the real world, I can easily see that if a member of a dental team in private practice is not working to successfully accomplish their duties, the owner may make the decision of letting go of an employee if it effects the team like it has in the situation that was described above.(3)

The owner did recieve a formal ethical training in school briefly for his degree in kinesiology, but the majority of his ethical education came from extra business professional development courses with business structuring. The owner uses judgement to ensure fair application fo the core principles of honesty, respect, equality, and well-being of others at all levels of their business system; For example at an individual, organzational and societal level. For his business, he created a a code of conduct and ethics policy for the business is also a document created to ensure a framework. The development policy handbook allows everybody to understand the guidelines. The business does not operate by any ethical theories, just by ethical principles and guidelines document that we developed. Nielsen R (1989) also support that it is not always applicable to follow ethical theories and that ethical reasoning "as an action as opposed to a knowing strategy is not always effective in guilding ethical, stopping or turning around unethical organizational behavior."(4)

The development of this document was from gathering several resources from multi-disciplinary practices and from personal experience, as well as from regulatory associations.This is similar to the UBC Dental Clinic Operations Manual that encompasses professional conduct and regulation, clinic operations, and quality assurance and can be thought of as analagous because UBC Dental Clinic also practices in a multi-disciplinary fashion and in order to develop the manual, they had to draw code of ethics standards from the various professional regulatory bodies.(5)

The owner's perspective of an ethical dilemma is a situation in which a decision to act upon one’s moral beliefs or standards results in a compromise or less than desired outcome, in comparison to a decision that would be made without the dilemma being present. The point at which a decision would be made to contact the regulatory body would be a situation where there is a potential threat to the safety or well being of our staff and/or patients that if addressed would result in a breach of confidentially. I see an ethical dilemma in the same way as the owner, in that an ethical dilemma is any situation where you are faced with making a decision that will lead to not satisfying all the parties involved and making those decisions based on the guidelines and code of ethics manual as created by the College of Dental Hygienists of British Columbia (CDHBC).(6) The point at when a dental hygienist may require contacting their regulatory body would also be when there is any potential threat to the safety or well being of a client or fellow colleague. Specifically, reporting negligence or malpractice of a dentist or certified dental assistant to the College of Dental Surgeons of BC, and for another dental hygienist to the CDHBC.(6)

References: 1. https://secure.dentistry.ubc.ca/intranet/feeschedule/preventive.asp 2. http://www.cdha.ca/AM/Template.cfm?Section=Policy_and_Action&Template=/CM/ContentDisplay.cfm&ContentID=4945 3. Neish N, MacDonald L. CDHA Code of Ethics Workshop: Application to Day-to-Day Work. Probe 2003; 37(1):27-33 4. Nielsen RP. Negotiating as an ethics action (praxis). Journal of Business Ethics 1989;8:383-390. 5. https://secure.dentistry.ubc.ca/intranet/operations_manual/default.asp 6. http://www.cdhbc.org/resources/handbook.aspx

Rosie Gao's Summary

As health care professionals, we can be faced with ethical dilemma's any time, any where and with anything. Ethical behavior is a prerequisite for a society to function in an orderly way.(1) Therefore, it may be the glue that binds the health care world together. It is tempting to set ethical values into laws and regulations, but that would be unethical in itself.(1) We all come with our own set of morals and values, thus it is impossible to enforce one set of ethical values in society. As dental hygienists practicing in British Columbia, we are not only health care professionals but also often employees of an organization. Employees face an array of moral issues in their everyday decision-making.(2) In my interview with a pharmacist who graduated from UBC, she was faced with ethical dilemma at her workplace. This is similar to what dental hygienists may go through , sometimes the interest and regulations of being an employee at a dental office may contrast against the dental hygienist's own morals and values as an individual.

The pharmacist I interviewed was faced with the dilemma of a man who wanted a mental illness medication without prescription. He stated that he would be in withdrawal and suffer if he did not receive the prescription. As a pharmacist working under BC, one may not distribute drugs without a prescription. In this situation, the interest of the man conflicts with the interest of the pharmacist. This is very similar to our dental hygiene profession where the dental hygienist’s own personal interests, is often in conflict with her/his professional obligation.(3) For example, an elder patient who is immunocompromised may want to receive a concentration of local anesthetics that may go past the therapeutic level and into the toxic level. He or she may want that because they are afraid of sensing any pain.

As a dental hygienist, one may be responsibility to work in the interest of the client. According to the IFDH, the dental hygienist provides services consistent with the patient’s needs and requests.(4) However, this also goes against the ethics of beneficence where dental hygienists must demonstrate caring about and acting to promote the good of another.(3) In both cases, the elder man requested for the prescription and the elder woman requested to receive local anesthetics, but according to the Canadian Dental Hygienist's Code of Ethics, beneficence would be violated.(3) For the pharmacist, she was not certain of the mental condition of the man and thus administrating drugs without the approval of a physician may potentially harm the client. Similarly, the dental hygienist can only administer the optimal dose of local anesthetics. If more than optimal dosage is administered, the client may potentially have undesirable effects. Thus, both health professionals have chosen to not administer the prescription and increased local anesthetics because they deem that the action can be justified by beneficence, or well-being for the clients.

The solution to both health professionals include communication but the underlying foundation is negotiation. This can be exemplified by the "negotiating as an ethics action (Praxis) strategy".(5) By finding alternatives to the solution, potential unethical behaviors can be avoided. The two health care professionals should either explain to the clients of his or her values behind not administering the drug and also provide insights into how their action benefits the clients. For example, the dental hygienist can reassure the client that if the injection were to be done correctly, one does not need an excess amount of local anesthetics. The pharmacist can also offer alternatives by perhaps contacting the client's physician directly to see if the prescription can be refilled or possibly sending the client to a nearby walk in clinic. In many dental hygiene situations, a win win situation may not be established for both parties.(5) However, the attempt at negotiation by compromising and giving alternatives can appease the client and make them feel more respected.

As a health care professional, when an ethical dilemma arise from the collision of two interests, it is equally important to address the two conflicting interests to the client. This demonstrates integrity, which includes moral soundness, uprightness, sincerity and honesty.(4) To simply say no to the elder man and the elder woman's requests would be disrespectful and insincere. In the case of the pharmacist, a great way to show respect and insincerity would be to explain about the laws of the province and stress that administering medication without the consent of a physician may be detrimental to one's health. In the case of the dental hygienist, he or she can also explain that the decision of the dental hygienist is solely based on the beneficence of the client. With proper communication and respect, although the clients may still not have their requests granted, they would feel respected and appreciate the honesty of the health care professional.(4) Thus, explaining and communication may sometimes be the best way to resolve an ethical dilemma.

The pharmacist and the dental hygienist way of thinking and solving the ethical dilemma can be explained by the Throughput Modeling, which deals with "accounting information processed through various pathways by decision makers." (1) Both health care professionals followed the utilitarian position from the Throughput Modeling. In this position, one gathers information, some information may be from the rules of a profession.(1) Judgment about the situation is then made, which can be influenced by time, uncertain information and unstable environment as well as the rules of a profession. Finally a decision is made so that it yields the greatest good for the greatest amount of individuals.(1) In both the pharmacist and the dental hygienist case, the dental hygienist and pharmacist benefited in that they were practicing to the rules of their professions. The clients also benefited implicitly in that potential risks of receiving the drug (local anesthetics and mental illness drug) are avoided.

1. Rodgers W, Gago S. Cultural and Ethical Effects on Managerial Decisions: Examined in a Throughput Model. J of Business Ethics. Jun 2001 Part 2; 3(4):355-367. 2. Fang ML. Evaluating ethical decision-making of individual employees in organizations—an integrative framework. Journal of American Academy of Business 2006;8(2):105-112. 3. CDHA. CDHA code of ethics. Ottawa, ON:2002.http://www.cdha.ca/AM/Template.cfm?Section=Policy_and_Action&Template=/CM/ContentDisplay.cfm&ContentID=4945 4. IFDH. IFDH code of ethics. Victoria, Australia:2003. http://www.ifdh.org/dt/ifdh_ethics_code.pdf 5. Nielsen RP. Negotiating as an ethics action (praxis). Journal of Business Ethics. 1989;8:383-390.

Jenny Jamen's SUMMARY-

In my interview with an occupational therapist in regards to ethics, there were many parallels that can be identified in comparison to our future profession as dental hygienist’s and the subject of ethics.

Just as our profession has a regulatory body that protects the dental hygiene profession as well as the public, so does the profession of occupational therapy. The College of Occupational Therapists of B.C. (COTBC) has a mandate to ensure safe, ethical and competent practice of occupational therapy. (1) Similar to this mandate is that of the CDHBC, which ensures that dental hygiene practice is carried on in the best interest of the public. Both aim to protect public well being through ethical practice. (2)

In both these regulatory bodies, the code of ethics are guidelines that serve to assist the health professional in maintaining and continuing to develop professional traits, ethical decision making strategies and attributes which enhance these traits. In both these mandates the attributes are similar, specifically in regards to honesty and integrity, caring and compassion and reliability and responsibility. (1, 2) Of course, individual assertive and intuitive judgment must be exercised as neither the code of ethics of the CDHBC or the COTBC provide answers for hypothetical ethical dilemmas. Personal values, morale, and common senses should not be undermined when health professionals are faced with ethical dilemmas. This ensures the solid foundation for which we can base the code of ethics or regulations of just about any profession. As Guy argues in his literature review, ethical decision making in the workplace involves individual morality and work related judgment. (3)

The occupational therapist I interviewed described an ethical dilemma she was faced with where a physically disabled kid she was working with had suspected dysphagia. She was 2 yrs old. She had been living on Formula paid for by health care (MSP). Her mother did not have money and was a single mom. In order to keep getting formula paid for she needed to keep the dysphagia diagnosis. A swallowing assessment showed the 2 year old had improved and could now swallow with some difficulties. Her mother insisted that the 2 year old needed formula and that she had more trouble at home. It was evident that she needed support to feed her daughter. In the end they decided the dysphagia diagnosis should stay because there was still some difficulty swallowing.

In the ethical dilemma Casey was faced, she had to agree with the mother even though clinical assessment did not completely support a case for full support of baby formula. Casey had to use her better judgment and take into account the difficulty that this child was faced, although greatly improved, as well as the information provided by her mother, even though she believed the story to have been exaggerated because of financial concerns. In this case it was in the best interest of both the daughter and mother that Casey keep the dysphagia diagnoses to help the family survive. This decision was based on Caeys’s personal morale as well as her responsibility to protect her client under the code of ethics.

In our profession this dilemma would not have likely occurred due to the differences in our health care responsibilities. Regardless, the driving force to professionally handle and overcome these obstacles remains similar in a dilemma faced by an occupational therapist, a dental hygienist or any professional for that matter. In any case, I agree with Casey in that I would only consider going to a regulatory body if the situation could not be safely dealt with on my own or even after I had addressed the issue with my boss/supervisor, or if a severe compromise to my integrity and the well being of my client or other person(s) involved was put to test.

In our field as health care professionals the driving forces to effectively handle ethical dilemmas are based on some fundamental principles that I believe most professionals base their ethical decision making upon. These include, integrity, responsibility and intuitive personal judgment, the mandate of ethical principles, which guide one’s own profession, and the best interest of the public resulting in a potentially safe and ethically sound environment.

References 1.COTCH. Code of ethics. BC: Author, 2006

2.CDHBC. Code of ethics. Victoria, BC: Author, 2004

3.Fang ML. Evaluating ethical decision-making of individual employees in organizations-an integration framework. Mar 2006; 8(2): 105-112.