188. CCA Study Notes: The Four Principles of Health Care Ethics and Ethical Dilemmas

The Big Picture

Health care workers sometimes face choices where the right answer feels clear. Other situations involve two important concerns that point in different directions.

Health care ethics looks at what is morally right and wrong when providing health care services. Four basic principles help guide ethical thinking. Ethical dilemmas happen when moral choices conflict and choosing one goes against another.

Understanding these principles helps you think through difficult situations and behave ethically toward clients and co-workers.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

What Health Care Ethics Means

health care ethics is the philosophical ⓘ study of what is morally right and wrong when providing health care services.

Most codes of ethics draw from health care ethics principles. Codes of ethics give guidelines for ethical behaviour, but they do not provide answers or rules for every situation. The four principles help workers think through ethical decisions.

The four basic principles are:

Principle	Core Meaning
autonomy	Respecting the client’s right to make choices
justice	Being fair
beneficence	Doing or promoting good
nonmaleficence	Doing no harm

These principles sometimes support the same decision. At other times, one principle conflicts with another.

What an Ethical Dilemma Means

An ethical dilemma involves an apparent conflict between opposing moral choices. Choosing one option means going against another moral choice.

For example, respecting a client’s choice might support one action. Protecting the client from harm might support a different action. This conflict makes the decision more difficult.

A code of ethics gives guidance for ethical behaviour. It does not provide a rule for every situation.

Autonomy Means Freedom and Choice

autonomy, also called self-determination, means having freedom and choice in decisions that affect your life.

A mentally competent person has the right to make decisions about:

• lifestyle
• medical care
• services

Clients decide which treatment they want or do not want. Laws protect this right. Physicians, facilities, and agencies must ensure that clients give informed consent before a procedure takes place.

Respect Choices in Everyday Care

As a support worker, you must always respect your clients’ choices and preferences, including routine choices.

If a client wants personal blue sheets on the bed, respect that choice. If a client chooses a hairstyle that differs from your preference, follow the client’s choice rather than your own taste.

Key fact: Your personal preference does not replace the client’s preference.

Autonomy and Risk

Respecting autonomy gets harder when a client makes a choice that seems unsafe.

A client has the right to make choices and take risks. For example, an older client might refuse to use a cane despite knowing about the risk of falling.

After explaining why the client should use the cane, you must accept the client’s decision. Always consult your supervisor when you have concerns about the client’s safety.

Keep Personal Judgments Out of Care

Clients might have values, standards, beliefs, lifestyles, and preferences that differ from yours.

A worker might disagree with:

• a family’s decision to arrange long-term care for an older parent
• a client’s tattoos or body piercings
• a client’s decision not to seek treatment for cancer

Set aside your own biases ⓘ when caring for clients.

Avoid: Do not judge clients according to your own values or standards. Do not give clients advice or express disapproval about their choices, preferences, politics, religion, or lifestyle.

Justice Means Fair and Equal Treatment

justice means treating people fairly and equally.

Canada’s universal health care system uses justice as an ideal. Equal access to medical services regardless of ability to pay represents that ideal. In practice, some people pay for services that do not have the same availability for everyone, including private clinics, some medical tests and procedures, and elective procedures.

For support workers, justice also affects everyday care.

Give every client appropriate attention and care regardless of:

• the client’s condition
• the client’s temperament ⓘ
• how demanding the client seems
• whether the client’s lifestyle differs from yours

Spending less time with someone because you find the person difficult would treat that client unfairly.

Justice Also Includes Trust and Confidentiality

Clients trust support workers with their homes, belongings, privacy, conversations, and health information.

Treating clients justly includes:

• handling their possessions carefully
• respecting their privacy
• performing services competently and skillfully
• keeping conversations and health information confidential

Do not snoop through a client’s home. Do not pry into the client’s personal life. Do not gossip about clients with friends or co-workers, either in person or electronically.

Share client information only with your supervisor and the health care team. Never discuss a client where other people might overhear, such as dining rooms, lounges, locker rooms, or elevators.

Key fact: Confidentiality is a basic right, and laws protect it.

Beneficence Means Doing Good

beneficence means doing or promoting good.

Support work applies beneficence by promoting wellness, helping people in daily life, and supporting them through difficult times.

The client’s needs come first. Those needs take priority over the needs of the client’s family.

For example, in home care, a client’s son asks the support worker to skip an assigned bed bath so she can finish early because he expects a visitor. The support worker focuses on the client’s needs, reports the situation to her supervisor, and seeks guidance.

Beneficence and Professional Boundaries

Beneficence and professionalism connect closely. A professional supportive relationship focuses on the client’s needs, not the worker’s interests.

Do not ask a client to:

• buy something for your child’s fundraiser
• donate to a campaign you support
• help with your personal financial problems
• do something for your personal interests

Avoid burdening clients with your worries and problems.

Never ask for or accept money or loans from clients, regardless of how long you have worked with them.

Keep Client Relationships Professional

Clients sometimes become attached to support workers. A client with strained family relationships might begin treating the worker like a substitute family member.

Keep the relationship professional.

Do not:

• take advantage of strained family relationships
• take sides with a client against a family member
• flirt with or date a client or the client’s family member
• accept invitations from a client or the client’s family member
• become personally entangled in the client’s affairs

Being named as a beneficiary ⓘ in a client’s will might create legal problems for both the worker and employer.

Beneficence Through Advocacy and Good Work

Doing good sometimes involves advocating for a client.

If you observe that a client strongly prefers a bath over a shower, share that observation with the health care team. The team then has that information when addressing the client’s care plan.

Give your best effort at work. Unless unexpected problems or needs require your attention, finish your assigned tasks.

Follow instructions carefully and exactly. Show compassion and empathy.

Self-discipline matters, especially in home care. Do not spend work time watching television, talking on the phone, or taking extra breaks for your own interests.

Nonmaleficence Means Doing No Harm

nonmaleficence means doing no harm.

Harm might happen intentionally through abuse. Harm also happens unintentionally through accidental injury or negligence.

One major way to protect clients from harm involves respecting the limits of your training and knowledge.

Role limit: Perform only tasks you have received training to perform.

A client or family member might ask you to perform something outside your training. Good intentions do not make an unsafe task appropriate.

Do not take on work you have not received training to perform.

Do Not Give Medical Information Outside Your Role

Clients and family members might ask questions about:

• diagnoses
• medical plans
• surgical plans
• treatment plans

You must never reveal or discuss these details, whether or not someone asks you. Giving incorrect information can cause harm or distress, and discussing medical information is outside the support worker’s scope of practice.

Refer these questions to your supervisor.

Keep Your Knowledge and Skills Current

To provide safe and effective care, you must keep your skills and knowledge current.

Participate in education offered by your employer. Courses and workshops related to your work also support ongoing learning.

Support work changes over time. Training that applies today might become outdated later.

You must keep clients as safe as possible. Use infection control techniques, recognize common safety hazards, and know how to prevent accidents.

How the Four Principles Create Ethical Dilemmas

The four principles do not always point toward the same answer.

A choice might respect autonomy but increase the risk of harm. Another choice might protect the client from harm but go against the client’s wishes.

Several situations show how these conflicts arise.

Parenting Decisions and Child Safety

A parent directed a support worker to send a 2-year-old child to a room for at least 15 minutes after a tantrum or misbehaviour.

Different principles raise different questions:

• Autonomy: The mother has the right to make parenting decisions.
• Justice: Is leaving the child alone for that length of time fair?
• Beneficence: Does the discipline help the child, or do other actions offer benefit?
• Nonmaleficence: Does leaving the child alone risk harm?

Because the situation involves the child’s safety, discuss it with the supervisor.

A Resident Asks a Worker to Keep Alcohol Secret

A long-term care resident had a bottle of liquor in the room even though facility rules prohibited it. The resident asked the support worker not to tell anyone.

Keeping the secret would respect the resident’s wishes. Reporting the liquor protects against possible harm and follows the worker’s ethical and legal obligation to tell the supervisor.

The worker explains why the information requires reporting and refuses to make a promise that cannot be kept.

This approach follows nonmaleficence while avoiding a false promise to the resident.

A Client Chooses Sugary Food Against the Care Plan

A home care client’s care plan stated that the client was not allowed sugary foods because of uncontrolled diabetes. On the client’s birthday, the client asked the support worker to serve cake.

The worker did not serve the cake. The client still chose to eat it after someone else served it.

The worker respected autonomy by allowing the client to make the choice. The worker followed nonmaleficence by not serving the cake and by advising consultation with the case manager before the client ate it.

The worker later reported the incident to the supervisor and documented exactly what happened. Reporting also supported beneficence.

Privacy and Reporting Emotional Health

A resident told a support worker about a private family problem and asked the worker not to tell the nursing staff that she felt upset.

Keeping the family details private respected the resident’s privacy. The worker still had a responsibility to report observations about the resident’s emotional health.

The worker first explained this reporting responsibility to the resident. The worker then told the charge nurse that the resident felt upset about a private family matter.

This approach protected private family details while reporting the resident’s emotional state.

Client Choice Versus Risk of Harm

A client received all food and nutrients through a G-tube, a tube that went directly into her stomach through an opening in her abdomen. She also had severe swallowing problems. Food or fluids taken by mouth would enter the lungs and result in respiratory problems and pneumonia. The client had already experienced pneumonia twice that year.

The client felt thirsty and asked the support worker for a drink.

The worker cannot give the client anything to drink because doing so would violate nonmaleficence. The worker discusses the situation with the supervisor so they can look for a solution that respects autonomy and beneficence.

After discussion with the supervisor and the doctor, the support worker gives the client ice chips several times a day. Between the ice chips, the client is given mouthwashes to gargle and spit out and an oral spray to keep her oral membranes moist.

The solution addressed the client’s concern while respecting autonomy, beneficence, and nonmaleficence.

How to Work Through an Ethical Dilemma

When moral choices conflict, use the four principles to examine the situation.

1. Collect as much information about the situation as possible.
2. Consider all possible options for resolving the dilemma.
3. Examine each option using the four principles.

Ask these questions about every option:

• Does it respect the client’s wishes and preferences?
• Does it treat the client fairly?
• Does it give the client a short-term or long-term benefit?
• Does it cause harm or increase the risk of harm?
• What consequences might it have for the client, family, or other people?

The answers might conflict. One option might benefit the client while going against the client’s wishes. Another might respect the client’s preference while increasing the risk of harm.

Safety: If any option could harm the client, you must involve your supervisor in finding the solution. This protects the client from harm and helps avoid serious legal problems for you and your employer.