Physicians may choose whom to serve, but may not refuse a patient on the basis of race, color, religion, national origin, or any other illegal discrimination. It is unethical for physicians to deny treatment to HIV-infected individuals on that basis alone if they are qualified to treat the patient's condition. Once a physician takes a case, the patient cannot be neglected nor refused treatment unless official notice is given from the physician to withdraw from the case. Patients have the right to know their diagnoses, the nature and purpose of their treatment, and to have enough information to be able to make an informed choice about their treatment protocol. Physicians should inform families of a patient's death and not delegate that responsibility to others. Physicians should expose incompetent, corrupt, dishonest, and unethical conduct by other physicians to the disciplinary board. It is unethical for any physician to treat patients while under the influence of alcohol, controlled substances, or any other chemical that impairs the physician's ability.
Physicians who know they are HIV positive should refrain from any activity that would risk the transmission of the virus to others. Any activity that might be regarded as a "conflict of interest" (for example, a physician holding stock in a pharmaceutical company and prescribing medications only from that company) should be avoided. Financial interests are not to influence physicians in prescribing medications, devices, or appliances.
It is the responsibility of physicians and their employees to report all cases of suspected child abuse, to protect and care for the abused, and to treat the abuser (if known) as a victim also. This is not an easy task. Abuse is not easy to witness. While there are very specific laws regarding suspected child abuse, and in most states medical assistants are mandated to report abuse, the laws are vague or nonexistent in elderly and spousal abuse. However, whatever form the abuse takes, it is best to treat all forms of abuse in the same manner by providing a safe environment for those abused and seeking treatment for the abuser and the abused.
Bioethical Dilemmas
Guidelines for bioethical issues are even harder to define than are guidelines for ethics, because each of the bioethical issues calls upon us to make decisions that directly affect a person's life. In some instances, the bioethical issue requires a choice about who lives and requires a definition of the quality of life. Such dilemmas are difficult, if not impossible, to approach from a neutral point of view even though medical assistants should strive not to place their moral values upon patients or coworkers.
Allocation of Scarce Medical Resources
The issue faced daily by health care workers is the allocation of scarce medical resources. Even with the government's attempts at health care reform, medical resources still will not be available to everyone. When the receptionist determines who receives the only available appointment in a day, when patients are turned away because they have no insurance or financial resources to pay for services, when Medicare/Medicaid patients are denied services because of low return from state and federal insurance programs, scarce medical resources are being allocated.
Professional Rights and Responsibilities
Range of Psychological Suffering In AIDS
Health care professionals will always be called upon to care for patients who have infectious diseases, diseases not known to the medical community, or new diseases that are rare but that may become more common in the future. New diseases are likely to be seen when genetic change in causative organisms or changing modes of agriculture put human populations into contact with new pathogens. This is especially true in developing countries where populations are high, and people live in crowded conditions without proper sanitation. Even though health care professionals are prepared to respond to the medical, surgical, and psychological needs of patients, they face additional challenges when helping people with the acquired immunodeficiency syndrome AIDS, a deadly infectious disease.
One of the most important skills for medical assistants is the ability to respond to patients with special needs in an empathic way. Medical assistants will respond to the needs of patients with AIDS and individuals who test positive for the virus in an ambulatory care setting rather than a hospital or surgical center. In some measure, the ambulatory care setting removes the medical assistant from the demanding daily physical care of these individuals who can be so devastated by the ravages of AIDS. The psychological and emotional demands of the medical assistant, however, are as great, if not greater, than those placed upon health care professionals in a hospital or surgical center.
Infection with HIV causes extreme distress. The onset of symptoms is typically accompanied by the fear of developing AIDS. Distress is evident in the preoccupation with illness and patients' fears of getting cancer and other life-threatening diseases. Anxiety and depression are common. At the time of diagnosis, patients' responses may include denial, numbness, and inability to face the facts. Patients are angry at the disease, at the discrimination that often accompanies it, at the prospect of a lonely, painful death, at the lack of effective treatment, at medical staff, and at themselves. In many cases, guilt develops about past behavior and lifestyles, or about the possibility of having transmitted the disease to others. When the disease has been contracted through contaminated blood or blood products or by individuals who felt they were protected or safe from the disease, the anger may turn into rage. Sadness, hopelessness, helplessness, denial, and withdrawal are often exhibited. Some patients contemplate suicide. Because social and physical assistance are needed, a strong network of friends and family is particularly important. In the case of homosexuals and persons addicted to intravenous drugs, however, there are a large number who are estranged from their family's support system. Persons with AIDS may feel added strain if this is the first knowledge their families have of any high-risk behaviors associated with the transmission of disease. The psychological suffering leads to physical symptoms such as tension, tachycardia, agitation, insomnia, anorexia, and panic attacks. Persons who test positive for HIV often express an exaggerated sensitivity to disease and see any new symptom as bringing them closer to death.
As a medical assistant, you face the challenge of caring for persons with a life-threatening disease; you must comfort persons who face great suffering and death. You will become a source of information for patients with AIDS and their support members. You must be particularly sensitive and respectful toward individuals who are viewed as social pariahs. You will have to examine your own beliefs and lifestyle. You must be comfortable with your own sexuality and the sexuality of others whose lifestyle may differ from yours. You must replace any fear you have regarding the disease with knowledge based on medical fact, and always practice standard universal precautions As well as assisting your physician or employer in providing the best possible medical care, many nonmedical forms of assistance may be required by persons infected with HIV or AIDS. You may need to make referrals to community-based AIDS service groups, health departments, and to social workers for planning physical and financial assistance. Trained hospice volunteers or AIDS volunteers also are helpful to families and significant others, as well as to patients with AIDS.
There may be the need for patients with AIDS to obtain legal assistance and to identify their wishes and directions for care during the terminal stages of their illness. A living will or physician's directive might be encouraged. Refer to Chapter 10 for more information on physician directives. Patients who are losing mental acuity should be encouraged to appoint a legal guardian or durable power of attorney. As much as possible, be responsive to the family members or the significant others related to patients with AIDS. Answer any questions they may have regarding their fear of contracting the disease. It may be helpful to remind them that AIDS is difficult to contract, even among people at high risk for the disease. The risk of transmitting AIDS from daily contact at work, school, or at home is low. In virtually all cases, direct sexual contact or sharing of IV drug needles is the leading cause of transmission.
Few Issues For Contemplation And Discussion
Medical assistants will encounter ethical and bioethical issues across the lifespan. A few issues are identified for contemplation and discussion. Issues of bioethics common to every medical office are the allocation of scarce medical resources,
Infants:
In premature, deformed, or severely disabled babies, ethical issues include the decision to provide or withhold treatment. Health care professionals and parents are not always in agreement. Central to this issue, also, is the expense involved in certain treatments and deciding who pays the cost of treatment.
Vulnerability of infants can lead to issues of negligence, abuse, or rejection. Parents are vulnerable too, for often they may not understand the ramifications of certain decisions about care of family members. Sometimes these decisions can lead to hundreds of thousands of dollars in medical expenses. Parents are also vulnerable because they may be unable to cope with the needs of the entire family.
Children
Children who are ill-fed, housed, educated, and clothed exhibit great needs for preventive, curative, and rehabilitative health care.
Minors with sexually transmitted diseases often seek treatment without the parents' knowledge; they can be treated without parents' consent. Treatment also must be offered without parental consent to pregnant, infected, or addicted minors. Some health care professionals consider this an ethical issue and a violation of parents' rights. Child abuse presents an ethical dilemma, especially when a child confides physical, sexual, or emotional abuse to a health care worker but does not want the information divulged. Health care professionals, as mandated reporters, must report suspected child abuse. Will the child/patient view this as a violation of confidence or suffer dire consequences as a result of the reported abuse?
Adolescents
Adolescents as young as thirteen- to eighteen-years-old may seek abortion without parental knowledge or consent. Is this a violation of parents' right to medical information regarding their children? Or should the adolescent, fearful of parental reaction, have the right to decide? The adolescent's growing autonomy, need for independence, changing values, and desire for peer acceptance lead to a number of ethical issues that may involve the health care environment.
Adults:
Adults are increasingly faced with loss of jobs because of downsizing and layoffs. Previously with job loss, health care benefits could be lost. In August 1996, the Health Insurance Reform Act (Kassebaum-Kennedy Bill) was adopted. Among other things, this Act helps limit preexisting conditions and assures availability of individual policies for those who leave jobs voluntarily or involuntarily.
Many low-income women do not have sufficient access to prenatal care, which has proven to be a cost-saving medical measure that is critical to the health of both mother and infant. As employers seek to reduce the cost of health insurance benefit programs, many individuals and families are finding themselves shifted from one insurance program to another, leaving them with little or no continuity of care. Also, in some managed care programs, adults may receive medical services from a number of health care professionals with whom they have no opportunity to establish an ongoing physician-patient relationship. Even with a physician's directive or a living will, a dying patient's wishes may not be followed. Technological advances in medicine have created a situation where patients may not be able to exercise a choice in the death issue even in states that may allow physician-assisted suicide.
Senior Adults:
Dementia is a common problem that is physically and financially exhausting for the caregiver, who is usually a spouse or adult child. How do caregivers cope with their own needs and the needs of dependent adults? Decisions about how and where to provide care for the senior adult pose ethical dilemmas with no easy answers. Often, the elderly may reject nursing home placement, and there may be limited funds for such long-term care. Elderly patients have the right to maintain dignity and privacy, but often their dependency on others deprives them of these basic rights. Physician-assisted suicide for terminally ill patients is a prominent issue in our society, especially when elderly patients sense a total loss of dignity. Such a decision, however, is never easily made.
Ethics And Bioethics For Medical Assistants
It is impossible in today's world to function as a medical assistant without an awareness of the impact of ethics and bioethics on health care. Just as an understanding of the law and working within the law is vital information for the medical assistant, it is equally important to understand ethics and bioethics. From the previous blogposts, you have come to realize that there are many circumstances and situations that occur in health care that are guided and directed by state and federal laws. You, personally, are expected to be above reproach in all your actions in this regard.
You must also work with your employer and other members of the health care team to assure that each member of the staff functions within the law protecting both patients and providers. Ethics plays a huge role in such an endeavor. To function ethically demands that you never function outside the law. Ethics, however, demands something calls for honesty, trustworthiness, integrity, confidentiality, and fairness. To function ethically, you must know yourself well and understand weaknesses and any vulnerabilities that might prevent you from acting ethically.
On occasion, ethical dilemmas occur because patients are unsure of the role of the medical assistant. For example, the medical assistants of Inner City Health Care are truly multidisciplinary and have a range of administrative and clinical skills. However, patients sometimes think of them as nurses who have an entirely different set of skills. While most of the medical assistants gently correct patients and make it a point to practice only within their area of expertise, occasionally newer members of the medical assistant staff may feel more "important" when patients regard them as nurses or physicians' assistants. This is just one situation in which medical assistants may need to reflect on their actions and be sure that they are acting ethically and within the range of their skills. Medical assistants also need to recognize the warning signs that they, or some other staff member, may be about to breach a code of ethics. Often, this kind of breach occurs when one has, or seeks to have, too much power; when one attempts to take too much authority; and when one has too little knowledge and experience. When a breach seems about to occur, the individuals involved should be encouraged to step back and review their actions and the likely consequences of those actions.
Ethics:
Traditionally, ethics has been defined in terms of what is right or wrong. For health care professionals, ethics is often defined by a code or creed as seen in the Code of Ethics from the American Association of Medical Assistants (AAMA) or the Principles of Medical Ethics from the American Medical Association (AMA). While these codes, and many others like them, are essential and very helpful, they lose their vitality unless they are understood by individuals who possess a personal and sound moral code or set of values. Unlike the law, which seldom changes unless challenged and examined in the courts, codes of ethics constantly change and evolve just as personal values and morals change and evolve. Every time values are challenged and examined, a medical assistant's personal ethical codes become stronger, the understanding of others' perceptions becomes clearer, and professionalism is enhanced.
Bioethics:
Bioethics brings the entire focus of ethics into the field of health care and into those ethical issues dealing with life. Never before in the history of medical care has bioethics been such a topic of concern. In the past, most bioethical decisions were made by physicians and esteemed members of the medical and/or legal profession. However, advancing technology giving patients and consumers numerous choices regarding their health care causes each one of medical assistants to take an active role in bioethics.