What is important is to be clear about what specifically matters to the group and to justify its place relative to other value statements.
Our understanding of what is important in a day-to-day kind of way often aligns with broader value themes. This section is a place to see what kinds of value themes are typically understood as important in society (especially in a modern, Western social context).
Reviewing these value themes can help to remind us of other considerations that are important that we haven’t thought of, and to sharpen our own sense of what is important in a given situation and why it is important.
The extent to which a solution meets the expectations of a given individual or group. Use of this value requires being clear on acceptability to whom – whose standards or expectations are of concern? This value also doesn’t necessarily align with ethical justification – a solution may be acceptable to an individual or group, but may still not live up to important values of others or broadly accepted social norms.
Answerability of an individual or group to another individual or group for the kind and quality of decisions made or actions taken. Accountability can be to a supervisor or sponsor organization (e.g. to a professional association as part of one’s professional mandate). It can also be to an individual or group to whom one has a fiduciary responsibility (e.g. as a group’s representative at a meeting or to a community of people one accepts a duty to serve.)
The ability to present the amount of a resource (usually money) required to obtain a good or service. Often affordability implies the ability to pay for something without going into debt. However, the comfort or discomfort of going into some sort of debt to be able to pay for something itself depends on other values and is not inherent in the idea of affordability.
A commitment to identify, prioritize, and serve those who are marginalized and/or less able to meet important needs on their own. The idea is that those in need have a greater claim on resources (time, attention, capital, human resource hours, care and concern) than those relatively more well-off.
Two or more parties working together with the aim of understanding their own and each other’s needs and building common responses to common problems in a manner that meets the needs of all parties without sacrifice.
The commitment to understand and make decisions in line with such guides as institutional policy. There are many moral guides in the healthcare setting, including various professional codes of ethics, various legislation, organizational values and organizational policies. These guides offer direction for what various institutions and organizations believe are the appropriate values that should guide conduct. While these guides are a very important resource when doing an ethics analysis, they do not always offer consistent direction and are not always sensitive to the contextual features of actual situations. It is important to remember that the main justification for following a policy (or a law) is that the policy itself is based on justified values. If following a policy leads to action that goes against key values, then following it would not be justified.
Two or more parties seeking a response to a problem where each has to sacrifice something of importance in order to allow the other(s) to be able to live with the solution.
Two or more parties coming to agreement about the best response to an issue or problem. Different from shared understanding (where everyone achieves the same perception of the issues, but may disagree on solutions) and agreement to proceed (where everyone in a group agrees to move forward in a certain direction, but may not agree that the solution chosen is in fact the best or most appropriate).
The understanding that humanity is somehow connected and the well-being of a community is distinct, separate from, and more than the well-being of each individual constituent.
Can be understood as empathy plus action. It involves using one’s mind to understand what another thinks is true about the world and important in life, and using one’s heart to feel what it must be like to experience the world as the other might. And then, if the other is suffering, it involves doing something to assist with that suffering.
Ensuring that an appropriate forum is available for a sufficient period of time to raise questions or concerns about the facts in a case, what should matter most in the situation, or whether a given planned or pursued direction really aligns with what is most important.
A contested notion, the central idea of which is that decisions that determine the terms of a collective’s association are legitimate to the extent that those affected by the decisions are able to influence them, either directly or through some mediated mechanism.
The responsibility of society (or agents of society, such as a health authority) to respond to the needs and personal circumstances of healthcare providers who put themselves in harm’s way in times of crisis – commensurate with the degree and conditions of the harm.
Responsibility of healthcare providers to provide care to members of the community, even when this involves exposure to some risk of harm on the part of the health care provider.
The extent to which an intervention meets the objectives it is designed to achieve. This requires having a clear and shared understanding of the objectives for a given intervention strategy. In many cases, true objectives can be hard to measure and sometimes this leads to focusing on objectives that are easily measured. This could be a serious mistake where the measurable elbows out the important.
Achieving a desired objective using the fewest possible resources – thereby with the least waste of resource. Efficiency is never an end in itself, and always a means to achieve some greater value.
Understanding the world from another’s point of view. A necessary correlate of having unconditional positive regard for others because making an effort to understand and appreciate another’s views involves (and some might argue is what leads to) accepting that she is an individual who, like all of us, has developed her views based on particular circumstances that she has experienced.
The idea that when distributing a resource everyone should have the same access to the resource according to their need (as opposed to other criteria such as proximity to the resource, ability to pay, political authority, social status.)
The idea that the goal of resource distribution should be to enable all members of society to have an equal chance at receiving necessary resources. The focus is on the equal disbursement of the chance at receiving the resource – not the actual equal distribution of the resource or the equal achievement of the goals the resource is meant to provide. Note that this may not lead to equal outcomes.
The idea that the goal of distributing a resource should be to ensure that everyone achieves the same objective the resource is aimed at – to the same extent. In health care this would mean distributing resources in such a way as to ensure everyone achieves the same status of health and well-being. Note that this can require the unequal distribution of resources.
The idea that a resource should be distributed based on need as opposed to other criteria such as ability to pay, social status, etc. Equity can mean equal distribution if everyone has the same need or unequal distribution if the needs of some are greater than the needs of others. How need is defined and measured will depend on the objectives the resource is meant to achieve.
Performing an action or delivering a service to the highest standard – or maximally achieving the objectives of a strategy. This includes how the action is done and the outcome it achieves. In health care it requires constantly improving quality of service to better meeting patients’ needs. It implies growth and capacity building of human resources which requires ongoing learning, research and training.
This refers to the special relationship that certain individuals, usually professionals, have to those who are vulnerable and who put their trust in the professional to assist them in some manner. In health care, patients are much less powerful than healthcare professionals: They are usually ill, whereas caregivers are not; they are usually not in surroundings they are comfortable in, whereas health care professionals are; and most of all, they lack the expert knowledge and resources required to meet their healthcare goals – which health care professionals have. Patients must put themselves in the hands of their health care providers and trust that the care providers will help them to achieve the patient’s goals. This puts health care professionals in a conflict of interest where the conflict lies between meeting their personal interests and the needs of their patients. Fidelity to trust is about maintaining the trust patients put in their care providers to advance patient interests ahead of their own.
Giving without expecting anything in return. Giving may be of time, energy, money, or other valuable resource.
Ensuring that decisions for an organization are made through justified processes and substantively represents the values of the appropriate group over time. In the context of a public health care system, this includes ensuring that decisions are based on the best information available and on values that the public body being represented sees as appropriate. This implies a transparency of decision-making and accountability to the law, to political leaders, and to the public broadly.
Telling the truth to a party. Providing full access to relevant and wanted information. Honesty relates to the value of respect for human dignity. If part of what gives human beings dignity is the ability to make sense of reality and make decisions accordingly, withholding information or providing information that is not true deprives the receiving party of exercising the very ability that is the source of their dignity.
Commitment to ensuring that room is created for all relevant people and perspectives to be involved in a decision or action. It requires identifying and overcoming barriers to participation that would prevent such participation unjustifiably. Barriers can include language, power, financial resources, time, access to decision corridors, prejudice, and even style of discussion and debate.
The intentional and deliberate living of values in the decisions, actions and attitudes an individual, team or organization takes. This requires ensuring that all the decisions made and actions taken pay explicit attention to and are in keeping with the values of the party – recognizing that value trade-offs will be required from time to time. This value is about being clear on our talk and then walking that talk on a regular basis. Integrity by itself does not say what one’s talk should be. It does call for the honest assessment of values and the consistency between values and behaviour. It thus requires skills of moral reasoning. Integrity is supported by being in community as it is through dialogue and experience that people really understand what should matter most in various situations. And being in community requires the additional values of honesty, respect and trust.
Being truthful about the extent and limits of an individual or group’s knowledge or expertise.
Involves ensuring that the way decisions are made in a given situation meets certain standards. These include:
• Transparency: people should know that decisions are being made and what these are; they should have access to the criteria being used to make decisions
• Inclusion: those affected should be able to influence these decisions and not be limited by unjustified barriers
• Deliberation: influence should come from participation in a respectful conversation where reasons are exchanged
• Education: the conversation should follow an opportunity to understand the issues in question.
• Recursiveness: past decisions should be open for ongoing critical reflection and feedback
• Reflexiveness: decisions should be based on reasons, not power, authority, or access to resources
Those who are in similar circumstances should be treated similarly, unless there is good reason to treat them differently. Only morally relevant differences justify different treatment. In some moral traditions, justice also includes a special duty to those who are most vulnerable in society – those without resources necessary for living healthy, peaceful lives.
Treating people gently and well.
Commitment to provide care for the patient and their supports. This value is of particular concern to patients in the end-of-life context. It requires that whatever decisions are made and steps are taken in the care and treatment plan, they involve assurance and demonstration to the patient and family that even though aggressive treatments may not pursued, care for and attention to the patient will always be provided.
Patient benefit is about advancing the well-being of the patient – it is about working to meet the patient’s goals of care. One challenge with this value is that in the culture of western medicine, well-being has traditionally focused on the physiological functioning of the body. But as society becomes increasingly diverse, there is growing understanding that the psychological, emotional, spiritual, and relational needs of patients should also inform discussions of patient benefit. The related challenge with this value is that well-being involves a subjective assessment – so the question arises, well-being from whose perspective? This leads in to the value of respect for patient dignity and autonomy.
A philosophy of practice that sees the patient’s needs and perspective at the heart of the healthcare encounter. It includes a commitment to designing systems and processes to meet the needs of patients first and before the needs of care providers and the system. For example, were a treatment delivery system (say kidney dialysis) to be patient-centered, it would be provided where it is most convenient and effective for patients – likely in the home and as unobtrusively as possible – instead of in a hospital or outpatient facility.
Describes an affirmative response or disposition to the fact of diversity. The response is committed to respecting difference while at the same time pursuing the possibility of shared responses to common problems. It sees difference as a strength and focuses on the search for values to guide decisions that the diverse group of people affected can agree with – a cosmopolitan ethic. It requires education about the nature and types of differences that exist within a group and then engagement where individuals and sub-groups can come together in respectful dialogue to explore the possibility of guiding values that are shared amongst the individuals and sub-groups.
Specifically, pluralism requires that:
1. We believe that diversity is good
2. We treat all people with respect: a. treating them with kindness b. listening to their perspectives to understand – without judgment c. then sharing our own perspectives
3. Individuals and communities living and working together seek common values-based solutions to common problems without compromising their deepest values a. we believe that understanding each other’s values and beliefs will enhance our understanding of the issues b. we believe that achieving such solutions will actually allow us to live with greater integrity
4. Subgroups should be able to maintain their own identities (meaningfully held values, beliefs, practices) within the laws of the broader community
5. We shouldn’t want to change each other; we should try to build common foundations on which to move forward
Having and using the technical expertise, including knowledge and skill base, to carry out professional roles at accepted standards of practice, based in the context of the values of the patient, the institution and the organization. In the context of the team approach to health care delivery, part of competent care is ensuring the team has a shared understanding of the goals of care for a patient, room is provided for team members to identify ethical issues with aspects of the care plan, and if necessary, to ask to be removed from a care plan they feel morally problematic (assuming other healthcare providers can be found to provide the necessary care).
Related to excellence, this is a commitment to meeting the objectives of an intervention to increasingly higher standards over time. It starts with a commitment not to create new harms to patients – going against the objectives of the intervention. It requires identification and careful study of practice standards to develop better and better means of protecting against possible harms and improving service standards. Note that patient safety is often narrowly construed as risk to physical well-being, but should extend to holistic well-being, including psychological, emotional, and spiritual dimensions.
Recognizing the interconnectedness of all those who serve and are served by healthcare institutions, – this is a commitment to nurturing the relationships through which care is planned, delivered, and received. It acknowledges that without interrelationships care planners and providers would not have work and/or would be deprived of the opportunity to serve their calling, and care recipients would not receive the care they need to flourish in times of challenges to their well-being. It is about taking proactive organization-level action to strengthen the relationships of all the people in the health care community.
This value recognizes that no matter one’s perspective, religious or cultural background, or socio- economic status, one’s life is valuable and deserves to be treated with compassion and care. It calls for special attention to vulnerable members of the community who are easily marginalized and whose humanity is easily forgotten. It calls for three levels of response. First it requires treating others with kindness and care. Second, it requires empathy – actively listening to others with a view to understanding their minds and hearts without judgement. And third, it calls for engaging others in respectful dialogue, sharing one’s own experience and perspective with a view to arriving at a broader perspective on the world.
Recognizing an individual’s basic rights to freedom of speech, movement, association, etc., this value calls for free individual choice to govern matters from relationships to resource allocation. It argues against centralized intervention by external parties beyond the enforcement of contracts. On this view, individuals should be free to make agreements to exchange goods and services based on their means and preferences. Any forced participation is unjustified and individuals should not be required to enter agreements not of their choosing.
Perhaps the most basic principle in health care ethics today, this value calls for respecting the genuinely held values and beliefs of patients and having decisions about the care of the patient be guided by these values and beliefs. The idea here is that in part what gives human beings dignity is their ability to think about and make sense of their lives and to make decisions for themselves based on this cognitive ability. The thinking continues that if someone was able to make meaning of their lives, there is no reason why this thinking should not survive their ability to actively participate in decision-making. Respecting this thinking is indeed one way to continue to honour and respect the dignity of what is now a particularly vulnerable human being. According to this principle, patient values and beliefs should guide decision-making about a patient’s care even if the resulting decision is inconsistent with what care providers or family members may have chosen. When a patient is not able to participate in decision-making about their care or treatment plan, an appropriate substitute decision-making process should be put in place.
Not interfering in the personal space of individuals or groups without their consent or just cause. This sees information about patients as part of their personal space and requires that this information not be shared without their consent.
Health care professionals are moral agents who have their own values and beliefs about what a meaningful life looks like and how to best to pursue it. These values and beliefs can include personal convictions as well as professional ones, such as those found in professional codes of ethics and standards of practice. Wherever possible care providers should not be forced to participate in care plans they find excessively morally compromising, at least when it is possible to involve other care providers who are more comfortable with the care plan.
This value calls for careful management and distribution of community resources. It is about taking good care of the resources, both human and material, that have been invested with the organization. It is not only about resource allocation, but also about careful and deliberate modeling and direction setting for how resources should be established and used to serve and advance the interests of the broader community. It involves using resources effectively to meet the intended goals with minimal waste, allocating resources in a manner that is fair to all those who need them and that is sensitive to broader questions of justice in society. Stewardship also requires ensuring the long-term sustainability of the resources and clearly accounting for the decisions made about the use of the resources, including the value judgments on which resource decisions are based.
According to this view, the lives of all presently existing and future human beings are equally morally valuable in that everyone’s happiness is equally morally important. Fair distribution strategies are ones that result in the best outcome for all. To allocate resources, we should look at all of the distribution patterns available to us, add up the good that results from each – where the consequences for each person are weighed and where every individual can get a maximum of one unit of good – subtract the harm that results from each, and then select the option that results in the most net good. The goal is to look for the strategy whose consequences allow for the greatest overall good for the greatest number. Note that it is often difficult to know in advance what the consequences of a given pattern of distribution will be, it is difficult to weigh the relative good and relative harm that results from saving the life of one person while allowing another to die, that good and harm are themselves value-laden notions such that it is difficult to make objective calculations as this approach requires, and finally that this approach is counter-intuitive in some respects – for example, if two patterns of distribution result in equal outcomes then there is no moral difference between the two on this approach, even if the most vulnerable in one arrangement are treated poorly, while in another their lot is significantly improved.
Linked to the values of common good, relationships and community, this value recognizes the union of interests, goals and means of a group. Within a healthcare context it is a commitment to the health and well-being of all members of the community and to working together to achieve shared interests.
Nurturing the human spirit of all people, caregivers, care recipients, and families alike. This value is about attending to that subtle/intangible dimension of the human being, often called the soul, wherein is found peace and which is the seat of our creativity, compassion, love, inspiration and solace. It is where we experience our connection to other members of the community. Most would agree that having a meaningful life requires paying attention to one’s spirituality, however this is understood.
This value calls for supporting staff, physicians and leadership to help make the work experience an integral part of a meaningful life. It recognizes that health care providers have a tremendous stake in the experience of health care. Health care providers often spend more time with colleagues than families and derive much self-worth from their vocations. Conversely, because of the intimate nature of working in health care teams to serve vulnerable populations, they also have the potential to do much harm to colleagues and patients and to be harmed by professional experiences. Many are also reliant on employers for their livelihoods and are vulnerable as a result. This value indicates it is important for the needs of the care giving community to be attended to by the organization.
An important source of meaning in people’s lives is the relationships they have, especially with loved ones and family members. This value calls for special attention to supporting the relationships that a patient has as part of the broader experience of trying to advance their health and well-being. The value takes on particular significance in the end of life context where patients may experience greater fear which can be supported through relationships, and where there is recognition that relationships are coming to an end and where appropriate space, time and support is needed to make this closure as healthy and positive as possible.
Concerns the viability of a system over a long period of time. It calls for decisions that ensure the entity’s existence is not threatened and that it will be able to continue to meet its objectives into the future. It requires being clear about what the entity’s objectives are, and what might threaten its ability to meet these objectives. It also requires clarity within an organization about whether the desired sustainability is about a specific strategy, service, program, or the organization itself.
Exposing the process and rationale of decision-making to affected others for viewing and comment in a full, accurate and timely manner. It is a necessary part of demonstrating respect to affected others in the context of system-level decision-making. Poor transparency practices can lead to poor decisions, unfair suffering by those impacted, reinforcement of bad decision-making practices, poor understanding of the system, lack of trust for leadership, and missed opportunities for moral growth and reform for the community.
A commitment to create relationships where parties can be counted on to act consistently according to justified values. Central to any trusting relationship is honesty, open communication and transparency. To trust someone one needs to know that they will be treated with respect. They will not be lied to or deceived and that one will be forthcoming with important, relevant information in a manner that is respectful to the relationship.
A fundamental element of respect for human dignity, this value accepts that, whatever the differences of class or culture, education, or opinion, all people are basically equal as human beings, and deserving of recognition and respect. In practical terms it means separating people from the positions they take on issues. It calls for treating individuals with kindness and gentleness, honour and dignity whatever we may think of their views. The guiding idea is that whether or not I agree with your views, indeed even if I find them offensive or absurd, I will always treat you well. Put another way it calls for us to treat others with the same deference and kindness that is usually reserved for those who have more power in relationships than we do.