Karen is the Human Resources Director at the clinic where you work. A new position has opened for a CNA in the OB department where you work as a volunteer. You are aware that Karen’s daughter has applied for the position and that Karen has already stated that she knows that her daughter would be the perfect candidate for that position. You have met Karen’s daughter, Alexis, and are familiar with her feelings about different people, which bothers you. The clinic serves many low-income women and their babies and many of these women are minorities. Alexis, as a staunch Republican, is against welfare and many of the women that utilize the clinic are on state-funded insurance. As well, Alexis has spoken about how people that receive welfare are most usually drug addicted and should not get any help from the government at all. Alexis also has made racists jokes and you have felt uncomfortable around her.
Also, from a clinical standpoint, Alexis has also stated that she only received her CNA certification to make her mother happy and as a 21 year old girl, you feel that she is not ready to be a compassionate and competent part of the medical team. The CNA, who is to be replaced always performed her duties well and even went above and beyond to help patients by giving the women information on where to find resources to better the lives of them and their children. You feel as if Alexis would not only be clinically incompetent, but that she will not be able to fill the void left by the retiring CNA. As well, you feel that other women, who have shown an interest in the job would be better suited than Alexis, but Alexis’s mother is showing no interest in hiring the more qualified and compassionate candidates.
There are many ethical issues at play here and if a person put themselves in the situation described in the above case, it can easily be seen that many ethical conflicts arise on both the administrative and clinical side of medicine. Ethically one see a conflict of interest in Karen’s decision to look at her daughter to fill the CNA position over other more experienced candidates and some that are known personally to you as very compassionate and mature. On the other hand, you are not sure whether it is right to judge Alexis so harshly because she is young and her views, although not in line with your own, are a major part of the Republican party’s stance on social welfare. However, her racist jokes clearly are inappropriate. While carefully reviewing this information, you must wonder if you are being discriminatory toward Alexis because of her age and political affiliation. You also must wonder if you tell someone about the jokes that Karen will be angry and the issue be viewed to be a simple misunderstanding.
On the clinical side, Alexis has no experience, as she has just recently been certified. So you cannot say that she will not do a good job, however her lack of proper communication skills, empathy, and experience worry you. Certainly other candidates that feel more empathetic towards the low-income women would be better suited at the job and you know from your own experience that if you enjoy what you do and feel like you are really helping people holistically then it will make you a better professional. Alexis seems like the type that might burn out quickly given her attitude towards the women and this could have a lasting effect on patients, who may be treated with disrespect or contempt by Alexis. It also seems clear to you that Alexis is simply doing what her mother wants her to do and this seems like it may cause issues with Alexis and Karen that could complicate the workplace, distracting others from their duties.
By looking at Utilitarian ethics, it is hard to judge what the outcome of Alexis’s performance will be like, so you must then hone down exactly what you believe the dilemma is. Barring the unfairness of Karen’s choice to overlook other candidates, you then realize that the most pressing ethical issue is that you believe that women have the right to bear children at their discretion. Alexis, however, believes that women that must go to free clinics or to clinics that serve mostly poor women, should not have children at all. Based on her beliefs, then, you come to the conclusion that the outcome of her employment would be to act in a derogatory fashion toward people that she does not respect or agree with. However, you do not know the outcome of her performance and you are well aware that utilitarianism is concerned with consequences. On the other hand, you see the benefit of having Alexis working in the same clinic as her mom, in case she needs emotional support in a very emotionally draining position.
By looking at deontology, you also begin to wonder if Alexis will not simply use her patients as a means to an end; that being simply making her mother happy. Therefore, you believe that you must only work in medicine if that is the field that you honestly want to work in and working in the medical field for any other reason is simply unethical. However, looking at Rawl’s theory seems to be the most fitting in this dilemma, because you believe that Alexis may limit services or at least not give out helpful information to these women, based on her egalitarian stance. “It is also rational and self-interested for persons in the original position not to make every good or service available to everyone at all times” (Darr, 20). However, Rawl’s theory concludes that this type of selective clinical behavior only be used if it helps the most disadvantaged. You believe that Alexis is so self-interested that she believes that she is making the right choice in doing what she is doing and that her rationale might be to try to help the women by pushing her politics on them and denying them information in the guise of helping.
You decide to research the ethical debate of the right to bear children on the part of the poor to be able to talk to Alexis and her mother about what you learn. This decision is made because, you do not want to hurt Karen by suggesting that she is being unethical in wanting to hire her daughter, because you realize that using these means will likely alienate you from Karen as an end. Using Kantian ethics, the only moral way to go about addressing this issue is to assume that both Karen and Alexis have rationalized their own good intentions and do not think that they are intentionally hurting anyone. Therefore, you cannot make any sort of suggestions that either women is ill-intentioned. Instead, you will use the means of information that you collect on the ethical issues you see as most central to this problem and one that can potentially hurt many. You decide to try to be as rational as possible with both women and only voice concerns to the supervisor if they are not receptive to your rational plea.
You present what you find to both Alexis and Karen in a meeting that you call. You have discovered that the opposition to social welfare in medicine has it’s own type of ethics that are rational to the people that are opposed to it. However, when working with people on welfare this is just as much a conflict of interest as Karen appointing her daughter a position; this is your firm, moral belief. You talk to the women about a group called Americans for Free Choice in Medicine and ask the women to explain this to you. “The Declaration of Independence applies to the medical profession too. We must reject the idea that doctors are slaves destined to serve others at the behest of the state” (Peikoff, 1993). Karen and Alexis both explain their theory that doctors and other health care workers should stand up for their right to oppose free health care and to work to change the system from within by educating patients about getting a job or getting off welfare. You see the two women as extremely self interested and both interpret the Declaration of Independence differently than you. While they believe in their own right to pursue their interests, you see the inherent need to protect the rights of all people and their conversation with you proves that you must consult a person that has more authority and experience in this matter.
You realize that you are now employing Casuistry, as you cannot continue a rational discussion with either woman. Therefore, using the Declaration of Independence and the human rights laid out in this document, you present your case to your supervisor. You express your concerns about all the ethical issues that are evident and the issues you see arising from Alexis’s possible employment. You tell your supervisor that you have exhausted all means by which to resolve this issue rationally and since you see things differently than Karen and Alexis, then Casuistry must be used as the last resort. Your supervisor agrees. In addition to interpreting the Declaration of Independence as a document that was the first to uphold basic human rights, she also added that it was unethical to not follow the Universal Declaration of Human Rights, Article 1. “All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood” (UN, 1948). Due to the lack of dignity that both Karen and Alexis thought should be given to all women at the clinic, Karen was ordered to go to a Diversity Training course and Alexis was not hired for the position. The supervisor also decided that the Universal Declaration of Human Rights should be incorporated into a mission statement that spelled out the rights of patients and the responsibilities of any employee at the clinic.
These ethical problems and others were found to be easily solved by having a document that relayed what the foundation of the clinic was and what was expected of employees in terms of ethics. These kinds of documents are the best way to help guide prospective and current employees in times of doubt. Ethical problems many times arise, simply from organizations having the idea that people will always intuitively know how to handle situations. However, with differing views, personality, and self-fulfilling goals inherent in individuals it is necessary to have a document that unifies the ethical expectations of a healthcare organization or any organization for that matter. Since Kathy was ordered to take a course on Diversity at the local university in order to keep her job she is now more informed and treats everyone with respect. Though the clinic can not afford to send everyone to these courses, they are recommended and if an ethical violation is deemed to have occurred then the individual must pay to attend an Diversity Awareness course or a different course, depending on the ethical violation.
It was also fairly easy to devise a document that encompassed the mission of the organization, using both the Declaration of Independence and the Universal Declaration of Human Rights. These documents are especially helpful in that they are useful to all employees in the way they treat patients or their fellow coworkers. Even non-medical staff can benefit from having this mission statement that affirms the rights of all people, this includes the right to disagree, as well. But the document is helpful in that most people understand what is expected of them and agree to the terms of the statement by signing their affirmation.
References
- Darr, Kurt. (2005). “Considering Moral Philosophies and Principles” in Ethics in Health Service Management 4th Ed. Health Professions Press.
- Jefferson, Thomas. (1776) The Declaration of Independence.
- Peikoff, Leonard. (1993). “Health Care is Not a Right”. Accessible Online http://afcm.org/hcinar2.html. Last Accessed 13 August 2010.
- United Nations. (1948). The Universal Declaration of Human Rights. Accessible online http://www.un.org/en/documents/udhr/index.shtml. Last Accessed 13 August 2010.
