The Ethical Goal of Professional Practice
A Caring Response
Objectives
The reader should be able to:
• Describe the basic idea of a caring response and its function in healthcare.
• List some types of claims on professionals and the reasoning supporting that patient interests generally must take priority.
• Describe patient-centered care.
• Compare at least two important differences between caring expressed in friendships or family life and caring expressed in a professional relationship.
• Identify the two components of professional responsibility and why both are essential for a caring response.
• List three social determinants of care that impact the professional’s intent to meet the ethical gold standard through a professional caring response and its impact on patients and families.
• Discuss how the ethical concept of justice figures into the intent to meet the goal of a professional caring response in regard to an individual patient.
• Discuss some burdens and benefits of being a caregiver as they arise in the health professional and patient relationship.
New terms and ideas you will encounter in this chapter
a caring response
care
care plan
claim
patient-centered care
relationship-based care
technical competence
professional responsibility
due care
accountability
responsiveness
right
human rights
social determinants of care
cultural competence
justice
Topics in this chapter introduced in earlier chapter
| Topic | Introduced in chapter |
| Ethics gold standard | 1 |
| Interprofessional care team | 1 |
| Professional morality as a group morality | 1 |
| Moral community | 1 |
| Code of ethics | 1 |
Introduction
The goal of professional ethics is to arrive at a caring response in situations you encounter in the course of carrying out your professional role and its functions. In Chapter 1, we introduced the ethics gold standard of upholding every person’s dignity in your professional relationships. We now introduce care as the fundamental means by which you can recognize whether or not you are practicing according to that standard.
Some ethics texts do not spend much time focused specifically on the notion of care. As authors, we have found that students and professionals alike often measure their professional effectiveness and satisfaction by whether they can conclude that they did a good job of caring for patients. Still, when asked, they do not find it easy to grasp fully what care is. This is not too surprising because, as one wise colleague put it succinctly:
You can’t bottle care. It is not a formula. Just as in a loving relationship there is no one formula, so it is with care. Whatever is expressed as care has to be authenticated by going deeper into the spirit through which it is offered. Care connects you not only with the other but also reflects back who you are as a human being. In this regard it is not like the contributions you make through applying your technical expertise. At the same time this is what makes care the special gift of a health professional and patient relationship because it sets you squarely in a human to human encounter where not only your patients’ well being but your own is at stake. You must work together to find the shape that a caring response will take in each case.1
The effect and science of care has been well established throughout the years. A recent review traces a long history of care as the central feature that divides the mere science of medicine from its essential quality. The investigators showed that recent physiologic and neuroimaging studies indicated positive findings in patients who believed that their professionals really cared. They based their conclusion on the professionals’ attitudes and conduct, not just their technical expertise.2
Although the deep motivations for expressing care are personal, some expressions of professional caregiving are so similar that almost everyone can recognize them. As noted in Chapter 1, this goal seldom is fully reached alone: The whole team is needed to collaborate in efforts to show the patient that “We’ve got your back!” “We are on your side!” “Your dignity is safe with us!” As noted in the previous quote, the specific shape this care takes in a specific patient’s care plan depends on what each member of the interprofessional care team collaborating with the patient and the patient’s loved ones comes up with that helps preserve the patient’s dignity. At the same time, this chapter shares some themes and expressions of care that will help you learn how others have come to recognize and use this key component of a successful professional career.
Summary
A caring response is the ethical goal of every health professional and patient relationship. It is the key to honoring a patient’s dignity. Care requires a human-to-human exchange that needs participation by all involved. The goal is realized most often through the interactions and combined contributions of the interprofessional care team.
After these introductory chapters, you will have many opportunities to consider different types of situations in which you must determine what a caring response involves; every situation will be an adventure into the unknown territory of another unique person’s values, preferences, and life experiences. To get started, consider the following story that highlights some challenges that Pat Jackson, a physician assistant, and the interprofessional care team encounter as they try to live by their intention to promote a caring response.
The Story of Pat Jackson, the Interprofessional Care Team, and Mr. Sanchez
Pat Jackson was excited to be invited into a rural group practice in her home state. During her hiring interview, she found the team of physicians, nurses, technologists, therapists, and others compatible with her own commitment to high-quality healthcare. She told the team how she had welcomed the opportunity to attend school in a large city but now was eager to return as a physician assistant to the type of rural setting she had so enjoyed as a child. The group was impressed with her enthusiasm and the several academic and humanitarian awards she had received during her training.
So it was a terrible moment for her when, with the honeymoon period barely over, she misdiagnosed Mr. Sanchez’s symptoms of asthma as a temporary allergic response attributable to the very high pollen count that month. (You will return to this part of the story later in the chapter, but for the moment, read on). Mr. Sanchez came to the clinic with a characteristic stuffy nose and watery eyes she had seen several times earlier in the week. Although his wheezing concerned her, she was eager to leave work that Friday evening in time to keep her commitment to serve at a community church supper down the road from where she lived. Her initial response to being paged by the departing receptionist had been annoyance at having to see yet one more patient. “Stop thinking this way,” she chided herself.
Assuredly, this patient did look more miserable than others she had seen that week, but in an interprofessional care team meeting on Wednesday, the discussion included how much the presenting symptoms of pollen allergy can vary among migrant workers who come to harvest the fields during this season. Many workers developed allergies they had not encountered previously. When she asked him whether he had ever had such symptoms before, Mr. Sanchez wheezed, “No, señora.” She noted that he may or may not have completely understood her question. Still, his “No, señora” seemed emphatic enough that she did not think she needed to run after her colleague who was just getting into his car but could pose the question to Mr. Sanchez in his native Spanish. Noting her hesitance, Mr. Sanchez said, “Gracias, thank you, okay me.” “Thank me for what?” she thought. He did not look okay. But overall, she was relieved that he was another pollen sufferer she could quickly send on his way with a prescription to relieve his respiratory stuffiness and wheezing.3
Many issues can be raised in this story, but your opportunity here is to focus on your opinion about Pat’s professional mandate to provide a caring response to Mr. Sanchez’ problem.
Reflection
When Mr. Sanchez came to the clinic, did Pat reflect attitudes and conduct that are consistent with your assumptions of how a caring professional should respond?
Yes____ No____ Somewhat____
If you answered yes or somewhat, which aspects of her approach are consistent with your assumptions?
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Most readers also sympathize with Pat’s situation. Do you? If so, what is the basis of your sympathy about her responses when he arrived? Are they sufficiently understandable that any shortcomings in her approach are relatively inconsequential?
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Jot down some thoughts about what role other members of the interprofessional care team play in ensuring a caring response to Mr. Sanchez.
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As in many ethical challenges, Pat’s situation contains details that can cause you to see more than one side of the story, which is when ethical analysis becomes a resource. We discuss this at more length in Chapter 5. At the moment, our attention is on whether or how she was expressing care.
The Patient as the Focus of a Caring Response
A caring response involves a claim on you as a professional to give priority to optimizing positive results and minimizing damage to the patient. What do we mean by a claim? A claim is a request made verbally or nonverbally based on the expectations people have of your professional role. It says, “Give me your expert attention.” You know that your professional role involves many types of relationships, with patients or clients and other times with families, professional teammates, research participants, policymakers, and the public. And the list is not complete if you fail to include your relationship with yourself. For instance, an unfair conclusion is that Pat’s desire to serve the larger community at the church supper and to build personal relationships there was unreasonable. Each and every one of the parties you will encounter comes with claims on your time, services, expertise, or other type of attention. From time to time, you will find yourself torn between more than one of them, just as Pat did. She understood that her patient Mr. Sanchez had a strong claim on her to be treated with dignity and have her full attention. But still, her desire to be caring of herself by participating in a social event on this Friday night in her newly adopted town understandably was pressing in on her while she was trying to treat him, and no one would fault her for the wish to meet new people there.
Reflection
Stop here and think about your day so far. What competing claims on your time, attention, or other resources have you already faced?
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Competing claims are part and parcel of everyday life. But the ethical dimension of Pat’s professional role helps her to set priorities in relation to Mr. Sanchez, with the awareness that when other claims tempt her to override this priority, there must be very compelling reasons to do so.
Patient-Centered Care
Patient-centered care is a term adopted in the health professions literature to emphasize the imperative that professionals keep their focus on the well-being of their patients. In other words, the patient’s claim on you is a very compelling one. Nothing is more central to professional morality than this imperative. Nursing and medicine have led the way in developing models of the health professional and patient relationship based on this concept, but almost all health professions have followed suit.4 The central theme that runs through them is that a patient’s values, concerns, and informed preferences have more moral weight in your everyday clinical decision making than anything else calling for your attention. Patient-centered care acts as the orienting point on the professional’s moral compass when deciding what direction to take at a crossroads of decision-making between two or more priorities.
You can easily see that patient-centered care means that the care is tailored to fit each patient as a unique person, not simply as a diagnosis or collection of symptoms. This focus on the whole patient frequently is challenged in an era of clinical specialization. A particular disease, symptom, body part, or biologic system can capture the attention of an individual professional, or the patient can be divided up according to the expertise of different members of the interprofessional care team. The dehumanizing effect that this fragmentation has on the health professional and the patient is illustrated in Figure 2-1. Two guidelines toward avoiding this mistake are close attention to details about the patient as a person and use of individualized appropriate communication tools for each patient situation.
Pay Close Attention to Details
As obvious as this guideline sounds, today’s stimulus-rich environment offers distractions at every turn. Pat was distracted by her desire to get out of the clinic that Friday night when Mr. Sanchez needed her full attention. Something as mundane as a cell phone buzzing at your waist can divert you from what a patient is trying to express through verbal or nonverbal means. And the care team itself can engage in conversation triggered by something the patient says or does that cuts into your line of thought and attention.5 In an era in which our attention span is shorter and shorter as a result of the constant sources of input, remaining an active listener throughout the patient’s attempt to tell his story is a greater challenge than ever.
Seek Appropriate Communication Tools
Patient-centered approaches also highlight that the form of communication with the patient either can profoundly enhance your ability to arrive at a caring response or throw the focus of care off-kilter. For instance, Pat Jackson may or may not have communicated basic information to Mr. Sanchez, but a high probability exists that he would have felt more cared for as a person if she had included her interprofessional care team colleague who knew how to communicate with him in his native Spanish. With an interpreter’s support, Mr. Sanchez may have opened up with more detailed information that would have provided a better clinical picture overall. And in today’s technology-intensive world, new avenues of effective communication are arising. For instance, creative adaptations of video game concepts are being developed within health care that a few years ago would have not been imagined as a tool for patient communication and education.6 Effective communication is so important that we devote an entire chapter to it (see Chapter 10).
Most of the discussion so far has been about direct care. However, about a decade or so ago, a group of U.S. health professionals took the challenge of a professional caring response to the level of healthcare institutional practices and policies. The Minneapolis-based consulting company, Creative Health Care Management, Inc, introduced the concept of relationship-based care, which emphasizes that intentional presence by healthcare providers is a catalyst that transforms care at the systems level of institutions and policies and on the interpersonal level.7 Note the inferences to paying attention and selecting appropriate forms of communication in one of their values statements:
Caring is a conscious, intentional decision to interact with others with compassion, mutual respect and open and honest communication. Caring activity promotes meaningful connections between human beings and is built on the knowing that we’re all in this together. Such connection facilitates healing and prevents isolation.
Summary
In your practice, you will be torn by competing claims for your attention. Your primary professional priority is the patient. Patient-centered care and relationship-based care are concepts that help remind you of this priority and enhance the probability that your response can and will be tailored to suit each individual.
Three Characteristics of a Caring Response
So far, we have emphasized that a professional caring response is not a set formula (i.e., it cannot be bottled) and that, at the same time, some general guidelines that point in that direction are paying attention to each person as a unique individual and working toward effective communication. We turn your attention now to how a professional caring response can further be understood with a comparison of conduct appropriate in the health professional and patient relationship and that for other significant relationships.
Navigation Between Friendly and Professional Conduct
A professional caring response includes aspects of conduct that are identical to the ones you show toward a friend or relative. So, let us begin with your own experience.
Reflection
If you have been to a physician, therapist, or other health professional for an ailment recently, what are some aspects of your exchange that were similar to those you might have with a friend or family member and that you would characterize as signs of their care for you?
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If you listed some things you each did that were sensitive to making each other comfortable, showed mutual regard for the other, or were light and in appropriate good humor, they are apt examples of everyday caring relationships. These are the human sensitivities, affection, and politeness that also bolster a patient’s belief that you care about him or her.8 This friendly caring calls on your creativity to meet another person in ways consistent with that person’s personality and unique needs. It may include taking the extra few minutes to attend to a bedridden patient’s personal hygiene needs (e.g., putting her water glass and toothbrush within reach), decreasing physical discomfort (e.g., offering a support pillow or straight-back chair), or complimenting a patient. Acknowledging a patient’s birthday or anniversary can bring a smile. And the professional caring that is in common with other human relationships also goes deeper, of course, so that basic trust and appreciation develop between you. Given just the little we know about Pat Jackson and Mr. Sanchez, this is a good moment to reflect on some things she could have done to show basic human caring toward him.
Summary
A professional caring response includes common everyday expressions of kindness and thoughtfulness that create trust and lay foundations of a friendship.
At the same time, a health professional’s relationships with patients are different too, with moral and legal dimensions not fully applicable to other relationships. Therefore, a caring response must mean something more than common everyday expressions of affection, nurturance, or protectiveness associated with care.
Reflection
Examine the picture of these friends in Figure 2-2. What do you see that may not seem appropriate for a health professional and patient relationship?
Figure 2-2
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Their physical proximity is one cautionary message. A governing characteristic of your professional caring response is that you must not cross psychological, physical, and sexual boundaries that could make the patient responsible or responsive to you in ways that go outside of (or create opposition to) the healing core of the relationship.9 For instance, if you have just been faced with a big disappointment, pouring your heart out to a patient like you would to a friend not only may take attention from the patient’s issues but also may create a feeling that you are the one who came to be cared for instead of the patient. An apt question to ask yourself is “Does my conduct help keep the patient and me focused on the health-related matters that I am competent to address through extensive training in my field?” This point of difference is what distinguishes you and members of the patient’s interprofessional care team from other caring people in the patient’s life. Communication also figures in regarding the type of information you solicit from the patient. And so a second question to ask yourself is, “What do I and the team need to know about the patient to provide the best care possible?” You will likely come to know other things too, but your intent should be guided by this “need to know.” Pat did not cross the line of personal sharing—she could have explained to Mr. Sanchez that she was running late for another appointment. Instead, her conduct suggests to the reader that she may have erred on the side of not taking the initiative to solicit enough “need to know” information about his history and symptoms. Their situation highlights how delicate the balance can be between too much and too little.
Touching a patient also warrants your disciplined attention. As you learned in Chapter 1, you may have legal license to touch this stranger in ways that go beyond what a nonprofessional can morally and legally do. Great respect for the privileges health professionals have earned through their professional preparation must be enveloped in an equally deep respect for the effect the physical contact may have on the patient’s dignity. For instance, the knowledge that Mr. Sanchez is a Hispanic farm laborer can provide Pat with clues about the environment in which he lives each day and may help to guide her in how to approach him. His age and ethnicity can provide more clues as to how he may feel about having a young woman palpate him on the face, neck, or trunk and ask questions he may believe are a private matter. As a reader making your way through the examples in this textbook, you will be able to further flesh out what health professionals have done in different situations to provide a friendly caring response tempered by professional role boundaries and to identify ways to exercise the discipline of staying focused on the patient’s needs.
Care Expressed Through Technical Competence
A professional caring response depends on competently and conscientiously carrying out your professional duties. The bottom line is that without technical competence or expertise, the goal of a caring response cannot be achieved. The patient’s trust goes beyond the hope that you will offer a kind or even generous personal response to the clinical issue that has brought this person to you. Your technical expertise places you in a unique position to aid persons in maintaining or regaining health (or relief of suffering or a peaceful death) in ways that they cannot achieve without you. Fortunately, professionals today can rely more than ever before on evidence-based practices that help ensure optimal clinical outcomes.
Many clinical approaches make use of the tools of modern medical technology. The concern that technology will take the place of more traditional types of hands-on treatments often is discussed in the literature.10 Because both professionals and patients are at risk of putting too much trust in what technology can do, misuse can lead to untoward or harmful effects and you will benefit by taking advantage of the caveats as well as the opportunities that modern technologic discoveries in your field offer.11 However, that being said, technology is an important extension of more traditional understandings of how to apply one’s technical expertise and should be welcomed. Moreover, the entire professional team enhances the likelihood of success; their combined technical expertise distinguishes what one professional acting alone can achieve from the combined competence of all. The well-coordinated efforts of the team give patients the best chance of feeling that their dignity as a whole person is upheld. In short, competent application of your technical skills is in itself an essential component of a caring response.
Summary
A professional caring response includes the conscientious expression of technical competence. In most cases, the optimal result is reached through the coordinated efforts of the interprofessional care team because the many-faceted aspects of the patient’s situation can be more fully assessed. Modern technology is an asset when used wisely as a tool of technical competence.
Care as Professional Responsibility
The idea of a caring response is also partially captured in the common phrase professional responsibility. In legal language, professional responsibility can be summarized with the term due care. Due care specifies what is reasonably expected of you in your role as a provider of professional service to a particular purpose.12 You can see how technical expertise applies to this idea. Before we go into more detail, take a minute to draw on your commonsense idea of responsibility.
Reflection
Previously in this chapter, you had an opportunity to identify some competing claims on you as you move through this day. Take it a bit further now and try to describe your understanding of your responsibilities to yourself or others involved in each of those claims.
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Accountability and Responsiveness
From an ethical point of view, the authors find that one of the most helpful interpretations of professional responsibility is that described by theologian Richard Niebuhr in his now classic book The Responsible Self.13
Accountability
The most common understanding of professional responsibility associated with the health professions grows out of the western philosophic traditions that emphasize the individual’s functions in upholding the moral life. Accountability, holding one to account for one’s actions, assumes that one is not only capable of acting in a certain way and has the appropriate knowledge to do so but is also free to go ahead unimpeded. Once those conditions are met, your decisions rest entirely with you.
Accountability also implies that an ethical standard exists against which one’s actions can be measured. Recall that the ethical gold standard of healthcare is to uphold the patient’s dignity. In one form or another, all accountability is related to upholding the dignity of ourselves and those with whom we are in relationship. If you go back to examine your own profession’s code of ethics through the lens of accountability, you will note that it is very duty oriented and describes the basic characteristics and conduct expected of anyone in your field. In that regard, we could all benefit from the sign that former U.S. President Harry Truman kept on his desk, “The Buck Stops Here,” which means “I am the one who has to finally answer to what happens in those relationships where I am entrusted to uphold human dignity. In these situations, I deserve to be held to account.”
Your own list of claims likely evoked different kinds of accountabilities you know that you and others are counting on to keep your relationships from self-destructing. Whether with a friend or spouse, with a patient, or sitting at the desk of a president, a caring response requires accountability. As you can quickly discern, accountability can also lead to abuse of the power invested in one by virtue of one’s societal role. Part of a caring response in the health professions is not to take advantage of that position. It is within this framework that Niebuhr proposes the necessary complement of responsiveness.
Responsiveness
An important contribution by Niebuhr often overlooked in ethical discussions of responsibility is that it is relational. Accountability, taken alone, is unidirectional and does not require a detailed understanding of what one is being accountable to, and why. Responsiveness requires willingness to engage with the other to try to gain a deep understanding of the person or group to whom one is accountable and a willingness to adapt conduct to honor them. With this, we are back in the territory of paying attention to and communicating effectively with the other, those essential general ingredients of a professional caring response. The importance of adding responsiveness to the concept of responsibility is emphasized in this excerpt by ethicist Thomas Ogletree, who also highlights how creative a process effective caring is:
Responsive judgments are guided by the notion of what is fitting. The fitting action may be largely self-evident once we have grasped what is morally at stake in a situation. Yet it may emerge only gradually, through the thoughtful balancing of multiple variables in their negative and positive features. Moral imagination and discernment are as important to this balancing process as are conceptual precision and logical rigor. The reasoning involved, moreover, is often more akin to weaving a tapestry than to forging a chain.14
Reflection
Given these insights, jot down some aspects of Mr. Sanchez’s situation to which Pat Jackson and her colleagues must be responsive in choosing a course of action that meets the general requirements of accountability.
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In Chapter 4, you will be introduced to some approaches to ethics that show how over time the field itself is increasingly acknowledging the contributions of the patient’s story in the professional’s deliberation about morally right conduct that aligns with providing a caring response.
Professional Responsibility and Rights
As you know, the idea of rights plays prominently in ethical and legal discourse regarding our responsibility toward each other, animals, and the environment. What is a right? Basically a right is a concept that identifies stringent claims or demands of one person or group on another. If I present you with something that is my right, you must honor this quality or need in me. The weight of your demand creates a duty for me to respond to it. For instance, in a founding document of the United States, the Declaration of Independence, we find the phrase that Americans are “endowed” with the rights of life, liberty, and the pursuit of happiness. If I have a right to life, you have a duty to help protect it and you certainly must not rob me of it. Therefore, rights and duties are inextricably linked, although as you will learn in Chapter 4, not all duty-driven ethical theories or approaches rely (historically speaking) on the relatively recent concept of rights.
When rights are interpreted as applying to everyone alike, they are said to be human rights. The core idea of human rights is that they are an important means of expressing a common hope for humanity that flows beneath differences of culture, civilization, and ways of life, like the magma that flows beneath the earth’s varied surface. We are born to nourish our life individually and as a society, and we have invented the language of human rights to try to help us understand what we must do to make this nourishment available to everyone when we are different in so many external ways.
Some rights are associated with healthcare and the health professional and patient relationship in the United States and other countries. Healthcare itself is viewed as a right in many parts of the world.
Reflection
If you think back to the relationship between Mr. Sanchez and Pat Jackson, what do you believe are the rights of each?
The patient, Mr. Sanchez’s, rights:
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The health professional, Pat Jackson’s, rights:
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Compare what you wrote with the following commonly cited rights of patients and health professionals.
The patient has a right to:
• Respect from the health professionals and healthcare system
• A clean and welcoming environment
• High-quality care
• Confidentiality of sensitive information
• Shared decision making about course of treatment
• Truthful information about one’s condition to enhance self-determination about what to do in regard to treatment options
Health professionals have a right to:
• Relevant information necessary for treatment to be effective
• Freedom to freely exercise clinical best judgment (i.e., professional autonomy)
• Fair payment for professional services
Critics of rights approaches point out that an emphasis on rights in healthcare has the following shortcomings:
• Rights are highly individualistic and emphasize the demands of one individual or group on another, thereby often obscuring their common interests or other interests that also are relevant to the situation.
• When rights conflict, very little within rights approaches exists to help to resolve the problem.
• Rights often are too general for the responder to determine which duties adequately meet the demand for a response. An example is the right to healthcare. My demand for health-related services based on my right to healthcare can be interpreted by you as anything from a right to a band aid to all the services and goods you can provide.
We urge you to pay attention to rights language that you find in your ethics codes, policy statements, or institutional documents; in licensing laws; and in use by colleagues or patients. In each case, the language is designed to urgently summon a caring response to a request that is embedded in the demand. Your professional responsibility is to discern the particulars of such a response. You will discover that no one formula for implementing a professional caring response based on human rights fits all patients, any more than it fits all nations, cultures, or civilizations. However, use of rights as a general guide takes the professional a long way toward understanding what is involved.
Summary
A professional caring response includes a specific understanding of responsibility toward others that includes accountability and responsiveness. A deep understanding of responsibility has evolved through the language of rights. Rights are stringent claims on someone else or society for a caring response to a person’s or group’s needs. Human rights usually are viewed as universal needs such as food, shelter, healthcare, and the protection of life itself. Rights claims may come from both health professionals and patients and help to shape professional responsibility and summon a truly caring response.
Social Determinants of a Caring Response
So far in this chapter, you have been reading about ways the goal of a professional caring response can be met. Some external factors influence the likelihood of this good intent being realized, and taken together, they can be recognized as social determinants of care.
Three important such determinants are discussed here: challenges incurred by the rich cultural diversity of patients and others, unpreventable compromises as a result of limited resources, or unjust policies and practices that may limit you from providing evidence-based best practices in your care delivery.
Cultural Differences
One key consideration is the rich, radical, ethnic, and cultural diversity of humans. Professionals and patients not only come in all sizes and shapes but also bring to their relationships their personal and group identities associated with their ethnicity, age, gender, sexual orientation, religion, geography, socioeconomic standing, nationality, and education. Taken together, these traits compose a person’s or group’s culture and help determine their understanding of health and how it should be addressed. Cultural competence is part of your mastery directed toward meeting the goal of a caring response with patients. Cultural competence is “an ongoing process in which the healthcare professional continually strives to achieve the ability and availability to work effectively within the cultural context of the patient.”15 Cultural competence is supported by an inclusive environment that upholds dignity and respect for all.
Reflection
What assumptions can you make about the cultural differences between Pat Jackson and Mr. Sanchez from the smidgen of information you have about each of these parties?
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Such differences among members of the interprofessional care team may also raise challenges to effective teamwork.
Reflection
Look around the room of your classroom or clinic. What observations can you make about the cultural differences between you and your colleagues from the information you have about each of them?
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Observations are an integral part of good clinical assessment. Reflection on observations provides an opportunity to acknowledge key differences and work through assumptions so that they need not be a barrier to achieving a caring response for the patient. Sometimes the smallest things can make the biggest impact.
Limited Resources and Justice Considerations
The ethical idea of justice, addressed in later chapters of this book and the focus of the final section, requires you to take into account how a particular important good or service can be distributed fairly among persons with similar needs. The rub comes when a limited supply of the valued good such as money, beds, or equipment, or even clinics, prevents professionals from providing enough of the valued good to a patient to satisfy what an optimal care plan requires. It also arises when there is a limited supply of health professionals or the time each can devote to a patient. If you think back to the rights discussion in this chapter, you can understand the moral bind this puts the professional in because rights suggest that your duty is to give each and every patient what he or she needs, and the full extent of meeting that expectation cannot always be met.
Limitation reminds us that ours is not a perfect world. Butting up against this kind of external constraint requires that great care be directed to how the least harm will result. Theories of distributive justice are available to help professionals think through the options. Policies and practices that focus on fairness are attempts to help come to the professional’s rescue and are included for your more thorough consideration in later chapters.
Limited Resources and Unjust Practices
At the same time, seemingly unjust policies and practices that arbitrarily tie the professional’s hands sometimes occur.16 At the time this book goes to press, a grave concern in the United States shared by many professionals (and prospective patients) is whether access to healthcare is made available and, if accessed at all, whether the quality is similar across the board. Should money (i.e., ability to pay) be the single most important qualification for healthcare services? Many say no. Policies that give disproportionate advantage to those who are economically much better off are judged as one injustice in the U.S. system.
To better understand the relationship between Pat Jackson and Mr. Sanchez from the larger perspectives of culture and justice considerations, consider the follow-up to what happened after he left the clinic.
The Story of Pat Jackson, the Interprofessional Care Team, and Mr. Sanchez (continued)
During the interprofessional care team meeting the week after her interaction with Mr. Sanchez, Pat had the haunting feeling that she may have misdiagnosed Mr. Sanchez’s problem. In the ensuing discussion, she was made more acutely aware that asthma can be a serious life-threatening health problem for the migrant field workers because it is exacerbated by allergic responses to pollen. Being so new to the environment and this population of patients, she previously had not been fully cognizant of this fact.
Pat also had not been employed at the clinic long enough to know that the migrant workers come with no healthcare coverage, but this, too, came up at the meeting. The administration of the health system in which the clinic is situated has not been supportive of the clinic giving the migrant workers the same welcome as “paying customers” and follow-up often falls short of ensuring effective long-term clinical management of the problem. Although this policy has not been put in writing, at the team meeting, several members expressed increasing distress at the quiet pressure they have felt to do only the minimal and move this population of patients out.
This increased Pat’s own concern about her lack of diligence. “I should have documented his wheezing more fully,” she thought. “If everyone who saw migrant workers would document their own distress about the suffering of these patients, our reports over time could have an impact on the hospital administrators who are the primary policymakers.” This knowledge gave her sufficient motivation to make an appointment with the attending physician on the team to discuss her own distress further. He reminded her that owning up to one’s shortcomings or mistakes as she had done is part of how good teamwork can continue to maintain its standard of excellence and that she had done the right thing by bringing it up at the meeting. He showed sympathy for how this could have happened because she was so new to this environment but also reminded her that due diligence is always required.17
The very next Friday, Mr. Sanchez was brought in by his foreman, this time in acute respiratory distress. The receptionist helped him onto a stretcher and into a clinic booth, where a nurse placed an oxygen mask over his face and took his vital signs. The attending physician stood ready to perform resuscitation if necessary, frowning while he scanned the patient’s clinical record. “Serious asthma attack,” he said to the nurse. “Glad you were right here!” Pat hovered near the curtain of the treatment booth, her heart pounding. Now she knew beyond a doubt that she had misdiagnosed his problem during his initial visit. She was ambivalent about joining the nurse and doctor but felt a wave of gratitude to these teammates for being there.
New thoughts went through her mind. What if she was shunned by patients in this population because the word got out that she was not competent to treat them? And what about her clinic’s pride in providing quality care to Mr. Sanchez’s previously underserved Hispanic community, even in spite of the administration’s current resistance? Where would that community find clinical care if not with them?
Later that evening, Pat emailed her whole team to say that she wanted to be an agent in supporting the team’s efforts to work with the administration toward a more just solution for the migrant population and other poor rural dwellers who could not pay for optimal treatment. She wrote that her own commitment as a caregiver must include efforts to change policy or practices that seemed unfair (or at least required closer scrutiny) and offered to work with administration to find a more workable solution. She assured the others that she understood the institution’s need to survive fiscally but that this should never warrant discrimination against a given population to balance the books. She invited others to join her because together they would probably increase the likelihood of coming up with strategies that would encourage the administration to invite discourse and, hopefully, make some changes.
In this follow-up to the first part of the story, we can see more clearly how attentiveness to patient diversity, justice considerations, and the professional’s participation at the policy level are part and parcel of how a professional caring response is realized. The creative energies that lead to job satisfaction over the long haul can emerge to support these extended efforts at improving care.
Summary
A professional caring response must be understood within the limits of constraints imposed by lack of cultural competence, limited resources, and unjust practices. Professionals have it within their ability to gain cultural proficiency and actively address the root sources of challenges to care imposed by limited resources and unjust practices or policies.
Burdens and Benefits of a Caring Response
At the core of all your caring, you have to be in touch with caring for yourself. That in turn means looking at all the ways caring in your professional role affects you. A caring response is such a fundamental goal in the health professions that sometimes the real burden and benefits of engaging in the professional relationship are overlooked. Hopefully this last section of the chapter helps to rectify the oversight.
The Burden of Care
Although care is usually cast in a positive light for good reason, it is easy to ignore the reality that searching for a caring response and acting according to what it requires of you is a burden at times.
Reflection
Have you ever been in a personal relationship in which your caring incurs a heavy burden on your energies, activities, and happiness? These may be burdens that you willingly carry or that you find yourself wishing you could be free of. You may want to name the types of things that feel like burdens in that relationship for a reference point as you read on.
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The burden of caring is not limited to personal relationships. In a graduate course of students in the health professions, one author asked the students to be brutally honest with themselves about negative feelings they had at times about caregiving. Some of their responses are shown in the subsequent box.
Are these health professionals expressing feelings that make them unfit for their professional role? Not necessarily. It goes beyond the purpose of this text to unpack all the underlying conditions that might lead a professional to make such statements regarding the feelings about caring that arise from time to time. The purpose of sharing their feelings here is to mark for you that professionals know they have to try to live up to their professional responsibility, but there are personal costs associated with doing so at times. In Chapter 6, where the focus is explicitly on caring for yourself, you will have an opportunity to explore how to overcome barriers to your own caring for others or find support that helps you not govern your responses to patients. For the time being, you have an opportunity to use this insight to prepare yourself for situations in which you do not automatically warm up to finding the caring response for a particular patient. We find it reassuring, for instance, that the burden Pat carried about her relationship with Mr. Sanchez was offset in part by her insight into the bigger picture of how she could express care at the larger institutional level. Although this cannot substitute for keeping the patient at the center of one’s caring, it does help to keep the bandwidth of expressions of care before the reader.
Benefits for the Caregiver
Fortunately, overall, the amount of negative burden a caring response incurs usually is small compared with the benefits. Developmental psychology tells us that one of the most important ways in which adults gain a recognized place in society is through their contributions to that society’s well-being. Professional caregiving benefits you by putting you in a position to participate in activities that society respects. For most health professionals, caregiving is also a basis for self-fulfillment and job satisfaction. Many can relate to the line in the prayer of Saint Francis of Assisi, “It is in giving that we receive.” What do professionals receive? You often hear those who have been in the field for a long time recount how much their work has given them, including remarkable insights into their own humanness, in both its vulnerability and strengths; how they have been inspired by patients’ “will to live” or gumption to continue on in spite of seemingly great challenges; and how the kindness and gratitude of patients and families help keep the professional going. What we hear, and as clinicians we have experienced, is that the search for a caring response to a patient is a creative activity in which the health professional also stands to gain something wonderful.
How then does this understanding and awareness help to shape a truly caring response to a patient’s situation? Your part in engendering mutual respect for what each offers the other as humans must burn at the core of the relationship. We can catch a glimpse of this when Pat Jackson began to take a second look at who Mr. Sanchez was when he came back a second time. It became an occasion for her to learn something important about herself and the kind of professional she wanted to be. It was an occasion for her to feel gratitude toward her team members who now were showing such care toward him. She had to move towards acknowledging that the only thing an individual professional or interprofessional care team can offer is to tap into a patient’s or group’s desire of healthfulness and try to support it.
Summary
Although caring involves burdens for most professionals, they find that the benefits outweigh the burdens. A professional’s acknowledgment of caring as a basic competence and resource tips the balance toward the likelihood that all, including themselves, benefit in the professional encounter.
Summary
This discussion of the ethical goal of a professional caring response supports thoughtful exploration into ways that care warrants special attention as health professionals strive to refine their unique contributions to individuals and societies. Looking ahead to the next chapters, you will be introduced to ethical challenges that present themselves in different forms or prototypes: moral distress and ethical dilemmas. Both call for you, the professional, to be guided by the goal of a caring response. You are now ready to take what you have learned about a caring response into the specifics of recognizing an ethical issue and submitting the situation to ethical analysis in your search for an ethically acceptable resolution and informed action. Indeed, for the rest of the text, the reader will be brought back time and again to the central role of care.
Questions for Thought and Discussion
1. As a health professional, you will be expected to provide a caring response to all kinds of people. Which populations of patients do you think will be the most difficult to truly care for and why? Give some specific examples of behaviors or other characteristics that you think would make caring about and for such patients especially challenging.
2. Describe a medical or dental visit in which something happened to make you feel that the professional’s attention was not centered on you. What happened? What could the professionals and others in that environment have done to make you feel more like they were motivated by the goal of a caring response to you?
3. The emergency departments of major hospitals are a whirlwind of activity, with many life or death situations for patients who literally have just come through the door. When asked to reflect on care in the emergency room, a young nurse recently said to one of the authors, “There’s no time for hand-holding here. We are too busy; it’s life-or-death interventions 24-7.”
a. What are some examples of how the emergency room interprofessional care team can demonstrate a caring response to patients?
b. Now do the same exercise in an operating room setting.
c. And finally, do the exercise as an interprofessional care team member working in a locked residence for patients with advanced Alzheimer’s disease.