Case study: an ethical dilemma involving a dying patientby Alsacia L. Pacsi

Abstract

Nursing often deals with ethical dilemmas in the clinical arena. A case study demonstrates

an ethical dilemma faced by healthcare providers who care for and treat Jehovah's

Witnesses who are placed in a critical situation due to medical life-threatening situations. A

20-year-old, pregnant, Black Hispanic female presented to the Emergency Department (ED)

in critical condition following a single-vehicle car accident. She exhibited signs and

symptoms of internal bleeding and was advised to have a blood transfusion and emergency

surgery in an attempt to save her and the fetus. She refused to accept blood or blood

products and rejected the surgery as well. Her refusal was based on a fear of blood

transfusion due to her belief in Bible scripture. The ethical dilemma presented is whether to

respect the patient's autonomy and compromise standards of care or ignore the patient's

wishes in an attempt to save her life. This paper presents the clinical case, identifies the

ethical dilemma, and discusses virtue ethical theory and principles that apply to this

situation.

"Juana" (fictitious name) a 20-year-old, Black Hispanic female, 32 weeks pregnant, was

brought to the emergency department (ED) in an ambulance by the paramedics. She arrived

in the ED immobilized on a flat board with a hard cervical collar in place. Juana was the

driver of a sedan involved in a single-vehicle collision. She stated she was driving at

approximately 60 miles per hour on the highway and suddenly lost control of the vehicle and

crashed into a light pole. She also stated her head hit the windshield and shattered the

glass. She denied loss of consciousness. Upon her arrival in the ED, Juana was alert and

oriented to person, place, and time and had a Glasgow Coma Scale of 15/15. Her initial

complaints were lightheadedness, weakness, left shoulder pain, and severe abdominal

cramping that started immediately following the car accident. She had a past medical

history of sickle cell disease and no previous pregnancies. Her lungs were clear bilaterally.

Juana's heart rate was 90 beats per minute (bpm), her respiratory rate was 28, and her

initial blood pressure (BP) was 130/80, and fetal pulse rate was 90. Once the cervical spine

films were taken and the flat board was removed, her BP reflected orthostatic changes of

100/60 and pulse of 120 bpm.

Diagnosis and interventions

Juana was placed on a 100% nonrebreather mask. Peripheral intravenous lines were started

bilaterally to replace fluid loss that was indicated by the change in vital signs. It was

suspected that she was bleeding internally into her thoracic or abdominal cavity. Blood

specimens were drawn and sent to the laboratory. A hemoglobin of 6 g/dl and hematocrit of

21% indicated internal bleeding. Ultrasound showed blood in the amniotic cavity and

Doppler confirmed a fetal heart rate of 90 bpm indicating fetal distress. The patient was

informed by the medical team of the critical nature of her condition.

The plan of care for her was an immediate blood transfusion and an emergency cesarean

section. Matters became complicated when Juana informed the medical team that she was a

Jehovah's Witness and refused the proposed plan of care. The physician then recommended

the use of alternative blood products. Juana insisted that this was also against her religion

and she refused the alternative treatments being offered. The medical team advised her

that Jehovah's Witnesses could choose certain blood byproducts, such as albumin,

cryoprecipitate, and globulin (Watchtower Bible and Tract Society, 2004).

According to Juana and her husband, both believed that if she accepted the blood

transfusion or blood products she would no longer be a Jehovah's Witness and would be

condemned to hell. The husband then presented the physician with Juana's blood card,

created by the Watchtower Bible and Tract Society, the governing organization of Jehovah's

Witnesses. The card stated her advance directives, including the prohibition of blood and

blood products.

The beliefs of Jehovah's Witnesses stem from their interpretation of passages from the old

testament of the Bible, which they believe is the inspired word of God (Watchtower, 2004).

For example, according to the New World Translation of the Bible, blood symbolizes the life

of the person or animal (Gen.9.36). Revelations (1.5) states, "The only appropriate use of

blood is the sacrificial blood of Jesus." Another passage that Jehovah's Witnesses emphasize

declares, "And whatsoever man there is among you, that eateth any manner of blood, I will

even set my face against that soul that eats blood, and will cut him off from among his

people" (Lev.7.10-14).

Juana's condition worsened within 2 hours of admission to the ED. She went into labor and

delivered a stillborn baby boy. She was immediately transferred to the intensive care unit

where, despite continued aggressive attempts to stabilize her, she went into cardiac arrest

and died.

The ethical dilemma

This case presents an ethical dilemma, a situation which arises when one must choose

between mutually exclusive alternatives (Beauchamp & Walters, 2003). Decisions may have

results that are desirable in some respects and undesirable in others. In Juana's case, her

decision to refuse the blood transfusion had the desired outcome of allowing her to remain

true to her religious beliefs. However, her choice also resulted in her death. If she had

followed the recommendation of the physicians and the team, the desirable outcome would

have been possible survival but would have had the undesired effect of violating her

religious principles. The major ethical dilemma was that by honoring the patient's autonomy

and religious beliefs, the physicians and interdisciplinary team were faced with

compromising their moral duty to administer professional care in accordance with

established standards (Chua & Tham, 2006). A brief review of the literature of Nursing

Collection II: Lippincott Nursing Journals (from Ovid) and CINAHL databases for the past 5

years found no evidence to support best practice for a Jehovah's Witness who is pregnant

and has experienced blunt trauma.

Healthcare providers faced with this situation have sometimes attempted to obtain court

orders that would overrule the patient's decision and result in her submitting to

recommended medical treatment. For example, the Illinois Supreme Court (Illinois v. Brown,

1996) upheld a mother's decision to refuse blood transfusions even though they were vital

for both the mother's and fetus' survival. The Patient's Bill of Rights states that the

healthcare providers' responsibility is to give patients accurate information and that patients

must consent to treatment (New York State Department of Health, 2008). This is consistent

with the Federal government's recommendations to create guidelines that assure healthcare

quality and to reaffirm the critical role consumers play in safeguarding their own health,

(United States Department of Health and Human Services, 1999).

Nursing practice is governed by the patient's right to autonomy rather than her religious

beliefs (Levy, 1999). The first item in the American Nurses Association (ANA) Code for

Nurses with Interpretative Statements (2001) addresses respect for human dignity:

"Truth telling and the process of reaching informed choice underlie the exercise of self-

determination, which is basic to respect for person ... Clients have the moral right to

determine what will be done with their own person; to be given accurate information, and all

the information necessary for making informed judgments; to be assisted with weighing the

benefits and burdens of options in their treatment; to accept, refuse, or terminate treatment

without coercion; and to be given necessary emotional support" (p. 1).

However, it is difficult to witness death based on a person's decision to forgo care when

medical options to sustain life are available. Treating this type of patient becomes

particularly challenging when it involves two lives.

Virtue ethics

To analyze this ethical dilemma, the principles of Western medicine and the religious beliefs

of Jehovah's Witnesses were examined. The questions that surfaced were (a) how would the

application of virtue ethics provide insight into Juana's situation, (b) what were the ethical

principles in conflict, and (c) why was it an issue to administer a blood transfusion to Juana

in an emergency situation.

Volbrecht's framework for ethical analysis was utilized to address the clinical dilemma and

the questions listed above. Virtue ethics was the primary theory employed prior to the 17th

century. This theory centers on shared familial and cultural histories and religious traditions

and acknowledges the community's ability to identify, interpret, prioritize, and adjust to

moral considerations within a particular context (Volbrecht, 2002). The following is an

exposition of this case according to virtue ethics.

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Virtue ethics focuses on what is morally correct from the patient's viewpoint and centers on

the patient's autonomy. Actions and character are intertwined, and the ability to act morally

is contingent on one's moral character and integrity. Virtue ethics focuses on the context of

the situation (Volbrecht, 2002). Ethical analysis of virtue ethics entails (a) identifying the

problem, (b) analyzing context, (c) exploring options, (d) applying the decision process, and

(e) implementing the plan and evaluating results (Volbrecht, 2002).

Identifying the problem

Juana, a 20-year-old Hispanic woman, 32 weeks pregnant, was involved in a car accident.

Internal bleeding to the thoracic or abdominal cavity was suspected. The stakeholders were

the woman, her husband, the fetus, and the interdisciplinary healthcare team. The team

thought the best method of treatment for this patient was to administer a blood transfusion

and perform an emergency cesarean section. Both the patient and her husband refused this

option because of their religious beliefs and provided written documentation indicating that

the patient would not accept blood or blood products. The value issues were the physical

survival of the woman and her fetus versus the woman's religious integrity.

Analyzing context

To understand the decision-making process in this case, one must consider the ethical

principles of autonomy, beneficence, nonmaleficence, justice, compassion, and respect. The

patient's religious beliefs and how they influenced her decision must also be taken into

consideration. Gardiner (2003) confirms that the ethical principles mentioned above

influence one's choices. In Juana's case, the healthcare team suspected she was

experiencing internal bleeding and that she and the fetus were in physiological distress.

Juana's decision to reject the proposed treatment was based on her stated religious beliefs.

The contextual factors of this case centered on the patient's religious beliefs. The patient

stated she would "rather be embraced in the hollow bosom of Jehovah than to be

condemned for all eternity," if she should receive a blood transfusion. Nurses draw from the

code of ethics to reflect upon and understand the person's perspective, and to honor her

wishes. "The nurse provides services with respect for human dignity and the uniqueness of

the client, unrestricted by considerations of social or economic status, personal attributes or

the nature of the health problem" (ANA, 2001, p.1). To respect the patient's decision and

honor her dignity, supportive care was provided to the patient in an effort to save her life,

while at the same time respecting her wishes. The ANA Code of Ethics supports the point of

view that healthcare providers should respect patients' wishes and decisions despite their

own personal beliefs (ANA, 2001).

Applying an ethical decision process

Looking through the lens of virtue ethics, the caregivers focused on Juana's autonomy and

her right to choose what she perceived best in spite of the possible outcomes. Juana was a

competent, pregnant woman who made informed decisions not to receive blood transfusions

or a caesarean section. Based on virtue ethics, the healthcare providers respected the

patient's autonomy by reflecting on and honoring the decision of the patient and her

husband based on her religious values and beliefs. The healthcare providers also drew on

the principle of beneficence, which centers on promoting the well-being of others. In this

case, the well-being was not physiological but spiritually oriented. The principle of

nonmaleficence was also employed by not intentionally inflicting harm on the patient and

honoring her wishes. Violation of a client's deeply held beliefs is a form of doing harm.

(Leonard & Plotnikoff, 2000). They also drew from the principles of veracity and respect,

which entail being truthful to the patient and allowing her to make an informed decision

(Volbrecht, 2002). The nursing virtues of compassion, moral courage, and self-reliance also

contribute to an understanding of this situation.

Evaluating results

At the time this clinical situation presented itself there were no specific guidelines in the

institution for dealing with the dilemma presented by this case. However, there are

guidelines for Jehovah's Witnesses specifically geared to early identification and

management of gynecological patients. For example, in Australasia, there are specific

guidelines for treating pregnant women that focus on stabilizing the patient by using

traditional and new treatment modalities to meet patient needs, particularly for Jehovah's

Witnesses or other patients who decline blood transfusions (Women's Hospitals Australasia,

2005). For antepartum patients, the guidelines focus on early identification of Jehovah's

Witnesses during prenatal visits, as well as placing these patients on a high risk protocol,

including maintenance of high hemoglobin and hematocrit levels, having advance directives

completed, and establishing affiliations with other hospitals that are well-equipped and

staffed to meet these patients' needs (Women's Hospitals Australasia, 2005). The Hartford

Hospital in Connecticut has a similar program and also performs bloodless procedures on

patients who are Jehovah's Witnesses (Miller, 1996).

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As a result of Juana's case being reviewed by the ethics committee post-mortem, a risk-

management protocol was developed requiring patients who refuse blood transfusions to

sign a waiver that removes the legal responsibility for the decision from the hospital and

caregivers. To support this type of protocol, the Society for the Advancement of Blood

Management maintains a database of hospitals that provide blood-conserving services in the

United States as well as in Canada, Chile, Korea, and South Africa (Society for the

Advancement of Blood Management, 2008).

The problem, however, in an emergency situation is that it may not be possible to get the

patient to a participating hospital. The Watchtower Bible and Tract Society (2004)

recommends that advance directives and other legal papers be in place should an

emergency arise. These documents should be easily accessible so that healthcare providers

can honor the patient's directives. In so doing, they will be applying the theory of virtue

ethics and, therefore, respect the patient's wishes (Macklin, 2003). Healthcare providers

should practice beneficence and non-maleficence without imposing their beliefs as to the

right thing to do. More explicit and universal guidelines would benefit both patients and

providers when faced with similar ethical dilemmas.

Ethical dilemma and resolution: a case scenarioJoseph K Wells1

Abstract

This article illustrates an ethical dilemma that I faced while treating an 86-year-old woman at her home. The ethical dilemma was caused due to several factors such as the expectations of the client (client/ consumer rights), organisational expectations (employer, governmental and payer-source regulations) and my own personal values (one's moral philosophies, perceived social responsibilities, sense of professional duty) and how they all interact with each other. The case is a classic example of a seemingly simple yet frequent dilemma encountered by occupational and physical therapists in the United States serving clients who are covered by Medicare (the government's health insurance) for home health. The article is aimed at highlighting the various ethical principles involved in clinical decision-making, and it suggests methods for resolution of ethical dilemmas. Although the article is based against the backdrop of the US health care system, students and health care practitioners globally can relate to it.

The ethical dilemma in the case discussed below involved whether or not to continue treating a client who clearly needed occupational therapy services based on medical necessity, yet the payer-source (Medicare) coverage criteria for services to be delivered at home was questionable. That is, should one continue to treat the client and uphold the principle of beneficence yet run afoul of the law, or should one discontinue treating the client to uphold the law but possibly cause harm to the client?

The case scenario

Three years ago, Ms EH, an 86-year-old woman, was referred to me after a debilitating stroke affected her right side (pre-morbidly her dominant side). Ms EH was admitted under home health after running out of Medicare allowable days at a skilled nursing facility (SNF).  Ms EH needed considerable assistance with all activities of daily living (ADL) and was primarily wheelchair-bound due to her inability to walk independently. She lived with her 88-year-old husband Mr. RH, who was also not in the best of health. Due to financial constraints the couple opted against long-term or assisted living placement in favour of their trailer home. Ms EH demonstrated good rehabilitation potential and progress with all her home health services.

One night, approximately three weeks after her return home from the SNF, Mr. RH suffered a massive myocardial infarction. He was hospitalised and underwent cardiac catheterisation. It indicated diffuse blockage of multiple vessels and he was deemed a poor candidate for surgery. Subsequent medical interventions were primarily conservative with a poor prognosis. He was later transferred to a nursing home. Ms EH obviously was very concerned and depressed about the situation. She was devoted and would visit Mr. RH for four to six hours everyday at the nursing home after being driven there by her friends and family. No one could persuade Ms EH to avoid the exertion. She would simply state, " He has always been there for me. Shouldn't I?"

Soon after her husband's admission to the nursing home, Ms EH began to have difficulty keeping up with her appointments with me and the other home health providers. Medicare's guidelines for clients to receive home health under Part-A Insurance Plan require them to meet certain "homebound" criteria. The Center for Medicare and Medicaid Services (CMS), formerly called the Health Care Financing Agency (HCFA), describing homebound status states that, "there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort. If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment..."   (1).

Ethical principles at risk

As per organisational requirements (Medicare's as the regulatory and the home health agency's as the regulated body), Ms EH was clearly homebound based upon her physical limitations; however, her daily absences did not exactly fit the "infrequent" or "short-duration" requirements for Medicare coverage. Much of the ethical confusion was also caused due to the inability of the coverage guideline to exactly quantify the terms "infrequent" and "short duration" and leaving it for further interpretations. The client's

expectation and what could be perceived as her right to receive health care at her home based upon her medical necessity (client/consumer rights), and my moral duty to provide treatments and my obligation toward her well-being (my personal beliefs) were thus in conflict with the organisational interpretation/ procedures based on regulations that set criteria for services (rules of practice, possible legal issues involved).

The various ethical principles at risk were as follows:

Autonomy: The client's right based upon her self-determination to receive occupational therapy services at home, and my own professional autonomy to decide where the client should receive the services were under question. As stated by Shanawani and Lowe, our professional schooling prepares us with, "guidelines, rules and regulations, and legal judgments relevant to our decisions about where to treat patients...(based on) medical variables of the patient's health... and the anticipated care needs of the patient. Nowhere do non-medical [italics added] variables of patient financial resources, insurance reimbursement, and patient and family preference play an explicit role in those decisions" (2).

Veracity: My professional obligation to speak and act truthfully regarding the client's inability to follow the homebound criteria to continue receiving services at home interfered with my respect for the client's autonomy.

Justice: While I felt a strong sense of duty to care for my client, I realised that the client did not clearly satisfy all Medicare coverage criteria (3).

Fidelity: I viewed this principle as my ability to uphold my commitments to all parties involved, such as the client, my organisation, and the government (via Medicare regulations) and my self as a moral agent.

Beneficence: The client strongly believed that she needed home occupational therapy services and that she was truly benefiting from these.  In my professional judgement, too, the client certainly could benefit with continued services. However, this beneficence seemed to conflict with the legal and ethical aspects of delivering services. 

Other ethical principles caused me to introspect on what kinds of consequences were good or valuable.  I hoped that I was able to be truthful, moral and of benefit to my client through my actions. I also contemplated on what would be a virtuous route to meet the care needs of my client, act in her best interests and cause her maximum gains.

My dilemma forced me to explore the meta-ethical bases of these principles, since several principles were at risk or were conflicting. Do I resolve my ethics based on reason as taught by Immanuel Kant or do I base it on sympathy as proposed by Hume? Do my professional duties conflict with my personal religious beliefs to do good unto others?  Will my social contract as a therapist be broken if I discharged my client from my care since she did not meet the Medicare (legal) requirements (4)?

The theories of ethics applicable to my dilemma

My dilemma involved various ethical principles that are based upon different ethical theories. My case, as with most occurrences in health care, had elements of all major ethical theories. The theories influencing my decision process were:

(a) Teleology, in my pursuit to benefit my client (consequentialism); (b) Virtue-based ethics to strive for my client to receive the care and goodness that I or any human may hope for; (c) Value-based ethics to be truthful and good as a person and professional and cause happiness for my client, and (d) Ethics of care due to the therapist-client relationship I had developed and my concern for my client's care. However, I believe that my dilemma and its resolution were derived from and best explained by the theory of deontology.

Deontologism focuses on the very action and its process, and the moral rules and principles involved with

the act versus the consequences of the action itself. It emphasises that one must act in accordance with rules and principles of ethics such as respect for autonomy, non-malfeasance, beneficence, justice, fidelity, veracity and avoidance of killing (5). That is, it focuses on acting morally based on one's duty versus basing one's action on the results that it causes.

The resolution and the methods used

After detailed discussions with the client and her family, I discontinued home-based occupational therapy services and referred the client for outpatient rehabilitation.

Jonsen, Seigler, and Winslade (1998), Purtillo (1993) and, Trompetter, Hansen, and Kyler-Hutchinson (1998) have all proposed several methods or processing tools to analyse ethical dilemmas (6,7,8). Kornblau and Starling (1999) also proposed a framework for ethical decision-making. It was called the CELIBATE method (an acronym for 'Clinical Ethics and Legal Issues Bait All Therapists Equally'). The acronym acts as a cue for the user of the framework with each letter representing an aspect for analysis (for example: C for clinical situation, E for ethical issues, L for legal issues, I for information, B for brainstorming action steps, A for analysing action steps, T for taking the action and E for evaluating the results) (5).

In the course of analysing and applying a methodology to resolve my ethical dilemma, I charted my ethical course via a framework. Based on this model, we can divide the entire ethical process when faced by a dilemma into three phases, namely the ethical encounter, the ethical loading and ethical unloading.

The ethical encounter: This phase as applied to my case has been discussed under the section titled 'The case scenario'. The parties involved are the client, my self, the home health agency that employs my services, the CMS, the State Occupational Therapy Board due to its judiciary powers over the practice of occupational therapy, the American Occupational Therapy Association (AOTA) as it regulates the profession and sets codes of ethics (9), the scope (10) and standards of practice (11); the client's family, and the community as a whole based upon the potential impact of my services (or the lack of services) on my client's health and well-being. In the encounter phase, we face all the interacting human and/or organisational components of the ethical issue.

The ethical loading: In this phase we analyse the various issues facing us. Whether the law has been violated, or is at risk, or was there just an ethical problem with no legal implications? My dilemma involves whether or not to continue services although there is a medical necessity, but the client may not necessarily meet the coverage criteria for payment. In this case, one may clearly recognise both ethical and legal issues. Legal issues are based upon Medicare and state practice acts governing the profession as well as the AOTA code of ethics (9) and standards of practice (11). This phase bears the load to introspect and discover legal and ethical violations or risks and analyse methods and the future course of action. We have discussed the ethical issues pertaining to my client in the section titled 'Ethical principles at risk'.  In this case, we determined that the theory of deontology best guided our course of resolution.

The ethical unloading: Based upon my realisation and analysis of the ethical-legal aspects involved, I mainly geared my actions toward ethical resolution since there were no legal violations as yet and no separate legal actions were warranted other than those implied by ethical actions. My ethical actions were aimed at mainly upholding deontological principles by following my professional duty as perceived under Medicare and state practice acts, and by not interfering with the regulation with my own interpretation and attempt to liberalise it. I chose to rather use the regulation in its most restrictive form in order to ensure that no confusing elements could cause further dilemmas.  This upheld the cause of justice, veracity, and my fidelity toward the law that governs my professional practice.

With the ability to visit her husband at the nursing home at will, the client's autonomy was upheld as well. Ms EH was also counselled on her options to receive services under Medicare Part-B plan at an outpatient rehabilitation clinic or other qualifying health care facilities. Fortunately, the facility where her spouse was admitted agreed to also treat her as an outpatient. The client found this acceptable and feasible as well.

My course of action also ensured non- malfeasance and beneficence by ensuring continuity of services desired and needed by the client in an environment that was acceptable to her. It is in this phase where I "unloaded" my ethical burden through actions that I chose based upon my prior experience, training and/or conscience.

As with any clinical case, we may view the "ethical encounter" as a phase where we focus on the demographics and situation at hand. The "ethical loading" phase mainly deals with recognising the ethical and legal issues involved (like the diagnostic process), and investigating and selecting the best course of action (formulating a plan for intervention). Finally, the "ethical unloading" phase involves the application of actions/ interventions with the aim of resolving an issue (outcome). Therefore, this phase must also reflect on the effectiveness of the actions/ interventions in meeting the interests of all parties in the situation.

Commentary

In my opinion, this case presents an ethical conflict frequently faced by home health care providers, where they strive to best serve their clients' needs while navigating through complex financial coverage issues. Emanuel, a physician-philosopher, and Fuchs, an economist, propose the coupling of much-valued freedom of choice with universal health coverage for Americans (12).

The scope of this article was not to address the efficacy of the American health policy but to recognise an everyday dilemma faced in the health care arena.  Through experience and common knowledge, we know that health care professionals face similar ethical issues globally. Advances in client education and awareness have led to increased sensitivity and applicability of client rights and autonomy.  This has also led to several legal developments and awareness of biomedical-ethics internationally.

A clinician, more than ever before, must be prepared to not only address the clinical needs of his/ her clients but also base this on socio-cultural and ethical constructs. A sound knowledge of ethical theories and principles helps to guide a clinician's actions. As Abraham Lincoln once stated, "Let us have faith that right makes might, and in that faith, let us, to the end, dare to do our duty as we understand it (13)."

References

1. Center for Medicare and Medicaid Services [web page on the Internet]. Home health manual (Rev. 302): Chapter II-Coverage of services. Baltimore (MD): Center for Medicare and Medicaid Services; c2003- [cited 2005 July 24]. Available from: http://www.cMshhs.gov/manuals/11_hha/hh200.asp

2. Shanawani H, Lowe KN. Is Greenacres (SNF) the place to be? Virtual Mentor [serial on the Internet]. 2005 [cited 2005 July 24]; 7 (7). Available from: http://www.ama-assn.org/ama/pub/category/3040.html

3. Prosser WL. Law of torts. St Paul (MN): West Publishing Co; 1971.

4. Veatch RM. The basics of bioethics. 2nd ed. Upper Saddle River (NJ): Prentice Hall; 2000.

5. Kornblau BL, Starling SP.  Ethics in rehabilitation: aclinical perspective. Thorafare (NJ): Slack Inc; 1999. p 53-4.

6. Jonsen AR, Seigler M, Winslade WJ. Clinical ethics. New York: McGraw Hill; 1998.

7. Purtillo R. Ethical dimensions in the health professions. Philadelphia, PA: WB Saunders; 1993.

8. Trompetter L, Hansen R, Kyler- Hutchison P. Reference guide to the occupational therapy code of ethics. Bethesda (MD): American Occupational Therapy Association; 1998.

9. American Occupational Therapy Association [web page on Internet]. Occupational therapy codes of ethics. Bethesda (MD): The Association; c2005- [cited 2005 July 25]. Available from:http://www.aota.org/general/docs/ethicscode05.pdf

10. American Occupational Therapy Association [web page on Internet]. Scope of practice. Bethesda (MD): The Association; c2004- [cited 2005 July 25]. Available from:http://www.aota.org/members/area2/docs/scope.pdf

11. American Occupational Therapy Association [web page on the Internet]. Standards of practice for occupational therapy. Bethesda (MD): The Association; c2005- [cited 2005 July 25]. Available from:http://www.aota.org/members/area2/docs/otsp05.pdf

12. Emanuel EJ, Fuchs VR. Health care vouchers�"a proposal for universal change. N Engl J Med. 2005; 352: 1255-1260.

13. Quotable Online [web page on the Internet]. Quotes by subject: Duty quotes. Web Publishing Group, LLC; c2004-[ cited 2005, July 25]. Available from: http://www.quotableonline.com/quotesubjectss.php?subject=Duty&page=2

Ethical Dilemma in Today's Business

Global interdependence is a compelling dimension of the global business environment, creating

demands on international managers to take a positive stance on issues of ethical behavior, social

responsibility, economic development in host countries, and environmental protection around the

world. However, there were still several large multinational companies indulging in ethically

questionable practices. If MNCs behave unethically, it soon comes to the notice of the public and

the company’s image is tainted. Multinationals are often worse off for having behaved

unethically in the interest of short term gains, as the bad publicity generated by unethical

practices leads to far greater losses in the long run.

 

In the challenge of modern society, manager or worker often encounters a situation than

challenges one’s ethical beliefs and standards. Managing across border increasingly includes

difficult ethical dilemmas. It is less clear where to draw the line between ethical behavior and the

corporation’s other concerns, or between the conflicting expectations of ethical behavior among

different countries. The paper aims to (1) discuss current ethical dilemmas in global

environmental ethics, (2) examine how multinational would address conflicting norms and

expectations by illustrating one case study of ethical dilemma and its resolution.

Nestlé’s Corporate Crimes           

1.0 Nestlé’s ethical dilemmas

1.1.      Unethical marketing practices

Infant formula

In 1977, Nestle got embroiled in a controversy, when it was criticized for using unethical

marketing practices endangering consumer health to promote its infant formula in developing

nation. A number of aid agencies called for the boycott of Nestle products and this protest

continued right into the 1980s, when Nestle agreed to adopt the infant formula marketing code

laid down by the World Health Organization and UNICEF. Although Nestle had a charter on

infant formula, the company is usually violated the principles laid down in it (Refer to

reference3).

 

Genetically Modified Foods

Nestle was criticized for using genetically modified (GM)[1] ingredients in its food products, and

was accused of dumping products rejected in Europe in developing Asian countries where the

laws on GM products were either absent or less stringent.

For Kant, the company’s decision makers would have to be willing to advocate marketing the

product even if they were themselves in the position of uniformed consumers. Therefore,

providing unsafe products standard and ill-informed consumers by Nestle is absolutely wrong.

 

1.2.      Overcharged prices

Nestle launched bottled water, called “Pure Life” in some Asian countries

like Pakistan andIndia (in 1998 and 2001 respectively). Nestle introduced bottled water, which

provided safe clean water but priced it so high that it was unaffordable for the lower income

groups. It turned water into a luxury by pricing it around $ 0.4 (in Pakistan) for a one liter bottle.

 

According to utilitarianism, ethical action is evaluated by looking at its consequences, weighing

the good effects against the bad effects on all the people affect by it (Shaw & Barry, 2004). Most

developing countries laced basic drinking water facilities. A very high water price was charged

by Nestle limiting a number of people to buy it. Nestlé’s action produces the worse for the

greatest number of South Asian because people could not afford for water which is basic human

needs and is sporadic and contaminated in south Asiacountries.

 

1.3.      Unfair labor practices

Nestle was one of the biggest purchasers of cocoa from Ivory Coast, a country in West Africa.

UNICEF studies and International Labor Organization (2002) revealed that the workers on these

plantation lived and worked in poor conditions. They were paid minimal wages and exploited by

the land-owners. Most of the workers had been trafficked by bought and sold, making them

practically slave labor. Nestle purchased cocoa from these farms despite its awareness of the

conditions of the laborers, thus making it a party to their exploitation.

 

Child labor was also employed on the plantation. UNICEF and The International Institute of

Tropical Agriculture (IITA) studies (2002) revealed that over 200,000 children were shipped to

Ivory Coast and other cocoa producing countries in Western Africa from neighboring countries

like Mali and Burkina Faso, to work on the plantations, especially during the harvesting of cocoa

or coffee beans.

 

Another unfair labor practice was occurred in Thailand. When a group of 13 workers, wording in

a sub-contracting facility of Nestle in Thailand, organized themselves to form a union, Nestle

immediately cut the number of orders to that company and asked the company to put the

unionized workers on indefinite leave with half pay. The workers were force to quit because of

their lowered pay (Manager 2001). In doing so, Nestle had clearly denied these workers their

right to organize themselves to better their interests.

 

1.2.   Applying De George’s principles

 

International business ethics refers to the conduct of MNCs in their relationships to all

individuals and entities with whom they come into contact (Daft, 2002). Ethical behavior is

judged and based largely on the cultural value system and the generally accepted ways of doing

business in each country or society. MNC Manager must decide whether to base their ethical

standards on those of the host country or those of the home country and whether these different

standards can be reconciled (Donalson, 1996).

 

1.2.1.      Do no harm

Thompson & Stickerland, (2003, p. 65) asserts that “a company has ethical

duties to owners, employees, customers, suppliers, the communities where it

operates, and the public at large.” The norm of doing no harm requires Nestlé’s

management to look beyond its own interests (i.e., cheap cocoa, and high market-share).

Unethical marketing of infant formula and GM foods in developing countries are example of

doing harm knowingly and willingly and of benefiting from the lack of legal restraints to the

detriment of the eventual consumers. If business follow Kant’s rule, it will provide a quality and

safe product to its entire market. Nestle decide to sell unsafe (GM) foods even it knows that the

product is unsafe. In addition, Nestlé’s marketing strategy in developing countries was to

distribute free samples to nursing mothers, thus getting the baby used to the formula very early in

order to get a hold on its captive market. Unethically, Nestlé promoted the use of infant milk

formula as a substitute for mother’s milk. This unethical manner causes widespread infant

malnutrition and susceptibility to infection, which could even lead to infant death. Following this

norm, Nestle should preserve the safety and health of consumers by disclosure of appropriate

information, proper labeling and accurate advertising.

 

Workers on cocoa production from Ivory cost were paid below minimal wages and were

practiced as slave labor. Despite its awareness of the conditions of the labors, Nestle continued

purchased of cocoa from these suppliers. The company must pressurize its suppliers to change

because it is in a position of major buyer. Regarding to Nestlé’s inThailand, the company should

respect the right of employees to organize for the purpose of collective bargaining. Nestle had

better prohibit retaliation to their employees, though disciplinary action, or an anti-harassment

policy.  In addition to Anti- harassment, companies need to develop policies and procedures to

prevent retaliation against individual who file complaints of harassment or discrimination or who

participate in their investigation (Zimmerman, 2002).

 

1.2.2.      Do more good

In Ivory Coast, Children worked in hazardous conditions using machetes and spraying pesticides

and insecticides without the necessary protective equipments. Such exploitation involves in

significant Nestlé’s profit since the labors received only a very small proportion of the price paid

for the Nestle product by the final consumer. According to the norm of doing more good than

harm to host country, Nestle must stop buying cocoa from South Africa, which is under

apartheid and uses child labor in hazardous working condition.  For a utilitarian, however, these

are considerations that can be balanced against other considerations, such as the benefit to others.

On the other side of the balance are factors like corporate reputation (Orts, 1995). These factors

can make corporate altruism worthwhile in the long run, even at the short-run expense of the

stockholders. Nestle should demonstrate its ethical commitment through philanthropic

contribution and use of its expertise and resources on numerous social problem in host countries.

 

Importantly, Nestle should integrate social and ethical issue in strategic process (see figure4).

Along with an investment appraisal, such planning should include an environmental impact

assessment. According to Whetton & Cameron (2005) leadership is the key success for

organizational change as well as the key to aligning organizational systems and follower

behaviors around a new organizational vision. Ethical leadership practices are necessary

prerequisite for organizational effectiveness (Ausguien, 2001). Therefore, Nestle top

management must train to be ethical leadership (see Recommendation action in appendix3).

 

Figure4: Integrating social and ethical issues in the strategic management processSocial & Ethical Issues

Environmental AnalysisEstablishing Organizational Direction

StrategicImplementation

Strategic FormulationStrategicControl

Source: Adapted from Thompson & Stickerland (2003, p.7)

To upgrade company’s ethics, Nestle must impose codes of conduct that treating other person

with respect and should provide leadership’s ethical training as leaderships are key person to

make a strategic-decision. Examples of codes of conduct include do not use child or forced labor,

provide a safe working environment, and respect worker rights to unionize (Refer to figure2).

Corporate moral excellence can be alternative to develop Nestlé’s ethical culture. For a corporate

to be morally excellent, it must develop and act out of a moral corporate culture (Hoffman,

1994). In a situation with intolerance arise, manager should be guided by precise statements that

spell out the behavior and operating practices that Nestlé’s demand. Nestle must be careful when

placing a foreign manager in a country whose values are incongruent with his own because this

could lead to conflict with local managers, governmental bodies, customers and suppliers.

 

1.2.3.      Respect the human rights of their employees

Doing good business and being a good employer is pivotal and important guidelines in doing

today’s multinationals. In fact, ethical business must respect for human dignity, and protect the

fundamental rights of people. According to Aristotelian, equal should be treated equally and

unequal unequally (Hirschman, 2001). This infers that individuals should be treated the same,

unless they differ in ways that are relevant to the situation in which they are involved. If labors

work the same jobs, they should be paid the same wage. If Nestle pays its labors less than other

companies, then Nestle has an injustice in remuneration system. Violating human rights is

immoral practices due to Kant’s principle. This indicates that Nestle exploited and treated others

as means rather than as ends, as thing rather than as person. Not only does Nestle (exploiter) fail

to do its duty to others, but also fails to do this duty to itself; Nestle make itself into an object.

 

1.2.4.      Respect local regulations

MNCs are subject to the laws, regulations, and jurisdiction of the countries in which they operate

(OECD, 2004). Nestle must not resist against law that protect the country’s workers or

consumers, even if such laws make operating in these countries less profitable. It is evidence that

Nestle did not respect for domestic rules and regulation. Nestle broke Thai law bys paying

workers less than minimum wage and cut them off. For consumer safety, Nestle did not respect

the laws and regulations of the countries in which they operate with regard to consumer

protection. In China, there is a regulation of GM food, which required that all products which

were contained GM ingredients, be labeled explicitly. Despite consist of GM ingredients, Nestle

products were not labeled. Indeed, it could not unilaterally continue with its double standard

practice and ignore the concerns and demands of the general public in Asia.

[1] Genetically modified foods are lab-crated grains, vegetables, fruits and other primary foods. Their use has been somewhat controversial. Some people are concerned about the consequences to their health of the use of these products. European countries require all GM foods to be clearly labeled as such; however, in countries Canada and the US, labeling is optional.

Ethical Dilemmas in Business

There are many areas where ethical dilemmas arise.  Here are five categories of common ethical dilemmas in business:

1. Human resource issues2. Employee safety issues3. Conflicts of interest4. Customer confidence5. Use of corporate resources

We shall discuss ethical dilemmas related to human resource issues here.

Human resource issuesHuman is the most important resource to an organization. Issues associated with human resources occur as a result of employees working together. These issues are by far the largest category of ethical dilemmas in business.

The four main types of human resource issues are as follows:

• Hiring and Termination Issues

Recruitment or hiring process is the first step in selecting human resource into an organization, and will significantly influence the successful performance of the organization.

Ethics plays a very important role during the recruitment of new employees. Law and regulations dictate that we have to be ethical in hiring. However, ethical hiring practice goes beyond them as well. It has been widely reported by many researchers that ethical hiring practices actually result in better employees being recruited.

It is therefore important that sound ethical rules are followed when hiring a new employee.

It is of vital importance that candidates are to be selected based on merits.  Applicants are to be hired based purely on merits such as knowledge, skills, and ability in accordance to the needs of the organization.  

If a company provides any special considerations, for example affirmative action, where certain groups are given special considerations, these considerations should be well stated in the company's policy statement.  In any case, any preferential treatment should be one that is legally allowed.  

While preferential treatments to certain specific group may be allowed, there should be no discrimination to people from any other group due to race, religion, gender, marital or even pregnancy status.

Consistency and objectivity during the recruitment process are very important.  Criteria, including any changes in the criteria, used for evaluating candidates should be stated and explained to order to avoid unnecessary claim of biasness in the recruitment process.  Objective evaluation results in the best employees being recruited while consistency ensures 

high morale among employees.

When we recruit new employees, we should tell the applicants about the true state of the organization.  We should not mislead the applicants. In particular, the applicants should be told all pertinent information, including those information that are not publicly known but that will materially affect the new employee's future employment prospect with the organization. We can learn from the case involving Phil McConkey. Phil McConkey was recruited but he was not aware that the company was in the process of being taken over by another entity. One year after joining the company he lost his job with he new company. He sued the company for with-holding important information from me during the recruitment process.  He won the case and was awarded $10 million.

We should never place misleading job advertisement in order to get applications if we are offering a job contract different from what we advertised for. For instance, if we want to engage independent contractors instead of normal salaried employment.  The reason why we choose to engage independent contractors is that we do not have to be burdened with high salary cost for employees that are not competent, but we are willing to compensate employees according to performance. We should always state clearly our terms of employment.  In any case, we do not want to be accused of any job scam.

We have to be extra careful when we are recruiting employees from organizations that have material dealing with us include our suppliers, customers and competitors. If we are not careful ethical issues very damaging to us can arise.

When we employ somebody from our suppliers, the suppliers may feel that we have unethically poached their good employee. After all, it is through the working relationship we have with the suppliers that we can to know the quality of this employee.

When we employ somebody from our customers we can be accused of returning favor to that person. This rule applies especially when employing a former senior government employee that has an influence on the awards of contracts to an organization like yours. The case of Ms. Darleen Druyun at the Department of Defense and Mr. Michael Sears at Boeing is a good illustration of the importance of such a rule. In this case, employment favor was apparently granted by Boeing in exchange for favorable consideration for the awards of contracts by Department of Defense. Also, be careful not to employ former government employees for the purpose of lobbying for contracts from their previous government departments. At least, do not do so within the first two years of the employee leaving the government service.

It is also not very wise to employ somebody from our competitors because we can be accused of stealing trade secrets from our competitors. If that employee can pass on his previous employer's secrets unethically, what is there to sop him from passing your trade secrets to others?

Even though it may not be considered as unethical by some employers, as a matter of courtesy and good public relationship to inform an unsuccessful applicant.

When an employee is asked to leave, it is also of vital importance that it is handled with fairness and care.  If it is a case of poor performance or disciplines, the employee has to be given prior warning (unless it is violation of a well stated policy or is of a very serious nature) and fair hearing.  In any case, do not hurt the dignity of the employee and offer to provide the necessary assistance where appropriate.  

Before an employee leave for any reason, provide him/her with an opportunity to provide 

feedback on the overall state of the organization by conducting exit interviews.

• Discrimination is the unfair or preferential treatment of a person on the basis of one or more uncontrollable characteristics, including race, gender, age, color, religion, or national origin, as well as handicapped or pregnancy status.

Discrimination against others in the workplace can impair your ability to perform your job according to company expectations.

In most countries, there are laws that protect potential and current employees from discrimination based on age, race, color, national origin, religion, and gender, as well as pregnancy or handicapped status.

• Performance Appraisals are conducted to evaluate an employee’s performance over a set period of time.

When evaluating subordinates, one has to remain consistent and objective. Consistency is even more important when evaluating an existing employee than a prospective employee.

Consistency requires that you treat every employee's misbehaviour the same way.  For example, it would be wrong to punish one employee's tardiness while leaving another employee's tardiness unchecked.

In order to maintain objectivity, the company’s standardized evaluation forms should be used.  In this way, uniform criteria can be used for the appraisal of all employees under you.  Also, all employees in the company are evaluated based on the same criteria.

Constant feedback and communication between you and your subordinates is necessary to facilitate a positive and productive working relationship. Don’t wait until periodic performance evaluations to express your observations and suggestions. In fact, it is unethical to base salary adjustments upon performance problems that have not been brought to the employee’s attention.

For employees being evaluated, honesty and acceptance of responsibility for performance problems are important ethical considerations.

• Disciplinary issuesDisciplining employees is one of the most difficult parts of a manager’s job.  Nevertheless, it is vital to the growth and overall success of the organization.

Disciplining employees both ensures productivity and sets standards for the future.

Discipline should occur immediately after a problem has occurred. It is imperative that the disciplinary actions remain consistent for all employees.

A serious disciplinary issue is sexual harassment where female employees (less so for male employees) are subjected to an unwanted sexual behavior that creates an intimidating or hostile work environment. This includes unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature. This conduct is not only unethical, but illegal as well.