Ethics in Healthcare — Strategies and Tips for Improving Patient-Centered Care

What is ethics in healthcare and how does it benefit patient-centered care?

The American Medical Association (AMA) dates its Code of Medical Ethics back to its founding meeting in 1847, but ethics in healthcare can be said to date back to Hippocrates, the “Father of Medicine,” in the fifth century B.C. Medical ethics has certainly evolved over the centuries, with disciplines establishing their own specific codes. There are codes of ethics for doctors, nurses, and healthcare executives, among others. All of these codes share similar elements.

Patient-centered care (PCC) is a relatively new concept dating back to the late 1980s, but it may be seen as a natural outgrowth of ethical considerations in healthcare. The need to improve care quality, effectiveness, safety, and equality comes from healthcare codes of ethics, and ethics is a core element of clinical training and healthcare management programs.

Over the last 30 and more years, healthcare leaders and clinical providers have identified strategies to improve patient-centered care through an ethical model.

What is ethics in healthcare?

Healthcare ethics is the collection of principles that guide doctors, nurses, and other clinicians in providing medical care. It combines moral beliefs — a sense of right and wrong — with a sense of the provider’s duty toward others.

Healthcare ethics covers how providers treat patients. It also provides guidelines for ethical behaviors such as relationships with patients and colleagues; relationships with vendors such as pharmaceutical companies, in which doctors may be offered incentives to prescribe medications; and financial incentives to overtreat or undertreat patients.

Wherever a conflict of interest between the patient and the provider arises, ethics in healthcare demand that the decision come down on the side of the patient.

Guiding principles

Providing the appropriate care, treatment, and safety of patients is the guiding principle of the code of ethics in healthcare. This principle has four key elements:

Autonomy: Care providers respect a patient´s right to make decisions on their own behalf and don´t try to impose treatment according to their own beliefs.
Beneficence: Providers make choices for the patient´s own good, based on the patient´s beliefs, cultural outlook, and personal desires.
Nonmaleficence: The famed quote "First, do no harm" falls under nonmaleficence. This principle can be applied to interactions with colleagues as well as patients.
Justice: Providers should treat all patients fairly and equally.

Why is ethics important in the healthcare profession?

Ethics is defined as the moral principles that govern a person’s behavior, or how a profession conducts itself. Because healthcare deals with moral dilemmas regarding life and death, it requires a strong ethical code to provide guidance in making decisions. When healthcare providers take ethical concerns into consideration, they are better prepared to make decisions that are respectful, equitable, and effective.

While codes of ethics can’t always provide hard and fast rules about healthcare decisions, they do provide a framework for decision-making. For example:

Ethical guidance can help doctors communicate with patients and their families on end-of-life decisions.
They can inform care considerations, especially in fast-paced emergency situations.
When combined with patient-centered care, they can help create an environment of compassionate care that works for patients, their families, and providers.

The nature of healthcare is such that there will always be ethical conflicts. Providers will have different professional and moral opinions on how best to treat patients. The value of a code of ethics is that these disagreements can be resolved with respect and communication.

Some benefits of a code of ethics include:

Dispute resolution: A code of ethics can help untangle conflicts with patients, families, and colleagues.
Provider support: Ethical guidelines support physicians, nurses, and other providers, allowing them to work with a clear conscience and easing decision-making.
Reducing burnout and moral injury: A code of ethics can help providers align their decisions and actions with that of the organization, and vice versa.
Establishing an ethical work environment: Providers can be confident that their colleagues share the same ethical framework, preventing unethical behavior.
Improved regulatory compliance: A code of ethics can keep everyone operating within the same regulatory framework.
Risk mitigation: The goal of healthcare ethics and patient-centered care is to improve patient outcomes and quality of care, which helps mitigate risk.

What codes of ethics exist in healthcare?

Healthcare professionals are bound by the specific code of ethics of their field. For example, the American Medical Association code of ethics is specific to physicians. Healthcare executives have their own ethical policies, as do nurses, social workers, and other providers.

American Medical Association

The nine principles of the physician’s code of ethics cover all aspects of the relationship with patients and colleagues. The code requires doctors to put patients’ care first, to support access to medical care for everyone, and to respect the privacy of patients and colleagues. The code also requires doctors to follow the law, uphold professional standards, and continue their medical education.

American Nurses Association

The nine provisions of the nursing code of ethics require compassion and respect for patients, and call for nurses to make patients their first priority. The code requires nurses to act ethically and professionally toward patients and colleagues as well as toward themselves. It calls for continuing education and collaboration with other health professionals and with the public.

National Association of Social Workers

Social workers’ code of ethics covers the following ethical principles: Social workers must treat people in need and address social problems, they must challenge social injustice, and they must value the worth and dignity of all people and recognize the importance of human relationships. The code of ethics also encourages social workers to contribute some of their time to volunteer work.

American College of Healthcare Executives

The code of ethics for healthcare executives covers both management considerations and patient care concerns. Executives are expected to act professionally and comply with laws and regulations. They must avoid conflicts of interest and disclose them if any arise. They must act in such a way that they gain the trust of healthcare professionals. The code also requires executives to prioritize patients and ensure care quality. They must ensure patient safety and privacy, and also make sure that the organization commits to patient-centered care. They are also responsible for a professional, supportive, and inclusive workplace.

What is the role of ethics committees in healthcare?

Perhaps the best way to define the role of a healthcare ethics committee is to describe what it does not do: The committee does not hand down judgments. Rather, ethics committees advise and educate administrators and clinical staff on ethical considerations regarding patient care, policies, and procedures. They help establish a code of ethics through discussion with stakeholders.

Some of the issues that may be brought before an ethics committee include:

Emergency procedures: Ethics committees may be asked to weigh in on triage questions, do not resuscitate (DNR) orders, and other issues that require a quick response.
Human research: Research ethics committees consider research proposals to ensure they follow ethical guidelines.
Care rationing: During the COVID-19 pandemic, some hospitals had to ration care due to staff and equipment shortages.

How do ethics impact the concept of patient-centered care?

One area in which ethics can have a considerable impact is that of patient-centered care. Although both ethics-centered healthcare and patient-centered care have the same goals, they can sometimes be at odds. For instance, some experts caution there is a potential for privacy breaches and clinician overreach into a patient’s personal matters in the patient-centered care model.

Definition of patient-centered care

Patient-centered care (PPC), also called ‘person-centered care’, is defined as care that empowers patients and their families in medical decisions and treatment plans. Clinicians work with patients to understand them in a holistic manner, rather than as just passive recipients of medical procedures. PCC encourages a relationship between patients and healthcare providers. The goal of PCC is to improve outcomes by giving patients autonomy in making health decisions that work for their specific needs and goals.

The importance of patient-centered care is illustrated by the shift in healthcare organizations from the traditional care model to PCC. That traditional healthcare model adhered to a rigid, hierarchical structure that gave doctors all the decision-making power. As evidence for the effectiveness of PCC grew, it became clear that the old model was no longer adequate to modern healthcare’s needs.

Principles of PCC include:

Holism: Considering the patient as a whole person, not just a collection of symptoms
Personal relationship: Meeting the patient with empathy and understanding
Shared decision-making: Including the patient in making treatment decisions

Clinicians express these key principles through the following:

Respect: PCC takes the patient’s values and needs into consideration.
Coordination: Providers coordinate medical treatments and support services, as well as post-discharge care.
Communication: Nurses keep patients informed of their clinical status, including post-discharge instructions.
Physical comfort: Providers meet patients’ needs.
Emotional support: Illness and medical treatments can be frightening. Providers seek to alleviate patients’ fears.
Family involvement: Providers take the needs of families and caregivers into account.
Care access: Healthcare facilities make access to care as simple as possible, including access to scheduling, referrals, and transportation.

Examples — and failures — of patient-centered care

The benefits of patient-centered care are well-documented. Patient-centered care varies by provider and patient population. However, despite its best intentions, PCC may not always be effective. This is where an ethics review can be helpful.

Patients with multimorbidity

In 2017 and 2018, researchers in the Netherlands studied 138 patients with two or more chronic conditions from seven primary care practices. The study, published in BMC Family Practice, looked at best practices to improve care under a PCC model. The study looked at the following areas:

Moving from rigid protocols to patient preferences: Creating individualized care plans
Helping patients understand their medical data: Taking the time to educate patients
Improving access to care: Streamlining appointment options and reducing wait times
Prioritizing physical and emotional comfort: Including mental and physical health concerns in treatment
Coordinating care with other providers: Establishing a care team, not just a collection of specialists
Providing continuity of care: Ensuring all providers have the same information
Emotional support: Recognizing that patients need compassion
Including family and friends: Making time to educate a patient’s sources of support

During the year of the study, the patients reported that their overall healthcare experience and satisfaction improved.

Dialysis patients

In the UK, two studies in 2016 and 2017 published in the Clinical Journal of the American Society of Nephrology investigated the impact of patient-centered care on patients who required dialysis. Doctors offered different options to patients based on their needs and requirements. They offered advanced directive planning for patients as they needed it, rather than forcing it on them due to a health crisis. Doctors treating young adult kidney patients, on the other hand, after consulting with families and patients, offered personalized care, career counseling, and benefits counseling, which the clinic added to its services long-term.

Case study: Mrs. Z

In a 2021 case study in the AMA Journal of Ethics, researchers illustrated what happens when, despite doctors’ best intentions, patient-centered care doesn’t work. Doctors diagnosed Mrs. Z with lymphoma. Mrs. Z spoke limited English, so her grown son translated for her. The son didn’t want to tell his mother about her diagnosis and never brought his mother back for follow-up care. In this case, the PCC principle of autonomy conflicted with relational autonomy; the oncologists failed to take into account the family’s concerns or cultural differences.

Meta analysis of patients with depression or anxiety

In 2021 research, published in the Journal of Personalized Medicine, analysis was conducted of the literature dating back decades regarding person-centered care for patients with depression or anxiety. Researchers determined that PCC is more effective than traditional treatments for patients with these emotional disorders. In particular, the studies showed that patients who were given care that included personalized treatment and care planning, patient education, family involvement, and other aspects of PCC had more successful outcomes when compared to those who had traditional treatment programs.

Importance and benefits of patient-centered care

When patients are treated under the guiding principles of PCC, they tend to have better outcomes. It can mean higher satisfaction levels with received care, which in turn can make patients more likely to return for follow-up care, annual appointments, and immunizations, improving their overall health. Patient-centered care is in line with the shift toward value-added care. Under the value-added care model, payors such as insurance companies and Medicare reimburse providers based on the patient’s health outcome, rather than per treatment.

Families who are kept informed regarding their loved one’s care also report higher satisfaction with the provider and are better prepared to help the patient with post-discharge instructions.

Ethical pitfalls in patient-centered care

Health experts have pointed out a number of potential ethical concerns with PCC. These can arise out of the personal connections that PCC fosters as well as the principle of shared decision-making.

Ethical concerns include:

Privacy: Patients may reveal private information that isn´t necessary for treatment.
Data security: The move toward electronic health records (EHRs) can put patient data at risk of data breaches.
Overreach: Because of the personal connection, medical professionals may become enmeshed in patients´ nonmedical issues.
Medical professionals´ well-being: Providers run the risk of becoming attached to patients and their families, potentially impacting their own mental health.
Shared decision-making: Ethical concerns include patients making uninformed decisions, and doctors having to negotiate treatment.

Strategies for improving patient-centered care via ethical policies

Despite the potential conflict between healthcare ethics and PCC, ethical policies can be used to improve the patient-centered care model. For example, the core principles of healthcare ethics are a match for the key principles of PCC: autonomy, beneficence, nonmaleficence, and justice.

Like healthcare itself, strategies for improving patient-centered care are not one-size-fits-all solutions. Clinical providers must take an individual patient’s situation into account and meet patients with respect, humility, and empathy, as well as with professional health and medical care.

Tips for providing ethics-based patient-centered care include:

Respect and gratitude

Treat patients with respect and thank them for their trust. Begin with empathy and establish open communication. Something as simple as making eye contact can go a long way..

Family involvement

Patients are at their most vulnerable when seeking healthcare. Including families and friends and welcoming their support can help patients through medical procedures. Enlisting family support has been shown to have a positive effect on reducing intensive care unit (ICU) delirium.

Encourage feedback

Stay open to questions from patients and their families. Keep patients aware of their care plan and involved in making decisions about their care. Let patients know that feedback is welcome. Many hospitals use patient surveys to improve protocols.

Mental health awareness

Patients may have come to doctors due to a physical illness, but they are vulnerable to mental and emotional health issues as a result. Stress can have an impact on a patient’s physical health and affect their recovery. Providers who are aware of their patients’ mental health issues can help them receive the services they need, such as speaking with a social worker or hospital chaplain.

Care management and care coordination

When patients have multiple providers and complex health concerns, coordinating appointments, medications, and procedures can go a long way toward improving the patients’ experience and streamlining their access to care. Using healthcare technology can help with care management and coordination. Telehealth, scheduling, and EHRs can all be used to make care easier to access. Automated reminders can help patients remember their medications.

Ethics in healthcare and the Northern Arizona University online MBA in Healthcare

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