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If a favorable resolution cannot be formed, counselors have the choice to act in accordance with the law or regulation. Psychology researchers have suggested ethical models for professionals to use during times of dilemma within the military setting. The first model presented considers three overarching approaches to address ethical dilemmas; and the second model presented is a more specific stage model with which to approach dilemmas.

These models may serve to assist counselors as the counseling profession gains more experience in the VA system and eventually develops counselor-specific decision-making models. Approach model. Johnson and Wilson identified three approaches for psychologists to consider when navigating the ethical quandaries of the military mental health system. Although most professionals have deemed this approach the best option, it also leads to the most ambiguity. Under certain circumstances, the counselor also must take into account what is in the best interest for society as a whole, while also navigating a responsibility to the client and the military mental health system.

Researchers in psychology responded to the ambiguity of this model by developing a more specific stage model to assist professionals with ethical dilemmas. Stage model.

Ethics matters in health

Barnett and Johnson proposed a stage model to follow when navigating an ethical dilemma. They advise that professionals must do the following:. Barnett and Johnson also noted that once a decision is made, the process does not end. It is best practice to monitor the implications and, if necessary, modify the plan. Documentation throughout this entire process is necessary for the protection of the counselor, the client and other involved stakeholders.

Counselors working in the military mental health system may find this stage model helpful when navigating ethical dilemmas. To better understand the implementation of the two presented ethical decision-making models, a case study was developed. The case is then conceptualized from both the approach model and stage model, and the ethical dilemmas associated with the case are discussed.

Megan is a licensed professional counselor employed at a clinic that serves military service members. She provides individual outpatient counseling to veterans and family members, as well as facilitates veteran support groups. Robert is married with two children.

Recently, Robert described a weekend of heavy drinking at the local bar. Although Robert drove after leaving the bar both nights, Megan suspected that he was not sober enough to drive. During his most recent session, Robert was visibly distressed as he disclosed to Megan that he received orders for a deployment in 3 months. Robert is anxious about informing his wife and children of the pending 6-month deployment, as he knows it will only increase conflict at home.

Robert reported that his family could use the increase in pay associated with family separation and tax-free wages during deployment. While leaving the session, he mentioned with a laugh that he would rather go to the bar than go home. Analysis from approach model. And although Robert has not been caught drinking and driving or charged with a crime, his behavior also puts him at risk of military conduct violations. However, when Robert originally came to the clinic, he did so of his own accord, not under orders, which could mean that notifying a commanding officer is an ethical violation.

Analysis from stage model. In stage 2, Megan considers who may be affected in this situation. Megan also notes that the family is already negatively impacted by his recent drinking binge e. Robert has a right to confidentiality B. Megan considers the importance of his support network A. In stage 4, Megan considers the pertinent laws and regulations of the dilemma. Megan also is aware that Robert has not committed a documented crime of driving under the influence. In stage 5 of the stage ethical decision-making model, Megan must reflect on her personal thoughts and competencies.

Megan feels less confident in her ability to accurately assess for substance use problems. She facilitates the PTSD support group for the clinic, which is her specialty area. Megan recognizes that she is fond of Robert as a client and is disappointed that he could be jeopardizing his family and career with his alcohol abuse. She considers whether she is overreacting to his binge-drinking incident because of her higher expectations of him.

In stage 6, Megan consults with her colleague who leads the substance use support groups at the clinic. In stage 7, Megan develops her course of action to refer Robert to the substance use group. Then, in stage 8, she evaluates the plan for potential impact on parties involved. Megan conceptualizes that Robert may be at risk for losing his deployment orders if he is accessing substance use treatment. Megan believes she has reduced this potential impact by referring to the substance support group, rather than an inpatient treatment facility, which may be more appropriate for a dependence issue.

Ethics in a regulatory framework

Megan recognizes that attending a minute group each week will take Robert away from his family, but she also realizes that the minute commitment is less than his current time spent away from the family when binge drinking. Megan reflects upon how her therapeutic relationship with Robert may be strained at the time of referral, and is prepared for a potential negative response from her client. She trusts in their therapeutic relationship and moves forward. In stage 9, Megan presents her planned course of action to her supervisor at the clinic. The supervisor approves the referral for the support group, but also suggests that Megan consider a referral to couples counseling for Robert and his wife, which may assist with resolving conflicts before the deployment.

In the final stage, Megan proposes the treatment plan of action to Robert in their next session. Megan explains that she feels ethically obligated to refer Robert to the substance use support group, and that as of now, Robert may make this choice for himself. Megan and Robert discuss the potential that substance use treatment may no longer be a choice in the future if his current drinking behavior continues.

There is more discussion of fitness for duty and how participation in the support group will positively reflect upon the assessment in the future. Megan also presents Robert with the recommendation of couples counseling to help mediate relationship conflicts before deployment.

She reports that if Robert and his wife decide to receive couples counseling, she can provide a referral for them at that time. With the ethical decision-making models presented, the counselor is able to successfully navigate the military mental health system, while still maintaining the professional standards of the counseling profession.

Psychologists developed the two ethical models presented, and counselors may choose to utilize these approaches until more counselor-specific ethical processes are created. As counselors become more permanent fixtures in the VA mental health system and as TRICARE providers, opportunities to develop an ethical decision-making model will likely arise. The recent inclusion of counselors as mental health professionals within the VA system and as TRICARE providers allows for new employment opportunities with the military population.

However, these new opportunities are not without potential dilemmas. Counselors interested in working with service members need to be educated on the potential conflict between counselor professional ethical guidelines and military protocols. Future research in the counseling field may develop a counselor-specific ethical decision-making model.

In the meantime, counselors may utilize or adapt the ethical decision-making models created by other mental health professionals, who have a longer history working with the military population. American Counseling Association. ACA code of ethics. Barnett, J. The ethics desk reference for psychologists.

Barstow, S. Counseling Today, 54 8 , Retrieved from. Garvey Wilson, A. Social Psychiatry and Psychiatric Epidemiology , 44 , — Hall, L. The importance of understanding military culture. Social Work in Health Care , 50 , 4 — Hoge, C. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. The Journal of the American Medical Association , 9 , — Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care.

The creation of CPGs is driven by the need to achieve several objectives 45, :. It is recommended that all CPG address some basic ethical considerations prior to their scientific or technical development. The CPG are recommendations on the correct way to proceed, based on the best available current evidence; thus, their value in healthcare should be specified 45,56 :. The Physician and Professional Practice. The dilemma of physicians in view of the purpose of medicine.

The true purposes of medicine are :. According to the above, it can be stated that currently physicians have multiple social functions 12,45, :. All this can lead to a certain crisis regarding professional identity, the development of tension within the healthcare setting, professional burnout, and becoming demoralized. Lex artis. Risks and dangers. At all times, medicine has an obligation to define the general scientific criteria for action or "good practice," known as lex artis.

This involves an assessment criterion to determine the suitability of a given medical action or professional conduct. Malpractice or poor practice is understood as not conforming to lex artis. Accusations against physicians due to presumed mistakes, carelessness, or negligence have recently increased in Spain. Medical practice involves applying certain procedures and interventions of varying risk, which sometimes have unsatisfactory outcomes for the patient, or do not lead to cure.

This can be seen as a failure or even an error due to the creation of false or unrealistic expectations. Ethical Framework of Professional Practice. A core issue. Ethical responsibility involves respecting the ethical principles that govern the exercise of our medical profession.


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Legal responsibility will be fulfilled by following the given demands regarding diligence and abiding by civil, penal, and administrative law. Bioethical principles. Since the 4th century C. This relates to the physician's competence and is defined by lex artis and criteria for indication, non-indication, and contraindication.. This relates to the capacity to make decisions and deal with factors related to our own life and death.. The term "distributive justice" is used when referring to healthcare resources..

There is a certain hierarchy within these four principles and none is absolute. This means that there is room for exceptions in all of them, but these exceptions must always be chosen as the lesser evil, and should never become the norm. The burden of proof, or the obligation to rationally justify such a decision, lies with the person proposing the exception. Recently, an attempt to define universal "statutes of the medical profession" has been made, based on three fundamental principles 85 :. Conscientious objection. Conscientious objection refers to that which the professional considers immoral and which the law does not prohibit due to not being defined as harmful or unjust.

When physicians have a definite conscientious objection this does not mean their obligations cease, 8,9,14 as they still have the obligation to provide caring medical assistance to the patients affected by the problem, both before and after declaring their objection, and must always provide this in vital emergencies. Similarly, there should be no double standards whereby objections are raised in the public arena but not in the private one, due to profit motives, privileges, or any other unjustifiable circumstance..

Legal Framework for Professional Practice. Assessing medical liability. The law states that a medical intervention is correct if it is medically indicated, has been done in line with lex artis, and was done with the consent of the patient. In Spain, the physician's liability currently falls within three procedural areas: contentious-administrative public healthcare , civil private healthcare , and criminal private and public healthcare procedures. Several elements have to come together to be able to claim medical liability via criminal or civil procedures:.

The burden of proof normally rests with the claimant. A working team should not only share knowledge and skills but also attitudes; their relationships should be governed by criteria of hierarchy and coordination. In order to delimit responsibilities within the team, two principles have been put forward 93 : trust, since a person who acts correctly should trust that the other will also do so; and division of tasks, which results from specialization and scientific progress..

The relationships between physicians and nurses have two dimensions: vertical, involving supraordinate, and subordinate relationships; and horizontal, involving the essential skills exclusive to nursing.. The Physician and the Clinical Relationship. Information and Consent are Ethical and Legal Issues. The clinical relationship between health professionals and patients or users has changed due to the legal recognition of the moral autonomy of people to make decisions regarding their own life, health, and body.

Every patient should always know who is the physician responsible for giving suitable information and coordinating clinical decisions. The obligation to inform the patient and obtain their consent constitutes an ethical and legal obligation on the part of the physician. Although there are limits to the obligation to provide information, there will always be exceptions that have to be justified.

Informed Consent is a Verbal Process. Printed Forms. The process of informed consent should not be reduced to a signature on the printed form; rather, this should serve to support previous dialogue. In any case, the information provided should be suitable, truthful, intelligible, understandable, and adapted to the needs and demands of each patient. The physician always has the obligation to describe the risks typical to each procedure and any specific personal risks.

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The SEC has defined the risks typical to different medical activities in this specialty, identified the procedures that need written informed consent and the requirements of such forms. Confidentiality, Privacy, and Protection of Health Data. Confidentiality is a fundamental right of the patient which has its counterpart in the following: the obligation of the physician to respect the privacy of the patient in the healthcare relationship. The obligation regarding confidentiality can be broken to prevent harm to the patient or third parties, or due to legal requirements, but whenever the physician has to do this the patient affected must be informed.

The Value of the Medical Record. The medical record is a set of documents with ethical and legal value. Health centers should guarantee the protection of health data of all the patients and users included in their records. Access to medical records is restricted to the healthcare personnel with direct responsibility for treating and caring for the patient; any other personnel are only allowed to verify certain administrative data.

The use of computerized health data for statistical or epidemiological analysis, or inspection will be done under due legal guarantees and always anonymously. In cases of legal action against health professionals, the judge can obtain the medical record as expert evidence, while under the obligation to specify the purpose for requiring this. Biomedical Research on Human Beings. Scientific and technical advances in biomedicine should be at the service of patients and contribute to their health, development, and well-being.

Scientific evidence differentiates validated practices from empirical practices.

Code of Ethics - Australasian Menopause Society

The validation procedure consists in clinical research which should be logically justified even before being ethically justified. Every clinical research ethics committee should analyze the methodological, ethical, and legal aspects of clinical trials in human beings, in line with the principles of bioethics 18,37,70,77, :. Conflict-Resolution Scenarios. The Physician As Expert Witness. The first body to address ethical problems in healthcare institutions are the healthcare ethics committees, which are advisory and multidisciplinary.

The SEC, within its field, will support collaboration between expert witnesses in cardiology and forensic scientists regarding managing risk, evaluating medical errors and assessing physical harm. The SEC notes that the roles of expert witness and medical practitioner are incompatible regarding the same patient and encourages the cultivation of certain attitudes when making an expert witness report: objectivity, impartiality, rigor, truth, restraint, balanced critical judgment, independence, and not going beyond competence, or capability.

Distributive Justice in Healthcare. Efficiency and Equity. The debate on efficiency needs to address some core issues: the rational and sensible use of drugs, tools, and healthcare technology; the appropriate, inappropriate, or questionable use of diagnostic tests and therapies; the most suitable approach to statements of incapacity to work sick notes regarding duration, harm assessment, vital risk and associated comorbidity; or the waiting-list problem.. The SEC supports decisions that encourage equity, given that healthcare resources are finite.

However, this involves: demonstrating the effectiveness of every action, considering the opportunity cost of diagnostic and therapeutic choices, affirming that the patient's utilities are the most relevant, emphasizing that "optimal is not maximal" or that "more is not always better," and assessing the different categories of care, since not all are equally effective. Medical prescription. The industry's promotional methods. There is a medical obligation to prescribe both rationally and efficiently.

This involves: weighing up its validity, therapeutic usefulness and efficacy, meeting safety criteria, selecting the best option bearing in mind the patient's clinical condition and preferences, obtaining the necessary consent from the patient, and taking into account the economic aspects of the decision, which are sometimes influenced by incentives deriving from external companies or healthcare administrations.

Promoting Legal and Ethical Awareness: A Primer for Health Professionals and Patients / Edition 1

The SEC will avoid endorsing promotional campaigns with obvious commercial interests, and will inform the public when messages, or recommendations are disseminated without sufficient scientific evidence, especially if this can generate disproportionate, unjustifiable, or unreal expectations in patients or users, and create distrust towards physicians for not offering them these hypothetical advances. A framework for agreement: self-criticism, transparency and agreement.

The physician has the obligation not to accept any type of gift that decreases, or appears to decrease, the objectivity and impartiality of clinical judgment. All the agents involved need to be brought together and provide the ethical motivation needed to reach an agreement which includes various commitments 20,21,26,, :. These can provide the members of the SEC with useful pointers concerning their activities in daily practice: some concern actual legal obligations with important ethical implications; others relate to moral obligations that must be fulfilled although they are not laws; and finally, some constitute various pieces of sensible advice.

The main aim is to improve quality in the search for professional excellence.. Notify patients of the risks and possible unwanted side-effects of the treatment, strongly urging them to report any unexpected adverse effect should this occur.. This could unjustifiably delay diagnosis or treatment and perhaps expose the patient to inadmissible risk..

Proposals of the Spanish Society of Cardiology. Given its civic commitments, several proposals are set out within the framework of the SEC:.

The education of healthcare professionals should be promoted and encouraged concerning bioethics as well as the socioeconomic aspects and management of healthcare, with the aim of improving their knowledge and skills in decision-making regarding these issues. Attitudes that promote human values in line with authentic medicine aims should be reinforced, especially to prevent the professionals involved becoming demoralized.

In this sense, the SEC will promote education and raising awareness in relation to medical ethics.. Committed and collective responsibility should be encouraged in everyone in the socio-healthcare world, regarding both achievements and failures, especially because the public's expectations should not grow beyond the real chances of meeting their demands. In this line, awareness of costs should be gradually introduced:. A deep and transparent political, economic, social, and professional debate should be encouraged regarding:.

Hence, it is neither ethical to forget them nor to be satisfied with less.. The full document includes a large glossary of terms and can be found at www. The SEC would like to publicly thank all of them.. The authors declare that they have not received any financial support, have not experienced any conflicts of interest before, during, or after preparing the document and have carried out the task with full autonomy.. Correspondence: Dr. Facultad de Medicina UCM. E-mail: mdelosreyes telefonica. Descargar PDF. This document is divided into two distinct parts that deal, respectively, with the responsibilities of the SEC as an organization and the responsibilities of its professional members.

The SEC makes recommendations on how its members should carry out their daily clinical practice, provides a professional perspective on public commitments as a scientific association, and aims to ensure that any views, recommendations, and advice expressed provide the basis for an informed debate on ethical problems in our field of work..

Key Concepts

Palabras clave:. Texto completo. The SEC thus offers itself as a forum. Such members implicitly adopt the official position of the society, although the SEC cannot support all professional actions, especially when in serious conflict with its institutional obligations. Ethical Values and Excellence The ethics of any scientific society or company can no longer focus on merely preparing an ethical code, but should encompass a new moral culture of "convinced and shared responsibility" for the entire organization, especially when developing and applying accreditation systems or quality assessment.

Consistency between what is said, written and done. The obligation to respect confidentiality and privacy in any healthcare relationship, and to protect health data. This exists by virtue of the credibility and good reputation the SEC merits from third parties when offering good service to the public, quality healthcare to patients and quality of life to users, plus continuing education to its members, honest cooperation with companies from the health sector, as well as promoting respect and consideration toward other scientific associations and social institutions.

Autonomy for managing its resources. Providing intelligible and rigorous information on health, as well as supplying the mass media with scientific reports free of bias or deception. Respecting and promoting human rights without discrimination regarding any type of condition, or social or personal circumstance. Open and participatory attitude toward its members, other health professionals and the public, official bodies, associations and organizations, in the search for agreement.

This cooperative responsibility, based on justice and solidarity, involves the ability to respond to the health needs and expectations of the community which, in the context of globalization, goes beyond our borders. Applying efficiency and equity criteria to action within the framework of the Spanish National Health System. Complying with the law and current regulations, without impinging on ethical obligations. Conflicts of Interest The SEC has articulated and maintained a strict code of conduct regarding its own institutional relationships, which are in line with the guidelines of professional associations, 8,9 and regulatory bodies in Spain, in addition to following the guidelines provided by reputable scientific societies.

The scientific program of the Congress is divided into two types of educational activity: an official program round tables, debates on controversial issues, lectures, continuing education, special issues, workshops and an unofficial program industry-sponsored round tables. The Lines of Conduct Governing the Spanish Society of Cardiology The SEC organizes its annual Congress based on high ethical standards and content, which means that sponsorship and the accreditation of educational activities is strictly regulated.

Scope of Relationships Pharmaceutical industry, health technology companies, and others. The SEC will maintain relationships with the Ministry of Education and Culture, central, and regional Administrations and universities to study and develop the academic potential of Spanish cardiologists in graduate and post-gradate teaching. Legal and ethical obligations to provide care Ch. Legal and ethical issues in termination or refusal of care Ch.

Human reproduction Pt. Legal and ethical issues in managed care Ch. Selective contracting with providers Ch. Financial incentives to provide less care Ch. Controlling utilization of healthcare services. Published: Ask Us: Live Chat. Harris, Dean M.