How to accommodate patients’ religious views while maintaining a standard of optimal medical care.

How has access to health care changed? By that, I mean, what were your healthcare needs twenty years ago and how did you meet them; and, what are your health care needs today and how do you meet them?
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November 29, 2020

How to accommodate patients’ religious views while maintaining a standard of optimal medical care.

Which issue frames the values in tension?
How to accommodate patients’ religious views while maintaining a standard of optimal medical care.

How to overcome parental objections to appropriate care without filing a dependency action.

How best to assure that Rachel and her baby get appropriate medical care while respecting hospital policy and the wishes of the parents.

How to assure nurses are trained to provide care for minors while deflecting any parental opposition.

Who are the primary stakeholders in this problem?
Rachel Banks
She is the pregnant patient who may need more medical care than her parents want.

Mr. and Mrs. Banks, Rachel’s parents
They are the patient’s legal guardians and do not appear to want additional care for their daughter.

Joseph Banks, Rachel’s brother
He is concerned for his sister’s well-being and for the safety of her child.

Rachel’s unborn daughter
This is the child who is about to be born and may need medical intervention to assure safety.

Dr. Emerson Rogers, Chief of Staff
He is responsible for everything that goes on in the organization and often liable for ethical mistakes.

Rachel’s physician
The doctor is dealing with another emergency, but Rachel is still a patient for whom the doctor is responsible.

You, Supervising Nurse
You have to make and implement the decision.

Father Giles Mumford, hospital chaplain
He may be called on to provide religious support.

Yvonne Napier, RN
She is the one primarily responsible for assuring Rachel has a safe delivery.

Other Ob/Gyn nurses
They are responsible for assuring that Ob/Gyn patients receive appropriate and timely medical care

Which duties do you owe the stakeholders?
Duty to follow hospital policy.

Duty not to interfere with competent staff in doing their jobs.

Duty to support your staff’s professional improvement.

Duty not to accommodate parents who are harming their child.

Duty to make parents do the right thing for their daughter.

Duty to provide the best patient care possible.

Which option best fulfills your duties?
Option 1
Confront the parents about their daughter’s need for medical attention.
Option 2
Ask the nurse to do a thorough check to verify that the situation has not reached the point where intervention is necessary.
Option 3
Trust your nurse to provide sufficient care to prevent the fetus from going into medically dangerous distress.
Option 4
Call the physician on duty without seeking input from or informing the parents or the assigned nurse.
Option 5
Ask the assigned nurse to call a physician and a chaplain. Make sure that the mother is assessed medically and that the parents are provided a ministerial response.
Option 6
Involve the assigned nurse and the parents in assessing need for medical intervention to ensure a safe delivery. Provide contacts for aftercare support and education.

What are each stakeholder’s criteria for ethically mature action?
Rachel Banks, who wants her baby to be delivered safely, is happy in this situation if…
The hospital staff do not make her situation with her parents worse.

The hospital gives her medication to reduce pain or advance her labor.

The hospital provides care so that she is not in unnecessary pain and her baby is delivered safely.

Rachel’s parents, who do not agree with their daughter’s choices, but do not want her or their grandchild to be harmed, are happy in this situation if…
They do not have to raise their grandchild.

Their values are respected by medical care providers.

Their daughter and their grandchild receive the care they need to be safe.

Rachel’s daughter, who is about to be born and may need medical attention to prevent injury, is happy in this situation if…
Her mother’s choices are validated.

Her mother gets the medical attention she needs for a safe delivery.

She is born without injury or unnecessary pain.

Rachel’s physician is happy in this situation if…
Rachel is given the best medical care possible.

The doctor has final approval on every decision regarding Rachel’s care.

Rachel’s parents are given all appropriate medical information.

You, as you have to make and implement the decision, are happy in this situation if…
Your nurses do not provoke patients to sue the hospital by giving them necessary medical care.

Your nurses give appropriate and necessary care to all patients without discrimination.

Your nurses do not provoke lawsuits because of their religious beliefs.

Yvonne Napier, Rachel’s nurse, who is primarily responsible for Rachel having a safe, uneventful delivery, is happy in this situation if…
She is trusted to determine when patients assigned to her need additional medical attention.

She is able to promote the safe delivery of healthy children.

She is allowed to determine when patients assigned to her should not receive additional medical care.

Which option best meets each stakeholder’s ethical desires?
Option 1:
Confront the parents about their daughter’s need for medical attention.
Option 2:
Ask the nurse to do a thorough check to verify that the situation has not reached the point where intervention is necessary.
Option 3:
Trust your nurse to provide sufficient care to prevent the fetus from going into medically dangerous distress.
Option 4:
Call the physician on duty without seeking input from or informing the parents or the assigned nurse.
Option 5:
Ask the assigned nurse to call a physician and a chaplain. Make sure that the mother is assessed medically and that the parents are provided a ministerial response.
Option 6:
Involve the assigned nurse and the parents in assessing need for medical intervention to ensure a safe delivery. Provide contacts for aftercare support and education.

Rachel Banks 6
1. The hospital staff do not make her situation with her parents worse.
2. The hospital provides care so that she is not in unnecessary pain and her baby is delivered safely.

—— Options ——
1 2 3
4 5 6

Mr. and Mrs. Banks, Rachel’s parents 5
1. Their values are respected by medical care providers.
2. Their daughter and their grandchild receive the care they need to be safe.

—— Options ——
1 2 3
4 5 6

Rachel’s unborn daughter 3
1. Her mother gets the medical attention she needs for a safe delivery.
2. She is born without injury or unnecessary pain.

—— Options ——
1 2 3
4 5 6

Rachel’s physician 6
1. Rachel is given the best medical care possible.
2. Rachel’s parents are given all appropriate medical information.

—— Options ——
1 2 3
4 5 6

You, Supervising Nurse 5
1. Your nurses give appropriate and necessary care to all patients without discrimination.
2. Your nurses do not provoke lawsuits because of their religious beliefs.

—— Options ——
1 2 3
4 5 6

Yvonne Napier, RN 2
1. She is trusted to determine when patients assigned to her need additional medical attention.
2. She is able to promote the safe delivery of healthy children.

Which option creates the greatest good?
Option 1:
Confront the parents about their daughter’s need for medical attention.
Option 2:
Ask the nurse to do a thorough check to verify that the situation has not reached the point where intervention is necessary.
Option 3:
Trust your nurse to provide sufficient care to prevent the fetus from going into medically dangerous distress.
Option 4:
Call the physician on duty without seeking input from or informing the parents or the assigned nurse.
Option 5:
Ask the assigned nurse to call a physician and a chaplain. Make sure that the mother is assessed medically and that the parents are provided a ministerial response.
Option 6:
Involve the assigned nurse and the parents in assessing need for medical intervention to ensure a safe delivery. Provide contacts for aftercare support and education.

—— Options ——
1 2 3
4 5 6

Settled Law

Legal issues involved in this scenario include equal access, decision-making, accommodation of religious beliefs, and legal liability for foreseeable harm. Unless a

minor mother has been legally emancipated, her parents have legal authority to make decisions for her. In the vast majority of cases, courts will defer to the wishes

of competent parents about their children’s medical care. In rare cases, such as where a routine medical treatment means the difference between life and death for a

child, a court may order that treatment be provided in the face of parental opposition.

Because neither the mother nor the fetus is a “legal person,” the adult parents have a great deal of control in this case. Ham-fisted interference by medical providers

may very well provoke a lawsuit by the parents. They might sue simply on the basis that the hospital has illegally interfered with their parental rights—which are

virtually sacrosanct under the law. In addition, they might sue on the basis that the hospital violated not only their parental rights but also their religious rights

by forcing unwanted medical care on their daughter.

At the same time, if the hospital fails to act and the mother and/or the baby are harmed because of the lack of medical attention, the parents may also sue. The

hospital is in a real bind in either case. Whether the hospital would prevail at trial is the least of its worries, as there would be little or no hope of recovering

legal fees, and reputational damage may be significant. While the legal ramifications of action in this case may be significant, they are only one factor among many

that should govern decision-making in this case.

Emerging Trends

So long as the baby in this dilemma is born healthy and without incident, the likelihood of a lawsuit is relatively small (unless the parents believe their religious

views have been compromised). This is unfortunate, because this situation is rife with opportunities to improve both decision-making and the delivery of care.

Family members typically do not plan for emergencies and extraordinary medical care, making everything more complicated for family as well as medical providers when

emergencies do occur. However, just because most patients don’t prepare for emergencies does not mean that medical providers can’t develop protocols to help people in

crisis make decisions they can live with long-term. Doing so may not be the medical providers’ “responsibility,” but it can help reduce legal liability.

Regardless of medical outcome, those who feel they have had a full opportunity to participate in the process or make fully-informed decisions are less likely to sue

than those who do not. Routinely thinking in terms of “what’s the worst that could happen?” can be a helpful tool in avoiding crises and reducing the consequences of

those crises which do occur despite best efforts. More work may need to be done up front, but patient outcomes are likely to improve, which translates into more job

satisfaction for medical providers. In other words, everyone benefits in the long-run.

Which issue frames the values in tension?
How best to assure access for gay partners of Seva’s patients on equal footing with straight couples.

Whether Yves can sue the hospital for denying access if he and Alain are not domestic partners.

How best to challenge Carlotta’s narrow interpretation of ‘domestic partner.’

Whether gay couples should be required to provide documentation of their relationship

Who are the primary stakeholders in this problem?
The Shareholders
Actions that affect the value of the company affect their ownership interest.

Dr. Emerson Rogers, Chief of Staff
He is responsible for everything that goes on in the organization and often liable for ethical mistakes.

Eugene Moreland, General Counsel
He would have to manage any litigation arising from this situation.

Carlotta Baldwin, RN, Shift Supervisor
She believes the hospital’s policy on who is family does not include Alain and Yves.

You, Staff Nurse
You are the one that has to make and implement the decision.

David Thoreau, Hospital Administrator
He oversees all functions of Seva Regional Medical Center.

Alain Trottier, Patient in ICU
He is the one whose family is in question on the basis of Carlotta’s decision.

Yves St. Martin, Alain’s partner
He is seeking access to his partner in the ICU.

Amelia Finch, Director of Nursing Services
She is your supervisor as well as Carlotta Baldwin’s supervisor.

Which of the following rights represent basic liberties?
Right to participate in decision-making for an unconscious family member.
Right to have hospital policy regarding participation by family members implemented.
Right to have access to family members at all times.
Right to have your relationship acknowledged.
Right to be informed that your interpretation of hospital policy is inaccurate.
Right to refuse to follow hospital protocols you do not agree with.

Who are the most and least advantaged stakeholders?

The shareholders

Carlotta Baldwin, RN, Shift Supervisor

You, Staff Nurse

Alain Trottier, Patient in ICU

Yves St. Martin, Alain Trottier’s partner

Amelia Finch, Director of Nursing Services

Resources: Ethics Game; University of Phoenix Material: Ethics Game Simulation Worksheet; Grading Criteria: Ethics Game Simulation

Access the Ethics Game simulation.

Complete the Ethics Game.

Document the results in the Ethics Game Simulation Worksheet.

Write a 1050- to 1,400-word reflective journal in which you answer the following questions:
•What were the ethical issues presented in the simulation?
•What decision-making steps did you take to ethically address these issues?
•What ethical perspectives, or lenses, did you use to make your decisions in the simulation?
•How did these ethical perspectives, or lenses, influence your decisions?
•How might concepts from this simulation relate to your workplace?

Ethics Game Simulation Worksheet

Student Name: ________________ Facilitator: ______________

Complete the interactive Ethics Game Simulation, located on the student website.

You will only be able to go through the simulation once, so please use this worksheet to take notes.

The simulation will use the following decision model with the indicated critical decision points. Take notes about your decisions or make a copy of the screen when you

complete the work to assure that you have the information needed to write your reflection at the end of the simulation.

The Case of the Troubled Teen
Step 1:
Be Attentive
What is the issue? Screen
4
Your notes:

Step 2
Be Intelligent
Who are the stakeholders? Screen
6
Your notes:

Step 3a:
Be Reasonable
Rights/Responsibility Lens
-Identify duties.
Which option best fulfills the requirements of this lens? Screens
8-10
Your notes:

Step 3b:
Be Reasonable Results Lens
-Determine impact on stakeholders.
-Determine values of stakeholders.
-Determine criteria for happiness.
Which option best fulfills the requirements of this lens? Screens
12-17

Your notes:

Step 3:
Be Responsible Which option that best reflects your core values in this situation? Screen
19
Your notes:

Step 4:
Be Reflective Write a memo that explains your choice and modifies the decision in a way that reflects your core values and your notion of the best solution to the

problem. Screen
20
Your notes:

The Case of Policies and Politics
Step 1:
Be Attentive
What is the issue? Screen
25
Your notes:

Step 2
Be Intelligent
Who are the stakeholders? Screen
27
Your notes:

Step 3a:
Be Reasonable
Relationship Lens
-Identify basic rights.
-Choose process for basic liberties.
Which option best fulfills the requirements of this lens? Screens
29-33
Your notes:

Step 3b:
Be Reasonable Reputation Lens
-Determine impact on stakeholders.
-Determine values of stakeholders.
-Determine criteria for happiness.
Which option best fulfills the requirements of this lens? Screens
35-40

Your notes:

Step 3:
Be Responsible Which option that best reflects your core values in this situation? Screen
42
Your notes:

Step 4:
Be Reflective Write a memo that explains your choice and modifies the decision in a way that reflects your core values and your notion of the best solution to the

problem. Screen
43
Your notes:

The two good answers focus only on your responsibilities to one or two stakeholders instead of taking the wider systemic perspective.
• Relationship: Using the Relationship Lens, the good decision isn’t a bad option because you have provided for immediate access. However, your solo action fails to

implement the system and ends up being somewhat authoritarian. Merely noting that Yves has access is too limited in scope as a solution, although the action is moving

in a good direction, ethically.
• Reputation: Using the Reputation Lens, the good decision you have provided immediate access. However, you haven’t assured access long-term. Even though you advise

your replacement to continue the access for Yves, you haven’t acted with courage in seeking a system solution that relies on the integrity of the policy already in

place.
The two least ethically mature answers focus only on yourself and your particular interests.
• Relationship: Using the Relationship Lens, with the poor decision, you aren’t implementing the chain of command, you’re simply shirking responsibility. Yves

continues to have no access and you merely ignore the injustice, which is counter to the Relationship Lens.
• Reputation: Using the Reputation Lens, with the poor decision you have demonstrated no character yourself. Instead, you have simply perpetuated the problem of

unequal access for gay and lesbian couples. Further, you’ve lied about Yves’ real relationship by documenting that he’s a ‘brother’ of Alain.

Relationships Reputation
Best 1. Note on Alain’s chart that Yves is to be given access and treated as family. Notify your supervisor that hospital policy is not being followed. 4. Note on

Alain’s chart that Yves is to be given access and treated as family. Speak to Carlotta about your decision and let your supervisor know.
Good 6. Note on Alain’s chart that Yves is to be given access and treated as family. 3. Give Yves access and involve him in decision-making during your shift and

advise your replacement to continue the practice.
Poor 5. Tell Yves nothing as to whether he can or cannot be in the room. When he comes into Alain’s room, don’t take any action. 2. Advise Yves to say he is Alain’s

brother and identify them as siblings on Alain’s chart.

Case Closed!

The final step, Being Reflective, doesn’t end when you’ve made your choice. This step is an ongoing process as you watch the consequences of your decision unfold.

Would you make the same choice again? Were you happy with the results? Of course, it’s important to take the time to think about hypothetical consequences before you

carry your decision forward. Let’s see how your decision played out….

You chose the following option:
Tell Yves nothing as to whether he can or cannot be in the room. When he comes into Alain’s room, don’t take any action.
On a scale of 0 to 5, from low to high risk, your decision rates a 4. It represents high risk.

Taking no action leaves the least advantaged at risk of harm. You have not reduced the risk of litigation because you have failed to implement the system. Increasing

the risk of liability also decreases the opportunity to improve the hospital’s standing in the community. You have not provided access to the partner, which is the

primary risk of liability here.

Settled Law

Although inequities in access to health care plague the United States health care system, once a patient is admitted to a hospital, most disparities in care disappear.

Married couples generally assume that they will be given access to a spouse who is a patient and consulted for decision-making purposes if the patient spouse is unable

to make their own decisions. Hospitals tend to gather family and friends of a patient for decision-making purposes when the patient is unable to make their own

decisions. Visitation by anyone who meets generic criteria is generally permitted so long as the visitor poses no risk of harm to the patient or others.

For Gay, Lesbian, Bisexual, and Transgendered (GLBT) patients, however, this is not always the case. Despite an increase in hospitals with non-discrimination policies

and the proliferation of legally recognized same-sex relationships in many states, common wisdom in the GLBT community still suggests you may be better off identifying

as a partner’s brother or sister to assure access and participation in decision making. The patchwork of state laws and hospital policies makes it difficult even for

married same-sex couples with Advanced Healthcare Directives (AHDs) to be certain they will be treated the same as opposite-sex couples or provided access to a loved

one in the event of a catastrophic emergency.

Hospitals who deny access to same-sex partners may be liable in a variety of circumstances. In addition, the cost to a hospital’s reputation for discriminating in

patient care and access may do far more damage than a lawsuit. Hospitals must initially comply with the federal Patient Self-Determination Act, providing information

to patients at the time of admission about their decision-making rights and the hospital’s policy on AHDs. Even if the patient is not conscious when admitted, many

hospitals have Patient’s Bill of Rights, which may include a right to visitors or to have one’s designated decision maker act on one’s behalf. Hospitals which receive

federal funding are required to comply with the federal government’s non-discrimination policies, which include prohibitions of discrimination based on sexual

orientation. A number of states also have state non-discrimination requirements for public accommodations, which typically include hospitals. In some cases, a

hospital’s accreditation is dependent on compliance with non-discrimination requirements which explicitly prohibit discrimination on the basis of sexual orientation.

When a patient who is unable to make decisions does not have an AHD, the hospital will turn to a state-designated list of default decision makers. Default decision-

maker lists, although different from state to state, tend to identify and rank relatives similarly. The lists can be grouped into three categories with respect to

same-sex partners: 1) same-sex partners are explicitly listed along with spouses as the first choice of surrogate decision maker, 2) “special friend” is listed as a

final category, but is only chosen after all other categories of biological and legally recognized family have been exhausted, and 3) no provision at all is made for

same-sex partners. This matters because in many states, the hospital is shielded from liability only if they choose a surrogate decision maker from the state-

designated list.

Emerging Trends

Who people love is not a medical issue. Treating people with the best possible care includes assuring that the people a patient cares for and trusts are available for

them and allowed to participate in their care and treatment. Treating people with the best possible care does not mean you condone their behavior or need to compromise

your values. Medical ethics do not permit care providers to refuse to treat a GLBT person even on the basis of religious conviction.

The best facilities use a broad definition of family that takes into consideration the increasing diversity of actual families. They train their staff on non-

discrimination policies and are explicit about prohibiting discrimination on the basis of sexual orientation and gender identity; they consistently update their

policies to reflect current state law. Hospitals which provide the best care also train staff and inform patients at the point of admission about ADHs so that wherever

possible, patients can assure in advance of any need that the person they want to make decisions if they are incapacitated is allowed to do so.

The Gay and Lesbian Medical Association and the Human Rights Campaign administer an annual Healthcare Equality Index (HEI) for the purpose of benchmarking and sharing

best practices in the treatment of GLBT persons and their families. Information about the HEI can be found at https://www.hrc.org/issues/hei.asp Far too many stories

exist of same-sex partners and their children being excluded from the bedside of a loved one, who died alone despite the partners having taken every legal precaution

to support and care for each other. No court decision and no damages award can ever undo the fact that one was unable to be present at the death of a loved one,

because someone misunderstood hospital policy or refused to acknowledge a legally valid ADH.

By now, you’ve solved two ethical dilemmas and used all four of the Ethical Lenses. You can use the knowledge you’ve gained to solve the ethical dilemmas that arise in

your everyday life. Just remember the steps:
• Being Attentive: Collect the facts and notice what’s being said.
• Being Intelligent: Find the underlying issue and determine who’s really involved.
• Being Reasonable: Use the lenses to consider what is good, what is true, what is fair, and what is virtuous.
• Being Responsible: Make an ethical choice based on your analysis.
• Being Reflective: Defend your choice with careful thought and observe the aftermath closely.
With time and practice, the conflicts inherent in moral dilemmas can become opportunities for developing your ethical self. When you encounter disagreement, remember

that we all have our preferred lens. Arguments over the “right thing to do” often stem from differing definitions of what actions are ethical:
• Rights/Responsibilities Lens: Ethical action fulfills your duties and honors the rights of the individual.
• Results Lens: Ethical action respects the desires of others and seeks win-win solutions.
• Relationship Lens: Ethical action is fair and guarantees fundamental liberties for all.
• Reputation Lens: Ethical action lives up to the standards of the community and follows established virtues.
To achieve ethical mastery, we must be aware of the priorities of all four lenses and know how to communicate with and draw ideas from those who favor other lenses.

The development of mastery is an ongoing process—not an end, but a means to continual improvement.

Remember that you can review any of the previous pages to refresh your knowledge of the decision steps or the lenses. Once again, congratulations on your

accomplishments. I’d wish you luck in your future dilemmas, but you shouldn’t need luck now that you’ve had

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