This essay is a reflection on the Ethics course, a part of York PA program curriculum, and it includes aspects I foresee as central to my clinical practice as well as ethical frameworks I am looking to implement to achieve their accomplishment.
My desire to become a Physician Assistant stemmed from interactions with a few very inspiring people who dedicated themselves to helping others, not only at their workplace, but everywhere they went, without expecting anything in return. I believe it is the ultimate higher purpose that I want to dedicate myself to and becoming a Physician Assistant helps me fulfill it. We meet clinicians at the worst times of our lives, and the ability to be a person others turn to in times of distress is a big honor.
Analyzing some of the clinical practice I have had and thinking ahead about what the future will hold, I believe aspects such as continuous education, patient-centered care, transparency, shared decision making and ensuring patient autonomy will be central to my practice since in the place where I grew up those components of health care were almost absent. I was raised in a small town in Ukraine where access to healthcare was very limited and its quality was poor due to lack of financing. Both of my grandparents died at a young age at the hospital due to completely preventable causes and I have promised myself that the way I will practice medicine is going to be the way I would have wanted for them to be treated.
Beneficence is a principle based on the practice of providing benefit, which can mean either “preventing/ removing harm or directly producing a good”2. Interesting thing about beneficence is that it means not only to mean good, but to actually result in good produced. If the clinician means good but simply does not possess enough expertise to provide the best treatment possible, he or she has a moral obligation to refer the patient to another provider who does, that is why adapting to emerging changes in demand by continuous education is one of the key hallmarks of an advanced practice.
Beneficence runs parallel to non-maleficence which means minimizing harm. Minimizing harm requires thinking ahead. Defining goals of care of every shareholder is a good place to start. What might be a goal of care for the clinician or a family member, might not necessarily reflect patient’s desires and, from the patient’s perspective, produce more harm than good. According to Kirk, beneficence is producing an outcome that is consistent with patient’s goal of care. For example, a clinician may think the cancer patient would want an advanced aggressive treatment that has promising outcomes, but patient’s priority may be to spend as much time as they can at home with people they love and die in peace. A family member of an adult with a decision-making capacity may insist on futile treatments where the patient him/herself might not want them. In that case, opting out of treatments that would not align with patient’s goals of care would mean a practice of non-maleficence. Thus, knowing patient’s priorities and being able to attend to them is eminent to a successful patient-centered practice.
So how do we define “good” and who dictates it? The answer is simple: every shareholder is taken into consideration, but patient’s desires overrides everyone else’s if patient has decision making capacity (or unless proven otherwise) and is acting truly autonomously.
Patient centered care and shared decision-making employ ensuring patient Autonomy. It has many different aspects, all equally important. Autonomy as free action is ability to do what one wishes to do and not being forced to do what one does not want to1. Since my experience and main interest is mostly in radiation oncology, issues of patient autonomy in my practice may arise very often. When patient is diagnosed with cancer, his/her decisions affect not only them but everyone around them, of which they are very well aware. This pressure may at times cloud patient’s judgement when making decisions regards treatment. It is my direct responsibility to recognize and ensure every aspect of patient autonomy throughout every step of our interaction.
Cancer is a very multifaceted disease, different approaches to treatment of which may produce different outcomes. Defining goals of care for the patient making sure the priorities are established properly should be the first step of agreeing on a treatment strategy. In order to do that, a complete transparency and proper enforcement of every aspect of informed consent would need to take place. By giving the patient all the options, including opting out of treatment with proper explanation of harms and benefits that come with them and time to ponder on their decision, I would ensure Autonomy as Free action as well as Autonomy as Effective Deliberation that has to do with the rationality of a person’s thought process as well as ensuring that the action chosen is consistent with the outcome desired1. That transparency makes sure patient’s thought process is not compromised by a lack of information and that patient has all the tools to make decisions autonomously.
One of the reasons I chose to become a PA over any other profession is because PAs are able to spend more time with patients than the physicians are, thus getting to know their patients and their moral character. Prolonged sickness can affect a patient in many different ways including making them act out of character. Being a steward of Autonomy as Authenticity making sure my patients’ decisions and behaviors are in check with their moral values is a great honor.
Sometimes patient’s goal of care gets lost in a sea of voices of people who care for them which may result in patient agreeing to a treatment they don’t truly want, just to keep their significant other/son/daughter happy. In some cultures, if the patient is a married woman, decisions about her healthcare may be made by her husband or father. Same often happens with the elderly – they give up their right to make decisions to their loved ones because the culture/religion dictates that. It is my job to help patient analyze whether values guiding their action have been freely and deliberately chosen or they have been adopted unconsciously and uncritically1, thus upholding the tenets Autonomy as moral reflection which requires that type of self-assessment. Only by establishing a trusting relationship can that type of advisement take place and I’m looking forward to refining those skills in order to become the best version of myself and a proud representative of the Physician Assistant profession.
This essay briefly summarized some of the key aspects of my future clinical practice and their support by ethical principles of beneficence, non-maleficence and Autonomy as well as their application and analysis. Ethics course provided some clarity on ways to become a better provider and think critically in difficult situations.
1Yeo, M et al. (2010). Autonomy [selections]. In M Yeo et al. (eds.). Concepts and Cases in Nursing Ethics. [3rd edition] Ontario: Broadview Press, pp. 91-97, 103-109.
2Yeo, Michael et al. (2010). Beneficence . In M Yeo et al. (eds.). Concepts and Cases in Nursing Ethics. [3rd edition] Ontario: Broadview Press, pp. 103-116.
3T. Kirk, HPPA 514: Building Arguments in Health Care Ethics Cases , p.2.